Monitoring fever treatment behaviour and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries

Abstract

BackgroundAccess to artemisinin-based combination therapy (ACT) remains limited in high malaria-burden countries, and there are concerns that the poorest people are particularly disadvantaged. This paper presents new evidence on household treatment-seeking behaviour in six African countries. These data provide a baseline for monitoring interventions to increase ACT coverage, such as the Affordable Medicines Facility for malaria (AMFm).MethodsNationally representative household surveys were conducted in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia between 2008 and 2010. Caregivers responded to questions about management of recent fevers in children under five. Treatment indicators were tabulated across countries, and differences in case management provided by the public versus private sector were examined using chi-square tests. Logistic regression was used to test for association between socioeconomic status and 1) malaria blood testing, and 2) ACT treatment.ResultsFever treatment with an ACT is low in Benin (10%), the DRC (5%), Madagascar (3%) and Nigeria (5%), but higher in Uganda (21%) and Zambia (21%). The wealthiest children are significantly more likely to receive ACT compared to the poorest children in Benin (OR = 2.68, 95% CI = 1.12-6.42); the DRC (OR = 2.18, 95% CI = 1.12-4.24); Madagascar (OR = 5.37, 95% CI = 1.58-18.24); and Nigeria (OR = 6.59, 95% CI = 2.73-15.89). Most caregivers seek treatment outside of the home, and private sector outlets are commonly the sole external source of treatment (except in Zambia). However, children treated in the public sector are significantly more likely to receive ACT treatment than those treated in the private sector (except in Madagascar). Nonetheless, levels of testing and ACT treatment in the public sector are low. Few caregivers name the national first-line drug as most effective for treating malaria in Madagascar (2%), the DRC (2%), Nigeria (4%) and Benin (10%). Awareness is higher in Zambia (49%) and Uganda (33%).ConclusionsLevels of effective fever treatment are low and inequitable in many contexts. The private sector is frequently accessed however case management practices are relatively poor in comparison with the public sector. Supporting interventions to inform caregiver demand for ACT and to improve provider behaviour in both the public and private sectors are needed to achieve maximum gains in the context of improved access to effective treatment.

Response of patent medicine vendors in rural areas of Lagos state Nigeria to antimalarial policy change

“…The sale mirrors the stock of AMDs found on drug audit, which showed that CQ and SP still had dominion of the market. These findings are in consonance with other studies in Nigeria 21,26,27 and elsewhere 19,22 where, despite change in treatment policy, formerly used AMDs were still on sale in drug shops even years after the change. The wide availability and sale of CQ and SP implies that many cases of uncomplicated malaria were still receiving inappropriate treatment with consequences including progression to severe illness, increased mortality and growing drug resistance.…”

“…18 Studies have shown that despite change in antimalarial drug policy, both providers and consumers continued to use the erstwhile drugs for a long time for various reasons. [19][20][21][22] This slow adoption is not without consequences as the problems that necessitated the change remain.…”

Impact of health facilities on malaria control interventions among children under five years of age and pregnant women in Nigeria

“…A study conducted in Uganda also show that only about a quarter of pregnant women receive two doses of IPTp with SP. 48 However, these findings are in contrast with studies conducted in Central Mozambique 59 Most children under 5 years of age and pregnant women in Nigeria often have a poor economy that constraint them from seeking the best medical care. This group constitute a larger percentage of the Nigerian population and are prone to infectious diseases.…”

Can Rapid Diagnostic Testing for Malaria Increase Adherence to Artemether–Lumefantrine?: A Randomized Controlled Trial in Uganda

“…34 As is common in the rest of Uganda, Luwero residents frequently treat episodes of suspected malaria with over-the-counter medicines at formal or informal retail shops and pharmacies. 22,35 At the time, approximately 44% of drug shops in Uganda sold ACTs, though these drugs were expensive, costing roughly five times as much as the most popular antimalarial drug, sulfadoxinepyrimethamine. 23 Consequently, at the time of study launch, only about 23% of suspected malaria episodes among children under the age of 5 years were being treated with ACTs in Uganda.…”

“…[17][18][19][20] We hypothesized that an important driver of nonadherence is diagnostic uncertainty, as few patients with suspected malaria receive diagnostic confirmation of malaria via blood test. 1,21,22 At the time of the study, malaria diagnostic testing was available in 35% of public health facilities in Uganda (4% had rapid diagnostic tests [RDTs]), 47% of private facilities, and 4% of private drug shops. 23 Since the symptoms of malaria overlap with several common diseases such as pneumonia, as well as other bacterial and viral infections, [24][25][26] untested patients may face significant uncertainty over whether the illness they are suffering from is malaria, particularly in contexts where they have less confidence in the provider's ability to clinically diagnose the disease.…”