1
|
Woldeghebriel M, Aso E, Berlin E, Fashanu C, Kirumira SN, Lam F, Mugerwa R, Nakiganda J, Olaleye T, Opigo J, Osinupebi F, Priestley N, Stringham R, Uhomoibhi P, Visser T, Ward A, Wiwa O, Woolsey A. Assessing availability, prices, and market share of quality-assured malaria ACT and RDT in the private retail sector in Nigeria and Uganda. Malar J 2024; 23:41. [PMID: 38321459 PMCID: PMC10848491 DOI: 10.1186/s12936-024-04863-9] [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: 08/04/2023] [Accepted: 01/25/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND An estimated 50% of suspected malaria cases in sub-Saharan Africa first seek care in the private sector, especially in private medicine retail outlets. Quality of care in these outlets is generally unknown but considered poor with many patients not receiving a confirmatory diagnosis or the recommended first-line artemisinin-based combination therapy (ACT). In 2010, a subsidy pilot scheme, the Affordable Medicines Facility malaria, was introduced to crowd out the use of monotherapies in favour of WHO-pre-qualified artemisinin-based combinations (WHO-PQ-ACTs) in the private health sector. The scheme improved the availability, market share, and cost of WHO-PQ-ACTs in countries like Nigeria and Uganda, but in 2018, the subsidies were halted in Nigeria and significantly reduced in Uganda. This paper presents findings from six retail audit surveys conducted from 2014 to 2021 in Nigeria and Uganda to assess whether the impact of subsidies on the price, availability, and market share of artemisinin-based combinations has been sustained after the subsidies were reduced or discontinued. METHODS Six independent retail audits were conducted in private medicine retail outlets, including pharmacies, drug shops, and clinics in Nigeria (2016, 2018, 2021), and Uganda (2014, 2019, 2020) to assess the availability, price, and market share of anti-malarials, including WHO-PQ-ACTs and non-WHO-PQ-ACTs, and malaria rapid diagnostic tests (RDTs). RESULTS Between 2016 and 2021, there was a 57% decrease in WHO-PQ-ACT availability in Nigeria and a 9% decrease in Uganda. During the same period, non-WHO-PQ-ACT availability increased in Nigeria by 41% and by 34% in Uganda. The price of WHO-PQ-ACTs increased by 42% in Nigeria to $0.68 and increased in Uganda by 24% to $0.95. The price of non-WHO-PQ-ACTs decreased in Nigeria by 26% to $1.08 and decreased in Uganda by 64% to $1.23. There was a 76% decrease in the market share of WHO-PQ-ACTs in Nigeria and a 17% decrease in Uganda. Malaria RDT availability remained low throughout. CONCLUSION With the reduction or termination of subsidies for WHO-PQ-ACTs in Uganda and Nigeria, retail prices have increased, and retail prices of non-WHO-PQ-ACTs decreased, likely contributing to a shift of higher availability and increased use of non-WHO-PQ-ACTs.
Collapse
Affiliation(s)
| | - Ezinne Aso
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Erica Berlin
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | | | | | - Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Robert Mugerwa
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | | | - Tayo Olaleye
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Jimmy Opigo
- National Malaria Control Division, Ministry of Health, Kampala, Uganda
| | | | | | | | | | - Theodoor Visser
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Abigail Ward
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Owens Wiwa
- Clinton Health Access Initiative, Abuja, Nigeria
| | - Aaron Woolsey
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Ocan M, Bakubi R, Tayebwa M, Basemera J, Nsobya S. Experiences of healthcare personnel on the efficacy of artemisinin-based combination therapy and malaria diagnosis in hospitals in Uganda. Malar J 2023; 22:362. [PMID: 38012717 PMCID: PMC10683277 DOI: 10.1186/s12936-023-04800-2] [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: 07/23/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND The risk of widespread resistance to artemisinin-based combination therapy (ACT) remains high in Uganda following detection of Plasmodium falciparum parasites with delayed artemisinin clearance genotype and phenotype. Establishment of context specific interventions to mitigate emergence and spread of artemisinin resistance is thus key in the fight against malaria in the country. The aim of this study was to explore the experiences of healthcare personnel on malaria diagnosis and self-reported efficacy of ACT in the management of malaria symptomatic patients in hospitals in low and high malaria transmission settings in Uganda. METHODS This was a qualitative study in which data was collected from healthcare personnel in hospitals using key informant interviews. The key informant interview guide was developed, pre-tested prior to use and covered the following areas, (i) sociodemographic characteristics, (ii) malaria diagnosis (clinical and parasite based), (iii) quality-assured artemisinin-based combination therapy, (iv) malaria patient follow-up, (v) artemisinin resistance, (vi) anti-malarial self-medication. Data was entered in Atlas.ti ver 9.0 and analysis done following a framework criterion. RESULTS A total of 22 respondents were interviewed of which 16 (72.7%) were clinicians. Majority, 81.8% (18/22) of the respondents were male. The following themes were developed from the analysis, malaria diagnosis (procedures and challenges), use of malaria laboratory test results, malaria treatment in hospitals, use of quality assured ACT (QAACT) in malaria treatment, and efficacy of ACT in malaria treatment. CONCLUSION Most healthcare personnel-initiated malaria treatment after a positive laboratory test. Cases of malaria patients who report remaining symptomatic after prior use of ACT exist especially in high malaria transmission settings in Uganda. There is need for regular monitoring of artemisinin resistance emergence and spread in the country.
