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Thomford NE, Kellermann T, Biney RP, Dixon C, Nyarko SB, Ateko RO, Ekor M, Kyei GB. Therapeutic efficacy of generic artemether-lumefantrine in the treatment of uncomplicated malaria in Ghana: assessing anti-malarial efficacy amidst pharmacogenetic variations. Malar J 2024; 23:125. [PMID: 38685044 PMCID: PMC11059713 DOI: 10.1186/s12936-024-04930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Despite efforts made to reduce morbidity and mortality associated with malaria, especially in sub-Saharan Africa, malaria continues to be a public health concern that requires innovative efforts to reach the WHO-set zero malaria agenda. Among the innovations is the use of artemisinin-based combination therapy (ACT) that is effective against Plasmodium falciparum. Generic artemether-lumefantrine (AL) is used to treat uncomplicated malaria after appropriate diagnosis. AL is metabolized by the cytochrome P450 family of enzymes, such as CYP2B6, CYP3A4 and CYP3A5, which can be under pharmacogenetic influence. Pharmacogenetics affecting AL metabolism, significantly influence the overall anti-malarial activity leading to variable therapeutic efficacy. This study focused on generic AL drugs used in malarial treatment as prescribed at health facilities and evaluated pharmacogenomic influences on their efficacy. METHODS Patients who have been diagnosed with malaria and confirmed through RDT and microscopy were recruited in this study. Blood samples were taken on days 1, 2, 3 and 7 for parasite count and blood levels of lumefantrine, artemisinin, desbutyl-lumefantrine (DBL), and dihydroartemisinin (DHA), the active metabolites of lumefantrine and artemether, respectively, were analysed using established methods. Pharmacogene variation analysis was undertaken using iPLEX microarray and PCR-RFLP. RESULTS A total of 52 patients completed the study. Median parasite density from day 1 to 7 ranged from 0-2666/μL of blood, with days 3 and 7 recording 0 parasite density. Highest median plasma concentration for lumefantrine and desbutyl lumefantrine, which are the long-acting components of artemisinin-based combinations, was 4123.75 ng/mL and 35.87 ng/mL, respectively. Day 7 plasma lumefantrine concentration across all generic ACT brands was ≥ 200 ng/mL which potentially accounted for the parasitaemia profile observed. Monomorphism was observed for CYP3A4 variants, while there were observed variations in CYP2B6 and CYP3A5 alleles. Among the CYP3A5 genotypes, significant differences in genotypes and plasma concentration for DBL were seen on day 3 between 1/*1 versus *1/*6 (p = 0.002), *1/*3 versus *1/*6 (p = 0.006) and *1/*7 versus *1/*6 (p = 0.008). Day 7 plasma DBL concentrations showed a significant difference between *1/*6 and *1/*3 (p = 0.026) expressors. CONCLUSIONS The study findings show that CYP2B6 and CYP3A5 pharmacogenetic variations may lead to higher plasma exposure of AL metabolites.
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Affiliation(s)
- Nicholas Ekow Thomford
- Pharmacogenomics and Genomic Medicine Group, Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana.
- Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925, South Africa.
| | - Tracy Kellermann
- Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robert Peter Biney
- Pharmacogenomics and Genomic Medicine Group, Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Pharmacotherpaeutics and Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Charné Dixon
- Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Samuel Badu Nyarko
- Pharmacogenomics and Genomic Medicine Group, Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Richmond Owusu Ateko
- Department of Chemical Pathology, University of Ghana Medical School, University of Ghana, Legon, Accra, Ghana
- Division of Chemical Pathology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Martins Ekor
- Department of Pharmacology, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | - George B Kyei
- Department of Virology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Rotimi K, Fagbemi B, Itiola AJ, Ibinaiye T, Aidenagbon A, Dabes C, Biambo AA, Iwegbu A, Onabajo S, Oguoma C, Oresanya O. Private sector availability and affordability of under 5 malaria health commodities in selected states in Nigeria and the Federal Capital Territory. J Pharm Policy Pract 2023; 17:2294024. [PMID: 38223355 PMCID: PMC10783550 DOI: 10.1080/20523211.2023.2294024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background To guarantee uninterrupted service delivery, quality-assured products must be affordable and continuously available across all sectors, including the private sector, which provides more than 60% of healthcare services in Nigeria. We investigated the private sector availability and affordability of under 5 malaria commodities to establish the level of access in this sector. Methods We surveyed patent medicine and pharmacy stores across seven states in Nigeria and the Federal Capital Territory to establish the availability and affordability of selected malaria commodities for children under 5 years. Availability was measured as the percentage of visited outlets with the product of interest on the day of visit, while affordability was assessed by establishing if it cost more than a day's wage for the least-paid government worker to purchase a full course of malaria diagnostic test and/or medication. Results Artemisinin-based antimalarials for uncomplicated and severe malaria were the most available commodities. SPAQ1 and SPAQ2 used for seasonal malaria chemoprevention campaign were surprisingly also available in some outlets. However, only about half (48.3% and 53.3%) of the surveyed outlets had stock of artemether/lumefantrine (AL1) and artesunate injection, respectively. The median price of surveyed products ranged from USD (United States Dollars) 0.38 to USD 2.17 per treatment/test. Except for amodiaquine tablet and artemether injection, which cost less, all other originator brands cost the same or more than the lowest-priced generic. Antimalarial products were affordable as their median prices were not more than a day's wage for the least-paid government worker. However, when the cost of testing and treatment with artemisinin-based combination therapies (ACTs) was assessed, testing and treatment with dihydroartemisinin/piperaquine were unaffordable as the they cost more than 1.5 times the daily wage of the least-paid government worker. Conclusion The overall private sector availability of under-five malaria commodities in surveyed locations was suboptimal. Also, testing and treatment with recommended ACTs were not affordable for all surveyed products. These findings suggest the need for interventions to improve access to affordable under-five malaria commodities.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sarah Onabajo
- National Agency for Food and Drug Administration and Control, Lagos, Nigeria
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Weathers PJ. Artemisinin as a therapeutic vs. its more complex Artemisia source material. Nat Prod Rep 2023; 40:1158-1169. [PMID: 36541391 DOI: 10.1039/d2np00072e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Covering: up to 2017-2022Many small molecule drugs are first discovered in nature, commonly the result of long ethnopharmacological use by people, and then characterized and purified from their biological sources. Traditional medicines are often more sustainable, but issues related to source consistency and efficacy present challenges. Modern medicine has focused solely on purified molecules, but evidence is mounting to support some of the more traditional uses of medicinal biologics. When is a more traditional delivery of a therapeutic appropriate and warranted? What studies are required to establish validity of a traditional medicine approach? Artemisia annua and A. afra are two related but unique medicinal plant species with long histories of ethnopharmacological use. A. annua produces the sesquiterpene lactone antimalarial drug, artemisinin, while A. afra produces at most, trace amounts of the compound. Both species also have an increasing repertoire of modern scientific and pharmacological data that make them ideal candidates for a case study. Here accumulated recent data on A. annua and A. afra are reviewed as a basis for establishing a decision tree for querying their therapeutic use, as well as that of other medicinal plant species.
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Affiliation(s)
- Pamela J Weathers
- Department of Biology and Biotechnology, 100 Institute Rd, Worcester Polytechnic Institute, Worcester, MA, 01609, USA.
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4
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Atun R, Bhakta N, Denburg A, Frazier AL, Friedrich P, Gupta S, Lam CG, Ward ZJ, Yeh JM, Allemani C, Coleman MP, Di Carlo V, Loucaides E, Fitchett E, Girardi F, Horton SE, Bray F, Steliarova-Foucher E, Sullivan R, Aitken JF, Banavali S, Binagwaho A, Alcasabas P, Antillon F, Arora RS, Barr RD, Bouffet E, Challinor J, Fuentes-Alabi S, Gross T, Hagander L, Hoffman RI, Herrera C, Kutluk T, Marcus KJ, Moreira C, Pritchard-Jones K, Ramirez O, Renner L, Robison LL, Shalkow J, Sung L, Yeoh A, Rodriguez-Galindo C. Sustainable care for children with cancer: a Lancet Oncology Commission. Lancet Oncol 2020; 21:e185-e224. [PMID: 32240612 DOI: 10.1016/s1470-2045(20)30022-x] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/22/2019] [Accepted: 01/14/2020] [Indexed: 12/29/2022]
Abstract
We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.
