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Luangasanatip N, Khonputsa P, Caillet C, Vickers S, Zambrzycki S, Fernández FM, Newton PN, Lubell Y. Implementation of field detection devices for antimalarial quality screening in Lao PDR-A cost-effectiveness analysis. PLoS Negl Trop Dis 2021; 15:e0009539. [PMID: 34591842 PMCID: PMC8483304 DOI: 10.1371/journal.pntd.0009539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/04/2021] [Indexed: 12/02/2022] Open
Abstract
Substandard and falsified (SF) antimalarials have devastating consequences including increased morbidity, mortality and economic losses. Portable medicine quality screening devices are increasingly available, but whether their use for the detection of SF antimalarials is cost-effective is not known. We evaluated the cost-effectiveness of introducing such devices in post-market surveillance in pharmacies in Laos, conservatively focusing on their outcome in detecting SF artemisinin-based combination therapies (ACTs). We simulated the deployment of six portable screening devices: two handheld near-infrared [MicroPHAZIR RX, NIR-S-G1], two handheld Raman [Progeny, TruScan RM]; one portable mid-infrared [4500a FTIR] spectrometers, and single-use disposable paper analytical devices [PADs]. We considered two scenarios with high and low levels of SF ACTs. Different sampling strategies in which medicine inspectors would test 1, 2, or 3 sample(s) of each brand of ACT were evaluated. Costs of inspection including device procurement, inspector time, reagents, reference testing, and replacement with genuine ACTs were estimated. Outcomes were measured as disability adjusted life years (DALYs) and incremental cost-effectiveness ratios were estimated for each device compared with a baseline of visual inspections alone. In the scenario with high levels of SF ACTs, all devices were cost-effective with a 1-sample strategy. In the scenario of low levels of SF ACTs, only four devices (MicroPHAZIR RX, 4500a FTIR, NIR-S-G1, and PADs) were cost-effective with a 1-sample strategy. In the multi-way comparative analysis, in both scenarios the NIR-S-G1 testing 2 samples was the most cost-effective option. Routine inspection of ACT quality using portable screening devices is likely to be cost-effective in the Laos context. This work should encourage policy-makers or regulators to further investigate investment in portable screening devices to detect SF medicines and reduce their associated undesired health and economic burdens.
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Affiliation(s)
- Nantasit Luangasanatip
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Panarasri Khonputsa
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Céline Caillet
- Lao-Oxford Mahosot Hospital Wellcome Trust Research Unit, Microbiology laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/Worldwide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Serena Vickers
- Lao-Oxford Mahosot Hospital Wellcome Trust Research Unit, Microbiology laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/Worldwide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Stephen Zambrzycki
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Facundo M. Fernández
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Paul N. Newton
- Lao-Oxford Mahosot Hospital Wellcome Trust Research Unit, Microbiology laboratory, Mahosot Hospital, Vientiane, Lao PDR
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Infectious Diseases Data Observatory (IDDO)/Worldwide Antimalarial Resistance Network (WWARN), University of Oxford, Oxford, United Kingdom
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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Devine A, Battle KE, Meagher N, Howes RE, Dini S, Gething PW, Simpson JA, Price RN, Lubell Y. Global economic costs due to vivax malaria and the potential impact of its radical cure: A modelling study. PLoS Med 2021; 18:e1003614. [PMID: 34061843 PMCID: PMC8168905 DOI: 10.1371/journal.pmed.1003614] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 04/07/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In 2017, an estimated 14 million cases of Plasmodium vivax malaria were reported from Asia, Central and South America, and the Horn of Africa. The clinical burden of vivax malaria is largely driven by its ability to form dormant liver stages (hypnozoites) that can reactivate to cause recurrent episodes of malaria. Elimination of both the blood and liver stages of the parasites ("radical cure") is required to achieve a sustained clinical response and prevent ongoing transmission of the parasite. Novel treatment options and point-of-care diagnostics are now available to ensure that radical cure can be administered safely and effectively. We quantified the global economic cost of vivax malaria and estimated the potential cost benefit of a policy of radical cure after testing patients for glucose-6-phosphate dehydrogenase (G6PD) deficiency. METHODS AND FINDINGS Estimates of the healthcare provider and household costs due to vivax malaria were collated and combined with national case estimates for 44 endemic countries in 2017. These provider and household costs were compared with those that would be incurred under 2 scenarios for radical cure following G6PD screening: (1) complete adherence following daily supervised primaquine therapy and (2) unsupervised treatment with an assumed 40% effectiveness. A probabilistic sensitivity analysis generated credible intervals (CrIs) for the estimates. Globally, the annual cost of vivax malaria was US$359 million (95% CrI: US$222 to 563 million), attributable to 14.2 million cases of vivax malaria in 2017. From a societal perspective, adopting a policy of G6PD deficiency screening and supervision of primaquine to all eligible patients would prevent 6.1 million cases and reduce the global cost of vivax malaria to US$266 million (95% CrI: US$161 to 415 million), although healthcare provider costs would increase by US$39 million. If perfect adherence could be achieved with a single visit, then the global cost would fall further to US$225 million, equivalent to $135 million in cost savings from the baseline global costs. A policy of unsupervised primaquine reduced the cost to US$342 million (95% CrI: US$209 to 532 million) while preventing 2.1 million cases. Limitations of the study include partial availability of country-level cost data and parameter uncertainty for the proportion of patients prescribed primaquine, patient adherence to a full course of primaquine, and effectiveness of primaquine when unsupervised. CONCLUSIONS Our modelling study highlights a substantial global economic burden of vivax malaria that could be reduced through investment in safe and effective radical cure achieved by routine screening for G6PD deficiency and supervision of treatment. Novel, low-cost interventions for improving adherence to primaquine to ensure effective radical cure and widespread access to screening for G6PD deficiency will be critical to achieving the timely global elimination of P. vivax.
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Affiliation(s)
- Angela Devine
- Division of Global and Tropical Health, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Katherine E. Battle
- Institute for Disease Modeling, Seattle, Washington, United States of America
| | - Niamh Meagher
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory Epidemiology Unit, Royal Melbourne Hospital, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Rosalind E. Howes
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
- Oxford Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Saber Dini
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter W. Gething
- Telethon Kids Institute, Perth Children’s Hospital, Nedlands, Western Australia, Australia
- Curtin University, Bentley, Western Australia, Australia
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ric N. Price
- Division of Global and Tropical Health, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Yoel Lubell
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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Paintain L, Hill J, Ahmed R, Umbu Reku Landuwulang C, Ansariadi A, Rini Poespoprodjo J, Syafruddin D, Khairallah C, Burdam FH, Bonsapia I, Ter Kuile FO, Webster J. Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial. Lancet Glob Health 2020; 8:e1524-e1533. [PMID: 33220216 DOI: 10.1016/s2214-109x(20)30386-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 07/07/2020] [Accepted: 08/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Malaria infection during pregnancy is associated with serious adverse maternal and birth outcomes. A randomised controlled trial in Papua, Indonesia, comparing the efficacy of intermittent preventive treatment with dihydroartemisinin-piperaquine with the current strategy of single screening and treatment showed that intermittent preventive treatment is a promising alternative treatment for the reduction of malaria in pregnancy. We aimed to estimate the incremental cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine compared with single screening and treatment with dihydroartemisinin-piperaquine. METHODS We did a provider perspective analysis. A decision tree model was analysed from a health provider perspective over a lifetime horizon. Model parameters were used in deterministic and probabilistic sensitivity analyses. Simulations were run in hypothetical cohorts of 1000 women who received intermittent preventive treatment or single screening and treatment. Disability-adjusted life-years (DALYs) for fetal loss or neonatal death, low birthweight, moderate or severe maternal anaemia, and clinical malaria were calculated from trial data and cost estimates in 2016 US dollars from observational studies, health facility costings and public procurement databases. The main outcome measure was the incremental cost per DALY averted. FINDINGS Relative to single screening and treatment, intermittent preventive treatment resulted in an incremental cost of US$5657 (95% CI 1827 to 9448) and 107·4 incremental DALYs averted (-719·7 to 904·1) per 1000 women; the average incremental cost-effectiveness ratio was $53 per DALY averted. INTERPRETATION Intermittent preventive treatment with dihydroartemisinin-piperaquine offers a cost-effective alternative to single screening and treatment for the prevention of the adverse effects of malaria infection in pregnancy in the context of the moderate malaria transmission setting of Papua. The higher cost of intermittent preventive treatment was driven by monthly administration, as compared with single-administration single screening and treatment. However, acceptability and feasibility considerations will also be needed to inform decision making. FUNDING Medical Research Council, Department for International Development, and Wellcome Trust.
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Affiliation(s)
- Lucy Paintain
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Rukhsana Ahmed
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | | | - Ansariadi Ansariadi
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Department of Epidemiology, School of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Jeanne Rini Poespoprodjo
- Mimika District Health Authority, Timika, Papua, Indonesia; Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia; Pediatric Research Office, Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Din Syafruddin
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Irene Bonsapia
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
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Adeniji E, Asante KP, Boahen O, Compaoré G, Coulibaly B, Kaali S, Kabore Y, Lamy M, Lusingu J, Malabeja A, Mens P, Orsini M, Otieno L, Otieno W, Owusu-Agyei S, Oyieko J, Pirçon JY, Praet N, Roman F, Sie A, Sing’oei V, Sirima SB, Sylla K, Tine R, Tiono AB, Tivura M, Usuf E, Wéry S. Estimating Annual Fluctuations in Malaria Transmission Intensity and in the Use of Malaria Control Interventions in Five Sub-Saharan African Countries. Am J Trop Med Hyg 2020; 103:1883-1892. [PMID: 32959764 PMCID: PMC7646796 DOI: 10.4269/ajtmh.19-0795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 08/07/2020] [Indexed: 11/08/2022] Open
Abstract
RTS,S/AS01E malaria vaccine safety, effectiveness, and impact will be assessed in pre- and post-vaccine introduction studies, comparing the occurrence of malaria cases and adverse events in vaccinated versus unvaccinated children. Because those comparisons may be confounded by potential year-to-year fluctuations in malaria transmission intensity and malaria control intervention usage, the latter should be carefully monitored to adequately adjust the analyses. This observational cross-sectional study is assessing Plasmodium falciparum parasite prevalence (PfPR) and malaria control intervention usage over nine annual surveys performed at peak parasite transmission. Plasmodium falciparum parasite prevalence was measured by microscopy and nucleic acid amplification test (quantitative PCR) in parallel in all participants, and defined as the proportion of infected participants among participants tested. Results of surveys 1 (S1) and 2 (S2), conducted in five sub-Saharan African countries, including some participating in the Malaria Vaccine Implementation Programme (MVIP), are reported herein; 4,208 and 4,199 children were, respectively, included in the analyses. Plasmodium falciparum parasite prevalence estimated using microscopy varied between study sites in both surveys, with the lowest prevalence in Senegalese sites and the highest in Burkina Faso. In sites located in the MVIP areas (Kintampo and Kombewa), PfPR in children aged 6 months to 4 years ranged from 24.8% to 27.3%, depending on the study site and the survey. Overall, 89.5% and 86.4% of children used a bednet in S1 and S2, of whom 68.7% and 77.9% used impregnated bednets. No major difference was observed between the two surveys in terms of PfPR or use of malaria control interventions.
