The private for-profit sector is an important source of treatment for malaria. However, private patients face high prices for the recommended treatment for uncomplicated malaria, artemisinin combination therapies (ACTs), which makes them more likely to receive cheaper, less effective non-artemisinin therapies (nATs). This study seeks to better understand consumer antimalarial prices by documenting and exploring the pricing behaviour of retailers and wholesalers. Using data collected in 2009–10, we present survey estimates of antimalarial retail prices, and wholesale- and retail-level price mark-ups from six countries (Benin, Cambodia, the Democratic Republic of Congo, Nigeria, Uganda and Zambia), along with qualitative findings on factors affecting pricing decisions. Retail prices were lowest for nATs, followed by ACTs and artemisinin monotherapies (AMTs). Retailers applied the highest percentage mark-ups on nATs (range: 40% in Nigeria to 100% in Cambodia and Zambia), whereas mark-ups on ACTs (range: 22% in Nigeria to 71% in Zambia) and AMTs (range: 22% in Nigeria to 50% in Uganda) were similar in magnitude, but lower than those applied to nATs. Wholesale mark-ups were generally lower than those at retail level, and were similar across antimalarial categories in most countries. When setting prices wholesalers and retailers commonly considered supplier prices, prevailing market prices, product availability, product characteristics and the costs related to transporting goods, staff salaries and maintaining a property. Price discounts were regularly used to encourage sales and were sometimes used by wholesalers to reward long-term customers. Pricing constraints existed only in Benin where wholesaler and retailer mark-ups are regulated; however, unlicensed drug vendors based in open-air markets did not adhere to the pricing regime. These findings indicate that mark-ups on antimalarials are reasonable. Therefore, improving ACT affordability would be most readily achieved by interventions that reduce commodity prices for retailers, such as ACT subsidies, pooled purchasing mechanisms and cost-effective strategies to increase the distribution coverage area of wholesalers.

BackgroundIn many low-income countries, the private commercial sector plays an important role in the provision of malaria treatment. However, the quality of care it provides is often poor, with artemisinin combination therapy (ACT) generally being too costly for consumers. Decreasing ACT prices is critical for improving private sector treatment outcomes and reducing the spread of artemisinin resistance. Yet limited evidence exists on the factors influencing retailers’ pricing decisions. This study investigates the determinants of price mark-ups on anti-malarial drugs in retail outlets in Cambodia.MethodsTaking an economics perspective, the study tests the hypothesis that the structure of the anti-malarial market determines the way providers set their prices. Providers facing weak competition are hypothesized to apply high mark-ups and set prices above the competitive level. To analyse the relationship between market competition and provider pricing, the study used cross-sectional data from retail outlets selling anti-malarial drugs, including outlet characteristics data (e.g. outlet type, anti-malarial sales volumes), range of anti-malarial drugs stocked (e.g. dosage form, brand status) and purchase and selling prices. Market concentration, a measure of the level of market competition, was estimated using sales volume data. Market accessibility was defined based on travel time to the closest main commercial area. Percent mark-ups were calculated using price data. The relationship between mark-ups and market concentration was explored using regression analysis.ResultsThe anti-malarial market was on average highly concentrated, suggesting weak competition. Higher concentration was positively associated with higher mark-ups in moderately accessible markets only, with no significant relationship or a negative relationship in other markets. Other determinants of pricing included anti-malarial brand status and generic type, with higher mark-ups on cheaper products.ConclusionsThe results indicate that provider pricing as well as other key elements of anti-malarial supply and demand may have played an important role in the limited access to appropriate malaria treatment in Cambodia. The potential for an ACT price subsidy at manufacturer level combined with effective communications directed at consumers and supportive private sector regulation should be explored to improve access to quality malaria treatment in Cambodia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0737-9) contains supplementary material, which is available to authorized users.

Post-abortion care (PAC) integrates elements that are vital for women’s survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women’s perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients’ satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client–staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women’s rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women’s classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client–staff interaction (mean=3.8). Factors associated with clients’ higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.

BackgroundThere is increased interest in using commercial providers for improving access to quality malaria treatment. Understanding their current role is an essential first step, notably in terms of the volume of diagnostics and anti-malarials they sell. Sales volume data can be used to measure the importance of different provider and product types, frequency of parasitological diagnosis and impact of interventions. Several methods for measuring sales volumes are available, yet all have methodological challenges and evidence is lacking on the comparability of different methods.MethodsUsing sales volume data on anti-malarials and rapid diagnostic tests (RDTs) for malaria collected through provider recall (RC) and retail audits (RA), this study measures the degree of agreement between the two methods at wholesale and retail commercial providers in Cambodia following the Bland-Altman approach. Relative strengths and weaknesses of the methods were also investigated through qualitative research with fieldworkers.ResultsA total of 67 wholesalers and 107 retailers were sampled. Wholesale sales volumes were estimated through both methods for 62 anti-malarials and 23 RDTs and retail volumes for 113 anti-malarials and 33 RDTs. At wholesale outlets, RA estimates for anti-malarial sales were on average higher than RC estimates (mean difference of four adult equivalent treatment doses (95% CI 0.6-7.2)), equivalent to 30% of mean sales volumes. For RDTs at wholesalers, the between-method mean difference was not statistically significant (one test, 95% CI −6.0-4.0). At retail outlets, between-method differences for both anti-malarials and RDTs increased with larger volumes being measured, so mean differences were not a meaningful measure of agreement between the methods. Qualitative research revealed that in Cambodia where sales volumes are small, RC had key advantages: providers were perceived to remember more easily their sales volumes and find RC less invasive; fieldworkers found it more convenient; and it was cheaper to implement than RA.Discussion/conclusionsBoth RA and RC had implementation challenges and were prone to data collection errors. Choice of empirical methods is likely to have important implications for data quality depending on the study context.

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Objective To evaluate an intervention that aimed at strengthening voluntary access to long‐acting reversible contraception (LARC) within postabortion care (PAC) in hospitals in mainland Tanzania and Zanzibar. Methods From 2016 to 2018, we conducted PAC quality improvement interventions, emphasizing family planning (FP) counseling and voluntary access to LARC. Researchers conducted an interrupted time‐series analysis of service statistics compiled from 2014 to 2020 using segmented linear mixed effects regression models to assess the interventions' effect on postabortion contraceptive uptake. Results The intervention in mainland Tanzania was associated with an immediate 38% increase in postabortion LARC uptake, a trend that declined from late 2016 to mid‐2020 to 34%. In Zanzibar, the intervention was associated with a gradual increase in LARC uptake that peaked in late 2018 at 23% and stabilized at approximately 15% by mid‐2020. Whereas the interventions in mainland facilities did not generate significant changes in postabortion FP uptake overall, the launch of interventions in Zanzibar in mid‐2016 was associated with a precipitous rise in that outcome over time, which plateaued at approximately 54% by 2019. Conclusion Increased voluntary uptake of postabortion contraception was associated with the introduction of training in PAC, including FP, and quality improvement interventions and gains were sustained over time.

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