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Affiliation(s)
- Rifat Atun
- Department of Global health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston MA, USA.
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Avram Denburg
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - A Lindsay Frazier
- Dana-Farber and Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sumit Gupta
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Catherine G Lam
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Zachary J Ward
- Center for Health Decision Science, Harvard T H Chan School of Public Health, Harvard University, Boston MA, USA
| | - Jennifer M Yeh
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston MA, USA; Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Claudia Allemani
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Michel P Coleman
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Veronica Di Carlo
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Elizabeth Fitchett
- University College London Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Fabio Girardi
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan E Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, WHO, Lyon, France
| | - Eva Steliarova-Foucher
- Section of Cancer Surveillance, International Agency for Research on Cancer, WHO, Lyon, France
| | - Richard Sullivan
- Institute of Cancer Policy, Conflict and Health Research Group, School of Cancer Sciences, King's College London, London, UK
| | - Joanne F Aitken
- Cancer Council Queensland, Brisbane, QLD, Australia; School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Shripad Banavali
- Department of Medical and Pediatric Oncology, Tata Memorial Center, Mumbai, India; Homi Bhabha National Institute, Mumbai, India
| | | | - Patricia Alcasabas
- Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Federico Antillon
- Unidad Nacional de Oncología Pediátrica and the School of Medicine, Universidad Francisco Marroquín, Guatemala City, Guatemala
| | - Ramandeep S Arora
- Department of Medical Oncology, Max Super-Specialty Hospital, New Delhi, India
| | - Ronald D Barr
- Departments of Pediatrics, Pathology and Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Eric Bouffet
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Julia Challinor
- School of Nursing, University of California San Francisco, San Francisco, CA, USA
| | | | - Thomas Gross
- Center for Global Health, US National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lars Hagander
- Department of Clinical Sciences Lund, Pediatric Surgery, WHO Collaborating Centre for Surgery and Public Health, Lund University Faculty of Medicine, Lund, Sweden
| | - Ruth I Hoffman
- American Childhood Cancer Organization, Beltsville, MD, USA
| | - Cristian Herrera
- Health Division, Organization for Economic Cooperation and Development, Paris, France; Department of Public Health, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Tezer Kutluk
- Department of Pediatrics, Division of Pediatric Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Cancer Institute, Hacettepe University, Ankara, Turkey
| | - Karen J Marcus
- Department of Radiation Oncology, Harvard Medical School, Harvard University, Boston MA, USA; Division of Radiation Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Claude Moreira
- Institut Jean Lemerle, African Paediatric Oncology Formation, Dakar, Senegal; Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Senegal
| | - Kathy Pritchard-Jones
- University College London Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Oscar Ramirez
- Department of Pediatric Haematology and Oncology, Centro Médico Imbanaco de Cali, Cali, Colombia; Cali Cancer Population-based Registry, Universidad del Valle, Cali, Colombia
| | - Lorna Renner
- Department of Child Health, University of Ghana Medical School Accra, Ghana; Paediatric Oncology Unit, Korle Bu Teaching Hospital, Accra, Ghana
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jaime Shalkow
- Department of Pediatric Surgical Oncology, National Institute of Pediatrics, Mexico City, Mexico; School of Medicine, Anahuac University, Mexico City, Mexico
| | - Lillian Sung
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Allen Yeoh
- Division of Paediatric Haematology and Oncology, National University Cancer Institute, Singapore National University Health System, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
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5
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Cooke GS, Andrieux-Meyer I, Applegate TL, Atun R, Burry JR, Cheinquer H, Dusheiko G, Feld JJ, Gore C, Griswold MG, Hamid S, Hellard ME, Hou J, Howell J, Jia J, Kravchenko N, Lazarus JV, Lemoine M, Lesi OA, Maistat L, McMahon BJ, Razavi H, Roberts T, Simmons B, Sonderup MW, Spearman CW, Taylor BE, Thomas DL, Waked I, Ward JW, Wiktor SZ. Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2019; 4:135-184. [PMID: 30647010 DOI: 10.1016/s2468-1253(18)30270-x] [Citation(s) in RCA: 330] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 01/26/2023]
Abstract
Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.
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Affiliation(s)
- Graham S Cooke
- Division of Infectious Diseases, Imperial College London, London, UK.
| | | | | | - Rifat Atun
- Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | | | - Hugo Cheinquer
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | - Jordan J Feld
- Toronto Center for Liver Disease, Toronto General Hospital, Toronto, Canada
| | | | - Max G Griswold
- Institute of Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | | | | | - JinLin Hou
- Hepatology Unit and Department of Infectious Diseases, Nanfang Hospital, Guangzhou, China
| | - Jess Howell
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Beijing, China
| | | | - Jeffrey V Lazarus
- Health Systems Research Group, Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Maud Lemoine
- Division of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Brian J McMahon
- Liver Disease and Hepatitis Program, Alaska Native Tribal Health Consortium, Anchorage, AL, USA
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, CO, USA
| | | | - Bryony Simmons
- Division of Infectious Diseases, Imperial College London, London, UK
| | - Mark W Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, South Africa
| | | | - David L Thomas
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Imam Waked
- National Liver Institute, Menoufiya University, Egypt
| | - John W Ward
- Program for Viral Hepatitis Elimination, Task Force for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stefan Z Wiktor
- Department of Global Health, University of Washington, Seattle, WA, USA
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Innovative financing instruments for global health 2002-15: a systematic analysis. LANCET GLOBAL HEALTH 2018; 5:e720-e726. [PMID: 28619230 DOI: 10.1016/s2214-109x(17)30198-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 03/26/2017] [Accepted: 04/13/2017] [Indexed: 11/21/2022]
Abstract
Development assistance for health (DAH), the value of which peaked in 2013 and fell in 2015, is unlikely to rise substantially in the near future, increasing reliance on domestic and innovative financing sources to sustain health programmes in low-income and middle-income countries. We examined innovative financing instruments (IFIs)-financing schemes that generate and mobilise funds-to estimate the quantum of financing mobilised from 2002 to 2015. We identified ten IFIs, which mobilised US$8·9 billion (2·3% of overall DAH) in 2002-15. The funds generated by IFIs were channelled mostly through GAVI and the Global Fund, and used for programmes for new and underused vaccines, HIV/AIDS, malaria, tuberculosis, and maternal and child health. Vaccination programmes received the largest amount of funding ($2·6 billion), followed by HIV/AIDS ($1080·7 million) and malaria ($1028·9 million), with no discernible funding targeted to non-communicable diseases.
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Alonso S, Munguambe K, Sicuri E. Market for Artemether-Lumefantrine to treat childhood malaria in a district of southern Mozambique. HEALTH ECONOMICS 2017; 26:e345-e360. [PMID: 28548247 DOI: 10.1002/hec.3514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 01/24/2017] [Accepted: 03/13/2017] [Indexed: 06/07/2023]
Abstract
Malaria is one of the leading causes of death in sub-Saharan Africa. Artemisinin-based combination therapies are used as first-line treatment drugs, but their market is far from competitive. Market failures include limited availability, low quality, lack of information, and high costs of access. We estimated the theoretical demand for one of the most common artemisinin-based combination therapies, artemether-lumefantrine (AL), and its determinants among caregivers of children with malaria seeking care at public health facilities, thus, entitled to receive drugs for free, in southern Mozambique (year 2012). The predicted theoretical demand was contrasted with international and local private market AL prices. Respondents stated high willingness to pay but lower ability to pay (ATP), which was defined as the theoretical demand. The ATP was on average of 0.94 USD for the treatment of a malaria episode. This implied an average gap of 1.04 USD between average local private prices and theoretical demand. Predicted ATP decreased by 14% for every additional malaria episode that the child had suffered during the malaria season. The market price was unaffordable for a large share of our sample, highlighting an unequal welfare distribution between suppliers and potential consumers, as well as issues of inequity in the private delivery of AL.