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Affiliation(s)
- RTS,S Epidemiology EPI-MAL-005 Study Group The RTS,S Epidemiology EPI-MAL-005 study group is composed of (per alphabetical order):
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), Ouagadougou, Burkina Faso
- Aixial c/o GSK, Wavre, Belgium
- National Institute for Medical Research (NIMR), Korogwe, Tanzania
- University of Copenhagen, Copenhagen, Denmark
- Parasitology Unit, Department of Medical Microbiology, Academic Medical Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- 4Clinics c/o GSK, Wavre, Belgium
- KEMRI - Walter Reed Project, US Army Medical Research Directorate-Kenya, Kombewa, Kenya
- GSK, Wavre, Belgium
- Département de Parasitologie, Centre de Recherche de Keur Socé, Faculté de Médecine, Université Cheikh Anta Diop, Dakar, Senegal
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Elisha Adeniji
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Owusu Boahen
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | | | | | - Seyram Kaali
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Youssouf Kabore
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), Ouagadougou, Burkina Faso
| | | | - John Lusingu
- National Institute for Medical Research (NIMR), Korogwe, Tanzania
- University of Copenhagen, Copenhagen, Denmark
| | | | - Petra Mens
- Parasitology Unit, Department of Medical Microbiology, Academic Medical Center, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Lucas Otieno
- KEMRI - Walter Reed Project, US Army Medical Research Directorate-Kenya, Kombewa, Kenya
| | - Walter Otieno
- KEMRI - Walter Reed Project, US Army Medical Research Directorate-Kenya, Kombewa, Kenya
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Janet Oyieko
- KEMRI - Walter Reed Project, US Army Medical Research Directorate-Kenya, Kombewa, Kenya
| | | | | | | | - Ali Sie
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Valentine Sing’oei
- KEMRI - Walter Reed Project, US Army Medical Research Directorate-Kenya, Kombewa, Kenya
| | - Sodiomon B. Sirima
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), Ouagadougou, Burkina Faso
| | - Khadime Sylla
- Département de Parasitologie, Centre de Recherche de Keur Socé, Faculté de Médecine, Université Cheikh Anta Diop, Dakar, Senegal
| | - Roger Tine
- Département de Parasitologie, Centre de Recherche de Keur Socé, Faculté de Médecine, Université Cheikh Anta Diop, Dakar, Senegal
| | - Alfred B. Tiono
- Centre National de Recherche et de Formation sur le Paludisme (CNRFP), Ouagadougou, Burkina Faso
| | - Mathilda Tivura
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Effua Usuf
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
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Evans DR, Higgins CR, Laing SK, Awor P, Ozawa S. Poor-quality antimalarials further health inequities in Uganda. Health Policy Plan 2020; 34:iii36-iii47. [PMID: 31816072 PMCID: PMC6901073 DOI: 10.1093/heapol/czz012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/13/2018] [Accepted: 02/13/2019] [Indexed: 12/16/2022] Open
Abstract
Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index −0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.
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Affiliation(s)
- Daniel R Evans
- Duke University School of Medicine, DUMC 3710 Durham, NC 27710, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Sarah K Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
| | - Phyllis Awor
- Department of Community Health and Behavioural Sciences, Makerere University School of Public Health, Mulago Hospital Complex, Mulago Hill, P.O. Box 7072, Kampala, Uganda
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, 135 Dauer Dr., Chapel Hill, NC 27599, USA
- Corresponding author. Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, CB#7574, Beard Hall 115H, Chapel Hill, NC 27599, USA. E-mail:
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Devine A, Pasaribu AP, Teferi T, Pham HT, Awab GR, Contantia F, Nguyen TN, Ngo VT, Tran TH, Hailu A, Gilchrist K, Green JA, Koh GCKW, Thriemer K, Taylor WRJ, Day NPJ, Price RN, Lubell Y. Provider and household costs of Plasmodium vivax malaria episodes: a multicountry comparative analysis of primary trial data. Bull World Health Organ 2019; 97:828-836. [PMID: 31819291 PMCID: PMC6883272 DOI: 10.2471/blt.18.226688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 08/08/2019] [Accepted: 08/20/2019] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To determine household and health-care provider costs associated with Plasmodium vivax infection across a range of endemic settings. METHODS We collected cost data alongside three multicentre clinical trials of P. vivax treatment in Afghanistan, Brazil, Colombia, Ethiopia, Indonesia, Philippines, Peru, Thailand and Viet Nam conducted between April 2014 to December 2017. We derived household costs from trial participant surveys administered at enrolment and again 2 weeks later to determine the costs of treatment and transportation, and the number of days that patients and their household caregivers were unable to undertake their usual activities. We determined costs of routine care by health-care providers by micro-costing the resources used to diagnose and treat P. vivax at the study sites. FINDINGS The mean total household costs ranged from 8.7 United States dollars (US$; standard deviation, SD: 4.3) in Afghanistan to US$ 254.7 (SD: 148.4) in Colombia. Across all countries, productivity losses were the largest household cost component, resulting in mean indirect costs ranging from US$ 5.3 (SD: 3.0) to US$ 220.8 (SD: 158.40). The range of health-care provider costs for routine care was US$ 3.6-6.6. The cost of administering a glucose-6-phosphate-dehydrogenase rapid diagnostic test, ranged from US$ 0.9 to 13.5, consistently lower than the costs of the widely-used fluorescent spot test (US$ 6.3 to 17.4). CONCLUSION An episode of P. vivax malaria results in high costs to households. The costs of diagnosing and treating P. vivax are important inputs for future cost-effectiveness analyses to ensure optimal allocation of resources for malaria elimination.
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Affiliation(s)
- Angela Devine
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811, Australia
| | | | | | - Huong-Thu Pham
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | | | | | - Thuy-Nhien Nguyen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Viet-Thanh Ngo
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Tinh-Hien Tran
- Oxford University Clinical Research Unit, University of Oxford, Oxford, England
| | - Asrat Hailu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kim Gilchrist
- GlaxoSmithKline, Collegeville, Pennsylvania, United States of America
| | - Justin A Green
- GlaxoSmithKline Research & Development, Uxbridge, England
| | - Gavin CKW Koh
- GlaxoSmithKline Research & Development, Uxbridge, England
| | - Kamala Thriemer
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811, Australia
| | - Walter RJ Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Nicholas PJ Day
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory 0811, Australia
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
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Beargie SM, Higgins CR, Evans DR, Laing SK, Erim D, Ozawa S. The economic impact of substandard and falsified antimalarial medications in Nigeria. PLoS One 2019; 14:e0217910. [PMID: 31415560 PMCID: PMC6695148 DOI: 10.1371/journal.pone.0217910] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/22/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Substandard and falsified medications pose significant risks to global health. Nearly one in five antimalarials circulating in low- and middle-income countries are substandard or falsified. We assessed the health and economic impact of substandard and falsified antimalarials on children under five in Nigeria, where malaria is endemic and poor-quality medications are commonplace. METHODS We developed a dynamic agent-based SAFARI (Substandard and Falsified Antimalarial Research Impact) model to capture the impact of antimalarial use in Nigeria. The model simulated children with background characteristics, malaria infections, patient care-seeking, disease progression, treatment outcomes, and incurred costs. Using scenario analyses, we simulated the impact of substandard and falsified medicines, antimalarial resistance, as well as possible interventions to improve the quality of treatment, reduce stock-outs, and educate caregivers about antimalarial quality. RESULTS We estimated that poor quality antimalarials are responsible for 12,300 deaths and $892 million ($890-$893 million) in costs annually in Nigeria. If antimalarial resistance develops, we simulated that current costs of malaria could increase by $839 million (11% increase, $837-$841 million). The northern regions of Nigeria have a greater burden as compared to the southern regions, with 9,700 deaths and $698 million ($697-$700 million) in total economic losses annually due to substandard and falsified antimalarials. Furthermore, our scenario analyses demonstrated that possible interventions-such as removing stock-outs in all facilities ($1.11 billion), having only ACTs available for treatment ($594 million), and 20% more patients seeking care ($469 million)-can save hundreds of millions in costs annually in Nigeria. CONCLUSIONS The results highlight the significant health and economic burden of poor quality antimalarials in Nigeria, and the impact of potential interventions to counter them. In order to reduce the burden of malaria and prevent antimalarials from developing resistance, policymakers and donors must understand the problem and implement interventions to reduce the impact of ineffective and harmful antimalarials.
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Affiliation(s)
- Sarah M. Beargie
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Colleen R. Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Daniel R. Evans
- Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sarah K. Laing
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Daniel Erim
- Quality Measurement and Health Policy Group, RTI International, Research Triangle Park, North Carolina, United States of America
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
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9
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Apetoh E, Tilly M, Baxerres C, Le Hesran JY. Home treatment and use of informal market of pharmaceutical drugs for the management of paediatric malaria in Cotonou, Benin. Malar J 2018; 17:354. [PMID: 30305107 PMCID: PMC6180418 DOI: 10.1186/s12936-018-2504-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria is the main cause of hospital admissions in Benin and a leading cause of death in childhood. Beside consultations, various studies have underlined the management of the disease through home treatment. The medicines used can be purchased in informal market of pharmaceutical drugs (IMPD) without prescription or any involvement of healthcare professional. Pharmaceutical drugs are sold by informal private vendors, who operate at any time in the immediate environment of the patients. The present study was conducted in Cotonou to study the health-seeking behaviour of caregivers to treat malaria in children under 12 years old. Factors associated with malaria home treatment and drugs purchase in IMPD were studied. METHODS A cross-sectional study was carried out among 340 children's caregivers who were interviewed about their socio-demographic characteristics and their care-seeking behaviour during the most recent episode of malaria in their children under 12. Medicines used and purchase place were also collected. Multivariate logistic regression model was used to determine factors associated with malaria home treatment and drug purchase in IMPD. RESULTS Beyond all the 340 caregivers, 116 (34%) consulted healthcare professional, 224 (66%) home treat the children, among whom 207 (61%) gave pharmaceutical drugs and 17 (5%) gave traditional remedies to children. Malaria home treatment was associated with family size, health insurance (OR = 0.396, 95% CI 0.169-0.928), and wealth quintiles where home treatment was less used by the richest (OR = 0.199, 95% CI 0.0676-0.522) compared to those in the poorest quintile. The caregivers age group 30-39 years was associated to the use of IMPD (OR = 0.383, 95% CI 0.152-0.964), the most economically wealthy people were less likely to use IMPD (wealth quintile richest: OR = 0.239, 95% CI 0.064-0.887; wealth quintile fourth OR = 0.271, 95% CI 0.100-0.735) compared to those in the poorest quintile. All caregivers who benefited from health insurance did not use IMPD. CONCLUSION This study highlights the link between worse economic conditions and accessibility to medical care as one of the main factors of malaria home treatment and drug purchase in IMPD, even if those two phenomena need to be understood apart.
