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Osman A, Amoako Johnson F, Mariwah S, Amoako-Sakyi D, Asiedu Owusu S, Ekor M, Hamill H, Hampshire K. Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria. BMJ Glob Health 2023; 6:e013426. [PMID: 37734858 PMCID: PMC10846845 DOI: 10.1136/bmjgh-2023-013426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023] Open
Abstract
Global health efforts such as malarial control require efficient pharmaceutical supply chains to ensure effective delivery of quality-assured medicines to those who need them. However, very little is currently known about decision-making processes within antimalarial supply chains and potential vulnerabilities to substandard and falsified medicines. Addressing this gap, we report on a study that investigated decision-making around the stocking of antimalarial products among private-sector medicine retailers in Ghana. Licensed retail pharmacies and over-the-counter (OTC) medicine retail outlets were sampled across six regions of Ghana using a two-stage stratified sampling procedure, with antimalarial medicines categorised as 'expensive,' 'mid-range,' and 'cheaper,' relative to other products in the shop. Retailers were asked about their motivations for choosing to stock particular products over others. The reasons were grouped into three categories: financial, reputation/experience and professional recommendation. Reputation/experience (76%, 95% CI 72.0% to 80.7%) were the drivers of antimalarial stocking decisions, followed by financial reasons (53.2%, 95% CI 48.1% to 58.3%) and recommendation by certified health professionals (24.7%, 95% CI 20.3% to 29.1%). Financial considerations were particularly influential in stocking decisions of cheaper medicines. Moreover, pharmacies and OTCs without a qualified pharmacist were significantly more likely to indicate financial reasons as a motivation for stocking decisions. No significant differences in stocking decisions were found by geographical location (zone and urban/rural) or outlet (pharmacy/OTC). These findings have implications for the management of antimalarial quality across supply chains in Ghana, with potentially important consequences for malaria control, particularly in lower-income areas where people rely on low-cost medication.
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Affiliation(s)
- Adams Osman
- Department of Geography Education, University of Education, Winneba, Ghana
| | - Fiifi Amoako Johnson
- Department of Population and Health, University of Cape Coast Faculty of Social Sciences, Cape Coast, Ghana
| | - Simon Mariwah
- Department of Geography and Regional Planning, University of Cape Coast Faculty of Social Sciences, Cape Coast, Ghana
| | | | - Samuel Asiedu Owusu
- Directorate of Research, Innovation and Consultancy, University of Cape Coast, Cape Coast, Ghana
| | - Martins Ekor
- School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Kate Hampshire
- Department of Anthropology, Durham University, Durham, UK
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Omagha R, Idowu ET, Alimba CG, Otubanjo AO, Adeneye AK. Survey of ethnobotanical cocktails commonly used in the treatment of malaria in southwestern Nigeria. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2021. [DOI: 10.1186/s43094-021-00298-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Abstract
Background
Combination of different antimalarials has become the popular method of care for malaria morbidity in conventional and traditional treatment approaches due to the need to increase the efficacy and reduce the selection of drug resistance. A worrisome concern is the critical gaps with regards to the information available on antimalarial herbal cocktails. This study presents cocktail herbal remedies in ethnomedicinal approaches to malaria treatment in Oyo and Ogun states, South West Nigeria. Ethnobotanical information on indigenous antimalarials used in combination remedies was collected from herbal practitioners using a semi-structured questionnaire.
Results
Findings showed majority of respondents treat malaria with combination herbal remedies. They sighted their beliefs and customs, the efficacy, affordability and availability of these herbs as reasons for their adoption of herbal medicines as their preferred mode of treating malaria. Enquiry revealed 26 sets of cocktail antimalarials from a variety of plant species. The plants and ingredients are extracted and used as decoction, infusion or steam baths. Oral route was the most popular mode of administration. Respondents reported they drink one to two medium-sized cups of the recipe on an average of two times daily within a duration of about 10 days.
Conclusions
Herbal antimalarial remedies continue to be the popular treatments option in our localities. This study provides knowledge of the diverse ways respondents combine medicinal herbs and other local ingredients for malaria treatment. Pharmacological screening is urgently needed to validate their safety and efficacy in order to protect the health of our locals heavily relying on them to combat high burdens of malaria.
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Aikambe JN, Mnyone LL. Retrospective Analysis of Malaria Cases in a Potentially High Endemic Area of Morogoro Rural District, Eastern Tanzania. Res Rep Trop Med 2020; 11:37-44. [PMID: 32607048 PMCID: PMC7297450 DOI: 10.2147/rrtm.s254577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/25/2020] [Indexed: 11/23/2022] Open
Abstract
Background Malaria is increasingly characterized by appreciable fine-scale variability in ecology and topography, and it is likely that we are missing some salient foci with unprecedented malaria transmission intensity in different parts of Tanzania. Therefore, efforts aimed at identifying area-specific malaria situation and intervening are needed to preserve the realized health gains and achieve elimination. Mkuyuni and Kiroka, adjacent wards within Morogoro Rural District, are purported to form one of such foci. Patients and Methods A retrospective study was conducted to determine six-year (2014-2019) malaria prevalence rates based on outpatients and laboratory registers obtained from two health facilities, one per ward, carrying out diagnosis of malaria either through microscopy or malaria rapid diagnostic test (mRDT). These data were checked for completeness before carrying out statistical analysis. Results Overall, 35,386 (46.19%) out of 76,604 patients were positive for malaria. The average proportion of malaria cases was significantly higher in Mkuyuni (51.23%; n=19,438) than Kiroka (41.21%; n = 15,938) (P <0.001). Females were more affected than males (P <0.001);, and irrespective of the sex, most malaria cases were recorded in children <5 years of age (P <0.001) except at Mkuyuni. Malaria was recorded virtually all year round; however, the highest proportion of cases was recorded in April and July (P <0.001). Conclusion This study revealed high malaria endemicity in Mkuyuni and Kiroka, with prevalence rate as high as 60.98%, which is far higher than the overall national average prevalence of 9%. More studies are needed in these and other putatively high endemic foci in Tanzania in order to inform the future course of action in disease surveillance and control.
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Affiliation(s)
- Joseph N Aikambe
- Department of Microbiology, Parasitology and Biotechnology, College of Veterinary Medicine and Biomedical Sciences, Sokoine University of Agriculture, Morogoro, Tanzania.,Pest Management Centre, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Ladslaus L Mnyone
- Pest Management Centre, Sokoine University of Agriculture, Morogoro, Tanzania.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Shen Y, Hao T, Ou S, Hu C, Chen L. Applications and perspectives of nanomaterials in novel vaccine development. MEDCHEMCOMM 2018; 9:226-238. [PMID: 30108916 PMCID: PMC6083789 DOI: 10.1039/c7md00158d] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 10/17/2017] [Indexed: 01/22/2023]
Abstract
Vaccines show great potential for both prophylactic and therapeutic use in infections, cancer, and other diseases. With the rapid development of bio-technologies and materials sciences, nanomaterials are playing essential roles in novel vaccine formulations and can boost antigen effectiveness by operating as delivery systems to enhance antigen processing and/or as immune-potentiating adjuvants to induce or potentiate immune responses. The effect of nanoparticles in vaccinology showed enhanced antigen stability and immunogenicity as well as targeted delivery and slow release. However, obstacles remain due to the lack of fundamental knowledge on the detailed molecular working mechanism and in vivo bio-effects of nanoparticles. This review provides a broad overview of the current improvements in nanoparticles in vaccinology. Modern nanoparticle vaccines are classified by the nanoparticles' action based on either delivery system or immune potentiator approaches. The mechanisms of interaction of nanoparticles with the antigens and the immune system are discussed. Nanoparticle vaccines approved for use are also listed. A fundamental understanding of the in vivo bio-distribution and the fate of nanoparticles will accelerate the rational design of new nanoparticles comprising vaccines in the future.
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Affiliation(s)
- Yingbin Shen
- Department of Food Science and Engineering , School of Science and Engineering , Jinan University , Guangzhou 510632 , Guangdong , China . ; ; ; ; ; ; Tel: +86 138 801 32918
| | - Tianyao Hao
- Department of Food Science and Engineering , School of Science and Engineering , Jinan University , Guangzhou 510632 , Guangdong , China . ; ; ; ; ; ; Tel: +86 138 801 32918
| | - Shiyi Ou
- Department of Food Science and Engineering , School of Science and Engineering , Jinan University , Guangzhou 510632 , Guangdong , China . ; ; ; ; ; ; Tel: +86 138 801 32918
| | - Churan Hu
- Department of Food Science and Engineering , School of Science and Engineering , Jinan University , Guangzhou 510632 , Guangdong , China . ; ; ; ; ; ; Tel: +86 138 801 32918
| | - Long Chen
- Department of Food Science and Engineering , School of Science and Engineering , Jinan University , Guangzhou 510632 , Guangdong , China . ; ; ; ; ; ; Tel: +86 138 801 32918
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Hansen KS, Clarke SE, Lal S, Magnussen P, Mbonye AK. Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda. PLoS One 2017; 12:e0189758. [PMID: 29244829 PMCID: PMC5731679 DOI: 10.1371/journal.pone.0189758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 12/02/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops. METHODS Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers. FINDINGS The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results. CONCLUSION mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.
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Affiliation(s)
- Kristian Schultz Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Copenhagen, Denmark
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Pascal Magnussen
- Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Anthony K. Mbonye
- Directorate of Clinical and Community Services, Ministry of Health, Kampala, Uganda
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Bennett A, Avanceña ALV, Wegbreit J, Cotter C, Roberts K, Gosling R. Engaging the private sector in malaria surveillance: a review of strategies and recommendations for elimination settings. Malar J 2017; 16:252. [PMID: 28615026 PMCID: PMC5471855 DOI: 10.1186/s12936-017-1901-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/07/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In malaria elimination settings, all malaria cases must be identified, documented and investigated. To facilitate complete and timely reporting of all malaria cases and effective case management and follow-up, engagement with private providers is essential, particularly in settings where the private sector is a major source of healthcare. However, research on the role and performance of the private sector in malaria diagnosis, case management and reporting in malaria elimination settings is limited. Moreover, the most effective strategies for private sector engagement in malaria elimination settings remain unclear. METHODS Twenty-five experts in malaria elimination, disease surveillance and private sector engagement were purposively sampled and interviewed. An extensive review of grey and peer-reviewed literature on private sector testing, treatment, and reporting for malaria was performed. Additional in-depth literature review was conducted for six case studies on eliminating and neighbouring countries in Southeast Asia and Southern Africa. RESULTS The private health sector can be categorized based on their commercial orientation or business model (for-profit versus nonprofit) and their regulation status within a country (formal vs informal). A number of potentially effective strategies exist for engaging the private sector. Conducting a baseline assessment of the private sector is critical to understanding its composition, size, geographical distribution and quality of services provided. Facilitating reporting, referral and training linkages between the public and private sectors and making malaria a notifiable disease are important strategies to improve private sector involvement in malaria surveillance. Financial incentives for uptake of rapid diagnostic tests and artemisinin-based combination therapy should be combined with training and community awareness campaigns for improving uptake. Private sector providers can also be organized and better engaged through social franchising, effective regulation, professional organizations and government outreach. CONCLUSION This review highlights the importance of engaging private sector stakeholders early and often in the development of malaria elimination strategies.