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Affiliation(s)
- Sergi Alonso
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Elisa Sicuri
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Health Economics group, School of Public Health, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
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8
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Tougher S, Mann AG, Ye Y, Kourgueni IA, Thomson R, Amuasi JH, Ren R, Willey BA, Ansong D, Bruxvoort K, Diap G, Festo C, Johanes B, Kalolella A, Mallam O, Mberu B, Ndiaye S, Nguah SB, Seydou M, Taylor M, Wamukoya M, Arnold F, Hanson K, Goodman C. Improving access to malaria medicine through private-sector subsidies in seven African countries. Health Aff (Millwood) 2016; 33:1576-85. [PMID: 25201662 DOI: 10.1377/hlthaff.2014.0104] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Improving access to quality-assured artemisinin combination therapies (ACTs) is an important component of malaria control in low- and middle-income countries. In 2010 the Global Fund to Fight AIDS, Tuberculosis, and Malaria launched the Affordable Medicines Facility--malaria (AMFm) program in seven African countries. The goal of the program was to decrease malaria morbidity and delay drug resistance by increasing the use of ACTs, primarily through subsidies intended to reduce costs. We collected data on price and retail markups on antimalarial medicines from 19,625 private for-profit retail outlets before and 6-15 months after the program's implementation. We found that in six of the AMFm pilot programs, prices for quality-assured ACTs decreased by US$1.28-$4.34, and absolute retail markups on these therapies decreased by US$0.31-$1.03. Prices and markups on other classes of antimalarials also changed during the evaluation period, but not to the same extent. In all but two of the pilot programs, we found evidence that prices could fall further without suppliers' losing money. Thus, concerns may be warranted that wholesalers and retailers are capturing subsidies instead of passing them on to consumers. These findings demonstrate that supranational subsidies can dramatically reduce retail prices of health commodities and that recommended retail prices communicated to a wide audience may be an effective mechanism for controlling the market power of private-sector antimalarial retailers and wholesalers.
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Affiliation(s)
- Sarah Tougher
- Sarah Tougher is a research fellow in the Department of Global Health and Development, London School of Hygiene and Tropical Medicine, in the United Kingdom
| | - Andrea G Mann
- Andrea G. Mann is a lecturer in the Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
| | | | - Yazoume Ye
- Yazoume Ye is a fellow and technical director at ICF International in Rockville, Maryland
| | - Idrissa A Kourgueni
- Idrissa A. Kourgueni is general director of the Centre International d'Etudes et de Recherches sur les Populations Africaines and of the Institut National de la Statistique de Niger, both in Niamey, Niger
| | - Rebecca Thomson
- Rebecca Thomson is a research fellow at the London School of Hygiene and Tropical Medicine
| | - John H Amuasi
- John H. Amuasi is a doctoral candidate in the School of Public Health, University of Minnesota, in Minneapolis, and a researcher at the Komfo Anokye Teaching Hospital (KATH), in Kumasi, Ghana
| | - Ruilin Ren
- Ruilin Ren is a senior technical specialist at ICF International in Rockville, Maryland
| | - Barbara A Willey
- Barbara A. Willey is a lecturer in the Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine
| | - Daniel Ansong
- Daniel Ansong is a senior lecturer in the Department of Child Health, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, and deputy director of the Research and Development Unit, KATH
| | - Katia Bruxvoort
- Katia Bruxvoort is a research fellow at the London School of Hygiene and Tropical Medicine
| | - Graciela Diap
- Graciela Diap is a medical coordinator at the Drugs for Neglected Diseases initiative, in Geneva, Switzerland
| | - Charles Festo
- Charles Festo is a researcher at the Ifakara Health Institute, in Dar es Salaam, Tanzania
| | - Boniface Johanes
- Boniface Johanes is a researcher at the Ifakara Health Institute
| | | | - Oumarou Mallam
- Oumarou Mallam is head of central services at the Institut National de la Statistique du Niger
| | - Blessing Mberu
- Blessing Mberu is a research scientist at the African Population and Health Research Centre (APHRC), in Nairobi, Kenya
| | - Salif Ndiaye
- Salif Ndiaye is director of the Centre de Recherche pour le Développment Humain, in Dakar, Senegal
| | - Samual Blay Nguah
- Samual Blay Nguah is a researcher at the research and development unit at KATH
| | - Moctar Seydou
- Moctar Seydou is a specialist statistician at the Institut National de la Statistique du Niger
| | - Mark Taylor
- Mark Taylor is a Slovak Academic Information Agency (SAIA)-sponsored public health scholar at the University of Trnava, in Slovakia
| | | | - Fred Arnold
- Fred Arnold is a senior fellow at ICF International in Rockville, Maryland
| | - Kara Hanson
- Kara Hanson is a professor of health systems economics and head of the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine
| | - Catherine Goodman
- Catherine Goodman is a senior lecturer in health economics and policy at the London School of Hygiene and Tropical Medicine
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Mori AT, Norheim OF, Robberstad B. Budget Impact Analysis of Using Dihydroartemisinin-Piperaquine to Treat Uncomplicated Malaria in Children in Tanzania. PHARMACOECONOMICS 2016; 34:303-14. [PMID: 26521172 PMCID: PMC4766228 DOI: 10.1007/s40273-015-0344-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Dihydroartemisinin-piperaquine (DhP) is a very cost effective anti-malarial drug. The aim of this study was to predict the budget impact of using DhP as a first- or second-line drug to treat uncomplicated malaria in children in Tanzania. METHODS A dynamic Markov decision model was developed based on clinical and epidemiological data to estimate annual cases of malaria in children aged under 5 years. The model was used to predict the budget impact of introducing DhP as the first- or second-line anti-malarial drug, from the perspective of the National Malaria Control Program in 2014; thus, only the cost of drugs and diagnostics were considered. Probabilistic sensitivity analysis was performed to explore overall uncertainties in input parameters. RESULTS The model predicts that the policy that uses artemether-lumefantrine (AL) and DhP as the first- and second-line drugs (AL + DhP), respectively, will save about $US64,423 per year, while achieving a 3% reduction in the number of malaria cases, compared with that of AL + quinine. However, the policy that uses DhP as the first-line drug (DhP + AL) will consume an additional $US780,180 per year, while achieving a further 5% reduction in the number of malaria cases, compared with that of AL + DhP. CONCLUSION The use of DhP as the second-line drug to treat uncomplicated malaria in children in Tanzania is slightly cost saving. However, the policy that uses DhP as the first-line drug is somewhat more expensive but with more health benefits.
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Affiliation(s)
- Amani Thomas Mori
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
- Muhimbili University of Health and Allied Sciences, P.O. Box 65001, 11103, Dar es Salaam, Tanzania.
| | - Ole Frithjof Norheim
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
| | - Bjarne Robberstad
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
- Centre for Intervention Science in Maternal and Child Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
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Awor P, Wamani H, Bwire G, Jagoe G, Peterson S. Private sector drug shops in integrated community case management of malaria, pneumonia, and diarrhea in children in Uganda. Am J Trop Med Hyg 2015; 87:92-96. [PMID: 23136283 PMCID: PMC3748528 DOI: 10.4269/ajtmh.2012.11-0791] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We conducted a survey involving 1,604 households to determine community care-seeking patterns and 163 exit interviews to determine appropriateness of treatment of common childhood illnesses at private sector drug shops in two rural districts of Uganda. Of children sick within the last 2 weeks, 496 (53.1%) children first sought treatment in the private sector versus 154 (16.5%) children first sought treatment in a government health facility. Only 15 (10.3%) febrile children treated at drug shops received appropriate treatment for malaria. Five (15.6%) children with both cough and fast breathing received amoxicillin, although no children received treatment for 5–7 days. Similarly, only 8 (14.3%) children with diarrhea received oral rehydration salts, but none received zinc tablets. Management of common childhood illness at private sector drug shops in rural Uganda is largely inappropriate. There is urgent need to improve the standard of care at drug shops for common childhood illness through public–private partnerships.
