Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries

Abstract

BackgroundArtemisinin-based combination therapy (ACT) is the first-line malaria treatment throughout most of the malaria-endemic world. Data on ACT availability, price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality-assured ACT supply. This paper presents supply side data from ACTwatch outlet surveys in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia.MethodsBetween March 2009 and June 2010, nationally representative surveys of outlets providing anti-malarials to consumers were conducted. A census of all outlets with the potential to provide anti-malarials was conducted in clusters sampled randomly.Results28,263 outlets were censused, 51,158 anti-malarials were audited, and 9,118 providers interviewed. The proportion of public health facilities with at least one first-line quality-assured ACT in stock ranged between 43% and 85%. Among private sector outlets stocking at least one anti-malarial, non-artemisinin therapies, such as chloroquine and sulphadoxine-pyrimethamine, were widely available (> 95% of outlets) as compared to first-line quality-assured ACT (< 25%). In the public/not-for-profit sector, first-line quality-assured ACT was available for free in all countries except Benin and the DRC (US$1.29 [Inter Quartile Range (IQR): $1.29-$1.29] and $0.52[IQR: $0.00-$1.29] per adult equivalent dose respectively). In the private sector, first-line quality-assured ACT was 5-24 times more expensive than non-artemisinin therapies. The exception was Madagascar where, due to national social marketing of subsidized ACT, the price of first-line quality-assured ACT ($0.14 [IQR: $0.10, $0.57]) was significantly lower than the most popular treatment (chloroquine, $0.36 [IQR: $0.36, $0.36]). Quality-assured ACT accounted for less than 25% of total anti-malarial volumes; private-sector quality-assured ACT volumes represented less than 6% of the total market share. Most anti-malarials were distributed through the private sector, but often comprised non-artemisinin therapies, and in the DRC and Nigeria, oral artemisinin monotherapies. Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector.ConclusionsThese standardized, nationally representative results demonstrate the typically low availability, low market share and high prices of ACT, in the private sector where most anti-malarials are accessed, with some exceptions. The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries. The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa

“…Poor governance affects health systems' performance 67 and their ability to cope with shocks. As such, not only do insufficient and sub-optimally allocated resources attend the health needs of populations with some of the more complex health challenges in the world, but people's trust in health systems is shaken by frequent stock-outs of essential medicines [68][69][70] and overstretched health personnel, particularly in low-level health facilities and poor areas. 71,72 People's access to health services is in many cases is further obstructed by long distances, high travel costs, high out-of-pocket (OOP) payments, cultural beliefs, and queues.…”

Subsidizing the Distribution Channel: Donor Funding to Improve the Availability of Malaria Drugs

“…The great majority of malaria cases and deaths are in sub-Saharan Africa, where the Democratic Republic of Congo and Nigeria alone account for more than 40% of all malaria deaths (World Health Organization 2012). In malaria-endemic countries, in part because public health clinics lack deep geographic reach especially into rural areas, the majority of people purchase malaria drugs from private-sector outlets such as drug shops (Laxminarayan et al 2010, O'Connell et al 2011. The private sector accounts for 74% of malaria drug volume in the Democratic Republic of Congo and 98% in Nigeria (O'Connell et al 2011).…”

“…ACTs are the recommended first-line treatment for malaria because they are significantly more effective than previous generations of drugs to which the malaria parasite has developed resistance and because ACTs themselves are much less prone to encouraging the development of drug-resistant strains of malaria. In a study of availability of ACTs in sub-Saharan Africa, O'Connell et al (2011) report that of private-sector outlets stocking malaria drugs, fewer than 25% had first-line quality-assured ACTs in stock. Further, the private-sector outlets priced ACTs 5 to 24 times higher than the previous generation, inferior malaria drugs.…”

“…In malaria-endemic countries, in part because public health clinics lack deep geographic reach especially into rural areas, the majority of people purchase malaria drugs from private-sector outlets such as drug shops (Laxminarayan et al 2010, O'Connell et al 2011. The private sector accounts for 74% of malaria drug volume in the Democratic Republic of Congo and 98% in Nigeria (O'Connell et al 2011). Unfortunately, the private sector supply chain fails in providing high levels of availability for the drugs recommended to treat malaria, artemisinin combination therapies (ACTs).…”

Changes in key constituents of clonally propagated Artemisia annua L. during preparation of compressed leaf tablets for possible therapeutic use

“…Artemisinin (AN; Fig. 1), extracted from Artemisia annua L., is delivered in concert with another antimalarial drug ( a rtemisinin c ombination t herapy; ACT) as the preferred treatment, but it is costly and supply is inadequate (Davis et al, 2013; O’Connell et al, 2011). We and others have proposed more direct consumption of this plant either as a tea infusion (Mueller et al, 2004; Räth et al, 2004; Silva et al, 2012; Suberu et al, 2013) or by oral consumption of the leaves (Elfawal et al, 2012; ICIPE, 2005; Onimus et al, 2013; Weathers et al, 2011).…”