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Affiliation(s)
- Adam Bennett
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA 94158 USA
| | - Anton L. V. Avanceña
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Jennifer Wegbreit
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Chris Cotter
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Kathryn Roberts
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Roly Gosling
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA 94158 USA
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Hutchinson E, Hutchison C, Lal S, Hansen K, Kayendeke M, Nabirye C, Magnussen P, Clarke SE, Mbonye A, Chandler CIR. Introducing rapid tests for malaria into the retail sector: what are the unintended consequences? BMJ Glob Health 2017; 2:e000067. [PMID: 28588992 PMCID: PMC5321379 DOI: 10.1136/bmjgh-2016-000067] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 11/03/2022] Open
Abstract
The observation that many people in Africa seek care for febrile illness in the retail sector has led to a number of public health initiatives to try to improve the quality of care provided in these settings. The potential to support the introduction of rapid diagnostic tests for malaria (mRDTs) into drug shops is coming under increased scrutiny. Those in favour argue that it enables the harmonisation of policy around testing and treatment for malaria and maintains a focus on market-based solutions to healthcare. Despite the enthusiasm among many global health actors for this policy option, there is a limited understanding of the consequences of the introduction of mRDTs in the retail sector. We undertook an interpretive, mixed methods study with drug shop vendors (DSVs), their clients and local health workers to explore the uses and interpretations of mRDTs as they became part of daily practice in drug shops during a trial in Mukono District, Uganda. This paper reports the unintended consequences of their introduction. It describes how the test engendered trust in the professional competence of DSVs; was misconstrued by clients and providers as enabling a more definitive diagnosis of disease in general rather than malaria alone; that blood testing made drug shops more attractive places to seek care than they had previously been; was described as shifting treatment-seeking behaviour away from formal health centres and into drug shops; and influenced an increase in sales of medications, particularly antibiotics. TRIAL REGISTRATION NUMBER NCT01194557; Results.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Coll Hutchison
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian Hansen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Pascal Magnussen
- Department of International Health, Immunology and Microbiology, Centre for Medical Parasitology & Institute for Veterinary Disease Biology, Section for Parasitology and Aquatic Diseases, University of Copenhagen, Kobenhavn, Denmark
| | - Siân E Clarke
- Faculty of Infectious and Tropical Diseases, Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Adjei AA, Winch P, Laar A, Sullivan DJ, Sakyi KS, Stephens JK, Adjei GO, Boateng IA, Aubyn VNA, Kubio C, Tuakli J, Vanotoo L, Bortei BB, Amo-Addae M, Sorvor F, Coleman N, Dalglish S, Owusu R, Gebreyesus T, Essuman E, Greene R, Ankomah E, Houston K, Bart-Plange C, Salamat S, Addison EA, Quakyi IA. Insights into the Affordable Medicines Facility-malaria in Ghana: the role of caregivers and licensed chemical sellers in four regions. Malar J 2016; 15:263. [PMID: 27160685 PMCID: PMC4862058 DOI: 10.1186/s12936-016-1307-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/23/2016] [Indexed: 12/03/2022] Open
Abstract
Background The Affordable Medicine Facility-malaria (AMFm) was an innovative global financing mechanism for the provision of quality-assured artemisinin-based combination therapy (ACT) across both the private and public health sectors in eight countries in sub-Saharan Africa. This study evaluated the effectiveness of AMFm subsidies in increasing access to ACT in Ghana and documented malaria management practices at the household and community levels during the implementation of the AMFm. Methods This study, conducted in four regions in Ghana between January, 2011 to December, 2012, employed cross-sectional mixed-methods design that included qualitative and quantitative elements, specifically household surveys, focus group discussions (FGD) and in-depth interviews. Results The study indicated high ACT availability, adequate provider knowledge and reasonably low quality-assured ACT use in the study areas, all of which are a reflection of a high market share of ACT in these hard-to-reach areas of the country. Adequate recognition of childhood malaria symptoms by licensed chemical seller (LCS) attendants was observed. A preference by caregivers for LCS over health facilities for seeking treatment solutions to childhood malaria was found. Conclusions Artemisinin-based combination therapy with the AMFm logo was accessible and affordable for most people seeking treatment from health facilities and LCS shops in rural areas. Caregivers and LCS were seen to play key roles in the health of the community especially with children under 5 years of age.
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Affiliation(s)
- Andrew A Adjei
- Office of Research, Innovation and Development, University of Ghana, Legon, Accra, Ghana
| | - Peter Winch
- Department of International Health, Social and Behavioural Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Amos Laar
- Department of Population, Family, and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Kwame S Sakyi
- Department of International Health, Social and Behavioural Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Judith K Stephens
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - George O Adjei
- Centre for Tropical, Clinical, Pharmacology and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Isaac A Boateng
- Ashanti Akim Central Municipal Health Directorate, Ghana Health Services, Konongo, Ghana
| | | | | | | | - Linda Vanotoo
- Regional Health Directorate, Ghana Health Services, Accra, Ghana
| | - Bernard B Bortei
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Maame Amo-Addae
- Shama District Health Directorate, Ghana Health Services, Shama, Ghana
| | - Felix Sorvor
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Nathaniel Coleman
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Sarah Dalglish
- Department of International Health, Social and Behavioural Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Richmond Owusu
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Tsega Gebreyesus
- Department of International Health, Social and Behavioural Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | - Edward Essuman
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Rebecca Greene
- Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ezekiel Ankomah
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Kiely Houston
- Department of International Health, Social and Behavioural Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
| | | | - Samuel Salamat
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| | - Ebenezer A Addison
- Kpone Katamanso District Health Directorate, Ghana Health Services, Kpone, Tema, Ghana
| | - Isabella A Quakyi
- Department of Biological, Environmental and Occupational Health Sciences, School of Public Health, College of Health Sciences, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana.
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Dixit A, Lee MC, Goettsch B, Afrane Y, Githeko AK, Yan G. Discovering the cost of care: consumer, provider, and retailer surveys shed light on the determinants of malaria health-seeking behaviours. Malar J 2016; 15:179. [PMID: 27006074 PMCID: PMC4802645 DOI: 10.1186/s12936-016-1232-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 03/11/2016] [Indexed: 11/21/2022] Open
Abstract
Background The growing threat of insecticide resistance in mosquitoes and drug resistance in the Plasmodium parasites increases the importance of ensuring appropriate malaria case management and enabling positive health-seeking behaviour. Treatment-seeking behaviours are poorly characterized in malaria-endemic regions that have been the focus of intensive control and elimination campaigns. This study uses a comprehensive approach to shed light on the determinants of malaria treatment-seeking behaviours from different perspectives. Methods The authors conducted cross-sectional surveys from 832 households, fifteen health centers, and 135 retailers across three sites in the Emuhaya and Kakamega districts of the western Kenyan highlands. Participants were recruited via random sampling and data were collected with the use of a structured questionnaire about malaria treatment-seeking behaviour. All households, healthcare facilities, and retailers were mapped using a handheld GPS and a GIS algorithm was used to calculate “walk distance” based on the Tobler rule; an estimate of this distance was used to calculate the travel time used in the analyses. Results Across the three sites, 47.5–78.9 % of the residents sought diagnosis and treatment at hospitals, clinics, or dispensaries; 6.3–26.1 % of the residents sought malaria care only at pharmaceutical retailers. Overall, 40.3–59.4 % of residents reported delaying seeking care for more than 24 h after fever onset. After adjustment, residents who chose to visit a pharmaceutical retail facility rather than a hospital were 121 and 307 % more likely to delay seeking medical care after fever onset than those who reported choosing a healthcare facility for treatment. No significant association was found between travel time and delay in seeking care. The surveys of the healthcare facilities indicated an average total cost per patient per visit was 112 KES ($1.40 US) for public facilities and 165 KES ($2.06 US) for private facilities. Conclusion Understanding the local health behaviours that perpetuate transmission of malaria will help develop targeted preventive measures and educational interventions that can empower the residents with the knowledge needed to combat malaria in a safe and effective manner. Ensuring patient access to health care facilities in countries with high disease burdens has broader implications on measures of equity and on public health prevention methodologies. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1232-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amruta Dixit
- Program in Public Health, University of California Irvine, Irvine, CA, USA
| | - Ming-Chieh Lee
- Program in Public Health, University of California Irvine, Irvine, CA, USA
| | | | - Yaw Afrane
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Andrew K Githeko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Guiyun Yan
- Program in Public Health, University of California Irvine, Irvine, CA, USA.
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Kassam R, Sekiwunga R, MacLeod D, Tembe J, Liow E. Patterns of treatment-seeking behaviors among caregivers of febrile young children: a Ugandan multiple case study. BMC Public Health 2016; 16:160. [PMID: 26883506 PMCID: PMC4755008 DOI: 10.1186/s12889-016-2813-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 02/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The vast majority of malaria deaths in Uganda occur in children five and under and in rural areas. This study's exploratory case study approach captured unique situations to illustrate special attributes and aspects of treatment-seeking during a malaria episode. METHODS During August 2010, a qualitative exploratory study was conducted in seven of Butaleja District's 12 sub-counties. Multiple case study methodology consisting of loosely-structured interviews were carried out with eight caregivers of children five and under in the local dialect. Caregivers were geographically distant and not known to each other. Interviews were translated into English and transcribed the same day. Data were analyzed using content analysis. RESULTS Of the eight cases, children recovered fully in three instances, survived but with deficits in three, and died in two. Common to all outcomes were (1) triggers to illness recognition, (2) similar treatment sequences and practices, (3) factors which influenced caregivers' treatment-seeking decisions, (4) challenges encountered while seeking care at public health facilities, (5) cost burdens associated with managing malaria, (6) life burdens resulting from negative outcomes from malaria, (7) variations in caregiver knowledge about artemisinin combination therapy, and (8) varying perspectives how malaria management could be improved. CONCLUSIONS Despite the reality that caregivers in Butaleja District generally share similar practices, experiences and challenges, very few children ever receive treatment in accordance with the Uganda's national guidelines. To bring national practice into conformance with policy, three advances must occur: (1) All key stakeholders (those affiliated with the formal health system--public facilities and licensed private outlets, unlicensed drug vendors, and caregivers of young children) must concur on the need and the means to improve malaria management, (2) all health providers (formal and unlicensed) need to be engaged in training and certification to improve timely access to affordable treatment irrespective of a region's remoteness or low population density, and (3) future public health interventions need to improve caregivers' capacity to take the necessary actions to best manage malaria in young children.
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Affiliation(s)
- Rosemin Kassam
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - Richard Sekiwunga
- Child Health and Development Centre, School of Medicine, Makerere University, Kampala, P.O.Box 7062, Uganda.
| | - Duncan MacLeod
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
| | | | - Eric Liow
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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Yadav P. Health Product Supply Chains in Developing Countries: Diagnosis of the Root Causes of Underperformance and an Agenda for Reform. Health Syst Reform 2015; 1:142-154. [PMID: 31546312 DOI: 10.4161/23288604.2014.968005] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract-Well-functioning supply chains to deliver medicines, vaccines, and other health products form the backbone of the health system. Health product supply chains in developing countries are fraught with many problems. Ineffective supply chains weaken the overall health system's ability to respond to the healthcare needs of the population and put treatment programs at risk. This article provides an overview of the structure of health product supply chains in developing countries and outlines the main challenges and their root causes. It aims to identify key areas of reform to ensure that supply chains enable-or at least do not impede-achieving the targeted health outcomes from the increased investments in global health.
