A pharmacy too far? Equity and spatial distribution of outcomes in the delivery of subsidized artemisinin-based combination therapies through private drug shops

Abstract

BackgroundMillions of individuals with malaria-like fevers purchase drugs from private retailers, but artemisinin-based combination therapies (ACTs), the only effective treatment in regions with high levels of resistance to older drugs, are rarely obtained through these outlets due to their relatively high cost. To encourage scale up of ACTs, the Affordable Medicines Facility – malaria is being launched to subsidize their price. The Government of Tanzania and the Clinton Foundation piloted this subsidized distribution model in two Tanzanian districts to examine concerns about whether the intervention will successfully reach poor, rural communities.MethodsStocking of ACTs and other antimalarial drugs in all retail shops was observed at baseline and in four subsequent surveys over 15 months. Exit interviews were conducted with antimalarial drug customers during each survey period. All shops and facilities were georeferenced, and variables related to population density and proximity to distribution hubs, roads, and other facilities were calculated. To understand the equity of impact, shops stocking ACTs and consumers buying them were compared to those that did not, according to geographic and socioeconomic variables. Patterning in ACT stocking and sales was evaluated against that of other common antimalarials to identify factors that may have impacted access. Qualitative data were used to assess motivations underlying stocking, distribution, and buying disparities.ResultsResults indicated that although total ACT purchases rose from negligible levels to nearly half of total antimalarial sales over the course of the pilot, considerable geographic variation in stocking and sales persisted and was related to a variety of socio-spatial factors; ACTs were stocked more often in shops located closer to district towns (p<0.01) and major roads (p<0.01) and frequented by individuals of higher socioeconomic status (p<0.01). However, other antimalarial drugs displayed similar patterning, indicating the existence of underlying disparities in access to antimalarial drugs in general in these districts.ConclusionsAs this subsidy model is scaled up across multiple countries, these results confirm the potential for increased ACT usage but suggest that additional efforts to increase access in remote areas will be needed for the scale-up to have equitable impact.Trial registrationCurrent Controlled Trials ISRCTN39125414.

Socioeconomic Determinants of Antimalarial Drug Use Behaviours: A Systematic Review

“…At the end of the assessment and appraisal exercise, seventeen (17) studies [14][15][16][17][18][19][20][21][23][24][25][26][27][28][29][30][31] that were of good quality based on the PCAqs assessment were included in this systematic review.…”

“…67.3% gave reason as financial/affordability; 16.8% got better after starting; 14.4% said symptoms were mild and hence no need buying full dosage [23] [23]…”

“…Urbanites are more likely to have blood test malaria diagnosis than rural dwellers [16] Adherence and source of drugs P=0.005 those who source from pharmacy/chemists and government institutions were more likely to take correct dose than those from street vendors, private clinics, family/friends [16] [ 16] Citation 25% of poorest SES will use home treatment first [14] 14% of wealthiest SES will use home treatment first [14] 61.6% took antimalarial drugs without prescription [23] Self-diagnosis was slightly higher in rural adults and children (A=89.7%; 85.9%) than in urban adults and children (A=83.3%; C=79.2%) [26] Those in the poorer SES groups were however more likely to have previously sought treatment for their current illness prior to seeking treatment at the study facilities (p=0.002). Of these, 62.7% used the patent medicine dealers [30] Self-diagnosis was the most common diagnostic method in both rural and urban for adult and child diagnosis [16] Reasons for selfmedication 39.0% said less expensive than consultation; 10% said health institution was far away; 12.5% said neighbour/friend/relative previously took the same drug [23] [15,23] For those who had no prescription, the reasons given were as follows: 39.0% said procedure of acquisition (without prescription) was less costly; 23.0% took same drug for similar symptoms; 10% said health institution was far from their location; 12.5% said neighbour/friend/relative previously took the same drug [15].…”

“…Of these, 62.7% used the patent medicine dealers [30] Self-diagnosis was the most common diagnostic method in both rural and urban for adult and child diagnosis [16] Reasons for selfmedication 39.0% said less expensive than consultation; 10% said health institution was far away; 12.5% said neighbour/friend/relative previously took the same drug [23] [15,23] For those who had no prescription, the reasons given were as follows: 39.0% said procedure of acquisition (without prescription) was less costly; 23.0% took same drug for similar symptoms; 10% said health institution was far from their location; 12.5% said neighbour/friend/relative previously took the same drug [15]. Household size significantly influenced the types of anti-malarial drugs used (b=0.092, P=0.049).…”

“…Nevertheless, the contributions of socioeconomic factors to antimalarial drug use behaviours have only been sparsely reported in studies; with most of the studies not primarily designed to identify or assess the association of these variables [15,17,19,21,[23][24][25]. In addition there is no existing systematic review of studies on the socioeconomic determinants of antimalarial drug use.…”