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Affiliation(s)
- Phyllis Awor
- *Address correspondence to Phyllis Awor, Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University College of Health Sciences, 7072 Kampala, Uganda. E-mail:
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11
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Ye Y, Arnold F, Noor A, Wamukoya M, Amuasi J, Blay S, Mberu B, Ren R, Kyobutungi C, Wekesah F, Gatakaa H, Toda M, Njogu J, Evance I, O'Connell K, Shewchuk T, Thougher S, Mann A, Willey B, Goodman C, Hanson K. The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention? Malar J 2015; 14:398. [PMID: 26452625 PMCID: PMC4600285 DOI: 10.1186/s12936-015-0904-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/13/2015] [Indexed: 11/19/2022] Open
Abstract
Background To assess the availability, price and
market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention. Methods Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country. Results QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001). Conclusion The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.
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Affiliation(s)
- Yazoume Ye
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | - Fred Arnold
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | | | | | - John Amuasi
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana.
| | - Samuel Blay
- Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Blessing Mberu
- African Population and Health Research Center, Nairobi, Kenya.
| | - Ruilin Ren
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | | | | | - Hellen Gatakaa
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | - Mitsuru Toda
- Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.
| | - Julius Njogu
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Illah Evance
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Kathryn O'Connell
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Tanya Shewchuk
- The ACTwatch project (Population Services International), Nairobi, Kenya.
| | - Sarah Thougher
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Andrea Mann
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Barbara Willey
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
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12
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Mannan AA, Elmardi KA, Idris YA, Spector JM, Ali NA, Malik EM. Do frontline health care providers know enough about artemisinin-based combination therapy to rationally treat malaria? A cross-sectional survey in Gezira State, Sudan. Malar J 2015; 14:131. [PMID: 25889428 PMCID: PMC4377190 DOI: 10.1186/s12936-015-0652-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 03/16/2015] [Indexed: 12/18/2022] Open
Abstract
Background In 2004, artemisinin-based combination therapy (ACT) was introduced in Sudan for the treatment of malaria. The role of health care providers working in first-level health care facilities is central for the effective implementation of this revised malaria treatment policy. However, information about their level of ACT knowledge is inadequate. This study sought to describe frontline health care providers’ knowledge about the formulations and dose regimens of nationally recommended ACT in Sudan. Methods This cross-sectional study took place in Gezira State, Sudan. Data were gathered from five localities comprising forty primary health care facilities. A total of 119 health care providers participated in the study (72 prescribers and 47 dispensers). The primary outcome was the proportion of health care providers who were ACT knowledgeable, a composite indicator of health care providers’ ability to (1) define what combination therapy is; (2) identify the recommended first- and second-line treatments; and (3) correctly state the dose regimens for each. Results All prescribers and 95.7% (46/47) of dispensers were aware of the new national malaria treatment policy. However, 93.1% (67/72) of prescribers compared to 87.2% (41/47) of dispensers recognized artesunate-sulphadoxine/pyrimethamine as the recommended first-line treatment in Sudan. Only a small number of prescribers and dispensers (9.4% and 13.6%, respectively) were able to correctly define the meaning of a combination therapy. Overall, only 22% (26/119, 95% CI 14.6-29.4) of health care providers were found to be ACT knowledgeable with no statistically significant difference between prescribers and dispensers. Conclusion Overall, ACT knowledge among frontline health care providers is very poor. This finding suggests that efforts are needed to improve knowledge of prescribers and dispensers working in first-level health care facilities, perhaps through implementing focused, provider-oriented training programmes. Additionally, a system for regularly monitoring and evaluating the quality of in-service training may be beneficial to ensure its responsiveness to the needs of the target health care providers.
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Affiliation(s)
- Abeer A Mannan
- Al Neelain University, Steen Street, P.O. Box 7294, Code: 11123, Khartoum, Sudan.
| | | | | | - Jonathan M Spector
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Nahid A Ali
- Federal Ministry of Health, Khartoum, Sudan.
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Mikkelsen-Lopez I, Shango W, Barrington J, Ziegler R, Smith T, deSavigny D. The challenge to avoid anti-malarial medicine stock-outs in an era of funding partners: the case of Tanzania. Malar J 2014; 13:181. [PMID: 24885420 PMCID: PMC4030285 DOI: 10.1186/1475-2875-13-181] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 04/27/2014] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Between 2007 and 2013, the Tanzanian public sector received 93.1 million doses of first-line anti-malarial artemisinin-based combination therapy (ACT) in the form of artemether-lumefantrine entirely supplied by funding partners. The introduction of a health facility ACT stock monitoring system using SMS technology by the National Malaria Control Programme in mid 2011 revealed a high frequency of stock-outs of ACT in primary care public health facilities. The objective of this study was to determine the pattern of availability of ACT and possible causes of observed stock-outs across public health facilities in Tanzania since mid-2011. METHODS Data were collected weekly by the mobile phone reporting tool SMS for Life on ACT availability from over 5,000 public health facilities in Tanzania starting from September 2011 to December 2012. Stock data for all four age-dose levels of ACT across health facilities were summarized and supply of ACT at the national level was also documented. RESULTS Over the period of 15 months, on average 29% of health facilities in Tanzania were completely stocked out of all four-age dose levels of the first-line anti-malarial with a median duration of total stock-out of six weeks. Patterns of total stock-out by region ranged from a low of 9% to a high of 52%. The ACT stock-outs were most likely caused by: a) insufficient ACT supplies entering Tanzania (e.g. in 2012 Tanzania received 10.9 million ACT doses compared with a forecast demand of 14.4 million doses); and b) irregular pattern of ACT supply (several months with no ACT stock). CONCLUSION The reduced ACT availability and irregular pattern of supply were due to cumbersome bureaucratic processes and delays both within the country and from the main donor, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Tanzania should invest in strengthening both the supply system and the health information system using mHealth solutions such as SMS for Life. This will continue to assist in tracking ACT availability across the country where all partners work towards more streamlined, demand driven and accountable procurement and supply chain systems.
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Affiliation(s)
- Inez Mikkelsen-Lopez
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Winna Shango
- Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
| | | | | | - Tom Smith
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Don deSavigny
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Thomson R, Festo C, Johanes B, Kalolella A, Bruxvoort K, Nchimbi H, Tougher S, Cairns M, Taylor M, Kleinschmidt I, Ye Y, Mann A, Ren R, Willey B, Arnold F, Hanson K, Kachur SP, Goodman C. Has Tanzania embraced the green leaf? Results from outlet and household surveys before and after implementation of the Affordable Medicines Facility-malaria. PLoS One 2014; 9:e95607. [PMID: 24816649 PMCID: PMC4015933 DOI: 10.1371/journal.pone.0095607] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/28/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Affordable Medicines Facility-malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side. METHODS Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks. RESULTS The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs. DISCUSSION Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.