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Affiliation(s)
- Edwige Apetoh
- Institut de recherche pour le développement, Unité mixte de recherche 216: Mères et enfants face aux infections tropicales, Université Paris-Descartes, 4 Avenue de l'Observatoire, 75006, Paris, France.
- Ecole doctorale Pierre Louis de santé publique, ED 393 Epidémiologie et Sciences de l'Information Biomédicale, Paris, France.
| | - Marina Tilly
- Institut de recherche pour le développement, Unité mixte de recherche 216: Mères et enfants face aux infections tropicales, Université Paris-Descartes, 4 Avenue de l'Observatoire, 75006, Paris, France
| | - Carine Baxerres
- Institut de recherche pour le développement, Unité mixte de recherche 216: Mères et enfants face aux infections tropicales, Université Paris-Descartes, 4 Avenue de l'Observatoire, 75006, Paris, France
- Centre Norbert Elias EHESS-Campus Marseille La Vieille Charité, 2 Rue de la Charité, 13002, Marseille, France
| | - Jean-Yves Le Hesran
- Institut de recherche pour le développement, Unité mixte de recherche 216: Mères et enfants face aux infections tropicales, Université Paris-Descartes, 4 Avenue de l'Observatoire, 75006, Paris, France
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10
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Prudhomme O’Meara W, Menya D, Laktabai J, Platt A, Saran I, Maffioli E, Kipkoech J, Mohanan M, Turner EL. Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya. PLoS Med 2018; 15:e1002607. [PMID: 30016316 PMCID: PMC6049880 DOI: 10.1371/journal.pmed.1002607] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/08/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. METHODS AND FINDINGS We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. CONCLUSIONS Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies. TRIAL REGISTRATION ClinicalTrials.gov NCT02461628.
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Affiliation(s)
- Wendy Prudhomme O’Meara
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Jeremiah Laktabai
- Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Alyssa Platt
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
| | - Indrani Saran
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Elisa Maffioli
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
| | - Joseph Kipkoech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Manoj Mohanan
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Economics, Duke University, Durham, North Carolina, United States of America
- Sanford School of Public Policy, Duke University, Durham, North Carolina, United States of America
| | - Elizabeth L. Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America
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Kushitor MK, Boatemaa S. The double burden of disease and the challenge of health access: Evidence from Access, Bottlenecks, Cost and Equity facility survey in Ghana. PLoS One 2018; 13:e0194677. [PMID: 29570720 PMCID: PMC5865721 DOI: 10.1371/journal.pone.0194677] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 03/07/2018] [Indexed: 11/18/2022] Open
Abstract
Despite the double burden of infectious and chronic non-communicable diseases in Africa, health care expenditure disproportionately favours infectious diseases. In this paper, we examine quantitatively the extent of this disproportionate access to diagnoses and treatment of diabetes, hypertension and malaria in Ghana. A total of 220 health facilities was surveyed across the country in 2011. Findings indicate that diagnoses and treatment of infectious diseases were more accessible than NCDs. In terms of treatment, 78% and 87% of health facilities had two of the recommended malaria drugs while less than 35% had essential diabetes and hypertension drugs. There is a significant unmet need for diagnoses and treatment of NCDs in Ghana. These inequities have implications for high morbidity and mortality from NCDs. We recommend the use of task shifting as a model to increase the delivery of NCD services.
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Affiliation(s)
| | - Sandra Boatemaa
- Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana
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12
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Thomson R, Johanes B, Festo C, Kalolella A, Taylor M, Tougher S, Ye Y, Mann A, Ren R, Bruxvoort K, Willey B, Arnold F, Hanson K, Goodman C. An assessment of the malaria-related knowledge and practices of Tanzania's drug retailers: exploring the impact of drug store accreditation. BMC Health Serv Res 2018; 18:169. [PMID: 29523139 PMCID: PMC5845369 DOI: 10.1186/s12913-018-2966-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 02/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since 2003 Tanzania has upgraded its approximately 7000 drug stores to Accredited Drug Dispensing Outlets (ADDOs), involving dispenser training, introduction of record keeping and enhanced regulation. Prior to accreditation, drug stores could officially stock over-the-counter medicines only, though many stocked prescription-only antimalarials. ADDOs are permitted to stock 49 prescription-only medicines, including artemisinin combination therapies and one form of quinine injectable. Oral artemisinin monotherapies and other injectables were not permitted at any time. By late 2011 conversion was complete in 14 of 21 regions. We explored variation in malaria-related knowledge and practices of drug retailers in ADDO and non-ADDO regions. METHODS Data were collected as part of the Independent Evaluation of the Affordable Medicines Facility - malaria (AMFm), involving a nationally representative survey of antimalarial retailers in October-December 2011. We randomly selected 49 wards and interviewed all drug stores stocking antimalarials. We compare ADDO and non-ADDO regions, excluding the largest city, Dar es Salaam, due to the unique characteristics of its market. RESULTS Interviews were conducted in 133 drug stores in ADDO regions and 119 in non-ADDO regions. Staff qualifications were very similar in both areas. There was no significant difference in the availability of the first line antimalarial (68.9% in ADDO regions and 65.2% in non-ADDO regions); both areas had over 98% availability of non-artemisinin therapies and below 3.0% of artemisinin monotherapies. Staff in ADDO regions had better knowledge of the first line antimalarial than non-ADDO regions (99.5% and 91.5%, p = 0.001). There was weak evidence of a lower price and higher market share of the first line antimalarial in ADDO regions. Drug stores in ADDO regions were more likely to stock ADDO-certified injectables than those in non-ADDO regions (23.0% and 3.9%, p = 0.005). CONCLUSIONS ADDO conversion is frequently cited as a model for improving retail sector drug provision. Drug stores in ADDO regions performed better on some indicators, possibly indicating some small benefits from ADDO conversion, but also weaknesses in ADDO regulation and high staff turnover. More evidence is needed on the value-added and value for money of the ADDO roll out to inform retail policy in Tanzania and elsewhere.
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Affiliation(s)
| | | | | | | | - Mark Taylor
- London School of Hygiene and Tropical Medicine, London, UK
- International Health Division, ICF International, Calverton, MD USA
| | - Sarah Tougher
- London School of Hygiene and Tropical Medicine, London, UK
| | - Yazoume Ye
- Department of Public Health, Trnava University, Trnava, Slovakia
| | - Andrea Mann
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ruilin Ren
- Department of Public Health, Trnava University, Trnava, Slovakia
| | | | - Barbara Willey
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fred Arnold
- Department of Public Health, Trnava University, Trnava, Slovakia
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, UK
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Dalinjong PA, Wang AY, Homer CSE. Has the free maternal health policy eliminated out of pocket payments for maternal health services? Views of women, health providers and insurance managers in Northern Ghana. PLoS One 2018; 13:e0184830. [PMID: 29389995 PMCID: PMC5794072 DOI: 10.1371/journal.pone.0184830] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 08/31/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored. METHODS A convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes. RESULTS The NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy. CONCLUSION Women needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.
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Affiliation(s)
| | - Alex Y. Wang
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Caroline S. E. Homer
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Hansen KS, Ndyomugyenyi R, Magnussen P, Lal S, Clarke SE. Cost-effectiveness analysis of malaria rapid diagnostic tests for appropriate treatment of malaria at the community level in Uganda. Health Policy Plan 2017; 32:676-689. [PMID: 28453718 PMCID: PMC5406761 DOI: 10.1093/heapol/czw171] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 11/21/2022] Open
Abstract
In Sub-Saharan Africa, malaria remains a major cause of morbidity and mortality among children under 5, due to lack of access to prompt and appropriate diagnosis and treatment. Many countries have scaled-up community health workers (CHWs) as a strategy towards improving access. The present study was a cost-effectiveness analysis of the introduction of malaria rapid diagnostic tests (mRDTs) performed by CHWs in two areas of moderate-to-high and low malaria transmission in rural Uganda. CHWs were trained to perform mRDTs and treat children with artemisinin-based combination therapy (ACT) in the intervention arm while CHWs offered treatment based on presumptive diagnosis in the control arm. Data on the proportion of children with fever ‘appropriately treated for malaria with ACT’ were captured from a randomised trial. Health sector costs included: training of CHWs, community sensitisation, supervision, allowances for CHWs and provision of mRDTs and ACTs. The opportunity costs of time utilised by CHWs were estimated based on self-reporting. Household costs of subsequent treatment-seeking at public health centres and private health providers were captured in a sample of households. mRDTs performed by CHWs was associated with large improvements in appropriate treatment of malaria in both transmission settings. This resulted in low incremental costs for the health sector at US$3.0 per appropriately treated child in the moderate-to-high transmission area. Higher incremental costs at US$13.3 were found in the low transmission area due to lower utilisation of CHW services and higher programme costs. Incremental costs from a societal perspective were marginally higher. The use of mRDTs by CHWs improved the targeting of ACTs to children with malaria and was likely to be considered a cost-effective intervention compared to a presumptive diagnosis in the moderate-to-high transmission area. In contrast to this, in the low transmission area with low attendance, RDT use by CHWs was not a low cost intervention.
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Affiliation(s)
- Kristian S Hansen
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Denmark
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
- Corresponding author. Department of Public Health, Section for Health Services Research, University of Copenhagen, Øster Farimagsgade 5, 1014 København K, Denmark. E-mail:
| | | | - Pascal Magnussen
- Centre for Medical Parasitology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
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Peixoto HM, Brito MAM, Romero GAS, Monteiro WM, de Lacerda MVG, de Oliveira MRF. Deficiência de glicose-6-fosfato desidrogenase e uso de primaquina: estimativa de custos de profissionais por macrocusteio e microcusteio. Rev Saude Publica 2017; 51:90. [PMID: 29020124 PMCID: PMC5676719 DOI: 10.11606/s1518-8787.2017051007084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 12/08/2016] [Indexed: 11/17/2022] Open
Abstract
The aim of this study has been to study whether the top-down method, based on the average value identified in the Brazilian Hospitalization System (SIH/SUS), is a good estimator of the cost of health professionals per patient, using the bottom-up method for comparison. The study has been developed from the context of hospital care offered to the patient carrier of glucose-6-phosphate dehydrogenase (G6PD) deficiency with severe adverse effect because of the use of primaquine, in the Brazilian Amazon. The top-down method based on the spending with SIH/SUS professional services, as a proxy for this cost, corresponded to R$60.71, and the bottom-up, based on the salaries of the physician (R$30.43), nurse (R$16.33), and nursing technician (R$5.93), estimated a total cost of R$52.68. The difference was only R$8.03, which shows that the amounts paid by the Hospital Inpatient Authorization (AIH) are estimates close to those obtained by the bottom-up technique for the professionals directly involved in the care.