Collapse
Affiliation(s)
- Moses Ocan
- Department of Pharmacology & Therapeutics, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Racheal Bakubi
- Department of Health Policy, Planning and Management, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Mordecai Tayebwa
- Grants office, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Joan Basemera
- Department of Immunology and Molecular Biology, College of Health Sciences, P. O. Box 7072, Kampala, Uganda
| | - Sam Nsobya
- Infectious Disease Research Collaboration (IDRC), P. O. Box 7475, Kampala, Uganda
| |
Collapse
|
3
|
Tougher S, Hanson K, Goodman CA. Does subsidizing the private for-profit sector benefit the poor? Evidence from national antimalarial subsidies in Nigeria and Uganda. HEALTH ECONOMICS 2021; 30:2510-2530. [PMID: 34291524 DOI: 10.1002/hec.4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 06/13/2023]
Abstract
Subsidising quality-assured artemisinin combination therapies (QAACTs) for distribution in the for-profit sector is a controversial strategy for improving access. The Affordable Medicines Facility-malaria (AMFm) was the largest initiative of this kind. We assessed the equity of AMFm in two ways using nationally representative household survey data on care seeking for children from Nigeria and Uganda. First, the delivery of subsidized drugs through the for-profit sector via AMFm was compared with two alternative mechanisms: subsidized delivery in public health facilities and unsubsidized delivery in the for-profit sector. Second, we developed a novel extension of benefit incidence analysis (BIA) methods based on the concept of pass-through, and applied them to Uganda. In Nigeria, the use of subsidized QAACTs from both public health facilities and for-profit outlets was concentrated among the rich, while in Uganda, the use of QAACTs from both sources was concentrated among the poor. Similarly, the BIA of AMFm found that the intervention was pro-poor in Uganda. Unsubsidized antimalarials from for-profit outlets were distributed equally across wealth quintiles in both countries. Private sector subsidies may have a role in bolstering access to effective malaria treatments, including among the poor, but the equity impact of subsidies may depend on context.
Collapse
Affiliation(s)
- Sarah Tougher
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Kara Hanson
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine A Goodman
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
4
|
Riley C, Dellicour S, Ouma P, Kioko U, Omar A, Kariuki S, Ng'ang'a Z, Desai M, Buff AM, Gutman JR. Knowledge and Adherence to the National Guidelines for Malaria Diagnosis in Pregnancy among Health-Care Providers and Drug-Outlet Dispensers in Rural Western Kenya. Am J Trop Med Hyg 2018; 98:1367-1373. [PMID: 29512480 DOI: 10.4269/ajtmh.17-0594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Prompt diagnosis and effective treatment of acute malaria in pregnancy (MiP) is important for the mother and fetus; data on health-care provider adherence to diagnostic guidelines in pregnancy are limited. From September to November 2013, a cross-sectional survey was conducted in 51 health facilities and 39 drug outlets in Western Kenya. Provider knowledge of national diagnostic guidelines for uncomplicated MiP were assessed using standardized questionnaires. The use of parasitologic testing was assessed in health facilities via exit interviews with febrile women of childbearing age and in drug outlets via simulated-client scenarios, posing as pregnant women or their spouses. Overall, 93% of providers tested for malaria or accurately described signs and symptoms consistent with clinical malaria. Malaria was parasitologically confirmed in 77% of all patients presenting with febrile illness at health facilities and 5% of simulated clients at drug outlets. Parasitological testing was available in 80% of health facilities; 92% of patients evaluated at these facilities were tested. Only 23% of drug outlets had malaria rapid diagnostic tests (RDTs); at these outlets, RDTs were offered in 17% of client simulations. No differences were observed in testing rates by pregnancy trimester. The study highlights gaps among health providers in diagnostic knowledge and practice related to MiP, and the lack of malaria diagnostic capacity, particularly in drug outlets. The most important factor associated with malaria testing of pregnant women was the availability of diagnostics at the point of service. Interventions that increase the availability of malaria diagnostic services might improve malaria case management in pregnant women.