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Affiliation(s)
- Rebecca Thomson
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Ifakara Health Institute, Dar es Salaam, Tanzania
- * E-mail:
| | | | | | | | - Katia Bruxvoort
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Sarah Tougher
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Matthew Cairns
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Taylor
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Public Health, Trnava University, Trnava, Slovakia
| | - Immo Kleinschmidt
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Yazoume Ye
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Andrea Mann
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ruilin Ren
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Barbara Willey
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Fred Arnold
- International Health Division, ICF International, Calverton, Maryland, United States of America
| | - Kara Hanson
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - S. Patrick Kachur
- Malaria Branch, Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Catherine Goodman
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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15
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Willey BA, Tougher S, Ye Y, Mann AG, Thomson R, Kourgueni IA, Amuasi JH, Ren R, Wamukoya M, Rueda ST, Taylor M, Seydou M, Nguah SB, Ndiaye S, Mberu B, Malam O, Kalolella A, Juma E, Johanes B, Festo C, Diap G, Diallo D, Bruxvoort K, Ansong D, Amin A, Adegoke CA, Hanson K, Arnold F, Goodman C. Communicating the AMFm message: exploring the effect of communication and training interventions on private for-profit provider awareness and knowledge related to a multi-country anti-malarial subsidy intervention. Malar J 2014; 13:46. [PMID: 24495691 PMCID: PMC3924415 DOI: 10.1186/1475-2875-13-46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Affordable Medicines Facility - malaria (AMFm), implemented at national scale in eight African countries or territories, subsidized quality-assured artemisinin combination therapy (ACT) and included communication campaigns to support implementation and promote appropriate anti-malarial use. This paper reports private for-profit provider awareness of key features of the AMFm programme, and changes in provider knowledge of appropriate malaria treatment. METHODS This study had a non-experimental design based on nationally representative surveys of outlets stocking anti-malarials before (2009/10) and after (2011) the AMFm roll-out. RESULTS Based on data from over 19,500 outlets, results show that in four of eight settings, where communication campaigns were implemented for 5-9 months, 76%-94% awareness of the AMFm 'green leaf' logo, 57%-74% awareness of the ACT subsidy programme, and 52%-80% awareness of the correct recommended retail price (RRP) of subsidized ACT were recorded. However, in the remaining four settings where communication campaigns were implemented for three months or less, levels were substantially lower. In six of eight settings, increases of at least 10 percentage points in private for-profit providers' knowledge of the correct first-line treatment for uncomplicated malaria were seen; and in three of these the levels of knowledge achieved at endline were over 80%. CONCLUSIONS The results support the interpretation that, in addition to the availability of subsidized ACT, the intensity of communication campaigns may have contributed to the reported levels of AMFm-related awareness and knowledge among private for-profit providers. Future subsidy programmes for anti-malarials or other treatments should similarly include communication activities.
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Affiliation(s)
- Barbara A Willey
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Do price subsidies on artemisinin combination therapy for malaria increase household use? Evidence from a repeated cross-sectional study in remote regions of Tanzania. PLoS One 2013; 8:e70713. [PMID: 23923018 PMCID: PMC3726608 DOI: 10.1371/journal.pone.0070713] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 06/27/2013] [Indexed: 11/19/2022] Open
Abstract
Background The Affordable Medicines Facility-malaria (AMFm) is a pilot program that uses price subsidies to increase access to Artemisinin Combination Therapies (ACTs), currently the most effective malaria treatment. Recent evidence suggests that availability and affordability of ACTs in retail sector drug shops (where many people treat malaria) has increased under the AMFm, but it is unclear whether household level ACT use has increased. Methods and Findings Household surveys were conducted in two remote regions of Tanzania (Mtwara and Rukwa) in three waves: March 2011, December 2011 and March 2012, corresponding to 3, 13 and 16 months into the AMFm implementation respectively. Information about suspected malaria episodes including treatment location and medications taken was collected. Respondents were also asked about antimalarial preferences and perceptions about the availability of these medications. Significant increases in ACT use, preference and perceived availability were found between Rounds 1 and 3 though not for all measures between Rounds 1 and 2. ACT use among suspected malaria episodes was 51.1% in March 2011 and increased by 10.9 percentage points by Round 3 (p = .017). The greatest increase was among retail sector patients, where ACT use increased from 31% in Round 1 to 49% in Round 2 (p = .037) and to 61% (p<.0001) by Round 3. The fraction of suspected malaria episodes treated in the retail sector increased from 30.2% in Round 1 to 46.7% in Round 3 (p = .0009), mostly due to a decrease in patients who sought no treatment at all. No significant changes in public sector treatment seeking were found. Conclusions The AMFm has led to significant increases in ACT use for suspected malaria, especially in the retail sector. No evidence is found supporting the concerns that the AMFm would crowd out public sector treatment or neglect patients in remote areas and from low SES groups.
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O'Connell KA, Poyer S, Solomon T, Munroe E, Patouillard E, Njogu J, Evance I, Hanson K, Shewchuk T, Goodman C. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malar J 2013; 12:52. [PMID: 23383972 PMCID: PMC3599752 DOI: 10.1186/1475-2875-12-52] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/25/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years an increasing number of public investments and policy changes have been made to improve the availability, affordability and quality of medicines available to consumers in developing countries, including anti-malarials. It is important to monitor the extent to which these interventions are successful in achieving their aims using quantitative data on the supply side of the market. There are a number of challenges related to studying supply, including outlet sampling, gaining provider cooperation and collecting accurate data on medicines. This paper provides guidance on key steps to address these issues when conducting a medicine outlet survey in a developing country context. While the basic principles of good survey design and implementation are important for all surveys, there are a set of specific issues that should be considered when conducting a medicine outlet survey. METHODS This paper draws on the authors' experience of designing and implementing outlet surveys, including the lessons learnt from ACTwatch outlet surveys on anti-malarial retail supply, and other key studies in the field. Key lessons and points of debate are distilled around the following areas: selecting a sample of outlets; techniques for collecting and analysing data on medicine availability, price and sales volumes; and methods for ensuring high quality data in general. RESULTS AND CONCLUSIONS The authors first consider the inclusion criteria for outlets, contrasting comprehensive versus more focused approaches. Methods for developing a reliable sampling frame of outlets are then presented, including use of existing lists, key informants and an outlet census. Specific issues in the collection of data on medicine prices and sales volumes are discussed; and approaches for generating comparable price and sales volume data across products using the adult equivalent treatment dose (AETD) are explored. The paper concludes with advice on practical considerations, including questionnaire design, field worker training, and data collection. Survey materials developed by ACTwatch for investigating anti-malarial markets in sub-Saharan Africa and Asia provide a helpful resource for future studies in this area.
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Affiliation(s)
- Kathryn A O'Connell
- Population Services International (PSI), Malaria & Child Survival Department (MCSD), Whitefield Place, Westlands, PO Box, Nairobi, 14355-00800, Kenya.
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Kedenge SV, Kangwana BP, Waweru EW, Nyandigisi AJ, Pandit J, Brooker SJ, Snow RW, Goodman CA. Understanding the impact of subsidizing artemisinin-based combination therapies (ACTs) in the retail sector--results from focus group discussions in rural Kenya. PLoS One 2013; 8:e54371. [PMID: 23342143 PMCID: PMC3544761 DOI: 10.1371/journal.pone.0054371] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 12/11/2012] [Indexed: 11/19/2022] Open
Abstract
Background There is considerable interest in the potential of private sector subsidies to increase availability and affordability of artemisinin-based combination therapies (ACTs) for malaria treatment. A cluster randomized trial of such subsidies was conducted in 3 districts in Kenya, comprising provision of subsidized packs of paediatric ACT to retail outlets, training of retail staff, and community awareness activities. The results demonstrated a substantial increase in ACT availability and coverage, though patient counselling and adherence were suboptimal. We conducted a qualitative study in order to understand why these successes and limitations occurred. Methodology/Principal Findings Eighteen focus group discussions were conducted, 9 with retailers and 9 with caregivers, to document experiences with the intervention. Respondents were positive about intervention components, praising the focused retailer training, affordable pricing, strong promotional activities, dispensing job aids, and consumer friendly packaging, which are likely to have contributed to the positive access and coverage outcomes observed. However, many retailers still did not stock ACT, due to insufficient supplies, lack of capital and staff turnover. Advice to caregivers was poor due to insufficient time, and poor recall of instructions. Adherence by caregivers to dosing guidelines was sub-optimal, because of a wish to save tablets for other episodes, doses being required at night, stopping treatment when the child felt better, and the number and bitter taste of the tablets. Caregivers used a number of strategies to obtain paediatric ACT for older age groups. Conclusions/Significance This study has highlighted that important components of a successful ACT subsidy intervention are regular retailer training, affordable pricing, a reliable supply chain and community mobilization emphasizing patient adherence and when to seek further care.