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Affiliation(s)
- Henry Maia Peixoto
- Núcleo de Medicina Tropical. Universidade de Brasília. Brasília, DF, Brasil
- Instituto de Avaliação de Tecnologia em Saúde. Porto Alegre, RS, Brasil
| | - Marcelo Augusto Mota Brito
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. Manaus, AM, Brasil
- Universidade Estadual do Amazonas. Manaus, AM, Brasil
| | - Gustavo Adolfo Sierra Romero
- Núcleo de Medicina Tropical. Universidade de Brasília. Brasília, DF, Brasil
- Instituto de Avaliação de Tecnologia em Saúde. Porto Alegre, RS, Brasil
| | - Wuelton Marcelo Monteiro
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. Manaus, AM, Brasil
- Universidade Estadual do Amazonas. Manaus, AM, Brasil
| | - Marcus Vinícius Guimarães de Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado. Manaus, AM, Brasil
- Instituto Leônidas e Maria Deane. Fundação Oswaldo Cruz. Manaus, AM, Brasil
| | - Maria Regina Fernandes de Oliveira
- Núcleo de Medicina Tropical. Universidade de Brasília. Brasília, DF, Brasil
- Instituto de Avaliação de Tecnologia em Saúde. Porto Alegre, RS, Brasil
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Kovacs SD, Mills BM, Stergachis A. Donor support for quality assurance and pharmacovigilance of anti-malarials in malaria-endemic countries. Malar J 2017; 16:282. [PMID: 28693488 PMCID: PMC5504670 DOI: 10.1186/s12936-017-1921-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Malaria control efforts have been strengthened by funding from donor groups and government agencies. The Global Fund to Fight AIDS, Tuberculosis and the Malaria (Global Fund), the US President's Malaria Initiative (PMI) account for the majority of donor support for malaria control and prevention efforts. Pharmacovigilance (PV), which encompasses all activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problem, is a necessary part of efforts to reduce drug resistance and improve treatment outcomes. This paper reports on an analysis of PV plans in the Global Fund and PMI and World Bank's grants for malaria prevention and control. METHODS All active malaria grants as of September 2015 funded by the Global Fund and World Bank, and fiscal year 2015 and 2016 PMI Malaria Operational Plans (MOP) were identified. The total amount awarded for PV-related activities and drug quality assurance was abstracted. A Key-Word-in-Context (KWIC) analysis was conducted for the content of each grant. Specific search terms consisted of pharmacovigilance, pregn*, registry, safety, adverse drug, mass drug administration, primaquine, counterfeit, sub-standard, and falsified. Grants that mentioned PV activities identified in the KWIC search, listed PV in their budgets, or included the keywords: counterfeit, sub-standard, falsified, mass drug administration, or adverse event were thematically coded using Dedoose software version 7.0. RESULTS The search identified 159 active malaria grants including 107 Global Fund grants, 39 fiscal year 2015 and 2016 PMI grants and 13 World Bank grants. These grants were primarily awarded to low-income countries (57.2%) and in sub-Saharan Africa (SSA) (70.4%). Thirty-seven (23.3%) grants included a budget line for PV- or drug quality assurance-related activities, including 21 PMI grants and 16 Global Fund grants. Only 23 (14.5%) grants directly mentioned PV. The primary focus area was improving drug quality monitoring, especially among the PMI grants. CONCLUSIONS The results of the analysis demonstrate that funding for PV has not been sufficiently prioritized by either the key malaria donor organizations or by the recipient countries, as reflected in their grant proposal submissions and MOPs.
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Affiliation(s)
- Stephanie D. Kovacs
- Department of Epidemiology, University of Washington, 6123 SW Stevens Street Apt 302, Seattle, WA 98116 USA
| | - Brianna M. Mills
- Department of Epidemiology, University of Washington, 6123 SW Stevens Street Apt 302, Seattle, WA 98116 USA
- Center for Studies in Demography and Ecology, University of Washington, Seattle, WA USA
| | - Andy Stergachis
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Pharmacy, University of Washington, Seattle, WA USA
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Suswardany DL, Sibbritt DW, Supardi S, Pardosi JF, Chang S, Adams J. A cross-sectional analysis of traditional medicine use for malaria alongside free antimalarial drugs treatment amongst adults in high-risk malaria endemic provinces of Indonesia. PLoS One 2017; 12:e0173522. [PMID: 28329019 PMCID: PMC5362041 DOI: 10.1371/journal.pone.0173522] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 02/21/2017] [Indexed: 01/21/2023] Open
Abstract
Background The level of traditional medicine use, particularly Jamu use, in Indonesia is substantial. Indonesians do not always seek timely treatment for malaria and may seek self-medication via traditional medicine. This paper reports findings from the first focused analyses of traditional medicine use for malaria in Indonesia and the first such analyses worldwide to draw upon a large sample of respondents across high-risk malaria endemic areas. Methods A sub-study of the Indonesia Basic Health Research/Riskesdas Study 2010 focused on 12,226 adults aged 15 years and above residing in high-risk malaria-endemic provinces. Logistic regression was undertaken to determine the significant associations for traditional medicine use for malaria symptoms. Findings Approximately one in five respondents use traditional medicine for malaria symptoms and the vast majority experiencing multiple episodes of malaria use traditional medicine alongside free antimalarial drug treatments. Respondents consuming traditional medicine for general health/common illness purposes every day (odds ratio: 3.75, 95% Confidence Interval: 2.93 4.79), those without a hospital in local vicinity (odds ratio: 1.31, 95% Confidence Interval: 1.10 1.57), and those living in poorer quality housing, were more likely to use traditional medicine for malaria symptoms. Conclusion A substantial percentage of those with malaria symptoms utilize traditional medicine for treating their malaria symptoms. In order to promote safe and effective malaria treatment, all providing malaria care in Indonesia need to enquire with their patients about possible traditional medicine use.
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Affiliation(s)
- Dwi Linna Suswardany
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Universitas Muhammadiyah Surakarta, Central Java, Indonesia
| | - David W. Sibbritt
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sudibyo Supardi
- National Institute of Health Research and Development, Ministry of Health, Indonesia
| | - Jerico F. Pardosi
- National Institute of Health Research and Development, Ministry of Health, Indonesia
- School of Public Health and Community Medicine, University of New South Wales, Australia
| | - Sungwon Chang
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jon Adams
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- * E-mail:
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Laktabai J, Lesser A, Platt A, Maffioli E, Mohanan M, Menya D, Prudhomme O'Meara W, Turner EL. Innovative public-private partnership to target subsidised antimalarials: a study protocol for a cluster randomised controlled trial to evaluate a community intervention in Western Kenya. BMJ Open 2017; 7:e013972. [PMID: 28320794 PMCID: PMC5372155 DOI: 10.1136/bmjopen-2016-013972] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION There are concerns of inappropriate use of subsidised antimalarials due to the large number of fevers treated in the informal sector with minimal access to diagnostic testing. Targeting antimalarial subsidies to confirmed malaria cases can lead to appropriate, effective therapy. There is evidence that community health volunteers (CHVs) can be trained to safely and correctly use rapid diagnostic tests (RDTs). This study seeks to evaluate the public health impact of targeted antimalarial subsidies delivered through a partnership between CHVs and the private retail sector. METHODS AND ANALYSIS We are conducting a stratified cluster-randomised controlled trial in Western Kenya where 32 community units were randomly assigned to the intervention or control (usual care) arm. In the intervention arm, CHVs offer free RDT testing to febrile individuals and, conditional on a positive test result, a voucher to purchase a WHO-qualified artemisinin combination therapy (ACT) at a reduced fixed price in the retail sector.Study outcomes in individuals with a febrile illness in the previous 4 weeks will be ascertained through population-based cross-sectional household surveys at four time points: baseline, 6, 12 and 18 months postbaseline. The primary outcome is the proportion of fevers that receives a malaria test from any source (CHV or health facility). The main secondary outcome is the proportion of ACTs used by people with a malaria-positive test. Other secondary outcomes include: the proportion of ACTs used by people without a test and adherence to test results. ETHICS AND DISSEMINATION The protocol has been approved by the National Institutes of Health, the Moi University School of Medicine Institutional Research and Ethics Committee and the Duke University Medical Center Institutional Review Board. Findings will be reported on clinicalstrials.gov, in peer-reviewed publications and through stakeholder meetings including those with the Kenyan Ministry of Health. TRIAL REGISTRATION NUMBER Pre-results, NCT02461628.
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Affiliation(s)
| | - Adriane Lesser
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Alyssa Platt
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Elisa Maffioli
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Economics, Duke University, Durham, North Carolina, USA
| | - Manoj Mohanan
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Economics, Duke University, Durham, North Carolina, USA
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
| | - Wendy Prudhomme O'Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth L Turner
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
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Abstract
The continued success of efforts to reduce the global malaria burden will require sustained funding for interventions specifically targeting Plasmodium vivax The optimal use of limited financial resources necessitates cost and cost-effectiveness analyses of strategies for diagnosing and treating P. vivax and vector control tools. Herein, we review the existing published evidence on the costs and cost-effectiveness of interventions for controlling P. vivax, identifying nine studies focused on diagnosis and treatment and seven studies focused on vector control. Although many of the results from the much more extensive P. falciparum literature can be applied to P. vivax, it is not always possible to extrapolate results from P. falciparum-specific cost-effectiveness analyses. Notably, there is a need for additional studies to evaluate the potential cost-effectiveness of radical cure with primaquine for the prevention of P. vivax relapses with glucose-6-phosphate dehydrogenase testing.
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Affiliation(s)
- Michael T. White
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom
| | - Shunmay Yeung
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Edith Patouillard
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Universität Basel, Basel, Switzerland
| | - Richard Cibulskis
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
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Karyana M, Devine A, Kenangalem E, Burdarm L, Poespoprodjo JR, Vemuri R, Anstey NM, Tjitra E, Price RN, Yeung S. Treatment-seeking behaviour and associated costs for malaria in Papua, Indonesia. Malar J 2016; 15:536. [PMID: 27821127 PMCID: PMC5100266 DOI: 10.1186/s12936-016-1588-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/28/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Malaria remains a significant public health issue in Eastern Indonesia, where multidrug resistant Plasmodium falciparum and Plasmodium vivax are highly prevalent. The objective of this study was to describe treatment-seeking behaviour and household costs prior to a change to a unified treatment policy of dihydroartemisinin-piperaquine in Mimika district, Papua province in 2006. METHODS In 2005 a randomized cross-sectional household survey was conducted to collect data on demographics, socio-economic status (SES), treatment-seeking, case management, and household costs. Information on the cost of illness was also collected from patients exiting health facilities, in order to compare the cost of episodes diagnosed as P. vivax compared with those diagnosed as P. falciparum. RESULTS 825 households were included in the survey. Of the 764 individuals who sought treatment for fever outside the home in the last month, 46% (349/764) went to a public health facility. Of the 894 reported visits to healthcare providers, 48% (433) resulted in a blood test, of which 78% (337) were reportedly positive. Only 10% (17/177) of individuals who reported testing positive for P. falciparum or mixed infection received the first-line treatment of chloroquine with SP, and 38% (61/159) of those with a diagnosis of P. vivax reportedly received the first-line treatment of chloroquine and primaquine. Overall, public facilities were more likely to prescribe the correct prevailing first-line drug combinations than private providers (OR = 3.77 [95% CI 2.31-6.14], p < 0.001). The mean cost to the household of an episode of P. vivax was similar to the cost of P. falciparum [US$44.50 (SD: 46.23) vs US$48.58 (SD: 64.65)]. CONCLUSIONS Private providers were a popular source of treatment for malaria, but adherence to the national guidelines was low and the economic burden of malaria for both P. falciparum and P. vivax infections was substantial. Engagement with the private sector is needed to ensure that patients have access to affordable good quality, effective diagnostics and anti-malarials for both P. falciparum and P. vivax.
