Increasing Access to Subsidized Artemisinin-based Combination Therapy through Accredited Drug Dispensing Outlets in Tanzania

Abstract

BackgroundIn Tanzania, many people seek malaria treatment from retail drug sellers. The National Malaria Control Program identified the accredited drug dispensing outlet (ADDO) program as a private sector mechanism to supplement the distribution of subsidized artemisinin-based combination therapies (ACTs) from public facilities and increase access to the first-line antimalarial in rural and underserved areas. The ADDO program strengthens private sector pharmaceutical services by improving regulatory and supervisory support, dispenser training, and record keeping practices.MethodsThe government's pilot program made subsidized ACTs available through ADDOs in 10 districts in the Morogoro and Ruvuma regions, covering about 2.9 million people. The program established a supply of subsidized ACTs, created a price system with a cost recovery plan, developed a plan to distribute the subsidized products to the ADDOs, trained dispensers, and strengthened the adverse drug reactions reporting system. As part of the evaluation, 448 ADDO dispensers brought their records to central locations for analysis, representing nearly 70% of ADDOs operating in the two regions. ADDO drug register data were available from July 2007-June 2008 for Morogoro and from July 2007-September 2008 for Ruvuma. This intervention was implemented from 2007-2008.ResultsDuring the pilot, over 300,000 people received treatment for malaria at the 448 ADDOs. The percentage of ADDOs that dispensed at least one course of ACT rose from 26.2% during July-September 2007 to 72.6% during April-June 2008. The number of malaria patients treated with ACTs gradually increased after the start of the pilot, while the use of non-ACT antimalarials declined; ACTs went from 3% of all antimalarials sold in July 2007 to 26% in June 2008. District-specific data showed substantial variation among the districts in ACT uptake through ADDOs, ranging from ACTs representing 10% of all antimalarial sales in Kilombero to 47% in Morogoro Rural.ConclusionsThe intervention increased access to affordable ACTs for underserved populations. Indications are that antimalarial monotherapies are being "crowded out" of the market. Importantly, the transition to ACTs has been accomplished in an environment where the safety and efficacy of the drugs and the quality of services are being monitored and regulated. This paper presents a description of the pilot program implementation, results of the program evaluation, and a discussion of the challenges and recommendations that will be used to guide rollout of subsidized ACT in ADDOs in the rest of Tanzania and possibly in other countries.

Population Pharmacokinetics and Clinical Response for Artemether-Lumefantrine in Pregnant and Nonpregnant Women with Uncomplicated Plasmodium falciparum Malaria in Tanzania

“…Detectable residual antimalarial levels in recruited participants were unexpectedly high. This might be explained by uncontrolled prescription of AL, a first-line malaria treatment, which is highly available and easily accessible from both private and public facilities (42,43). The prevalence of residual antimalarial among participants was higher than what was found 5 years ago from in vivo studies in Ifakara (Tanzania) and Praeh Vihear (Cambodia), which reported 74.3% and 50%, respectively (28,29).…”

Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System

“…For those who did go to a health facility for an acute illness, most ended up taking their prescriptions to ADDOs to fill, suggesting that the facility was out-of-stock. This aligns with other data on the percentage of ADDO sales that are based on prescriptions [11]. …”

“…The dispensers also fill prescriptions that customers bring in from the public/nongovernmental organization (NGO) health facility. Because they function as part of the health system, ADDOs have been used as a platform for public health interventions, including increasing access to artemisinin-based combination therapy for malaria, and they have been incorporated into multiple public health strategies, from family planning to achievement of the Millennium Development Goals [11–13]. …”

Availability and prescription practice of anti-malaria drugs in the private health sector in Yemen

“…Increasing availability and accessibility of ACTs will limit the usage of non-ACTs such as chloroquine. A Tanzanian study showed that anti-malaria monotherapy was being crowded out of the market [14]. In the current study, chloroquine is available in 80% of the studied pharmacies and was the most common drug purchased for malaria treatment in the pre-intervention period.…”

“…Interventions to increase accessibility of ACTs in private pharmacies were supported by a subsidized artemisinin-based combination therapy approach in different developing countries, resulting in an increase in marketing and an increase in malaria patients being treated with ACTs [14,15]. In this pilot project, despite the marketing of ACTs and other recommended antimalaria drugs, the private sector did not support any marketing interventions applied to increase the availability or use of ACTs in the private sector.…”