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Affiliation(s)
- Sarah V Kedenge
- Malaria Public Health Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.
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Tougher S, Ye Y, Amuasi JH, Kourgueni IA, Thomson R, Goodman C, Mann AG, Ren R, Willey BA, Adegoke CA, Amin A, Ansong D, Bruxvoort K, Diallo DA, Diap G, Festo C, Johanes B, Juma E, Kalolella A, Malam O, Mberu B, Ndiaye S, Nguah SB, Seydou M, Taylor M, Rueda ST, Wamukoya M, Arnold F, Hanson K. Effect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet 2012; 380:1916-26. [PMID: 23122217 DOI: 10.1016/s0140-6736(12)61732-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility--malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar). METHODS We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process. FINDINGS In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline. INTERPRETATION Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness. FUNDING The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sarah Tougher
- London School of Hygiene and Tropical Medicine, London, UK.
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Laxminarayan R, Arrow K, Jamison D, Bloom BR. From Financing to Fevers: Lessons of an Antimalarial Subsidy Program. Science 2012; 338:615-6. [DOI: 10.1126/science.1231010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Talisuna AO, Daumerie PG, Balyeku A, Egan T, Piot B, Coghlan R, Lugand M, Bwire G, Rwakimari JB, Ndyomugyenyi R, Kato F, Byangire M, Kagwa P, Sebisubi F, Nahamya D, Bonabana A, Mpanga-Mukasa S, Buyungo P, Lukwago J, Batte A, Nakanwagi G, Tibenderana J, Nayer K, Reddy K, Dokwal N, Rugumambaju S, Kidde S, Banerji J, Jagoe G. Closing the access barrier for effective anti-malarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study. Malar J 2012; 11:356. [PMID: 23107021 PMCID: PMC3523984 DOI: 10.1186/1475-2875-11-356] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/25/2012] [Indexed: 11/27/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT), the treatment of choice for uncomplicated falciparum malaria, is unaffordable and generally inaccessible in the private sector, the first port of call for most malaria treatment across rural Africa. Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to ACT in the private sector could be improved through the provision of a high level supply chain subsidy. Methods Four intervention districts were purposefully selected to receive branded subsidized medicines - “ACT with a leaf”, while the fifth district acted as the control. Baseline and evaluation outlet exit surveys and retail audits were conducted at licensed and unlicensed drug outlets in the intervention and control districts. A survey-adjusted, multivariate logistic regression model was used to analyse the intervention’s impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. Results At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, “ACT with a leaf” accounted for 69% of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8% at baseline to 26.2% (95% CI: 23.2-29.2%) at evaluation in the intervention districts. In the control district, it rose modestly from 1.8% to 5.6% (95% CI: 4.0-7.3%). The odds of purchasing ACT within 24 hours in the intervention districts compared to the control was 0.46 (95% CI: 0.08-2.68, p=0.4) at baseline and significant increased to 6.11 (95% CI: 4.32-8.62, p<0.0001) at evaluation. Children less than five years of age had “ACT with a leaf” purchased for them more often than those aged above five years. There was no evidence of price gouging. Conclusions These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.
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Affiliation(s)
- Ambrose O Talisuna
- Medicines for Malaria Venture-MMV, PO Box 1826 20, rte de Pré-Bois, Geneva 15, 1215, Switzerland.
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Amuasi JH, Diap G, Nguah SB, Karikari P, Boakye I, Jambai A, Lahai WK, Louie KS, Kiechel JR. Access to artemisinin-combination therapy (ACT) and other anti-malarials: national policy and markets in Sierra Leone. PLoS One 2012; 7:e47733. [PMID: 23133522 PMCID: PMC3485052 DOI: 10.1371/journal.pone.0047733] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/14/2012] [Indexed: 11/18/2022] Open
Abstract
Malaria remains the leading burden of disease in post-conflict Sierra Leone. To overcome the challenge of anti-malarial drug resistance and improve effective treatment, Sierra Leone adopted artemisinin-combination therapy artesunate-amodiaquine (AS+AQ) as first-line treatment for uncomplicated P. falciparum malaria. Other national policy anti-malarials include artemether-lumefantrine (AL) as an alternative to AS+AQ, quinine and artemether for treatment of complicated malaria; and sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment (IPTp). This study was conducted to evaluate access to national policy recommended anti-malarials. A cross-sectional survey of 127 medicine outlets (public, private and NGO) was conducted in urban and rural areas. The availability on the day of the survey, median prices, and affordability policy and available non-policy anti-malarials were calculated. Anti-malarials were stocked in 79% of all outlets surveyed. AS+AQ was widely available in public medicine outlets; AL was only available in the private and NGO sectors. Quinine was available in nearly two-thirds of public and NGO outlets and over one-third of private outlets. SP was widely available in all outlets. Non-policy anti-malarials were predominantly available in the private outlets. AS+AQ in the public sector was widely offered for free. Among the anti-malarials sold at a cost, the same median price of a course of AS+AQ (US$1.56), quinine tablets (US$0.63), were found in both the public and private sectors. Quinine injection had a median cost of US$0.31 in the public sector and US$0.47 in the private sector, while SP had a median cost of US$0.31 in the public sector compared to US$ 0.63 in the private sector. Non-policy anti-malarials were more affordable than first-line AS+AQ in all sectors. A course of AS+AQ was affordable at nearly two days' worth of wages in both the public and private sectors.
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Affiliation(s)
- John H Amuasi
- Division of Health Policy and Management, University of Minnesota School of Public Health, PhD Program, Minneapolis, Minnesota, United States of America.
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Howitt P, Darzi A, Yang GZ, Ashrafian H, Atun R, Barlow J, Blakemore A, Bull AMJ, Car J, Conteh L, Cooke GS, Ford N, Gregson SAJ, Kerr K, King D, Kulendran M, Malkin RA, Majeed A, Matlin S, Merrifield R, Penfold HA, Reid SD, Smith PC, Stevens MM, Templeton MR, Vincent C, Wilson E. Technologies for global health. Lancet 2012; 380:507-35. [PMID: 22857974 DOI: 10.1016/s0140-6736(12)61127-1] [Citation(s) in RCA: 190] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Peter Howitt
- Institute for Global Health Innovation, Imperial College London, London, UK.
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Malisa AL, Kiriba D. Artemisinin combination therapies price disparity between government and private health sectors and its implication on antimalarial drug consumption pattern in Morogoro Urban District, Tanzania. BMC Res Notes 2012; 5:165. [PMID: 22455367 PMCID: PMC3410816 DOI: 10.1186/1756-0500-5-165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 03/28/2012] [Indexed: 11/10/2022] Open
Abstract
Background Universal access to effective treatments is a goal of the Roll Back Malaria Partnership. However, despite official commitments and substantial increases in financing, this objective remains elusive, as development assistance continue to be routed largely through government channels, leaving the much needed highly effective treatments inaccessible or unaffordable to those seeking services in the private sector. Methods To quantify the effect of price disparity between the government and private health systems, this study have audited 92 government and private Drug Selling Units (DSUs) in Morogoro urban district in Tanzania to determine the levels, trend and consumption pattern of antimalarial drugs in the two health systems. A combination of observation, interviews and questionnaire administered to the service providers of the randomly selected DSUs were used to collect data. Results ALU was the most selling antimalarial drug in the government health system at a subsidized price of 300 TShs (0.18 US$). By contrast, ALU that was available in the private sector (coartem) was being sold at a price of about 10,000 TShs (5.9 US$), the price that was by far unaffordable, prompting people to resort to cheap but failed drugs. As a result, metakelfin (the phased out drug) was the most selling drug in the private health system at a price ranging from 500 to 2,000 TShs (0.29–1.18 US$). Conclusions In order for the prompt diagnosis and treatment with effective drugs intervention to have big impact on malaria in mostly low socioeconomic malaria-endemic areas of Africa, inequities in affordability and access to effective treatment must be eliminated. For this to be ensued, subsidized drugs should be made available in both government and private health sectors to promote a universal access to effective safe and affordable life saving antimalarial drugs.