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Affiliation(s)
- Muhammad Karyana
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Angela Devine
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Enny Kenangalem
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia
- Mimika District Health Authority, Timika, Papua Indonesia
| | - Lenny Burdarm
- Mimika District Health Authority, Timika, Papua Indonesia
| | - Jeanne Rini Poespoprodjo
- Timika Malaria Research Program, Papuan Health and Community Development Foundation, Timika, Papua Indonesia
- Mimika District Health Authority, Timika, Papua Indonesia
- Department of Child Health, Faculty of Medicine, University Gadjah Mada, Yogyakarta, Indonesia
| | - Ram Vemuri
- Business School, Charles Darwin University, Darwin, Australia
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
| | - Ric N. Price
- Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Shunmay Yeung
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
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Ansah EK, Whitty CJ, Bart-Plange C, Gyapong M. Changes in the availability and affordability of subsidised artemisinin combination therapy in the private drug retail sector in rural Ghana: before and after the introduction of the AMFm subsidy. Int Health 2016; 8:427-432. [PMID: 27744327 PMCID: PMC5181550 DOI: 10.1093/inthealth/ihw041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/24/2016] [Accepted: 08/09/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Most people with febrile illness are treated in the private drug retail sector. Ghana was among nine countries piloting the Global Fund Affordable Medicines Facility - malaria (AMFm). AMFm aimed to: increase artemisinin combination therapy (ACT) affordability; increase ACT availability; increase ACT use; and 'crowd out' artemisinin monotherapies. METHODS Three censuses were carried out 2 months before (2010), 2 months after and 2.5 years after (2013) the first co-paid ACTs to assess changes in antimalarial (AM) availability and price in private retail shops in a Ghanaian rural district to assess the sustainability of the initial gains. Supply, stock-out and cost were explored. RESULTS Of 62 shops in the district, 56 participated with 398, 388 and 442 brands of AMs in the shops during the 3 censuses. The proportion of ACTs increased over the period while monotherapies reduced. Herbal-based AM preparations comprised 40-45% of AMs in stock with minimal variation over the period. ACTs were the most sold AM type for all ages but overall buying and selling prices of Quality Assured-ACTs increased by 40-100%. CONCLUSIONS Initial gains in ACT availability were sustained, but not improved on 2.5 years after AMFm. Widespread availability of unproven herbal medicines is a concern; AMFm had little impact on this.
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Affiliation(s)
- Evelyn K Ansah
- Dangme West District Health Directorate, Ghana Health Service, P.O. Box DD1, Dodowa, Ghana
| | | | - Constance Bart-Plange
- National Malaria Control Programme, Ghana Health Service, P.O. Box KB493, Korle-Bu, Accra, Ghana
| | - Margaret Gyapong
- Dodowa Health Research Center, Ghana Health Service, P.O. Box DD1, Dodowa, Ghana
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Bôtto-Menezes C, Bardají A, dos Santos Campos G, Fernandes S, Hanson K, Martínez-Espinosa FE, Menéndez C, Sicuri E. Costs Associated with Malaria in Pregnancy in the Brazilian Amazon, a Low Endemic Area Where Plasmodium vivax Predominates. PLoS Negl Trop Dis 2016; 10:e0004494. [PMID: 27031515 PMCID: PMC4816546 DOI: 10.1371/journal.pntd.0004494] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 02/06/2016] [Indexed: 11/30/2022] Open
Abstract
Background Information on costs associated with malaria in pregnancy (MiP) in low transmission areas where Plasmodium vivax predominates is so far missing. This study estimates health system and patient costs of MiP in the Brazilian Amazon. Methods/Principal Findings Between January 2011 and March 2012 patient costs for the treatment of MiP were collected through an exit survey at a tertiary referral hospital and at a primary health care centre in the Manaus metropolitan area, Amazonas state. Pregnant and post-partum women diagnosed with malaria were interviewed after an outpatient consultation or at discharge after admission. Seventy-three interviews were included in the analysis. Ninety-six percent of episodes were due to P. vivax and 4% to Plasmodium falciparum. In 2010, the total median costs from the patient perspective were estimated at US $45.91 and US $216.29 for an outpatient consultation and an admission, respectively. When multiple P. vivax infections during the same pregnancy were considered, patient costs increased up to US $335.85, representing the costs of an admission plus an outpatient consultation. Provider direct and overhead cost data were obtained from several sources. The provider cost associated with an outpatient case, which includes several consultations at the tertiary hospital was US $103.51 for a P. vivax malaria episode and US $83.59 for a P. falciparum malaria episode. The cost of an inpatient day and average admission of 3 days was US $118.51 and US $355.53, respectively. Total provider costs for the diagnosis and treatment of all malaria cases reported in pregnant women in Manaus in 2010 (N = 364) were US $17,038.50, of which 92.4% (US$ 15,741.14) due to P. vivax infection. Conclusion Despite being an area of low risk malaria transmission, MiP is responsible for a significant economic burden in Manaus. Especially when multiple infections are considered, costs associated with P. vivax are higher than costs associated with P. falciparum. The information generated may help health policy decisions for the current control and future elimination of malaria in the area. Malaria in pregnancy (MiP) is associated with maternal and foetal morbidity and mortality. In addition to the clinical burden, MiP implies a significant economic burden, but the little available evidence on the economics of MiP is limited to Plasmodium falciparum malaria and to the sub-Saharan region. While an increasing interest has been recently devoted to the epidemiology and the clinical consequences of Plasmodium vivax, the economics of P. vivax malaria is neglected. P. vivax is endemic in Latin America, and Brazil is the country with the highest reported burden of MiP of the American continent. Between 2011 and 2012, we conducted a study in the city of Manaus, Brazilian Amazon, with the aim of estimating costs associated with MiP both from the health provider and the patient perspectives. Despite being an area of low transmission risk, we found that the costs of treating MiP are not negligible. In particular, both from the patient and the provider perspectives, costs underwent a remarkable increase when admission was required and when the cost of subsequent P. vivax malaria episodes during the same pregnancy occurred. The information generated may help health policy decisions for the current control and future elimination of malaria in the area.
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Affiliation(s)
- Camila Bôtto-Menezes
- Universidade do Estado do Amazonas (UEA), Programa de Pós-Graduação em Medicina Tropical, Manaus, Amazonas, Brazil
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil
- * E-mail:
| | - Azucena Bardají
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Giselane dos Santos Campos
- Núcleo de Estudos e Pesquisas das Cidades na Amazônia Brasileira da Universidade Federal do Amazonas (NEPECAB/UFAM), Manaus, Amazonas, Brazil
- Faculdade Metropolitana de Manaus (FAMETRO), Manaus, Amazonas, Brazil
| | - Silke Fernandes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Flor Ernestina Martínez-Espinosa
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil
- Centro de Pesquisa Leônidas e Maria Deane/Fundação Oswaldo Cruz, Manaus, Amazonas, Brazil
| | - Clara Menéndez
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Elisa Sicuri
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, United Kingdom
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Abstract
BACKGROUND Malaria causes ill health and death in Africa. Treating illness promptly with artemisinin-based combination therapy (ACT) is likely to cure people and avoid the disease progressing to more severe forms and death. In many countries, ACT use remains low. Part of the problem is that most people seek treatment from the retail sector where ACTs are expensive; this expense is a barrier to their use.The Global Fund and other international organisations are subsidising the cost of ACTs for private retail providers to improve access to ACTs. The subsidy was initially organised through a stand-alone initiative, called the Affordable Medicines Facility-malaria (AMFm), but has since been integrated into the Global Fund core grant management and financial processes. OBJECTIVES To assess the effect of programmes that include ACT price subsidies for private retailers on ACT use, availability, price and market share. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 1, The Cochrane Library, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register); MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHost), EconLit (ProQuest), Global Health (OvidSP), Regional Indexes (Global Health Library, WHO), LILACS (Global Health Library, WHO), Science Citation Index and Social Sciences Citation Index (ISI Web of Science) and Health Management (ProQuest). All databases were searched February 2015, except for Health Management which was searched November 2013, without any date, language or publication status restrictions. We also searched the International Clinical Trials Registry Platform (ICTRP; WHO), ClinicalTrials.gov (NIH) and various grey literature sources. We also conducted a cited reference search for all included studies in ISI Web of Knowledge, checked references of identified articles and contacted authors to identify additional studies. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies and interrupted-time-series studies that compared the effects of ACT price subsidies for private retailers to no subsidies or alternative ACT financing mechanisms were eligible for inclusion. Two authors independently screened and selected studies for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed study risk of bias and confidence in effect estimates (certainty of evidence) using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). MAIN RESULTS We included four trials (two cluster-randomised trials reported in three articles and two non-randomised cluster trials). Three trials assessed retail sector ACT subsidies combined with supportive interventions (retail outlet provider training, community awareness and mass media campaigns). One trial assessed vouchers provided to households to purchase subsidised ACTs. Price subsidies ranged from 80% to 95%. One trial enrolled children under five years of age; the other three trials studied people of all age groups. The studies were done in rural districts in East Africa (Kenya, Uganda and Tanzania).In this East Africa setting, these ACT subsidy programmes increased the percentage of children under five years of age receiving ACTs on the day, or following day, of fever onset by 25 percentage points (95% confidence interval (CI) 14.1 to 35.9 percentage points; 1 study, high certainty evidence). This suggests that in practice, among febrile children under five years of age with an ACT usage rate of 5% without a subsidy, subsidy programmes would increase usage by between 19% and 41% over a one year period.The ACT subsidy programmes increased the percentage of retail outlets stocking ACTs for children under five years of age by 31.9 percentage points (95% CI 26.3 to 37.5 percentage points; 1 study, high certainty evidence). Effects on ACT stocking for patients of any age is unknown because the certainty of evidence was very low.The ACT subsidy programmes decreased the median cost of ACTs for children under five years of age by US$ 0.84 (median cost per ACT course without subsidy: US$ 1.08 versus with subsidy: US$ 0.24; 1 study, high certainty evidence).The ACT subsidy programmes increased the market share of ACTs for children under five years of age by between 23.6 and 63.0 percentage points (1 study, high certainty evidence).The ACT subsidy programmes decreased the use of older antimalarial drugs (such as amodiaquine and sulphadoxine-pyrimethamine) among children under five years of age by 10.4 percentage points (95% CI 3.9 to 16.9 percentage points; 1 study, high certainty evidence).None of the three studies of ACT subsidies reported the number of patients treated who had confirmed malaria.Vouchers increased the likelihood that an illness is treated with an ACT by 16 to 23 percentage points; however, vouchers were associated with a high rate of over-treatment of malaria (only 56% of patients taking ACTs from the drug shop tested positive for malaria under the 92% subsidy; 1 study, high certainty evidence). AUTHORS' CONCLUSIONS Programmes that include substantive subsidies for private sector retailers combined with training of providers and social marketing improved use and availability of ACTs for children under five years of age with suspected malaria in research studies from three countries in East Africa. These programmes also reduced prices of ACTs, improved market share of ACTs and reduced the use of older antimalarial drugs among febrile children under five years of age. The research evaluates drug delivery but does not assess whether the patients had confirmed (parasite-diagnosed) malaria. None of the included studies assessed patient outcomes; it is therefore not known whether the effects seen in the studies would translate to an impact on health.
