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Relationship between treatment-seeking behaviour and artemisinin drug quality in Ghana

Eili Y Klein1, Ian A Lewis2, Christina Jung1, Manuel Llinás23 and Simon A Levin1*

Author Affiliations

1 Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA

2 Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ, USA

3 Molecular Biology Department, Princeton University, Princeton, NJ, USA

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Malaria Journal 2012, 11:110  doi:10.1186/1475-2875-11-110

Published: 6 April 2012



Artemisinin-based combination therapy (ACT) is currently the recommended first-line treatment for uncomplicated malaria infections. However, a significant proportion of ACT is assumed to be of poor quality, particularly in Africa. In addition, little is known about how treatment-seeking behaviour of individuals or drug price is associated with drug quality.


Caregivers of children less than 5 years of age were interviewed on their knowledge of malaria and their choices for treatment. Artemisinin drugs were then purchased from sellers that caregivers preferred or had previously patronized. The active ingredients were quantified by nuclear magnetic resonance spectroscopy.


A negative relationship was anticipated between the education level of caregivers and the quality of anti-malarial drugs purchased. However, of the 33 drugs collected from 16 different shops, only one contained less than 80% of its purported active ingredient, and most drugs were within 90% of their listed amounts. No link was found between drug quality and price. Nonetheless, while ACT is the recommended first-line treatment in Ghana, 21% of the drugs collected were artemisinin monotherapy, and 27% of the ACT was not co-formulated. Among caregivers, higher education was found to be associated with both an increased likelihood of seeking treatment in a clinic first, as opposed to visiting drug shops or using herbal remedies, and with purchasing drugs from licensed sellers.


Surprisingly, drug quality was found to be uniformly high and thus no significant relationship between price, treatment-seeking behaviour and the content of the active ingredients was observed. However, artemisinin monotherapy, which the WHO considers inappropriate therapy, was still widely available in Ghana in 2010. Monotherapy was more likely to be available in unlicensed vendors where less-educated caregivers generally shopped. This linkage between education, treatment-seeking behaviour and drug availability suggests that the global subsidy to reduce the cost of co-formulated ACT can play a significant role in increasing its availability.

Anti-malarial drugs; Counterfeit; Artemisinin; Drug quality; Ghana