Collapse
Affiliation(s)
- Christina Riley
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Peter Ouma
- KEMRI, Centre for Global Health Research, Kisumu, Kenya
| | - Urbanus Kioko
- Malaria Control Unit, Ministry of Health, Nairobi, Kenya
| | - Ahmeddin Omar
- Malaria Control Unit, Ministry of Health, Nairobi, Kenya
| | - Simon Kariuki
- KEMRI, Centre for Global Health Research, Kisumu, Kenya
| | - Zipporah Ng'ang'a
- College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia and Kenya
| | - Ann M Buff
- U.S. President's Malaria Initiative, Nairobi, Kenya.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia and Kenya
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia and Kenya
| |
Collapse
|
5
|
Quakyi IA, Adjei GO, Sullivan DJ, Stephens JK, Laar A, Ama Aubyn VN, Owusu R, Sakyi KS, Coleman N, Krampa FD, Vanotoo L, Tuakli J, Bortei BB, Essuman E, Sorvor F, Boateng IA, Bart-Plange C, Addison EA, Winch P, Adjei AA. Targeted community based interventions improved malaria management competencies in rural Ghana. Glob Health Res Policy 2017; 2:29. [PMID: 29202097 PMCID: PMC5683319 DOI: 10.1186/s41256-017-0048-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Malaria is one of the most challenging public health concerns in the developing world. To address its impact in endemic regions, several interventions are implemented by stakeholders. The Affordable Medicine Facility-malaria (AMFm) is an example of such interventions. Its activities include communication interventions to enhance the knowledge of caregivers of children under five years, licensed chemical sellers (LCS) and prescribers on malaria management with artemisinin-based combination therapy (ACT). This study was conducted to evaluate the effectiveness of the AMFm activities on malaria among targeted groups in two rural communities in Ghana. Methods A communication intervention study was conducted in the Asante-Akim North and South Districts of Ghana. Repeated cross-sectional pre and post surveys were deployed. Relevant malaria messages were designed and used to develop the information, education and communication (IEC) tools for the intervention. With the aid of posters and flipcharts developed by our study, community health workers (CHWs), prescribers, and licenced chemical sellers provided proper counselling to clients on malaria management. Trained CHWs and community based volunteers educated caregivers of children under five years on malaria management at their homes and at public gatherings such as churches, mosques, schools. Chi-square tests and logistic regression were run to determine associations and control for demographic differences respectively. Results There was significantly high exposure to malaria/ACT interventions in the intervention district than in the comparison district (OR = 16.02; 95% CI = 7.88–32.55) and same for malaria/ACT-related knowledge (OR = 3.63; 95% CI = 2.52–5.23). The participants in the intervention district were also more knowledgeable about correct administration of dispersible drug for children <5 years than their counterparts in the unexposed district. Conclusion Our data show that targeted interventions improve malaria based competences in rural community settings. The availability of subsidized ACTs and the intensity of the communication campaigns contributed to the AMFm-related awareness, improved knowledge on malaria/ACTs and management practices.
Collapse
Affiliation(s)
- 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
| | - George O Adjei
- Office of Research, Innovation and Development, 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
| | - 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
| | - Amos Laar
- Department of Population, Family, and Reproductive Health, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Richmond Owusu
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - 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
| | - 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
| | - Francis D Krampa
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, 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
| | - 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
| | - 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
| | - Isaac A Boateng
- Asante-Akim Central Municipal Health Directorate, Ghana Health Services, Konongo, Ghana
| | - Constance Bart-Plange
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Ebenezer A Addison
- Kpone Katamanso District Health Directorate, Ghana Health Services, Kpone, Tema, 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
| | - Andrew A Adjei
- Worldwide Universities Network, University of Ghana, P.O. Box LG 13, Legon, Accra, Ghana
| |
Collapse
|
6
|
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: 30] [Impact Index Per Article: 4.3] [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.