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Affiliation(s)
- Prashant Yadav
- William Davidson Institute; Ross School of Business and School of Public Health; University of Michigan ; Ann Arbor , MI , USA
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12
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13
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Metta E, Haisma H, Kessy F, Hutter I, Bailey A. "We have become doctors for ourselves": motives for malaria self-care among adults in southeastern Tanzania. Malar J 2014; 13:249. [PMID: 24986165 PMCID: PMC4085372 DOI: 10.1186/1475-2875-13-249] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 06/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prompt and appropriate treatment of malaria with effective medicines remains necessary if malaria control goals are to be achieved. The theoretical concepts from self-care and the health belief model were used to examine the motivations for malaria self-care among the adult population. METHODS A qualitative study was conducted through eight focus group discussions with adult community members to explore their general opinions, views and perceptions of malaria and of its treatments. These groups were followed by 15 in-depth interviews of participants with a recent malaria experience to allow for an in-depth exploration of their self-care practices. The analysis followed principles of grounded theory and was conducted using Nvivo 9 qualitative data management software. RESULTS The self-treatment of malaria at home was found to be a common practice among the study participants. The majority of the participants practiced self-medication with a painkiller as an initial response. The persistence and the worsening of the disease symptoms prompted participants to consider other self-care options. Perceptions that many malaria symptoms are suggestive of other conditions motivated participants to self-refer for malaria test. The accessibility of private laboratory facilities and drug shops motivated their use for malaria tests and for obtaining anti-malarial medicines, respectively. Self-treatment with anti-malarial monotherapy was common, motivated by their perceived effectiveness and availability. The perceived barriers to using the recommended combination treatment, artemether-lumefantrine, were related to the possible side-effects and to uncertainty about their effectiveness, and these doubts motivated some participants to consider self-medication with local herbs. Several factors were mentioned as motivating people for self-care practices. These included poor patient provider relationship, unavailability of medicine and the costs associated with accessing treatments from the health facilities. CONCLUSIONS Malaria self-care and self-treatment with anti-malarial monotherapy are common among adults, and are motivated by both individual characteristics and the limitations of the existing health care facilities. There is a need for public health interventions to take into account community perceptions and cultural schemas on malaria self-care practices.
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Affiliation(s)
- Emmy Metta
- Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania.
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Ezenduka CC, Ogbonna BO, Ekwunife OI, Okonta MJ, Esimone CO. Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy. Malar J 2014; 13:243. [PMID: 24961280 PMCID: PMC4079827 DOI: 10.1186/1475-2875-13-243] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/19/2014] [Indexed: 12/04/2022] Open
Abstract
Background Malaria treatment policy recommends regular monitoring of drug utilization to generate information for ensuring effective use of anti-malarial drugs in Nigeria. This information is currently limited in the retail sector which constitutes a major source of malaria treatment in Nigeria, but are characterized by significant inappropriate use of drugs. This study analyzed the use pattern of anti-malarial drugs in medicine outlets to assess the current state of compliance to policy on the use of artemisinin-based combination therapy (ACT). Methods A prospective cross-sectional survey of randomly selected medicine outlets in Enugu urban, southeast Nigeria, was conducted between May and August 2013, to determine the types, range, prices, and use pattern of anti-malarial drugs dispensed from pharmacies and patent medicine vendors (PMVs). Data were collected and analyzed for anti-malarial drugs dispensed for self-medication to patients, treatment by retail outlets and prescription from hospitals. Results A total of 1,321 anti-malarial drugs prescriptions were analyzed. ACT accounted for 72.7%, while monotherapy was 27.3%. Affordable Medicines Facility-malaria (AMFm) drugs contributed 33.9% (326/961) of ACT. Artemether-lumefantrine (AL), 668 (50.6%) was the most used anti-malarial drug, followed by monotherapy sulphadoxine-pyrimethamine (SP), 248 (18.8%). Median cost of ACT at $2.91 ($0.65-7.42) per dose, is about three times the median cost of monotherapy, $0.97 ($0.19-13.55). Total cost of medication (including co-medications) with ACT averaged $3.64 (95% CI; $3.53-3.75) per prescription, about twice the mean cost of treatment with monotherapy, $1.83 (95% CI; $1.57-2.1). Highest proportion 46.5% (614), of the anti-malarial drugs was dispensed to patients for self-treatment. Treatment by retail outlets accounted for 35.8% while 17.7% of the drugs were dispensed from hospital prescriptions. Self-medication, 82%, accounted for the highest source of monotherapy and a majority of prescriptions, 85.6%, was adults. Conclusion Findings suggest vastly improved use of ACT in the retail sector after eight years of policy change, with significant contributions from AMFm drugs. However the use of monotherapy, particularly through self-medication remains significant with increasing risk of undermining treatment policy, suggesting additional measures to directly target consumers and providers in the sector for improved use of anti-malarial drugs in Nigeria.
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Affiliation(s)
- Charles C Ezenduka
- Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Nigeria.
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Briggs MA, Kalolella A, Bruxvoort K, Wiegand R, Lopez G, Festo C, Lyaruu P, Kenani M, Abdulla S, Goodman C, Kachur SP. Prevalence of malaria parasitemia and purchase of artemisinin-based combination therapies (ACTs) among drug shop clients in two regions in Tanzania with ACT subsidies. PLoS One 2014; 9:e94074. [PMID: 24732258 PMCID: PMC3986050 DOI: 10.1371/journal.pone.0094074] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 03/11/2014] [Indexed: 11/17/2022] Open
Abstract
Background Throughout Africa, many people seek care for malaria in private-sector drug shops where diagnostic testing is often unavailable. Recently, subsidized artemisinin-based combination therapies (ACTs), a first-line medication for uncomplicated malaria, were made available in these drug shops in Tanzania. This study assessed the prevalence of malaria among and purchase of ACTs by drug shop clients in the setting of a national ACT subsidy program and sub-national drug shop accreditation program. Method and Findings A cross-sectional survey of drug shop clients was performed in two regions in Tanzania, one with a government drug shop accreditation program and one without, from March-May, 2012. Drug shops were randomly sampled from non-urban districts. Shop attendants were interviewed about their education, training, and accreditation status. Clients were interviewed about their symptoms and medication purchases, then underwent a limited physical examination and laboratory testing for malaria. Malaria prevalence and predictors of ACT purchase were assessed using univariate analysis and multiple logistic regression. Amongst 777 clients from 73 drug shops, the prevalence of laboratory-confirmed malaria was 12% (95% CI: 6–18%). Less than a third of clients with malaria had purchased ACTs, and less than a quarter of clients who purchased ACTs tested positive for malaria. Clients were more likely to have purchased ACTs if the participant was <5 years old (aOR: 6.6; 95% CI: 3.9–11.0) or the shop attendant had >5 years, experience (aOR: 2.8; 95% CI: 1.2–6.3). Having malaria was only a predictor of ACT purchase in the region with a drug shop accreditation program (aOR: 3.4; 95% CI: 1.5–7.4). Conclusion Malaria is common amongst persons presenting to drug shops with a complaint of fever. The low proportion of persons with malaria purchasing ACTs, and the high proportion of ACTs going to persons without malaria demonstrates a need to better target who receives ACTs in these drug shops.
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Affiliation(s)
- Melissa A Briggs
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Katia Bruxvoort
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ryan Wiegand
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Gerard Lopez
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Mitya Kenani
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Patrick Kachur
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Patouillard E, Kleinschmidt I, Hanson K, Pok S, Palafox B, Tougher S, O'Connell K, Goodman C. Comparative analysis of two methods for measuring sales volumes during malaria medicine outlet surveys. Malar J 2013; 12:311. [PMID: 24010526 PMCID: PMC3848597 DOI: 10.1186/1475-2875-12-311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/25/2013] [Indexed: 11/28/2022] Open
Abstract
Background There is increased interest in using commercial providers for improving access to quality malaria treatment. Understanding their current role is an essential first step, notably in terms of the volume of diagnostics and anti-malarials they sell. Sales volume data can be used to measure the importance of different provider and product types, frequency of parasitological diagnosis and impact of interventions. Several methods for measuring sales volumes are available, yet all have methodological challenges and evidence is lacking on the comparability of different methods. Methods Using sales volume data on anti-malarials and rapid diagnostic tests (RDTs) for malaria collected through provider recall (RC) and retail audits (RA), this study measures the degree of agreement between the two methods at wholesale and retail commercial providers in Cambodia following the Bland-Altman approach. Relative strengths and weaknesses of the methods were also investigated through qualitative research with fieldworkers. Results A total of 67 wholesalers and 107 retailers were sampled. Wholesale sales volumes were estimated through both methods for 62 anti-malarials and 23 RDTs and retail volumes for 113 anti-malarials and 33 RDTs. At wholesale outlets, RA estimates for anti-malarial sales were on average higher than RC estimates (mean difference of four adult equivalent treatment doses (95% CI 0.6-7.2)), equivalent to 30% of mean sales volumes. For RDTs at wholesalers, the between-method mean difference was not statistically significant (one test, 95% CI −6.0-4.0). At retail outlets, between-method differences for both anti-malarials and RDTs increased with larger volumes being measured, so mean differences were not a meaningful measure of agreement between the methods. Qualitative research revealed that in Cambodia where sales volumes are small, RC had key advantages: providers were perceived to remember more easily their sales volumes and find RC less invasive; fieldworkers found it more convenient; and it was cheaper to implement than RA. Discussion/conclusions Both RA and RC had implementation challenges and were prone to data collection errors. Choice of empirical methods is likely to have important implications for data quality depending on the study context.
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Affiliation(s)
- Edith Patouillard
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Njau JD, Kabanywanyi AM, Goodman CA, Macarthur JR, Kapella BK, Gimnig JE, Kahigwa E, Bloland PB, Abdulla SM, Kachur SP. Adverse drug events resulting from use of drugs with sulphonamide-containing anti-malarials and artemisinin-based ingredients: findings on incidence and household costs from three districts with routine demographic surveillance systems in rural Tanzania. Malar J 2013; 12:236. [PMID: 23844934 PMCID: PMC3710484 DOI: 10.1186/1475-2875-12-236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/24/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-malarial regimens containing sulphonamide or artemisinin ingredients are widely used in malaria-endemic countries. However, evidence of the incidence of adverse drug reactions (ADR) to these drugs is limited, especially in Africa, and there is a complete absence of information on the economic burden such ADR place on patients. This study aimed to document ADR incidence and associated household costs in three high malaria transmission districts in rural Tanzania covered by demographic surveillance systems. METHODS Active and passive surveillance methods were used to identify ADR from sulphadoxine-pyrimethamine (SP) and artemisinin (AS) use. ADR were identified by trained clinicians at health facilities (passive surveillance) and through cross-sectional household surveys (active surveillance). Potential cases were followed up at home, where a complete history and physical examination was undertaken, and household cost data collected. Patients were classified as having 'possible' or 'probable' ADR by a physician. RESULTS A total of 95 suspected ADR were identified during a two-year period, of which 79 were traced, and 67 reported use of SP and/or AS prior to ADR onset. Thirty-four cases were classified as 'probable' and 33 as 'possible' ADRs. Most (53) cases were associated with SP monotherapy, 13 with the AS/SP combination (available in one of the two areas only), and one with AS monotherapy. Annual ADR incidence per 100,000 exposures was estimated based on 'probable' ADR only at 5.6 for AS/SP in combination, and 25.0 and 11.6 for SP monotherapy. Median ADR treatment costs per episode ranged from US$2.23 for those making a single provider visit to US$146.93 for patients with four visits. Seventy-three per cent of patients used out-of-pocket funds or sold part of their farm harvests to pay for treatment, and 19% borrowed money. CONCLUSION Both passive and active surveillance methods proved feasible methods for anti-malarial ADR surveillance, with active surveillance being an important complement to facility-based surveillance, given the widespread practice of self-medication. Household costs associated with ADR treatment were high and potentially catastrophic. Efforts should be made to both improve pharmacovigilance across Africa and to identify strategies to reduce the economic burden endured by households suffering from ADR.
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Affiliation(s)
- Joseph D Njau
- Department of Health Policy and Management, Rollins School of Public Health (Emory University), Atlanta, GA 30322, USA.