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Affiliation(s)
- Allen Lewis Malisa
- Department of Biological Sciences, Faculty of Science, Sokoine University of Agriculture, Box 3038, Morogoro, Tanzaia.
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Cohen JL, Yavuz E, Morris A, Arkedis J, Sabot O. Do patients adhere to over-the-counter artemisinin combination therapy for malaria? evidence from an intervention study in Uganda. Malar J 2012; 11:83. [PMID: 22443291 PMCID: PMC3342228 DOI: 10.1186/1475-2875-11-83] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/23/2012] [Indexed: 11/20/2022] Open
Abstract
Background Increasing affordability of artemisinin combination therapy (ACT) in the African retail sector could be critical to expanding access to effective malaria treatment, but must be balanced by efforts to protect the efficacy of these drugs. Previous research estimates ACT adherence rates among public sector patients, but adherence among retail sector purchasers could differ substantially. This study aimed to estimate adherence rates to subsidized, over-the-counter ACT in rural Uganda. Methods An intervention study was conducted with four licensed drug shops in Eastern Uganda in December 2009. Artemether-lumefantrine (AL) was made available for sale at a 95% subsidy over-the counter. Customers completed a brief survey at the time of purchase and then were randomly assigned to one of three study arms: no follow-up, follow-up after two days or follow-up after three days. Surveyors recorded the number of pills remaining through blister pack observation or through self-report if the pack was unavailable. The purpose of the three-day follow-up arm was to capture non-adherence in the sense of an incomplete treatment course ("under-dosing"). The purpose of the two-day follow-up arm was to capture whether participants completed the full course too soon ("over-dosing"). Results Of the 106 patients in the two-day follow-up sample, 14 (13.2%) had finished the entire treatment course by the second day. Of the 152 patients in the three-day follow-up sample, 49 (32.2%) were definitely non-adherent, three (2%) were probably non-adherent and 100 (65.8%) were probably adherent. Among the 52 who were non-adherent, 31 (59.6%) had more than a full day of treatment remaining. Conclusions Overall, adherence to subsidized ACT purchased over-the-counter was found to be moderate. Further, a non-trivial fraction of those who complete treatment are taking the full course too quickly. Strategies to increase adherence in the retail sector are needed in the context of increasing availability and affordability of ACT in this sector.
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Affiliation(s)
- Jessica L Cohen
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
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Gibberellin biosynthetic inhibitors make human malaria parasite Plasmodium falciparum cells swell and rupture to death. PLoS One 2012; 7:e32246. [PMID: 22412858 PMCID: PMC3296703 DOI: 10.1371/journal.pone.0032246] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 01/24/2012] [Indexed: 01/25/2023] Open
Abstract
Malaria remains as one of the most devastating infectious disease, and continues to exact an enormous toll in medical cost and days of labor lost especially in the tropics. Effective malaria control and eventual eradication remain a huge challenge, with efficacious antimalarials as important intervention/management tool. Clearly new alternative drugs that are more affordable and with fewer side effects are desirable. After preliminary in vitro assays with plant growth regulators and inhibitors, here, we focus on biosynthetic inhibitors of gibberellin, a plant hormone with many important roles in plant growth, and show their inhibitory effect on the growth of both apicomplexa, Plasmodium falciparum and Toxoplasma gondii. Treatment of P. falciparum cultures with the gibberellin biosynthetic inhibitors resulted in marked morphological changes that can be reversed to a certain degree under hyperosmotic environment. These unique observations suggest that changes in the parasite membrane permeability may explain the pleiotropic effects observed within the intracellular parasites.
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Recent clinical and molecular insights into emerging artemisinin resistance in Plasmodium falciparum. Curr Opin Infect Dis 2012; 24:570-7. [PMID: 22001944 DOI: 10.1097/qco.0b013e32834cd3ed] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Artemisinin-based combination therapies (ACTs) have been deployed globally with remarkable success for more than 10 years without having lost their malaria treatment efficacy. However, recent reports from the Thai-Cambodian border reveal evidence of emerging resistance to artemisinins. The latest published clinical and molecular findings are summarized herein. RECENT FINDINGS Clinical studies have identified delayed parasite clearance time as the most robust marker of artemisinin resistance. Resistance has only been documented from South-east Asia and has been observed in isolates that show no significant decrease in drug susceptibility in vitro. Genetic investigations have yet to uncover robust molecular markers. In-vitro studies have identified parasite quiescence or dormancy mechanisms that protect early 'ring-stage' intra-erythrocytic parasites against short-term artemisinin exposure. This might be achieved by reducing the rate of hemoglobin degradation, important for artemisinin bioactivation. SUMMARY Should ACTs fail, no suitable alternatives exist as first-line treatments of P. falciparum malaria. Intensified efforts are essential to monitor the spread of resistance, define therapeutic and operational strategies to counter its impact, and understand its molecular basis. Success in these areas is critical to ensuring that recent gains in reducing the burden of malaria are not lost.
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Shewchuk T, O'Connell KA, Goodman C, Hanson K, Chapman S, Chavasse D. The ACTwatch project: methods to describe anti-malarial markets in seven countries. Malar J 2011; 10:325. [PMID: 22039780 PMCID: PMC3217875 DOI: 10.1186/1475-2875-10-325] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 10/31/2011] [Indexed: 11/10/2022] Open
Abstract
Background Policy makers, governments and donors are faced with an information gap when considering ways to improve access to artemisinin-based combination therapy (ACT) and malaria diagnostics including rapid diagnostic tests (RDTs). To help address some of these gaps, a five-year multi-country research project called ACTwatch was launched. The project is designed to provide a comprehensive picture of the anti-malarial market to inform national and international anti-malarial drug policy decision-making. Methods The project is being conducted in seven malaria-endemic countries: Benin, Cambodia, the Democratic Republic of Congo, Madagascar, Nigeria, Uganda and Zambia from 2008 to 2012. ACTwatch measures which anti-malarials are available, where they are available and at what price and who they are used by. These indicators are measured over time and across countries through three study components: outlet surveys, supply chain studies and household surveys. Nationally representative outlet surveys examine the market share of different anti-malarials passing through public facilities and private retail outlets. Supply chain research provides a picture of the supply chain serving drug outlets, and measures mark-ups at each supply chain level. On the demand side, nationally representative household surveys capture treatment seeking patterns and use of anti-malarial drugs, as well as respondent knowledge of anti-malarials. Discussion The research project provides findings on both the demand and supply side determinants of anti-malarial access. There are four key features of ACTwatch. First is the overlap of the three study components where nationally representative data are collected over similar periods, using a common sampling approach. A second feature is the number and diversity of countries that are studied which allows for cross-country comparisons. Another distinguishing feature is its ability to measure trends over time. Finally, the project aims to disseminate findings widely for decision-making. Conclusions ACTwatch is a unique multi-country research project that threads together anti-malarial supply and consumer behaviour to provide an evidence base to policy makers that can help determine where interventions may positively impact access to and use of quality-assured ACT and RDTs. Because of its ability to detect change over time, it is well suited to monitor the effects of policy or intervention developments in a country.
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Affiliation(s)
- Tanya Shewchuk
- Malaria & Child Survival Department, Population Services International, P,O, Box 43640-00800, Nairobi, Kenya, Africa.