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Affiliation(s)
- Newton Opiyo
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
| | - Gavin Yamey
- Duke UniversityDuke Global Health InstituteDurhamNCUSA27708
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Carias C, Greening B, Campbell CG, Meltzer MI, Hamel MJ. Preventive malaria treatment for contacts of patients with Ebola virus disease in the context of the west Africa 2014-15 Ebola virus disease response: an economic analysis. Lancet Infect Dis 2015; 16:449-58. [PMID: 26706716 DOI: 10.1016/s1473-3099(15)00465-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 10/24/2015] [Accepted: 11/05/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND After the detection of an Ebola virus disease outbreak in west Africa in 2014, one of the elements of the response was to contact trace and isolate patients in specialised Ebola treatment units (ETUs) at onset of fever. We aimed to assess the economic feasibility of administering preventive malaria treatment to all contacts of patients with Ebola virus disease, to prevent the onset of febrile malaria and subsequent admission to ETUs. METHODS We used a decision tree model to analyse the costs of preventive malaria treatment (artemisinin-based combination treatment [ACT]) for all contacts of patients with Ebola virus disease (in terms of administration and averted ETU-stay costs) and benefits (in terms of averted ETU admissions) in west Africa, from a health-care provider perspective. The period of analyses was 1 year, which is roughly similar to the duration of the 2014-15 west Africa Ebola outbreak response. We calculated the intervention's cost per ETU admission averted (average cost-effectiveness ratio) by season (wet and dry), country (Liberia, Sierra Leone, and Guinea), and age of contact (<5 years, 5-14 years, and ≥15 years). We did sensitivity analyses to assess how results varied with malaria parasite prevalence (in children aged 2-10 years), daily cost of ETU stay (for Liberian malaria incidence levels), and compliance and effectiveness of preventive malaria treatment. FINDINGS Administration of ACTs to contacts of patients with Ebola virus disease was cost saving for contacts of all ages in Liberia, Sierra Leone, and Guinea, in both seasons, from a health-care provider perspective. In the wet season, preventive malaria treatment was estimated to reduce the probability of a contact being admitted to an ETU by a maximum of 36% (in Guinea, for contacts aged <5 years), and a minimum of 10% (in Guinea and Sierra Leone, for those aged ≥15 years). Assuming 85% compliance and taking into account the African population pyramid, the intervention is expected to be cost saving in contacts of all age groups in areas with malaria parasite prevalence in children aged 2-10 years as low as 10%. In Liberia during the wet season, malaria preventive treatment was cost saving even when average daily bed-stay costs were as low as US$5 for children younger than 5 years, $9 for those aged 5-14 years, and $22 for those aged 15 years or older. INTERPRETATION Administration of preventive malaria treatment to contacts of patients with Ebola virus disease should be considered by public health officials when addressing Ebola virus disease outbreaks in countries and seasons where malaria reaches high levels of transmission. FUNDING Centers for Disease Control and Prevention.
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Affiliation(s)
- Cristina Carias
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Modeling Unit, Emergency Operations Center, 2014 Ebola Response, Centers for Disease Control and Prevention, Atlanta, GA, USA; IHRC, Inc, Atlanta, GA, USA.
| | - Bradford Greening
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Modeling Unit, Emergency Operations Center, 2014 Ebola Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Caresse G Campbell
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Modeling Unit, Emergency Operations Center, 2014 Ebola Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Martin I Meltzer
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA; Modeling Unit, Emergency Operations Center, 2014 Ebola Response, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mary J Hamel
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
Millions of people cannot access essential medicines they need for deadly diseases like malaria, tuberculosis (TB) and HIV/AIDS. There is good information on the need for drugs for these diseases but until now, no global estimate of the impact drugs are having on this burden. This paper presents a model measuring companies' key malaria, TB and HIV/AIDS drugs' consequences for global health (global-health-impact.org). It aggregates drugs' impacts in several ways-by disease, country and originator-company. The methodology can be extended across diseases as well as drugs to provide a more extensive picture of the impact companies' drugs are having on the global burden of disease. The study suggests that key malaria, TB and HIV/AIDS drugs are, together, ameliorating about 37% of the global burden of these diseases and Sanofi, Novartis, and Pfizer's drugs are having the largest effect on this burden. Moreover, drug impacts vary widely across countries. This index provides important information for policy makers, pharmaceutical companies, countries, and other stake-holders that can help increase access to essential medicines.
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Affiliation(s)
- Nicole Hassoun
- Department of Philosophy, Binghamton University, State University of New York, Binghamton, NY, United States of America
- * E-mail:
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Affiliation(s)
- Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, Massachusetts
| | - Lara R Maggs
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, Massachusetts
| | - Ameet Sarpatwari
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School, Boston, Massachusetts
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Mbonye AK, Magnussen P, Lal S, Hansen KS, Cundill B, Chandler C, Clarke SE. A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria. PLoS One 2015. [PMID: 26200467 PMCID: PMC4511673 DOI: 10.1371/journal.pone.0129545] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops. METHODS A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood slide collected at the time of consultation. The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as: malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate, and patients with no malaria parasites not given ACT. FINDINGS A total of 15,517 eligible patients (8672 intervention and 6845 control) received treatment for fever between January-December 2011. The proportion of febrile patients who received appropriate ACT treatment was 72·9% versus 33·7% in the control arm; a difference of 36·1% (95% CI: 21·3 - 50·9), p<0·001. The majority of patients with fever in the intervention arm accepted to purchase an mRDT (97·8%), of whom 58·5% tested mRDT-positive. Drug shop vendors adhered to the mRDT results, reducing over-treatment of malaria by 72·6% (95% CI: 46·7- 98·4), p<0·001) compared to drug shop vendors using presumptive diagnosis (control arm). CONCLUSION Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT. TRIAL REGISTRATION ClinicalTrials.gov NCT01194557.
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Affiliation(s)
- Anthony K. Mbonye
- Ministry of Health, Box 7272, Kampala, Uganda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- * E-mail:
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kristian S. Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Bonnie Cundill
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Abstract
BACKGROUND Patent medicine vendors (PMVs) play an important role in the treatment of malaria, especially in the rural areas. Nigeria recently changed her antimalarial treatment policy from chloroquine to artemisinin-based combination therapy (ACT). OBJECTIVES To determine the response of PMVs to the new policy. METHODS A baseline study was conducted in two local government areas (LGAs) of Lagos state Nigeria as the first phase in an intervention study aimed at improving the malarial treatment practices of PMVs in rural Lagos. A mixed method design involving a questionnaire survey of 180 PMVs and four key informant interviews were used. An antimalarial drug (AMD) audit was also performed. RESULTS More than 80% of respondents were aware of the policy change in malaria treatment, but only 23.9% sold an ACT for the last case of malaria treated in an under five child. The main determining factor of the particular AMD sold was PMV's personal choice (70.6%). About half (58.9%) of the shops stocked ACTs, the newly recommended antimalarials. CONCLUSIONS The high awareness of the policy change did not translate to a commensurate increase in the sale of the new drugs. Factors beyond the PMVs need to be addressed for a successful adoption of the new policy.
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Affiliation(s)
- Abisoye Oyeyemi
- Department of Community Medicine, Faculty of Clinical Sciences, College of Health Sciences, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria
| | - Babatunde Ogunnowo
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Oluwakemi Odukoya
- Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
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Sicuri E, Fernandes S, Macete E, González R, Mombo-Ngoma G, Massougbodgi A, Abdulla S, Kuwawenaruwa A, Katana A, Desai M, Cot M, Ramharter M, Kremsner P, Slustker L, Aponte J, Hanson K, Menéndez C. Economic evaluation of an alternative drug to sulfadoxine-pyrimethamine as intermittent preventive treatment of malaria in pregnancy. PLoS One 2015; 10:e0125072. [PMID: 25915616 PMCID: PMC4410941 DOI: 10.1371/journal.pone.0125072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 03/15/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in HIV-negative women to avert malaria, while this relies on cotrimoxazole prophylaxis (CTXp) in HIV-positive women. Alternative antimalarials are required in areas where parasite resistance to antifolate drugs is high. The cost-effectiveness of IPTp with alternative drugs is needed to inform policy. METHODS The cost-effectiveness of 2-dose IPTp-mefloquine (MQ) was compared with IPTp-SP in HIV-negative women (Benin, Gabon, Mozambique and Tanzania). In HIV-positive women the cost-effectiveness of 3-dose IPTp-MQ added to CTXp was compared with CTXp alone (Kenya, Mozambique and Tanzania). The outcomes used were maternal clinical malaria, anaemia at delivery and non-obstetric hospital admissions. The poor tolerability to MQ was included as the value of women's loss of working days. Incremental cost-effectiveness ratios (ICERs) were calculated and threshold analysis undertaken. RESULTS For HIV-negative women, the ICER for IPTp-MQ versus IPTp-SP was 136.30 US$ (2012 US$) (95%CI 131.41; 141.18) per disability-adjusted life-year (DALY) averted, or 237.78 US$ (95%CI 230.99; 244.57), depending on whether estimates from Gabon were included or not. For HIV-positive women, the ICER per DALY averted for IPTp-MQ added to CTXp, versus CTXp alone was 6.96 US$ (95%CI 4.22; 9.70). In HIV-negative women, moderate shifts of variables such as malaria incidence, drug cost, and IPTp efficacy increased the ICERs above the cost-effectiveness threshold. In HIV-positive women the intervention remained cost-effective for a substantial (up to 21 times) increase in cost per tablet. CONCLUSIONS Addition of IPTp with an effective antimalarial to CTXp was very cost-effective in HIV-positive women. IPTp with an efficacious antimalarial was more cost-effective than IPTp-SP in HIV-negative women. However, the poor tolerability of MQ does not favour its use as IPTp. Regardless of HIV status, prevention of malaria in pregnancy with a highly efficacious, well tolerated antimalarial would be cost-effective despite its high price. TRIALS REGISTRATION ClinicalTrials.gov NCT 00811421; Pan African Trials Registry PACTR2010020001429343 and PACTR2010020001813440.