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Davis B, Ladner J, Sams K, Tekinturhan E, de Korte D, Saba J. Artemisinin-based combination therapy availability and use in the private sector of five AMFm phase 1 countries. Malar J 2013; 12:135. [PMID: 23607504 PMCID: PMC3637826 DOI: 10.1186/1475-2875-12-135] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/17/2013] [Indexed: 01/27/2023] Open
Abstract
Background In 2009, the Global Fund to Fight AIDS, Tuberculosis and Malaria established the Affordable Medicines Facility-malaria (AMFm) in order to increase access to quality-assured artemisinin combination therapy (QAACT). AMFm Phase 1, which includes nine pilot programmes in eight countries, was launched in 2009. The objective of this study was to assess anti-malarial stock and purchase patterns at private outlets in five AMFm Phase 1 countries in regard to three of the core AMFm goals: increase the affordability of QAACT, increase the availability of QAACT, and crowd out artemisinin monotherapies and other substandard therapies. Methods The study was conducted between April and May 2012 and included interviews with personnel in 598 private pharmaceutical outlets in Ghana, Kenya, Nigeria, Tanzania, and Uganda. Questionnaires were administered at private retail outlets and the data were analyzed to assess within- and between-country differences in QAACT price, availability, and popularity. Results AMFm medications were less expensive than their non-AMFm counterparts, yet prices for both types were above country-specific suggested retail prices. Market penetration of AMFm QAACT in both urban and rural areas was high, although stock-outs of both AMFm and non-AMFm products were more common in rural compared with urban outlets in Ghana and Kenya (p = 0.0013). Government recommendation was the most significant factor influencing anti-malarial stock choices in urban (41.5%) and rural (31.9%) outlets. The three top-selling anti-malarials reported for both urban and rural areas in each country were, with the exception of rural Uganda and urban Nigeria, combination therapies. Conclusions Results from this study indicate that the AMFm has not fully achieved its affordability and crowd-out objectives. Still, the final purchase price of AMFm QAACT was substantially lower than non-AMFm equivalents. Moreover, for both urban and rural areas, AMFm QAACT availability was found to be high, and the various forms of QAACT were the best-selling products among all anti-malarials. These findings suggest a continued need for initiatives like the AMFm that improve the affordability and accessibility of QAACT. Similar programmes may be especially effective if employed in combination with rapid diagnostic testing to ensure the appropriate use of these products.
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Affiliation(s)
- Ben Davis
- Axios International, 7, Boulevard de Madeleine, Paris, 75001, France.
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O'Connell KA, Poyer S, Solomon T, Munroe E, Patouillard E, Njogu J, Evance I, Hanson K, Shewchuk T, Goodman C. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malar J 2013; 12:52. [PMID: 23383972 PMCID: PMC3599752 DOI: 10.1186/1475-2875-12-52] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 01/25/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years an increasing number of public investments and policy changes have been made to improve the availability, affordability and quality of medicines available to consumers in developing countries, including anti-malarials. It is important to monitor the extent to which these interventions are successful in achieving their aims using quantitative data on the supply side of the market. There are a number of challenges related to studying supply, including outlet sampling, gaining provider cooperation and collecting accurate data on medicines. This paper provides guidance on key steps to address these issues when conducting a medicine outlet survey in a developing country context. While the basic principles of good survey design and implementation are important for all surveys, there are a set of specific issues that should be considered when conducting a medicine outlet survey. METHODS This paper draws on the authors' experience of designing and implementing outlet surveys, including the lessons learnt from ACTwatch outlet surveys on anti-malarial retail supply, and other key studies in the field. Key lessons and points of debate are distilled around the following areas: selecting a sample of outlets; techniques for collecting and analysing data on medicine availability, price and sales volumes; and methods for ensuring high quality data in general. RESULTS AND CONCLUSIONS The authors first consider the inclusion criteria for outlets, contrasting comprehensive versus more focused approaches. Methods for developing a reliable sampling frame of outlets are then presented, including use of existing lists, key informants and an outlet census. Specific issues in the collection of data on medicine prices and sales volumes are discussed; and approaches for generating comparable price and sales volume data across products using the adult equivalent treatment dose (AETD) are explored. The paper concludes with advice on practical considerations, including questionnaire design, field worker training, and data collection. Survey materials developed by ACTwatch for investigating anti-malarial markets in sub-Saharan Africa and Asia provide a helpful resource for future studies in this area.
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Affiliation(s)
- Kathryn A O'Connell
- Population Services International (PSI), Malaria & Child Survival Department (MCSD), Whitefield Place, Westlands, PO Box, Nairobi, 14355-00800, Kenya.
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Berendes S, Adeyemi O, Oladele EA, Oresanya OB, Okoh F, Valadez JJ. Are patent medicine vendors effective agents in malaria control? Using lot quality assurance sampling to assess quality of practice in Jigawa, Nigeria. PLoS One 2012; 7:e44775. [PMID: 22984555 PMCID: PMC3440361 DOI: 10.1371/journal.pone.0044775] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 08/07/2012] [Indexed: 11/23/2022] Open
Abstract
Background Patent medicine vendors (PMV) provide antimalarial treatment and care throughout Sub-Saharan Africa, and can play an important role in the fight against malaria. Their close-to-client infrastructure could enable lifesaving artemisinin-based combination therapy (ACT) to reach patients in time. However, systematic assessments of drug sellers’ performance quality are crucial if their role is to be managed within the health system. Lot quality assurance sampling (LQAS) could be an efficient method to monitor and evaluate PMV practice, but has so far never been used for this purpose. Methods In support of the Nigeria Malaria Booster Program we assessed PMV practices in three Senatorial Districts (SDs) of Jigawa, Nigeria. A two-stage LQAS assessed whether at least 80% of PMV stores in SDs used national treatment guidelines. Acceptable sampling errors were set in consultation with government officials (alpha and beta <0.10). The hypergeometric formula determined sample sizes and cut-off values for SDs. A structured assessment tool identified high and low performing SDs for quality of care indicators. Findings Drug vendors performed poorly in all SDs of Jigawa for all indicators. For example, all SDs failed for stocking and selling first-line antimalarials. PMV sold no longer recommended antimalarials, such as Chloroquine, Sulfadoxine-Pyrimethamine and oral Artesunate monotherapy. Most PMV were ignorant of and lacked training about new treatment guidelines that had endorsed ACTs as first-line treatment for uncomplicated malaria. Conclusion There is urgent need to regularly monitor and improve the availability and quality of malaria treatment provided by medicine sellers in Nigeria; the irrational use of antimalarials in the ACT era revealed in this study bears a high risk of economic loss, death and development of drug resistance. LQAS has been shown to be a suitable method for monitoring malaria-related indicators among PMV, and should be applied in Nigeria and elsewhere to improve service delivery.
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Affiliation(s)
- Sima Berendes
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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Hidden costs: the direct and indirect impact of user fees on access to malaria treatment and primary care in Mali. Soc Sci Med 2012; 75:1786-92. [PMID: 22883255 DOI: 10.1016/j.socscimed.2012.07.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 07/16/2012] [Accepted: 07/18/2012] [Indexed: 11/23/2022]
Abstract
About 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socio-economic spectrum. Semi-structured interviews addressed participants' past medical history, socio-economic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation framework-one that can measure the health and socioeconomic impacts of user fee polices and of their removal.
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Malisa AL, Kiriba D. Artemisinin combination therapies price disparity between government and private health sectors and its implication on antimalarial drug consumption pattern in Morogoro Urban District, Tanzania. BMC Res Notes 2012; 5:165. [PMID: 22455367 PMCID: PMC3410816 DOI: 10.1186/1756-0500-5-165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 03/28/2012] [Indexed: 11/10/2022] Open
Abstract
Background Universal access to effective treatments is a goal of the Roll Back Malaria Partnership. However, despite official commitments and substantial increases in financing, this objective remains elusive, as development assistance continue to be routed largely through government channels, leaving the much needed highly effective treatments inaccessible or unaffordable to those seeking services in the private sector. Methods To quantify the effect of price disparity between the government and private health systems, this study have audited 92 government and private Drug Selling Units (DSUs) in Morogoro urban district in Tanzania to determine the levels, trend and consumption pattern of antimalarial drugs in the two health systems. A combination of observation, interviews and questionnaire administered to the service providers of the randomly selected DSUs were used to collect data. Results ALU was the most selling antimalarial drug in the government health system at a subsidized price of 300 TShs (0.18 US$). By contrast, ALU that was available in the private sector (coartem) was being sold at a price of about 10,000 TShs (5.9 US$), the price that was by far unaffordable, prompting people to resort to cheap but failed drugs. As a result, metakelfin (the phased out drug) was the most selling drug in the private health system at a price ranging from 500 to 2,000 TShs (0.29–1.18 US$). Conclusions In order for the prompt diagnosis and treatment with effective drugs intervention to have big impact on malaria in mostly low socioeconomic malaria-endemic areas of Africa, inequities in affordability and access to effective treatment must be eliminated. For this to be ensued, subsidized drugs should be made available in both government and private health sectors to promote a universal access to effective safe and affordable life saving antimalarial drugs.
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Affiliation(s)
- Allen Lewis Malisa
- Department of Biological Sciences, Faculty of Science, Sokoine University of Agriculture, Box 3038, Morogoro, Tanzaia.
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Littrell M, Gatakaa H, Evance I, Poyer S, Njogu J, Solomon T, Munroe E, Chapman S, Goodman C, Hanson K, Zinsou C, Akulayi L, Raharinjatovo J, Arogundade E, Buyungo P, Mpasela F, Adjibabi CB, Agbango JA, Ramarosandratana BF, Coker B, Rubahika D, Hamainza B, Shewchuk T, Chavasse D, O'Connell KA. 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. Malar J 2011; 10:327. [PMID: 22039892 PMCID: PMC3223147 DOI: 10.1186/1475-2875-10-327] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 10/31/2011] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Megan Littrell
- Population Services International, Malaria & Child Survival Department, PO Box 43640, Nairobi, Kenya, Africa.
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Shewchuk T, O'Connell KA, Goodman C, Hanson K, Chapman S, Chavasse D. The ACTwatch project: methods to describe anti-malarial markets in seven countries. Malar J 2011; 10:325. [PMID: 22039780 PMCID: PMC3217875 DOI: 10.1186/1475-2875-10-325] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 10/31/2011] [Indexed: 11/10/2022] Open
Abstract
Background Policy makers, governments and donors are faced with an information gap when considering ways to improve access to artemisinin-based combination therapy (ACT) and malaria diagnostics including rapid diagnostic tests (RDTs). To help address some of these gaps, a five-year multi-country research project called ACTwatch was launched. The project is designed to provide a comprehensive picture of the anti-malarial market to inform national and international anti-malarial drug policy decision-making. Methods The project is being conducted in seven malaria-endemic countries: Benin, Cambodia, the Democratic Republic of Congo, Madagascar, Nigeria, Uganda and Zambia from 2008 to 2012. ACTwatch measures which anti-malarials are available, where they are available and at what price and who they are used by. These indicators are measured over time and across countries through three study components: outlet surveys, supply chain studies and household surveys. Nationally representative outlet surveys examine the market share of different anti-malarials passing through public facilities and private retail outlets. Supply chain research provides a picture of the supply chain serving drug outlets, and measures mark-ups at each supply chain level. On the demand side, nationally representative household surveys capture treatment seeking patterns and use of anti-malarial drugs, as well as respondent knowledge of anti-malarials. Discussion The research project provides findings on both the demand and supply side determinants of anti-malarial access. There are four key features of ACTwatch. First is the overlap of the three study components where nationally representative data are collected over similar periods, using a common sampling approach. A second feature is the number and diversity of countries that are studied which allows for cross-country comparisons. Another distinguishing feature is its ability to measure trends over time. Finally, the project aims to disseminate findings widely for decision-making. Conclusions ACTwatch is a unique multi-country research project that threads together anti-malarial supply and consumer behaviour to provide an evidence base to policy makers that can help determine where interventions may positively impact access to and use of quality-assured ACT and RDTs. Because of its ability to detect change over time, it is well suited to monitor the effects of policy or intervention developments in a country.
