Research
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
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* Corresponding author: Megan Littrell mlittrell@psi.org
1 Population Services International, Malaria & Child Survival Department, P.O. Box 43640, Nairobi, Kenya, Africa
2 Population Services International, 1120 19th Street N.W., 20036, Washington D.C., USA
3 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
4 Associoation Beninoise pour le Marketing Socia/PSI, B.P. 08-0876, Tri Postal, Cotonou, Benin, Africa
5 Association de Santé Familiale, 232 Avenue Tombalbaye, Immeuble Socir, Kinshasa, Democratic Republic of Congo, Africa
6 PSI/Madagascar, Immeuble-FIARO, Rue Jules RANAIVO, ESCALIER-D, 2eme Etage, BP 7748, Antananarivo 101, Madagascar, Africa
7 Society for Family Health, 8 Port Harcourt Crescent, Area 11 Garki Abuja, Nigeria, Africa
8 PACE, Plot 2 Ibis Vale, P.O. Box 27659, Kololo, Kampala, Uganda, Africa
9 Society for Family Health, Plot No. 549, Ridgeway, P.O. Box 50770, Lusaka, Zambia, Africa
10 National Malaria Control Program, Benin, Africa
11 Malaria National Program, Ministry of Health, Democratic Republic of the Congo, Africa
12 Ministry of Health, Madagascar, Africa
13 National Malaria Control Programme, Nigeria, Africa
14 National Malaria Control Programme, Ministry of Health, Uganda, Africa
15 National Malaria Control Centre, Ministry of Health, Zambia, Africa
Malaria Journal 2011, 10:327 doi:10.1186/1475-2875-10-327
Published: 31 October 2011Abstract
Background
Access 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).
Methods
Nationally 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.
Results
Fever 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%).
Conclusions
Levels 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.