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Affiliation(s)
- Elisa Sicuri
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Silke Fernandes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eusebio Macete
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Raquel González
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Achille Massougbodgi
- Faculté des Sciences de la Santé (FSS), Université d’Abomey Calavi, Cotonou, Benin
| | | | | | - Abraham Katana
- Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya
| | - Michel Cot
- Institut de Recherche pour le Développement (IRD), Paris, France
- Université René Descartes, Paris, France
| | - Michael Ramharter
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Kremsner
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Laurence Slustker
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya
| | - John Aponte
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clara Menéndez
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
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Yeung S, Lawford HLS, Tabernero P, Nguon C, van Wyk A, Malik N, DeSousa M, Rada O, Boravann M, Dwivedi P, Hostetler DM, Swamidoss I, Green MD, Fernandez FM, Kaur H. Quality of antimalarials at the epicenter of antimalarial drug resistance: results from an overt and mystery client survey in Cambodia. Am J Trop Med Hyg 2015; 92:39-50. [PMID: 25897063 PMCID: PMC4455075 DOI: 10.4269/ajtmh.14-0391] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 12/07/2014] [Indexed: 12/02/2022] Open
Abstract
Widespread availability of monotherapies and falsified antimalarials is thought to have contributed to the historical development of multidrug-resistant malaria in Cambodia. This study aimed to document the quality of artemisinin-containing antimalarials (ACAs) and to compare two methods of collecting antimalarials from drug outlets: through open surveyors and mystery clients (MCs). Few oral artemisinin-based monotherapies and no suspected falsified medicines were found. All 291 samples contained the stated active pharmaceutical ingredient (API) of which 69% were considered good quality by chemical analysis. Overall, medicine quality did not differ by collection method, although open surveyors were less likely to obtain oral artemisinin-based monotherapies than MCs. The results are an encouraging indication of the positive impact of the country's efforts to tackle falsified antimalarials and artemisinin-based monotherapies. However, poor-quality medicines remain an ongoing challenge that demands sustained political will and investment of human and financial resources.
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Affiliation(s)
- Shunmay Yeung
- *Address correspondence to Shunmay Yeung, Faculty of Public Health and Policy, Department of Global Health and Development, LSHTM, 15-17 Tavistock Place, WC1H 9SH, London, United Kingdom. E-mail:
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Tabernero P, Mayxay M, Culzoni MJ, Dwivedi P, Swamidoss I, Allan EL, Khanthavong M, Phonlavong C, Vilayhong C, Yeuchaixiong S, Sichanh C, Sengaloundeth S, Kaur H, Fernández FM, Green MD, Newton PN. A Repeat Random Survey of the Prevalence of Falsified and Substandard Antimalarials in the Lao PDR: A Change for the Better. Am J Trop Med Hyg 2015; 92:95-104. [PMID: 25897062 PMCID: PMC4455074 DOI: 10.4269/ajtmh.15-0057] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/03/2015] [Indexed: 11/25/2022] Open
Abstract
In 2003, a stratified random sample survey was conducted in the Lao People's Democratic Republic (Laos) to study the availability and quality of antimalarials in the private sector. In 2012, this survey was repeated to allow a statistically valid analysis of change through time. The counterfeit detection device 3 (CD-3) was used to assess packaging quality in the field and HPLC and mass spectroscopy analysis chemical analysis performed. The availability of oral artesunate monotherapies had significantly decreased from 22.9% (22) of 96 outlets in southern Laos in 2003 to 4.8% (7) of 144 outlets in 2012 (P < 0.0001). All the samples collected in the 2012 survey contained the correct active pharmaceutical ingredients (APIs) in contrast to the 21 (84%) falsified artesunate samples found in the 2003 survey. Although none of the medicines found in 2012 survey had evidence for falsification, 25.4% (37) of the samples were outside the 90–110% pharmacopeial limits of the label claim, suggesting that they were substandard or degraded. Results obtained from this survey show that patients are still exposed to poorly manufactured drugs or to ineffective medicines such as chloroquine. The quality of artemisinin-based combination therapies (ACTs) used in Laos needs to be monitored, since falsified ACTs would have devastating consequences in public health.
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Affiliation(s)
- Patricia Tabernero
- *Address correspondence to Patricia Tabernero or Paul N. Newton, University of Oxford, Centre for Tropical Medicine and Global Health, Roosevelt Drive, Oxford OX3 7FZ. E-mails: or
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul N. Newton
- *Address correspondence to Patricia Tabernero or Paul N. Newton, University of Oxford, Centre for Tropical Medicine and Global Health, Roosevelt Drive, Oxford OX3 7FZ. E-mails: or
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Peixoto HM, Brito MAM, Romero GAS, Monteiro WM, de Lacerda MVG, de Oliveira MRF. G6PD deficiency in male individuals infected by Plasmodium vivax malaria in the Brazilian Amazon: a cost study. Malar J 2015; 14:126. [PMID: 25889063 PMCID: PMC4381355 DOI: 10.1186/s12936-015-0647-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/10/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Deficiency of the enzyme G6PD (G6PDd) is caused by mutations in the gene G6PD, which plays an important role in protecting the red blood cell against oxidizing agents; it is linked to chromosome X, and it may affects both sexes. The clinically relevant manifestations, such as acute haemolytic anaemia, mainly occur in men, however. The 8-aminoquinoline primaquine, which is the medication used in the radical treatment of malaria caused by Plasmodium vivax, represents the main factor that triggers complications associated with G6PDd. The current study aims to estimate the costs of G6PDd among male individuals infected by P. vivax in the Brazilian Amazon. METHODS This is an economic analysis developed within the Brazilian National Health System perspective for the years of 2009, 2010 and 2011. Direct medical and non-medical costs were estimated for G6PDd in the Brazilian Amazon, considering among those suffering from the deficiency the costs of diagnosing infection by P. vivax, its treatment and severe adverse events that require hospitalization and were connected to the use of primaquine. RESULTS The estimates of the average costs of diagnosing vivax malaria, of its treatment and of severe adverse events after using primaquine among the carriers of G6PDd, over the three evaluated years, corresponded to US$ 739,410.42; US$ 2,120.04 and US$ 4,858,108.87, respectively. The results indicate that the average total cost in the study period corresponded to US$ 5,599,639.33, varying in accordance with the sensitivity analysis between US$ 4,439,512.14 and US$ 6,702,619.24. CONCLUSION The results indicate that the use of primaquine among men with G6PDd who are infected by P. vivax represents a heavy burden on the public health service of Brazil.
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Affiliation(s)
- Henry M Peixoto
- Centre for Tropical Medicine, University of Brasília, Brasília, Federal District, Brazil.
- University Centre of Brasília, Brasília, Federal District, Brazil.
| | - Marcelo A M Brito
- Tropical Medicine Foundation Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brazil.
- University of the State of Amazonas, Manaus, Amazonas, Brazil.
| | - Gustavo A S Romero
- Centre for Tropical Medicine, University of Brasília, Brasília, Federal District, Brazil.
- National Institute for Science and Technology for Health Technology Assessment (IATS/CNPq), Porto Alegre, RS, Brazil.
| | - Wuelton M Monteiro
- Tropical Medicine Foundation Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brazil.
- University of the State of Amazonas, Manaus, Amazonas, Brazil.
| | - Marcus V G de Lacerda
- Tropical Medicine Foundation Dr. Heitor Vieira Dourado, Manaus, Amazonas, Brazil.
- University of the State of Amazonas, Manaus, Amazonas, Brazil.
- Centro de Pesquisas Leônidas & Maria Deane, FIOCRUZ, Manaus, Amazonas, Brazil.
| | - Maria Regina F de Oliveira
- Centre for Tropical Medicine, University of Brasília, Brasília, Federal District, Brazil.
- National Institute for Science and Technology for Health Technology Assessment (IATS/CNPq), Porto Alegre, RS, Brazil.
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Mangham-Jefferies L, Wiseman V, Achonduh OA, Drake TL, Cundill B, Onwujekwe O, Mbacham W. Economic evaluation of a cluster randomized trial of interventions to improve health workers' practice in diagnosing and treating uncomplicated malaria in Cameroon. Value Health 2014; 17:783-791. [PMID: 25498773 DOI: 10.1016/j.jval.2014.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/09/2014] [Accepted: 07/30/2014] [Indexed: 06/04/2023]
Abstract
BACKGROUND Malaria rapid diagnostic tests (RDTs) are a valid alternative to malaria testing with microscopy and are recommended for the testing of febrile patients before prescribing an antimalarial. There is a need for interventions to support the uptake of RDTs by health workers. OBJECTIVE To evaluate the cost-effectiveness of introducing RDTs with basic or enhanced training in health facilities in which microscopy was available, compared with current practice. METHODS A three-arm cluster randomized trial was conducted in 46 facilities in central and northwest Cameroon. Basic training had a practical session on RDTs and lectures on malaria treatment guidelines. Enhanced training included small-group activities designed to change health workers' practice and reduce the consumption of antimalarials among test-negative patients. The primary outcome was the proportion of febrile patients correctly treated: febrile patients should be tested for malaria, artemisinin combination therapy should be prescribed for confirmed cases, and no antimalarial should be prescribed for patients who are test-negative. Individual patient data were obtained from facility records and an exit survey. Costs were estimated from a societal perspective using project reports and patient exit data. The analysis used bivariate multilevel modeling and adjusted for imbalance in baseline covariates. RESULTS Incremental cost per febrile patient correctly treated was $8.40 for the basic arm and $3.71 for the enhanced arm. On scale-up, it was estimated that RDTs with enhanced training would save $0.75 per additional febrile patient correctly treated. CONCLUSIONS Introducing RDTs with enhanced training was more cost-effective than RDTs with basic training when each was compared with current practice.
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Affiliation(s)
- Lindsay Mangham-Jefferies
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Olivia A Achonduh
- Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, The Biotechnology Center, Yaoundé, Cameroon
| | - Thomas L Drake
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK; Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Oxford, UK; Faculty of Tropical Medicine, Mahidol University, Rajwithi Road, Bangkok, Thailand
| | - Bonnie Cundill
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Obinna Onwujekwe
- Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Enugu, Nigeria
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, University of Yaoundé I, The Biotechnology Center, Yaoundé, Cameroon
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Palhares RM, Drummond MG, Brasil BSAF, Krettli AU, Oliveira GC, Brandão MGL. The use of an integrated molecular-, chemical- and biological-based approach for promoting the better use and conservation of medicinal species: a case study of Brazilian quinas. J Ethnopharmacol 2014; 155:815-22. [PMID: 24971797 DOI: 10.1016/j.jep.2014.06.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 06/15/2014] [Accepted: 06/15/2014] [Indexed: 05/10/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Quina is a popular name originally attributed to Cinchona pubescens Vahl (=Cinchona succirubra) and Cinchona. calisaya Wedd., species native from Peru that have the antimalarial alkaloid quinine. In Brazil, bitter barks substitutes for the Peruvian species began to be used centuries ago, and they still are sold in popular markets. To assess the authenticity and the conditions on which samples of quinas have been commercialized, using the DNA barcode, chemical and biological assays. MATERIALS AND METHODS Starting with 28 samples of barks acquired on a popular market, 23 had their DNA extracted successfully. The regions matK and rbcL were amplified and sequenced for 15 and 23 samples, respectively. Phytochemical analyses were performed by chromatographic methods, and biological essays were done by antimalarial tests in vitro. RESULTS The identified species belonged to six different families, many of them endangered or with no correlation with use in traditional medicine as a Brazilian quina. The absence of typical bitter chemical substances indicated that barks have been collected from other species or from very young trees. The results of biological essays confirm the lack of standardization of the sold materials. CONCLUSION The integrated approaches proved to be efficient to evaluate medicinal plants sold in popular markets and can be useful for promoting their better use and conservation.