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Affiliation(s)
- Tanya Shewchuk
- Malaria & Child Survival Department, Population Services International, P,O, Box 43640-00800, Nairobi, Kenya, Africa.
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Albertini A, Djalle D, Faye B, Gamboa D, Luchavez J, Mationg ML, Mwangoka G, Oyibo W, Bennett J, Incardona S, Lee E. Preliminary enquiry into the availability, price and quality of malaria rapid diagnostic tests in the private health sector of six malaria-endemic countries. Trop Med Int Health 2011; 17:147-52. [PMID: 22032415 DOI: 10.1111/j.1365-3156.2011.02904.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This enquiry aimed to provide a snap-shot of availability, price and quality of malaria rapid diagnostic tests (RDTs) in private health facilities at selected sites in six malaria-endemic countries in Africa, South East Asia and South America. METHODS In each study site, data collectors surveyed private healthcare facilities which were selected based on accessibility from their home institution. Using a questionnaire, information was recorded about the facility itself and the malaria RDT(s) available. Where possible, a small number of RDTs were procured and quality control tested using a standardized procedure. RESULTS Of the 324 private healthcare facilities visited, 35 outlets (mainly private clinics and hospitals) were found to supply 10 different types of RDTs products. RDT prices across the six countries ranged from US$1.00 to $16.81. Five of the 14 malaria RDTs collected failed quality control testing. CONCLUSIONS In the private outlets sampled, the availability of RDTs was limited. Some of the RDTs whose quality we tested demonstrated inadequate sensitivity. This presents a number of risks. Given the more widespread distribution of antimalarials currently planned for private sector facilities, parasite-based diagnosis in this sector will be essential to adhere to the WHO guidelines for effective case management of malaria. Considerable regulation and quality control are also necessary to assure the availability of accurate and reliable RDTs, as well as adequate case management and provider adherence to RDT results. Public sector engagement is likely to be essential in this process.
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Affiliation(s)
- A Albertini
- FIND (Foundation for Innovative New Diagnostics), Geneva, Switzerland
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Malisa AL, Pearce RJ, Mutayoba BM, Abdullah S, Mshinda H, Kachur PS, Bloland P, Roper C. The evolution of pyrimethamine resistant dhfr in Plasmodium falciparum of south-eastern Tanzania: comparing selection under SP alone vs SP+artesunate combination. Malar J 2011; 10:317. [PMID: 22029848 PMCID: PMC3213132 DOI: 10.1186/1475-2875-10-317] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 10/26/2011] [Indexed: 11/15/2022] Open
Abstract
Background Sulphadoxine-pyrimethamine (SP) resistance is now widespread throughout east and southern Africa and artemisinin compounds in combination with synthetic drugs (ACT) are recommended as replacement treatments by the World Health Organization (WHO). As well as high cure rates, ACT has been shown to slow the development of resistance to the partner drug in areas of low to moderate transmission. This study looked for evidence of protection of the partner drug in a high transmission African context. The evaluation was part of large combination therapy pilot implementation programme in Tanzania, the Interdisciplinary Monitoring Programme for Antimalarial Combination Therapy (IMPACT-TZ) Methods The growth of resistant dhfr in a parasite population where SP Monotherapy was the first-line treatment was measured for four years (2002-2006), and compared with the development of resistant dhfr in a neighbouring population where SP + artesunate (SP+AS) was used as the first-line treatment during the same interval. The effect of the differing treatment regimes on the emergence of resistance was addressed in three ways. First, by looking at the rate of increase in frequency of pre-existing mutant dhfr alleles under monotherapy and combination therapy. Second, by examining whether de-novo mutant alleles emerged under either treatment. Finally, by measuring diversity at three dhfr flanking microsatellite loci upstream of the dhfr gene. Results The reduction in SP selection pressure resulting from the adoption of ACT slowed the rate of increase in the frequency of the triple mutant resistant dhfr allele. Comparing between the two populations, the higher levels of genetic diversity in sequence flanking the dhfr triple mutant allele in the population where the ACT regimen had been used indicates the reduction in SP selection pressure arising from combination therapy. Conclusion The study demonstrated that, alleles containing two mutations at the dhfr have arisen at least four times independently while those containing triple mutant dhfr arose only once, and were found carrying a single unique Asian-type flanking sequence, which apparently drives the spread of pyrimethamine resistance associated dhfr alleles in east Africa. SP+AS is not recommended for use in areas where SP cure rates are less than 80% but this study reports an observed principle of combination protection from an area where pyrimethamine resistance was already high.
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Affiliation(s)
- Allen L Malisa
- Sokoine University of Agriculture, Department of Biological Sciences, Faculty of Science, Box 3038, Morogoro, Tanzania.
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Ringsted FM, Massawe IS, Lemnge MM, Bygbjerg IC. Saleability of anti-malarials in private drug shops in Muheza, Tanzania: a baseline study in an era of assumed artemisinin combination therapy (ACT). Malar J 2011; 10:238. [PMID: 21843328 PMCID: PMC3167767 DOI: 10.1186/1475-2875-10-238] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 08/15/2011] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Artemether-lumefantrine (ALu) replaced sulphadoxine-pymimethamine (SP) as the official first-line anti-malarial in Tanzania in November 2006. So far, artemisinin combination therapy (ACT) is contra-indicated during pregnancy by the national malaria treatment guidelines, and pregnant women depend on SP for Intermittent Preventive Treatment (IPTp) during pregnancy. SP is still being dispensed by private drug stores, but it is unknown to which extent. If significant, it may undermine its official use for IPTp through induction of resistance. The main study objective was to perform a baseline study of the private market for anti-malarials in Muheza town, an area with widespread anti-malarial drug resistance, prior to the implementation of a provider training and accreditation programme that will allow accredited drug shops to sell subsidized ALu. METHODS All drug shops selling prescription-only anti-malarials, in Muheza town, Tanga Region voluntarily participated from July to December 2009. Qualitative in-depth interviews were conducted with owners or shopkeepers on saleability of anti-malarials, and structured questionnaires provided quantitative data on drugs sales volume. RESULTS All surveyed drug shops illicitly sold SP and quinine (QN), and legally amodiaquine (AQ). Calculated monthly sale was 4,041 doses, in a town with a population of 15,000 people. Local brands of SP accounted for 74% of sales volume, compared to AQ (13%), QN (11%) and ACT (2%). CONCLUSIONS In community practice, the saleability of ACT was negligible. SP was best-selling, and use was not reserved for IPTp, as stipulated in the national anti-malarial policy. It is a major reason for concern that such drug-pressure in the community equals de facto intermittent presumptive treatment. In an area where SP drug resistance remains high, unregulated SP dispensing to people other than pregnant women runs the risk of eventually jeopardizing the effectiveness of the IPTp strategy. Further studies are recommended to find out barriers for ACT utilization and preference for self-medication and to train private drug dispensers.
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Affiliation(s)
- Frank M Ringsted
- Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen, Øster Farimagsgade 5, DK 1014 Copenhagen K, Denmark.
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Adedeji AA, Sanusi B, Tella A, Akinsanya M, Ojo O, Akinwunmi MO, Tikare OA, Ogunwande IA, Ogundahunsi OA, Ayilara OO, Ademola TT, Fehintola FA, Ogundahunsi OAT. Exposure to anti-malarial drugs and monitoring of adverse drug reactions using toll-free mobile phone calls in private retail sector in Sagamu, Nigeria: implications for pharmacovigilance. Malar J 2011; 10:230. [PMID: 21827667 PMCID: PMC3162590 DOI: 10.1186/1475-2875-10-230] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 08/09/2011] [Indexed: 11/10/2022] Open
Abstract
Background Adverse drug reactions (ADRs) contribute to ill-health or life-threatening outcomes of therapy during management of infectious diseases. The exposure to anti-malarial and use of mobile phone technology to report ADRs following drug exposures were investigated in Sagamu - a peri-urban community in Southwest Nigeria. Methods Purchase of medicines was actively monitored for 28 days in three Community Pharmacies (CP) and four Patent and Proprietary Medicine Stores (PPMS) in the community. Information on experience of ADRs was obtained by telephone from 100 volunteers who purchased anti-malarials during the 28-day period. Results and Discussion A total of 12,093 purchases were recorded during the period. Antibiotics, analgesics, vitamins and anti-malarials were the most frequently purchased medicines. A total of 1,500 complete courses of anti-malarials were purchased (12.4% of total purchases); of this number, purchases of sulphadoxine-pyrimethamine (SP) and chloroquine (CQ) were highest (39.3 and 25.2% respectiuvely). Other anti-malarials purchased were artesunate monotherapy (AS) - 16.1%, artemether-lumefantrine (AL) 10.0%, amodiaquine (AQ) - 6.6%, quinine (QNN) - 1.9%, halofantrine (HF) - 0.2% and proguanil (PR) - 0.2%. CQ was the cheapest (USD 0.3) and halofantrine the most expensive (USD 7.7). AL was 15.6 times ($4.68) more expensive than CQ. The response to mobile phone monitoring of ADRs was 57% in the first 24 hours (day 1) after purchase and decreased to 33% by day 4. Participants in this monitoring exercise were mostly with low level of education (54%). Conclusion The findings from this study indicate that ineffective anti-malaria medicines including monotherapies remain widely available and are frequently purchased in the study area. Cost may be a factor in the continued use of ineffective monotherapies. Availability of a toll-free telephone line may facilitate pharmacovigilance and follow up of response to medicines in a resource-poor setting.
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Affiliation(s)
- Ahmed A Adedeji
- Communicable Disease Research Unit, Olabisi Onabanjo University Teaching Hospilal Sagamu, PMB 2002, Nigeria.
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Malisa A, Pearce R, Mutayoba B, Abdullah S, Mshinda H, Kachur P, Bloland P, Roper C. Media, health workers, and policy makers' relationship and their impact on antimalarial policy adoption: a population genetics perspective. Malar Res Treat 2011; 2011:217276. [PMID: 22347670 PMCID: PMC3278921 DOI: 10.4061/2011/217276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 04/19/2011] [Accepted: 04/26/2011] [Indexed: 11/23/2022] Open
Abstract
Drug resistance negatively impacts malaria treatments, making treatment policy revision unavoidable. So far, studies relating sociopolitical and technical issues on policy change with malaria parasite genetic change are lacking. We have quantified the effect of malaria treatment policy on drug pressure and the influence of the media, policy makers, and health worker relationship on parasite population genetic change in Kilombro/Ulanga district. Cross-sectional surveys of asymptomatic infections conducted before, during and after the switch from chloroquine to sulphadoxine/pyrimethamine were used for genetic analysis of SP resistance genes in 4,513 asymptomatic infections identified, and their frequency change was compared with retrospective study of the documented process of policy change. Highly significant changes of dhfr and dhps resistance alleles occurred within one year of switch to SP first line, followed by a decline of their rate of selection caused by reduction of SP usage, as a result of negative media reports on SP usage and lack of adequate preparations.