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O'Connell KA, Gatakaa H, Poyer S, Njogu J, Evance I, Munroe E, Solomon T, Goodman C, Hanson K, Zinsou C, Akulayi L, Raharinjatovo J, Arogundade E, Buyungo P, Mpasela F, Adjibabi CB, Agbango JA, Ramarosandratana BF, Coker B, Rubahika D, Hamainza B, Chapman S, Shewchuk T, Chavasse D. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malar J 2011; 10:326. [PMID: 22039838 PMCID: PMC3227612 DOI: 10.1186/1475-2875-10-326] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 10/31/2011] [Indexed: 12/16/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT) is the first-line malaria treatment throughout most of the malaria-endemic world. Data on ACT availability, price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality-assured ACT supply. This paper presents supply side data from ACTwatch outlet surveys in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia. Methods Between March 2009 and June 2010, nationally representative surveys of outlets providing anti-malarials to consumers were conducted. A census of all outlets with the potential to provide anti-malarials was conducted in clusters sampled randomly. Results 28,263 outlets were censused, 51,158 anti-malarials were audited, and 9,118 providers interviewed. The proportion of public health facilities with at least one first-line quality-assured ACT in stock ranged between 43% and 85%. Among private sector outlets stocking at least one anti-malarial, non-artemisinin therapies, such as chloroquine and sulphadoxine-pyrimethamine, were widely available (> 95% of outlets) as compared to first-line quality-assured ACT (< 25%). In the public/not-for-profit sector, first-line quality-assured ACT was available for free in all countries except Benin and the DRC (US$1.29 [Inter Quartile Range (IQR): $1.29-$1.29] and $0.52[IQR: $0.00-$1.29] per adult equivalent dose respectively). In the private sector, first-line quality-assured ACT was 5-24 times more expensive than non-artemisinin therapies. The exception was Madagascar where, due to national social marketing of subsidized ACT, the price of first-line quality-assured ACT ($0.14 [IQR: $0.10, $0.57]) was significantly lower than the most popular treatment (chloroquine, $0.36 [IQR: $0.36, $0.36]). Quality-assured ACT accounted for less than 25% of total anti-malarial volumes; private-sector quality-assured ACT volumes represented less than 6% of the total market share. Most anti-malarials were distributed through the private sector, but often comprised non-artemisinin therapies, and in the DRC and Nigeria, oral artemisinin monotherapies. Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector. Conclusions These standardized, nationally representative results demonstrate the typically low availability, low market share and high prices of ACT, in the private sector where most anti-malarials are accessed, with some exceptions. The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries. The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria.
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Affiliation(s)
- Kathryn A O'Connell
- Population Services International, Malaria & Child Survival Department, P.O. Box 43640, Nairobi, Kenya.
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Yeung S, Patouillard E, Allen H, Socheat D. Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia. Malar J 2011; 10:243. [PMID: 21851625 PMCID: PMC3173399 DOI: 10.1186/1475-2875-10-243] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 08/18/2011] [Indexed: 11/10/2022] Open
Abstract
Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.
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Affiliation(s)
- Shunmay Yeung
- Department of Global Health & Development, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Malisa A, Pearce R, Mutayoba B, Abdullah S, Mshinda H, Kachur P, Bloland P, Roper C. Media, health workers, and policy makers' relationship and their impact on antimalarial policy adoption: a population genetics perspective. Malar Res Treat 2011; 2011:217276. [PMID: 22347670 PMCID: PMC3278921 DOI: 10.4061/2011/217276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 04/19/2011] [Accepted: 04/26/2011] [Indexed: 11/23/2022] Open
Abstract
Drug resistance negatively impacts malaria treatments, making treatment policy revision unavoidable. So far, studies relating sociopolitical and technical issues on policy change with malaria parasite genetic change are lacking. We have quantified the effect of malaria treatment policy on drug pressure and the influence of the media, policy makers, and health worker relationship on parasite population genetic change in Kilombro/Ulanga district. Cross-sectional surveys of asymptomatic infections conducted before, during and after the switch from chloroquine to sulphadoxine/pyrimethamine were used for genetic analysis of SP resistance genes in 4,513 asymptomatic infections identified, and their frequency change was compared with retrospective study of the documented process of policy change. Highly significant changes of dhfr and dhps resistance alleles occurred within one year of switch to SP first line, followed by a decline of their rate of selection caused by reduction of SP usage, as a result of negative media reports on SP usage and lack of adequate preparations.
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Affiliation(s)
- Allen Malisa
- Department of Biological Sciences, Faculty of Science, Sokoine University of Agriculture, P.O. Box 3038, Morogoro, Tanzania
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Richard Pearce
- London School of Hygiene and Tropical Medicine, Pathogen Molecular Biology Unit, Department of Infectious Tropical Diseases, Keppel Street, London WC1E 7HT, UK
| | - Benezeth Mutayoba
- Department of Veterinary Physiology, Biochemistry, Pharmacology and Toxicology, Faculty of Veterinary Medicine, Sokoine University of Agriculture, P.O. Box 3017, Morogoro, Tanzania
| | - Salim Abdullah
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Hassan Mshinda
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Patrick Kachur
- Malaria Branch, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341, USA
| | - Peter Bloland
- Malaria Branch, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341, USA
| | - Cally Roper
- London School of Hygiene and Tropical Medicine, Pathogen Molecular Biology Unit, Department of Infectious Tropical Diseases, Keppel Street, London WC1E 7HT, UK
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Amuasi JH, Diap G, Blay-Nguah S, Boakye I, Karikari PE, Dismas B, Karenzo J, Nsabiyumva L, Louie KS, Kiechel JR. Access to artesunate-amodiaquine, quinine and other anti-malarials: policy and markets in Burundi. Malar J 2011; 10:34. [PMID: 21310057 PMCID: PMC3050774 DOI: 10.1186/1475-2875-10-34] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 02/10/2011] [Indexed: 11/25/2022] Open
Abstract
Background Malaria is the leading cause of morbidity and mortality in post-conflict Burundi. To counter the increasing challenge of anti-malarial drug resistance and improve highly effective treatment Burundi adopted artesunate-amodiaquine (AS-AQ) as first-line treatment for uncomplicated Plasmodium falciparum malaria and oral quinine as second-line treatment in its national treatment policy in 2003. Uptake of this policy in the public, private and non-governmental (NGO) retail market sectors of Burundi is relatively unknown. This study was conducted to evaluate access to national policy recommended anti-malarials. Methods Adapting a standardized methodology developed by Health Action International/World Health Organization (HAI/WHO), a cross-sectional survey of 70 (24 public, 36 private, and 10 NGO) medicine outlets was conducted in three regions of Burundi, representing different levels of transmission of malaria. The availability on day of the survey, the median prices, and affordability (in terms of number of days' wages to purchase treatment) of AS-AQ, quinine and other anti-malarials were calculated. Results Anti-malarials were stocked in all outlets surveyed. AS-AQ was available in 87.5%, 33.3%, and 90% of public, private, and NGO retail outlets, respectively. Quinine was the most common anti-malarial found in all outlet types. Non-policy recommended anti-malarials were mainly found in the private outlets (38.9%) compared to public (4.2%) and NGO (0%) outlets. The median price of a course of AS-AQ was US$0.16 (200 Burundi Francs, FBu) for the public and NGO markets, and 3.5-fold higher in the private sector (US$0.56 or 700 FBu). Quinine tablets were similarly priced in the public (US$1.53 or 1,892.50 FBu), private and NGO sectors (both US$1.61 or 2,000 FBu). Non-policy anti-malarials were priced 50-fold higher than the price of AS-AQ in the public sector. A course of AS-AQ was affordable at 0.4 of a day's wage in the public and NGO sectors, whereas, it was equivalent to 1.5 days worth of wages in the private sector. Conclusions AS-AQ was widely available and affordable in the public and NGO markets of hard-to-reach post-conflict communities in Burundi. However greater accessibility and affordability of policy recommended anti-malarials in the private market sector is needed to improve country-wide policy uptake.
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Affiliation(s)
- John H Amuasi
- Komfo Anokye Teaching Hospital, Kumasi, P,O, BOX KS 1934, Ghana.
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