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Affiliation(s)
- Rafael M Palhares
- Programa de Pós-graduação em Genética, Universidade Federal de Minas Gerais, Belo Horizonte, Brasil
| | | | | | - Antoniana U Krettli
- Laboratório de Malária, Centro de Pesquisa Rene Rachou, FIOCRUZ, Belo Horizonte, Brasil
| | - Guilherme C Oliveira
- Grupo de Genômica e Biologia Computacional, Centro de Pesquisa Rene Rachou, FIOCRUZ, Belo Horizonte, Brasil
| | - Maria G L Brandão
- CEPLAMT, Museu de História Natural e Jardim Botânico & Faculdade de Farmácia, Universidade Federal de Minas Gerais, Avenida Antônio Carlos, 6627 Belo Horizonte, Brasil.
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Lubell Y, White L, Varadan S, Drake T, Yeung S, Cheah PY, Maude RJ, Dondorp A, Day NPJ, White NJ, Parker M. Ethics, economics, and the use of primaquine to reduce falciparum malaria transmission in asymptomatic populations. PLoS Med 2014; 11:e1001704. [PMID: 25137246 PMCID: PMC4137981 DOI: 10.1371/journal.pmed.1001704] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Yoel Lubell and colleagues consider ethical and economic perspectives on mass drug administration of primaquine to limit transmission of P. falciparum malaria. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
- * E-mail:
| | - Lisa White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Sheila Varadan
- International Commission of Jurists, Geneva, Switzerland
| | - Tom Drake
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Shunmay Yeung
- Faculty of Public Health and Policy, The London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Richard J. Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Arjen Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Michael Parker
- The Ethox Centre, Nuffield Department of Population Health, University of Oxford, United Kingdom
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014; 9:e95681. [PMID: 24748395 PMCID: PMC3991722 DOI: 10.1371/journal.pone.0095681] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/31/2014] [Indexed: 12/31/2022] Open
Abstract
Background Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. Methods We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. Results First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006–0.07) and 0.001 deaths (95% CI: 0.00–0.002) and saved $0.96 (95% CI: 0.33–2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. Conclusions DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
- * E-mail:
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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014. [PMID: 24748395 DOI: 10.1371/journal.pone.0095681.ecollection] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. METHODS We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. RESULTS First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006-0.07) and 0.001 deaths (95% CI: 0.00-0.002) and saved $0.96 (95% CI: 0.33-2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. CONCLUSIONS DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany; German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
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Britton S. [Mala(robbery)--expensive for travelers]. Lakartidningen 2014; 111:99. [PMID: 24552016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Comfort AB, van Dijk JH, Mharakurwa S, Stillman K, Gabert R, Korde S, Nachbar N, Derriennic Y, Musau S, Hamazakaza P, Zyambo KD, Zyongwe NM, Hamainza B, Thuma PE. Hospitalizations and costs incurred at the facility level after scale-up of malaria control: pre-post comparisons from two hospitals in Zambia. Am J Trop Med Hyg 2013; 90:20-32. [PMID: 24218409 PMCID: PMC3886421 DOI: 10.4269/ajtmh.13-0019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
There is little evidence on the impact of malaria control on the health system, particularly at the facility level. Using retrospective, longitudinal facility-level and patient record data from two hospitals in Zambia, we report a pre-post comparison of hospital admissions and outpatient visits for malaria and estimated costs incurred for malaria admissions before and after malaria control scale-up. The results show a substantial reduction in inpatient admissions and outpatient visits for malaria at both hospitals after the scale-up, and malaria cases accounted for a smaller proportion of total hospital visits over time. Hospital spending on malaria admissions also decreased. In one hospital, malaria accounted for 11% of total hospital spending before large-scale malaria control compared with < 1% after malaria control. The findings demonstrate that facility-level resources are freed up as malaria is controlled, potentially making these resources available for other diseases and conditions.
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Affiliation(s)
- Alison B. Comfort
- *Address correspondence to Alison B. Comfort, Abt Associates, 55 Wheeler St., Cambridge, MA 02138. E-mail:
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Onwujekwe O, Uguru N, Etiaba E, Chikezie I, Uzochukwu B, Adjagba A. The economic burden of malaria on households and the health system in Enugu State southeast Nigeria. PLoS One 2013; 8:e78362. [PMID: 24223796 PMCID: PMC3817251 DOI: 10.1371/journal.pone.0078362] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/19/2013] [Indexed: 11/18/2022] Open
Abstract
Background Malaria is the number one public health problem in Nigeria, responsible for about 30% of deaths in under-fives and 25% of deaths in infants and 11% maternal mortality. This study estimated the economic burden of malaria in Nigeria using the cost of illness approach. Methods A cross-sectional study was undertaken in two malaria holo-endemic communities in Nigeria, involving both community and hospital based surveys. A random sample of 500 households was interviewed using interviewer administered questionnaire. In addition, 125 exit interviews for inpatient department stays (IPD) and outpatient department visits (OPD) were conducted and these were complemented with data abstraction from 125 patient records. Results From the household survey, over half of the households (57.6%) had an episode of malaria within one month to the date of the interview. The average household expenditure per case was 12.57US$ and 23.20US$ for OPD and IPD respectively. Indirect consumer costs of treatment were higher than direct consumer medical costs. From a health system perspective, the recurrent provider costs per case was 30.42 US$ and 48.02 US$ for OPD and IPD while non recurrent provider costs were 133.07US$ and 1857.15US$ for OPD and IPD. The mode of payment was mainly through out-of-pocket spending (OOPS). Conclusion Private expenditure on treatment of malaria constitutes a high economic burden to households and to the health system. Removal of user fees and interventions that will decrease the use of OOPS for treatment of malaria will significantly decrease the economic burden of malaria to both households and the health system.
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Affiliation(s)
- Obinna Onwujekwe
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Nkoli Uguru
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- Department of Preventive Dentistry, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- * E-mail:
| | - Ifeanyi Chikezie
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Benjamin Uzochukwu
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Alex Adjagba
- SIVAC (Supporting National Independent Immunization and Vaccine Advisory Committees) Initiative, Agence de Medecine Preventive (AMP), Paris, France
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Mikkelsen-Lopez I, Tediosi F, Abdallah G, Njozi M, Amuri B, Khatib R, Manzi F, de Savigny D. Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania. BMC Health Serv Res 2013; 13:444. [PMID: 24161029 PMCID: PMC3815072 DOI: 10.1186/1472-6963-13-444] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 10/09/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. METHODS We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. RESULTS Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. CONCLUSION System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.
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Affiliation(s)
- Inez Mikkelsen-Lopez
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | | | | | | | | | | | - Don de Savigny
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Osei-Kwakye K, Asante KP, Mahama E, Apanga S, Owusu R, Kwara E, Adjei G, Abokyi L, Yeetey E, Dosoo DK, Punguyire D, Owusu-Agyei S. The benefits or otherwise of managing malaria cases with or without laboratory diagnosis: the experience in a district hospital in Ghana. PLoS One 2013; 8:e58107. [PMID: 23505457 PMCID: PMC3591456 DOI: 10.1371/journal.pone.0058107] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/30/2013] [Indexed: 11/19/2022] Open
Abstract
Background This study was conducted at the Kintampo Municipal Hospital in Ghana to determine whether there was any benefit (or otherwise) in basing the management of cases of suspected malaria solely on laboratory confirmation (microscopy or by RDT) as compared with presumptive diagnosis. Method Children under five years who reported at the Out-Patient Department of the Hospital with axillary temperature ≥37.5°C or with a 48 hr history of fever were enrolled and had malaria microscopy and RDT performed. The attending clinician was blinded from laboratory results unless a request for these tests had been made earlier. Diagnosis of malaria was based on three main methods: presumptive or microscopy and/or RDT. Cost implication for adopting laboratory diagnosis or not was determined to inform malaria control programmes. Results In total, 936 children were enrolled in the study. Proportions of malaria diagnosed presumptively, by RDT and microscopy were 73.6% (689/936), 66.0% (618/936) and 43.2% (404/936) respectively. Over 50% (170/318) of the children who were RDT negative and 60% (321/532) who were microscopy negative were treated for malaria when presumptive diagnoses were used. Comparing the methods of diagnoses, the cost of malaria treatment could have been reduced by 24% and 46% in the RDT and microscopy groups respectively; the reduction was greater in the dry season (43% vs. 50%) compared with the wet season (20% vs. 45%) for the RDT and microscopy confirmed cases respectively. Discussion/Conclusion Over-diagnosis of malaria was prevalent in Kintampo during the period of the study. Though the use of RDT for diagnosis of malaria might have improved the quality of care for children, it appeared not to have a cost saving effect on the management of children with suspected malaria. Further research may be needed to confirm this.
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Affiliation(s)
- Kingsley Osei-Kwakye
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Emmanuel Mahama
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Stephen Apanga
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Ruth Owusu
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Evans Kwara
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - George Adjei
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Livesy Abokyi
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Enuameh Yeetey
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - David Kwame Dosoo
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Damien Punguyire
- Kintampo Municipal Hospital, Ghana Health Service, Ministry of Health, Kintampo, Ghana
| | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Ghana Health Service, Ministry of Health, Kintampo, Ghana
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
The Malaria Policy Advisory Committee to the World Health Organization met in Geneva, Switzerland from 11 to 13 September, 2012. This article provides a summary of the discussions, conclusions and recommendations from that meeting.Meeting sessions included: updated policy recommendations on the use of sulphadoxine-pyrimethamine for Intermittent Preventive Treatment of malaria in pregnancy, as well as the use of single dose primaquine as a Plasmodium falciparum gametocytocide; the need to develop a Global Technical Strategy for Malaria Control and Elimination 2016- 2025 and a global strategy for control of Plasmodium vivax; the Affordable Medicines Facility for malaria independent evaluation and promoting malaria case management in the private sector; updates from the Technical Expert Group on drug resistance and containment and the Evidence Review Group on malaria burden estimation; update on the RTS,S/AS01 malaria vaccine; progress on the policy setting process for malaria vector control; and the process for updating the WHO Guidelines for the Treatment of Malaria.Policy statements, position statements, and guidelines that arise from the MPAC meeting conclusions and recommendations will be formally issued and disseminated to World Health Organization Member States by the World Health Organization Global Malaria Programme.
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Affiliation(s)
- Kenneth J Arrow
- Department of Economics, Stanford University, Stanford, CA, USA
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