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Affiliation(s)
- Allen Malisa
- Department of Biological Sciences, Faculty of Science, Sokoine University of Agriculture, P.O. Box 3038, Morogoro, Tanzania
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Richard Pearce
- London School of Hygiene and Tropical Medicine, Pathogen Molecular Biology Unit, Department of Infectious Tropical Diseases, Keppel Street, London WC1E 7HT, UK
| | - Benezeth Mutayoba
- Department of Veterinary Physiology, Biochemistry, Pharmacology and Toxicology, Faculty of Veterinary Medicine, Sokoine University of Agriculture, P.O. Box 3017, Morogoro, Tanzania
| | - Salim Abdullah
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Hassan Mshinda
- Ifakara Health Institute (IHI), Research and Development Center (RDC), P.O. Box 53, Ifakara, Kilombero District, Tanzania
| | - Patrick Kachur
- Malaria Branch, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341, USA
| | - Peter Bloland
- Malaria Branch, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA 30341, USA
| | - Cally Roper
- London School of Hygiene and Tropical Medicine, Pathogen Molecular Biology Unit, Department of Infectious Tropical Diseases, Keppel Street, London WC1E 7HT, UK
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Matowe L, Adeyi O. The quest for universal access to effective malaria treatment: how can the AMFm contribute? Malar J 2010; 9:274. [PMID: 20932286 PMCID: PMC2959073 DOI: 10.1186/1475-2875-9-274] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 10/08/2010] [Indexed: 11/28/2022] Open
Abstract
Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin. Access to medicines frameworks paint a broad picture of dimensions of access to medicines and juxtapose components that enhance or hinder access to medicines. Access requires various activities--funding, institutions, interventions, and thinking--from public and private actors at global, national, and local levels. This paper examines, within access to medicines frameworks, the role of the AMFm across and within each dimension and discusses how the AMFm can help to solve access bottlenecks.
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Affiliation(s)
- Lloyd Matowe
- The Global fund to fight AIDS, Tuberculosis and Malaria, AMFm Unit, Chemin de Blandonnet 8, 1214 Vernier, Geneva, Switzerland
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Malisa AL, Pearce RJ, Abdulla S, Mshinda H, Kachur PS, Bloland P, Roper C. Drug coverage in treatment of malaria and the consequences for resistance evolution--evidence from the use of sulphadoxine/pyrimethamine. Malar J 2010; 9:190. [PMID: 20602754 PMCID: PMC2908640 DOI: 10.1186/1475-2875-9-190] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 07/05/2010] [Indexed: 11/24/2022] Open
Abstract
Background It is argued that, the efficacy of anti-malarials could be prolonged through policy-mediated reductions in drug pressure, but gathering evidence of the relationship between policy, treatment practice, drug pressure and the evolution of resistance in the field is challenging. Mathematical models indicate that drug coverage is the primary determinant of drug pressure and the driving force behind the evolution of drug resistance. These models show that where the basis of resistance is multigenic, the effects of selection can be moderated by high recombination rates, which disrupt the associations between co-selected resistance genes. Methods To test these predictions, dhfr and dhps frequency changes were measured during 2000-2001 while SP was the second-line treatment and contrasted these with changes during 2001-2002 when SP was used for first-line therapy. Annual cross sectional community surveys carried out before, during and after the policy switch in 2001 were used to collect samples. Genetic analysis of SP resistance genes was carried out on 4,950 Plasmodium falciparum infections and the selection pressure under the two policies compared. Results The influence of policy on the parasite reservoir was profound. The frequency of dhfr and dhps resistance alleles did not change significantly while SP was the recommended second-line treatment, but highly significant changes occurred during the subsequent year after the switch to first line SP. The frequency of the triple mutant dhfr (N51I,C59R,S108N) allele (conferring pyrimethamine resistance) increased by 37% - 63% and the frequency of the double A437G, K540E mutant dhps allele (conferring sulphadoxine resistance) increased 200%-300%. A strong association between these unlinked alleles also emerged, confirming that they are co-selected by SP. Conclusion The national policy change brought about a shift in treatment practice and the resulting increase in coverage had a substantial impact on drug pressure. The selection applied by first-line use is strong enough to overcome recombination pressure and create significant linkage disequilibrium between the unlinked genetic determinants of pyrimethamine and sulphadoxine resistance, showing that recombination is no barrier to the emergence of resistance to combination treatments when they are used as the first-line malaria therapy.
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Affiliation(s)
- Allen L Malisa
- Department of Biological Sciences, Faculty of Science, Sokoine University of Agriculture, SUA, PO Box 3038, Morogoro, Tanzania
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Cohen JM, Sabot O, Sabot K, Gordon M, Gross I, Bishop D, Odhiambo M, Ipuge Y, Ward L, Mwita A, Goodman C. A pharmacy too far? Equity and spatial distribution of outcomes in the delivery of subsidized artemisinin-based combination therapies through private drug shops. BMC Health Serv Res 2010; 10 Suppl 1:S6. [PMID: 20594372 PMCID: PMC2895750 DOI: 10.1186/1472-6963-10-s1-s6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Millions of individuals with malaria-like fevers purchase drugs from private retailers, but artemisinin-based combination therapies (ACTs), the only effective treatment in regions with high levels of resistance to older drugs, are rarely obtained through these outlets due to their relatively high cost. To encourage scale up of ACTs, the Affordable Medicines Facility--malaria is being launched to subsidize their price. The Government of Tanzania and the Clinton Foundation piloted this subsidized distribution model in two Tanzanian districts to examine concerns about whether the intervention will successfully reach poor, rural communities. METHODS Stocking of ACTs and other antimalarial drugs in all retail shops was observed at baseline and in four subsequent surveys over 15 months. Exit interviews were conducted with antimalarial drug customers during each survey period. All shops and facilities were georeferenced, and variables related to population density and proximity to distribution hubs, roads, and other facilities were calculated. To understand the equity of impact, shops stocking ACTs and consumers buying them were compared to those that did not, according to geographic and socioeconomic variables. Patterning in ACT stocking and sales was evaluated against that of other common antimalarials to identify factors that may have impacted access. Qualitative data were used to assess motivations underlying stocking, distribution, and buying disparities. RESULTS Results indicated that although total ACT purchases rose from negligible levels to nearly half of total antimalarial sales over the course of the pilot, considerable geographic variation in stocking and sales persisted and was related to a variety of socio-spatial factors; ACTs were stocked more often in shops located closer to district towns (p<0.01) and major roads (p<0.01) and frequented by individuals of higher socioeconomic status (p<0.01). However, other antimalarial drugs displayed similar patterning, indicating the existence of underlying disparities in access to antimalarial drugs in general in these districts. CONCLUSIONS As this subsidy model is scaled up across multiple countries, these results confirm the potential for increased ACT usage but suggest that additional efforts to increase access in remote areas will be needed for the scale-up to have equitable impact. TRIAL REGISTRATION Current Controlled Trials ISRCTN39125414.
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Affiliation(s)
- Justin M Cohen
- Clinton Health Access Initiative, 383 Dorchester Ave, Boston MA, 02127, USA.
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Alba S, Hetzel MW, Goodman C, Dillip A, Liana J, Mshinda H, Lengeler C. Improvements in access to malaria treatment in Tanzania after switch to artemisinin combination therapy and the introduction of accredited drug dispensing outlets - a provider perspective. Malar J 2010; 9:164. [PMID: 20550654 PMCID: PMC2910018 DOI: 10.1186/1475-2875-9-164] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 06/15/2010] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To improve access to treatment in the private retail sector a new class of outlets known as accredited drug dispensing outlets (ADDO) was created in Tanzania. Tanzania changed its first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (ALu) in 2007. Subsidized ALu was made available in both health facilities and ADDOs. The effect of these interventions on access to malaria treatment was studied in rural Tanzania. METHODS The study was carried out in the villages of Kilombero and Ulanga Demographic Surveillance System (DSS) and in Ifakara town. Data collection consisted of: 1) yearly censuses of shops selling drugs; 2) collection of monthly data on availability of anti-malarials in public health facilities; and 3) retail audits to measure anti-malarial sales volumes in all public, mission and private outlets. The data were complemented with DSS population data. RESULTS Between 2004 and 2008 access to malaria treatment greatly improved and the number of anti-malarial treatment doses dispensed increased by 78%. Particular improvements were observed in the availability (from 0.24 shops per 1,000 people in 2004 to 0.39 in 2008) and accessibility (from 71% of households within 5 km of a shop in 2004 to 87% in 2008) of drug shops. Despite no improvements in affordability this resulted in an increase of the market share from 49% of anti-malarial sales 2005 to 59% in 2008. The change of treatment policy from SP to ALu led to severe stock-outs of SP in health facilities in the months leading up to the introduction of ALu (only 40% months in stock), but these were compensated by the wide availability of SP in shops. After the introduction of ALu stock levels of the drug were relatively high in public health facilities (over 80% months in stock), but the drug could only be found in 30% of drug shops and in no general shops. This resulted in a low overall utilization of the drug (19% of all anti-malarial sales) CONCLUSIONS The public health and private retail sector are important complementary sources of treatment in rural Tanzania. Ensuring the availability of ALu in the private retail sector is important for its successful uptake.
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Affiliation(s)
- Sandra Alba
- Dept. Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, Tanzania
| | - Manuel W Hetzel
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK; and Kenya Medical Research Institute-Welcome Trust Research Programme, Nairobi, Kenya
| | - Angel Dillip
- Dept. Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, Tanzania
| | - Jafari Liana
- Management Sciences for Health, Dar es Salaam, Tanzania
| | - Hassan Mshinda
- Tanzanian Commission for Science and Technology, Dar es Salaam, Tanzania
| | - Christian Lengeler
- Dept. Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Rowa Y, Abuya TO, Mutemi WK, Ochola S, Molyneux S, Marsh V. Factors influencing implementation of the Ministry of Health-led private medicine retailer programmes on malaria in Kenya. BMC Public Health 2010; 10:93. [PMID: 20181234 PMCID: PMC2837856 DOI: 10.1186/1471-2458-10-93] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 02/24/2010] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Kenya has experienced a number of retail sector initiatives aimed at improving access to antimalarial medicines. This study explored stakeholders' perceptions of the role of private medicine retailers (PMRs), the value and feasibility of programme goals, perceived programme impact, factors influencing implementation and recommendations in three districts of Kenya. METHODS This study was part of a larger evaluation of PMR programmes, including quantitative and qualitative components. The qualitative research was conducted to assess implementation processes and actors' experiences in the programmes, through focus group discussions with trained PMRs and mothers of children under five years, and in-depth interviews with programme managers, trainers and co-trainers. RESULTS PMRs were perceived to provide rapid cheap treatment for non-serious conditions and used as a deliberate and continuously evaluated choice between different treatment sources. All stakeholders supported programme goals and most PMRs described increased customer satisfaction, more rational purchasing of medicine stock and increased medicine sales after participation. Factors undermining programme implementation included a lack of MoH resources to train and monitor large numbers of PMRs, the relative instability of outlets, medicines stocked and retail personnel, the large number of proprietary brands and financial challenges to retailers in stocking antimalarial medicines, and their customers in buying them. Unambiguous national support and a broad range of strategies are important to strengthen the feasibility of change in OTC antimalarial use. CONCLUSIONS Understanding the context and implementation processes of PMR programmes and the perspectives of key actors are critical to identifying measures to support their effective implementation. Financial barriers underlie many described challenges, with important implications for policies on subsidies in this sector. In spite of barriers to implementation, increased exposure to programme activities promoted trust and improved relationships between PMRs and their clients and trainers, strengthening feasibility of such interventions. Public information can strengthen PMR training programmes by engaging local communities and may facilitate performance monitoring of PMRs by their clients.
