Research
Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries
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* Corresponding author: Kathryn A O'Connell koconnell@psi.org
1 Population Services International, Malaria & Child Survival Department, P.O. Box 43640, Nairobi, Kenya
2 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
3 Association Béninoise pour le Marketing Social/PSI, B.P. 08-0876, Tri Postal, Cotonou, Benin
4 Association de Santé Familiale, 4630 Avenue de la Science, Immeuble USTC, Bloc C, Gombe, Kinshasa, Democratic Republic of Congo
5 PSI/Madagascar, Immeuble- FIARO, Rue Jules Ranaivo, Escalier-D, 2eme Etage, BP 7748, Antananarivo 101, Madagascar
6 Society for Family Health, 8 Port Harcourt Crescent, Area 11 Garki Abuja, Nigeria
7 PACE, Plot 2 Ibis Vale, P.O. Box 27659, Kololo, Kampala, Uganda
8 Society for Family Health, Plot No. 549, Ridgeway, P.O. Box 50770, Lusaka, Zambia
9 Ministère de la Santé, Programme National de Lutte contre le Paludisme (PNLP), Akpakpa, Cotonou, Bénin
10 National Malaria Control Programme, 1, Avenue du Tourisme, Ngaliema, Kinshasa, Democratic Republic of Congo
11 Ministre de la Santé Publique, Centre National de Lutte contre le Paludisme (CNLP), Androhibe Antananarivo, 101, Madagascar
12 National Malaria Control Programme, Abia House, Near Adamawa Plaza, First Avenue, Central District Area, Postal Code 900001, Federal Capital Territory, Abuja, Nigeria
13 Ministry of Health, Malaria Control Programme, Lourdel Rd Wandegeya, Kampala, Uganda
14 National Malaria Control Center, P.O Box 32509, Lusaka, Zambia
15 Population Services International, 1120 19th Street N.W., 20036, Washington D.C., USA
Malaria Journal 2011, 10:326 doi:10.1186/1475-2875-10-326
Published: 31 October 2011Abstract
Background
Artemisinin-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.
Methods
Between 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.
Results
28,263 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.
Conclusions
These 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.