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Affiliation(s)
- Yvonne Rowa
- Life & Peace Institute, Somalia Programme, PO Box 64495 - 00620 Nairobi, Kenya
| | - Timothy O Abuya
- Kenya Medical Research Institute/Wellcome Trust Centre for Geographic Medicine Research-Coast, 80108, PO Box 230 Kilifi, Kenya
| | | | - Sam Ochola
- Ministry of Health, PO Box 34349-00100 Nairobi, Kenya
| | - Sassy Molyneux
- Kenya Medical Research Institute/Wellcome Trust Centre for Geographic Medicine Research-Coast, 80108, PO Box 230 Kilifi, Kenya
- Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), University of Oxford, Headington, Oxford, OX3 9DU, UK
| | - Vicki Marsh
- Kenya Medical Research Institute/Wellcome Trust Centre for Geographic Medicine Research-Coast, 80108, PO Box 230 Kilifi, Kenya
- Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), University of Oxford, Headington, Oxford, OX3 9DU, UK
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Patouillard E, Hanson KG, Goodman CA. Retail sector distribution chains for malaria treatment in the developing world: a review of the literature. Malar J 2010; 9:50. [PMID: 20149246 PMCID: PMC2836367 DOI: 10.1186/1475-2875-9-50] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Accepted: 02/11/2010] [Indexed: 11/12/2022] Open
Abstract
Background In many low-income countries, the retail sector plays an important role in the treatment of malaria and is increasingly being considered as a channel for improving medicine availability. Retailers are the last link in a distribution chain and their supply sources are likely to have an important influence on the availability, quality and price of malaria treatment. This article presents the findings of a systematic literature review on the retail sector distribution chain for malaria treatment in low and middle-income countries. Methods Publication databases were searched using key terms relevant to the distribution chain serving all types of anti-malarial retailers. Organizations involved in malaria treatment and distribution chain related activities were contacted to identify unpublished studies. Results A total of 32 references distributed across 12 developing countries were identified. The distribution chain had a pyramid shape with numerous suppliers at the bottom and fewer at the top. The chain supplying rural and less-formal outlets was made of more levels than that serving urban and more formal outlets. Wholesale markets tended to be relatively concentrated, especially at the top of the chain where few importers accounted for most of the anti-malarial volumes sold. Wholesale price mark-ups varied across chain levels, ranging from 27% to 99% at the top of the chain, 8% at intermediate level (one study only) and 2% to 67% at the level supplying retailers directly. Retail mark-ups tended to be higher, and varied across outlet types, ranging from 3% to 566% in pharmacies, 29% to 669% in drug shops and 100% to 233% in general shops. Information on pricing determinants was very limited. Conclusions Evidence on the distribution chain for retail sector malaria treatment was mainly descriptive and lacked representative data on a national scale. These are important limitations in the advent of the Affordable Medicine Facility for Malaria, which aims to increase consumer access to artemisinin-based combination therapy (ACT), through a subsidy introduced at the top of the distribution chain. This review calls for rigorous distribution chain analysis, notably on the factors that influence ACT availability and prices in order to contribute to efforts towards improved access to effective malaria treatment.
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Affiliation(s)
- Edith Patouillard
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
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Russo G, McPake B. Medicine prices in urban Mozambique: a public health and economic study of pharmaceutical markets and price determinants in low-income settings. Health Policy Plan 2009; 25:70-84. [PMID: 19843636 DOI: 10.1093/heapol/czp042] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
It has been suggested that medicines are unaffordable in low-income countries and that world manufacturing and trade policies are responsible for high prices. This research investigates medicine prices in urban Mozambique with the objective of understanding how prices are formed and with what public health implications. The study adopts an economic framework and uses a combination of quantitative and qualitative methods to analyse local pharmaceutical prices and markets. The research findings suggest that: (a) local mark-ups are responsible for up to two-thirds of drugs' final prices in private pharmacies; (b) statutory profit and cost ceilings are applied unevenly, due to lack of government control and collusion among suppliers; and (c) the local market appears to respond effectively to the urban population's diverse needs through its low-cost and high-cost segments, although uncertainty around the quality of generics may be inducing consumers to purchase less affordable drugs. We conclude that local markets play a larger than expected role in the determination of prices in Mozambique, and that more research is needed to address the complex issue of affordability of medicines in low-income countries. We also argue that price controls may not be the most effective way to influence access to medicines in low-income countries, and managing demand and supply towards cheaper effective drugs appears a more suitable policy option.
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Affiliation(s)
- Giuliano Russo
- Instituto de Higiene e Medicina Tropical, Rua da Junqueira 96, 1349-008 Lisbon, Portugal.
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Sabot OJ, Mwita A, Cohen JM, Ipuge Y, Gordon M, Bishop D, Odhiambo M, Ward L, Goodman C. Piloting the global subsidy: the impact of subsidized artemisinin-based combination therapies distributed through private drug shops in rural Tanzania. PLoS One 2009; 4:e6857. [PMID: 19724644 PMCID: PMC2730578 DOI: 10.1371/journal.pone.0006857] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Accepted: 07/21/2009] [Indexed: 11/22/2022] Open
Abstract
Background WHO estimates that only 3% of fever patients use recommended artemisinin-based combination therapies (ACTs), partly reflecting their high prices in the retail sector from where many patients seek treatment. To overcome this challenge, a global ACT subsidy has been proposed. We tested this proposal through a pilot program in rural Tanzania. Methods/Principal Findings Three districts were assigned to serve either as a control or to receive the subsidy plus a package of supporting interventions. From October 2007, ACTs were sold at a 90% subsidy through the normal private supply chain to intervention district drug shops. Data were collected at baseline and during intervention using interviews with drug shop customers, retail audits, mystery shoppers, and audits of public and NGO facilities. The proportion of consumers in the intervention districts purchasing ACTs rose from 1% at baseline to 44.2% one year later (p<0.001), and was significantly higher among consumers purchasing for children under 5 than for adults (p = 0.005). No change in ACT usage was observed in the control district. Consumers paid a mean price of $0.58 for ACTs, which did not differ significantly from the price paid for sulphadoxine-pyrimethamine, the most common alternative. Drug shops in population centers were significantly more likely to stock ACTs than those in more remote areas (p<0.001). Conclusions A subsidy introduced at the top of the private sector supply chain can significantly increase usage of ACTs and reduce their retail price to the level of common monotherapies. Additional interventions may be needed to ensure access to ACTs in remote areas and for poorer individuals who appear to seek treatment at drug shops less frequently. Trial Registration Controlled-Trials.com ISRCTN39125414.
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Affiliation(s)
- Oliver J Sabot
- Malaria Control Team, Clinton Foundation HIV/AIDS Initiative, Boston, Massachusetts, USA.
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Hanson KG, Gilson L, Goodman C, Mills A. The fallacy of competing interest statements: no shortcut to rigour in research. J R Soc Med 2009; 102:126. [PMID: 19349497 DOI: 10.1258/jrsm.2009.09k016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Goodman C, Kachur SP, Abdulla S, Bloland P, Mills A. Concentration and drug prices in the retail market for malaria treatment in rural Tanzania. HEALTH ECONOMICS 2009; 18:727-742. [PMID: 19301420 PMCID: PMC2689512 DOI: 10.1002/hec.1473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The impact of market concentration has been little studied in markets for ambulatory care in the developing world, where the retail sector often accounts for a high proportion of treatments. This study begins to address this gap through an analysis of the consumer market for malaria treatment in rural areas of three districts in Tanzania. We developed methods for investigating market definition, sales volumes and concentration, and used these to explore the relationship between antimalarial retail prices and competition.The market was strongly geographically segmented and highly concentrated in terms of antimalarial sales. Antimalarial prices were positively associated with market concentration. High antimalarial prices were likely to be an important factor in the low proportion of care-seekers obtaining appropriate treatment.Retail sector distribution of subsidised antimalarials has been proposed to increase the coverage of effective treatment, but this analysis indicates that local market power may prevent such subsidies from being passed on to rural customers. Policymakers should consider the potential to maintain lower retail prices by decreasing concentration among antimalarial providers and recommending retail price levels.
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Affiliation(s)
- Catherine Goodman
- Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Hetzel MW, Dillip A, Lengeler C, Obrist B, Msechu JJ, Makemba AM, Mshana C, Schulze A, Mshinda H. Malaria treatment in the retail sector: knowledge and practices of drug sellers in rural Tanzania. BMC Public Health 2008; 8:157. [PMID: 18471299 PMCID: PMC2405791 DOI: 10.1186/1471-2458-8-157] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 05/09/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Throughout Africa, the private retail sector has been recognised as an important source of antimalarial treatment, complementing formal health services. However, the quality of advice and treatment at private outlets is a widespread concern, especially with the introduction of artemisinin-based combination therapies (ACTs). As a result, ACTs are often deployed exclusively through public health facilities, potentially leading to poorer access among parts of the population. This research aimed at assessing the performance of the retail sector in rural Tanzania. Such information is urgently required to improve and broaden delivery channels for life-saving drugs. METHODS During a comprehensive shop census in the districts of Kilombero and Ulanga, Tanzania, we interviewed 489 shopkeepers about their knowledge of malaria and malaria treatment. A complementary mystery shoppers study was conducted in 118 retail outlets in order to assess the vendors' drug selling practices. Both studies included drug stores as well as general shops. RESULTS Shopkeepers in drug stores were able to name more malaria symptoms and were more knowledgeable about malaria treatment than their peers in general shops. In drug stores, 52% mentioned the correct child-dosage of sulphadoxine-pyrimethamine (SP) compared to only 3% in general shops. In drug stores, mystery shoppers were more likely to receive an appropriate treatment (OR = 9.6), but at an approximately seven times higher price. Overall, adults were more often sold an antimalarial than children (OR = 11.3). On the other hand, general shopkeepers were often ready to refer especially children to a higher level if they felt unable to manage the case. CONCLUSION The quality of malaria case-management in the retail sector is not satisfactory. Drug stores should be supported and empowered to provide correct malaria-treatment with drugs they are allowed to dispense. At the same time, the role of general shops as first contact points for malaria patients needs to be re-considered. Interventions to improve availability of ACTs in the retail sector are urgently required within the given legal framework.
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Affiliation(s)
- Manuel W Hetzel
- Dept. of Public Health and Epidemiology, Swiss Tropical Institute, PO Box, CH-4002 Basel, Switzerland.
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Goodman C, Kachur SP, Abdulla S, Bloland P, Mills A. Drug shop regulation and malaria treatment in Tanzania--why do shops break the rules, and does it matter? Health Policy Plan 2007; 22:393-403. [PMID: 17921151 DOI: 10.1093/heapol/czm033] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Regulatory infringements are extremely common in low-income countries, especially with respect to retail pharmaceutical sales. There have been few practical suggestions on public policy responses other than stricter regulatory enforcement, which governments are often unable, or unwilling, to do. This paper explores the challenges of regulating retail drug sellers, and potential solutions, through a case study of malaria treatment in rural Tanzania where small drug shops are a common source of medicine. Infringement of health-related regulation was extremely common. Most stores lacked valid permits, and illegal stocking of prescription-only medicines and unpackaged tablets was the norm. Most stocked unregistered drugs, and no serving staff met the qualification requirements. Infringements are likely to have reflected infrequent regulatory inspections, a failure of regulatory authorities to implement sanctions, successful concealment of regulatory violations, and the tacit permission of local regulatory staff. Eliminating regulatory infringements is unlikely to be feasible, and could be undesirable if access to essential medicines is reduced. Alternatives include bringing official drug regulation closer into line with locally legitimate practices; greater use of positive incentives for providers; and consumer involvement. Such a change in approach has the potential to provide a firmer platform for public-private collaboration to improve shop-based treatment.
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Affiliation(s)
- Catherine Goodman
- Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Obrist B, Iteba N, Lengeler C, Makemba A, Mshana C, Nathan R, Alba S, Dillip A, Hetzel MW, Mayumana I, Schulze A, Mshinda H. Access to health care in contexts of livelihood insecurity: a framework for analysis and action. PLoS Med 2007; 4:1584-8. [PMID: 17958467 PMCID: PMC2039761 DOI: 10.1371/journal.pmed.0040308] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The authors present a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa.
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Affiliation(s)
- Brigit Obrist
- Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland.
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Rafael ME, Taylor T, Magill A, Lim YW, Girosi F, Allan R. Reducing the burden of childhood malaria in Africa: the role of improved. Nature 2007; 444 Suppl 1:39-48. [PMID: 17159893 DOI: 10.1038/nature05445] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maria E Rafael
- RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, California 90401-2138, USA
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Hetzel MW, Iteba N, Makemba A, Mshana C, Lengeler C, Obrist B, Schulze A, Nathan R, Dillip A, Alba S, Mayumana I, Khatib RA, Njau JD, Mshinda H. Understanding and improving access to prompt and effective malaria treatment and care in rural Tanzania: the ACCESS Programme. Malar J 2007; 6:83. [PMID: 17603898 PMCID: PMC1925101 DOI: 10.1186/1475-2875-6-83] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 06/29/2007] [Indexed: 12/05/2022] Open
Abstract
Background Prompt access to effective treatment is central in the fight against malaria. However, a variety of interlinked factors at household and health system level influence access to timely and appropriate treatment and care. Furthermore, access may be influenced by global and national health policies. As a consequence, many malaria episodes in highly endemic countries are not treated appropriately. Project The ACCESS Programme aims at understanding and improving access to prompt and effective malaria treatment and care in a rural Tanzanian setting. The programme's strategy is based on a set of integrated interventions, including social marketing for improved care seeking at community level as well as strengthening of quality of care at health facilities. This is complemented by a project that aims to improve the performance of drug stores. The interventions are accompanied by a comprehensive set of monitoring and evaluation activities measuring the programme's performance and (health) impact. Baseline data demonstrated heterogeneity in the availability of malaria treatment, unavailability of medicines and treatment providers in certain areas as well as quality problems with regard to drugs and services. Conclusion The ACCESS Programme is a combination of multiple complementary interventions with a strong evaluation component. With this approach, ACCESS aims to contribute to the development of a more comprehensive access framework and to inform and support public health professionals and policy-makers in the delivery of improved health services.
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Affiliation(s)
- Manuel W Hetzel
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Nelly Iteba
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Ahmed Makemba
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Christopher Mshana
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Christian Lengeler
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
| | - Brigit Obrist
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
| | - Alexander Schulze
- Novartis Foundation for Sustainable Development, WRO-1002.11.56, CH-4002 Basel, Switzerland
| | - Rose Nathan
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Angel Dillip
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Sandra Alba
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
| | - Iddy Mayumana
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Rashid A Khatib
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Joseph D Njau
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
| | - Hassan Mshinda
- Ifakara Health Research and Development Centre, P.O. Box 53, Ifakara, Tanzania
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Use of over-the-counter malaria medicines in children and adults in three districts in Kenya: implications for private medicine retailer interventions. Malar J 2007; 6:57. [PMID: 17493270 PMCID: PMC1872028 DOI: 10.1186/1475-2875-6-57] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 05/10/2007] [Indexed: 11/29/2022] Open
Abstract
Background Global malaria control strategies highlight the need to increase early uptake of effective antimalarials for childhood fevers in endemic settings, based on a presumptive diagnosis of malaria in this age group. Many control programmes identify private medicine sellers as important targets to promote effective early treatment, based on reported widespread inadequate childhood fever treatment practices involving the retail sector. Data on adult use of over-the-counter (OTC) medicines is limited. This study aimed to assess childhood and adult patterns of OTC medicine use to inform national medicine retailer programmes in Kenya and other similar settings. Methods Large-scale cluster randomized surveys of treatment seeking practices and malaria parasite prevalence were conducted for recent fevers in children under five years and recent acute illnesses in adults in three districts in Kenya with differing malaria endemicity. Results A total of 12, 445 households were visited and data collected on recent illnesses in 11, 505 children and 19, 914 adults. OTC medicines were the most popular first response to fever in children with fever (47.0%; 95% CI 45.5, 48.5) and adults with acute illnesses (56.8%; 95% CI 55.2, 58.3). 36.9% (95% CI 34.7, 39.2) adults and 22.7% (95% CI 20.9, 24.6) children using OTC medicines purchased antimalarials, with similar proportions in low and high endemicity districts. 1.9% (95% CI 0.8, 4.2) adults and 12.1% (95% CI 16.3,34.2) children used multidose antimalarials appropriately. Although the majority of children and adults sought no further treatment, self-referral to a health facility within 72 hours of illness onset was the commonest pattern amongst those seeking further help. Conclusion In these surveys, OTC medicines were popular first treatments for fever in children or acute illnesses in adults. The proportions using OTC antimalarials were similar in areas of high and low malaria endemicity. In all districts, adults were more likely to self-treat with OTC antimalarial medicines than febrile children were to receive them, and less likely to use them in recommended ways. Government health centres were the most common second resort for treatment and were often used within 72 hours. In view of these practices, more research is needed to assess the impact on the popularity of private medicine sellers of strengthened public sector policies on access to malaria treatment and insecticide-treated bed nets. Improved targeting of OTC antimalarials to high risk groups, better communication strategies regarding adult as well as children's dosages, and facilitating more rapid referral to trained health workers where needed are important challenges to private medicine seller programmes.
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Hetzel MW, Msechu JJ, Goodman C, Lengeler C, Obrist B, Kachur SP, Makemba A, Nathan R, Schulze A, Mshinda H. Decreased availability of antimalarials in the private sector following the policy change from chloroquine to sulphadoxine-pyrimethamine in the Kilombero Valley, Tanzania. Malar J 2006; 5:109. [PMID: 17105662 PMCID: PMC1654173 DOI: 10.1186/1475-2875-5-109] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Accepted: 11/14/2006] [Indexed: 11/28/2022] Open
Abstract
Background Malaria control strategies emphasize the need for prompt and effective treatment of malaria episodes. To increase treatment efficacy, Tanzania changed its first-line treatment from chloroquine to sulphadoxine-pyrimethamine (SP) in 2001. The effect of this policy change on the availability of antimalarials was studied in rural south-eastern Tanzania. Methods In 2001 and 2004, the study area was searched for commercial outlets selling drugs and their stocks were recorded. Household information was obtained from the local Demographic Surveillance System. Results From 2001 to 2004, the number of general shops stocking drugs increased by 15% and the number of drug stores nearly doubled. However, the proportion of general shops stocking antimalarials dropped markedly, resulting in an almost 50% decrease of antimalarial selling outlets. This led to more households being located farther from a treatment source. In 2004, five out of 25 studied villages with a total population of 13,506 (18%) had neither a health facility, nor a shop as source of malaria treatment. Conclusion While the change to SP resulted in a higher treatment efficacy, it also led to a decreased antimalarial availability in the study area. Although there was no apparent impact on overall antimalarial use, the decline in access may have disproportionately affected the poorest and most remote groups. In view of the imminent policy change to artemisinin-based combination therapy these issues need to be addressed urgently if the benefits of this new class of antimalarials are to be extended to the whole population.
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Affiliation(s)
- Manuel W Hetzel
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | - June J Msechu
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | - Catherine Goodman
- Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Christian Lengeler
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
| | - Brigit Obrist
- Department of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland
| | - S Patrick Kachur
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
- U. S. Public Health Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ahmed Makemba
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | - Rose Nathan
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
| | | | - Hassan Mshinda
- Ifakara Health Research and Development Centre, Ifakara, Tanzania
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Kamat VR. “I thought it was only ordinary fever!” cultural knowledge and the micropolitics of therapy seeking for childhood febrile illness in Tanzania. Soc Sci Med 2006; 62:2945-59. [PMID: 16403595 DOI: 10.1016/j.socscimed.2005.11.042] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2005] [Indexed: 10/25/2022]
Abstract
Economic considerations are often cited as important determinants of health-seeking behavior. This paper describes a situation in peri-urban Tanzania where user fees do not constitute the primary reason why mothers delay seeking prompt treatment at a public health facility for their young, febrile children. Mothers commonly believe that they are dealing with an ordinary fever and not malaria or any other serious illness complicated by fever. Hence, they engage in extended home-based treatment. Drawing upon an ethnographic study, this paper illustrates how cultural knowledge about disease symptomatology, cultural meanings associated with febrile illness, gender relations, and patterns of communication between health care providers and mothers significantly influence outcomes for childhood febrile illnesses. It is argued that an overemphasis on the correlation between user fees and treatment delays with regard to childhood illnesses tends to divert attention from other significant cultural factors and existing structural constraints that influence the dynamics of health care seeking and health outcomes. At a time when calls to implement artemisinine-based combination therapy as one of the front-line strategies in Tanzania are increasingly frequent, there is a need to pay closer attention to the contextual factors and socio-cultural dynamics that influence patterns of treatment-seeking for childhood malaria.
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Affiliation(s)
- Vinay R Kamat
- University of British Columbia, Vancouver, BC, Canada.
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50
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Patrick Kachur S, Schulden J, Goodman CA, Kassala H, Elling BF, Khatib RA, Causer LM, Mkikima S, Abdulla S, Bloland PB. Prevalence of malaria parasitemia among clients seeking treatment for fever or malaria at drug stores in rural Tanzania 2004. Trop Med Int Health 2006; 11:441-51. [PMID: 16553927 DOI: 10.1111/j.1365-3156.2006.01588.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the prevalence of malaria parasitemia and other common illnesses among drug store clients in one rural community, with a view to the potential role of specialist drug stores in expanding coverage of effective malaria treatment to households in highly endemic areas. METHOD Follow-back study of 2466 client visits selected from all 10 drug stores operating in the town of Ikwiriri between May 30 and August 31 2004. Of these, 521 (21.2%) were made by or on behalf of persons ill with fever or malaria. Two hundred and ninety three were eligible as residents of the surrounding nine villages and all agreed to participate in the study. Each patient was evaluated by a clinical officer and provided a blood sample for malaria on the day of the shop visit, either at the shop or at home. RESULTS Only 50 (17.1%) visits by or on behalf of febrile patients resulted in the purchase of an antimalarial drug, while an antipyretic medication was obtained at 226 visits (77.1%). Clinicians diagnosed malaria in 63.8% of patients. Malaria parasites were identified in blood film samples from 24.2% (95% CI: 19.6, 29.5). This is double the parasite prevalence rate of 10.7% (95% CI: 8.6, 13.1) obtained from a household survey of 1004 healthy individuals selected from these villages at the same time. It is not significantly lower than the prevalence observed among 880 clients presenting with fever at health facilities in the district: 29.7% (95% CI: 23.0, 37.3). The prevalence of malaria parasitemia among children younger than 5 years whose families sought fever treatment from drug stores (42.1%; 95% CI: 31.4, 53.5) was equal to that of children presenting with fever at health facilities (42.5%; 95% CI: 25.0, 62.2). CONCLUSIONS Currently, drug store clients do not obtain malaria-specific treatment in the majority of cases where it might be warranted. Parasitological findings indicate that drug store clients, especially children, are as likely to be infected with malaria as patients seeking care for similar illnesses at health facilities. Drug stores may be attractive partners for policy makers eager to engage the private retail sector in expanding coverage of malaria treatment.
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Affiliation(s)
- S Patrick Kachur
- Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA.
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