Collapse
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
| |
Collapse
|
7
|
Kaula H, Buyungo P, Opigo J. Private sector role, readiness and performance for malaria case management in Uganda, 2015. Malar J 2017; 16:219. [PMID: 28545583 PMCID: PMC5445348 DOI: 10.1186/s12936-017-1824-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/18/2017] [Indexed: 12/04/2022] Open
Abstract
Background Several interventions have been put in place to promote access to quality malaria case management services in Uganda’s private sector, where most people seek treatment. This paper describes evidence using a mixed-method approach to examine the role, readiness and performance of private providers at a national level in Uganda. These data will be useful to inform strategies and policies for improving malaria case management in the private sector. Methods The ACTwatch national anti-malarial outlet survey was conducted concurrently with a fever case management study. The ACTwatch nationally representative anti-malarial outlet survey was conducted in Uganda between May 18th 2015 and July 2nd 2015. A representative sample of sub-counties was selected in 14 urban and 13 rural clusters with probability proportional to size and a census approach was used to identify outlets. Outlets eligible for the survey met at least one of three criteria: (1) one or more anti-malarials were in stock on the day of the survey; (2) one or more anti-malarials were in stock in the 3 months preceding the survey; and/or (3) malaria blood testing (microscopy or RDT) was available. The fever case management study included observations of provider-patient interactions and patient exit interviews. Data were collected between May 20th and August 3rd, 2015. The fever case management study was implemented in the private sector. Potential outlets were identified during the main outlet survey and included in this sub-sample if they had both artemisinin-based combination therapy (ACT) [artemether–lumefantrine (AL)], in stock on the day of survey as well as diagnostic testing available. Results A total of 9438 outlets were screened for eligibility in the ACTwatch outlet survey and 4328 outlets were found to be stocking anti-malarials and were interviewed. A total of 9330 patients were screened for the fever case management study and 1273 had a complete patient observation and exit interview. Results from the outlet survey illustrate that the majority of anti-malarials were distributed through the private sector (54.3%), with 31.4% of all anti-malarials distributed through drug stores and 14.4% through private for-profit health facilities. Availability of different anti-malarials and diagnostic testing in the private sector was: ACT (80.7%), quality-assured (QA) ACT (72.0%), sulfadoxine–pyrimethamine (SP) (47.1%), quinine (73.2%) and any malaria blood testing (32.9%). Adult QAACT ($1.62) was three times more expensive than SP ($0.48). The results from the fever case management study found 44.4% of respondents received a malaria test, and among those who tested positive for malaria, 60.0% received an ACT, 48.5% received QAACT; 14.4% a non-artemisinin therapy; 14.9% artemether injection, and 42.5% received an antibiotic. Conclusion The private sector plays an important role in malaria case management in Uganda. While several private sector initiatives have improved availability of QAACT, there are gaps in malaria diagnosis and distribution of non-artemisinin monotherapies persists. Further private sector strategies, including those focusing on drug stores, are needed to increase coverage of parasitological testing and removal of non-artemisinin therapies from the marketplace. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1824-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Henry Kaula
- Programme for Accessible Communication and Education (PACE) Uganda, Plot # 2, Ibis Vale, Kololo-off Prince Charles Drive, Kampala, Uganda.
| | - Peter Buyungo
- Programme for Accessible Communication and Education (PACE) Uganda, Plot # 2, Ibis Vale, Kololo-off Prince Charles Drive, Kampala, Uganda
| | - Jimmy Opigo
- National Malaria Control Programme, Ministry of Health, Kampala, Uganda
| |
Collapse
|
8
|
Newton PN, Hanson K, Goodman C. Do anti-malarials in Africa meet quality standards? The market penetration of non quality-assured artemisinin combination therapy in eight African countries. Malar J 2017; 16:204. [PMID: 28539125 PMCID: PMC5444102 DOI: 10.1186/s12936-017-1818-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/11/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Quality of artemisinin-based combination therapy (ACT) is important for ensuring malaria parasite clearance and protecting the efficacy of artemisinin-based therapies. The extent to which non quality-assured ACT (non-QAACT), or those not granted global regulatory approval, are available and used to treat malaria in endemic countries is poorly documented. This paper uses national and sub-national medicine outlet surveys conducted in eight study countries (Benin, Kinshasa and Kantanga [Democratic Republic of the Congo, DRC], Kenya, Madagascar, Nigeria, Tanzania, Uganda and Zambia) between 2009 and 2015 to describe the non-QAACT market and to document trends in availability and distribution of non-QAACT in the public and private sector. RESULTS In 2014/15, non-QAACT were most commonly available in Kinshasa (83%), followed by Katanga (53%), Nigeria (48%), Kenya (42%), and Uganda (33%). Non-QAACT accounted for 20% of the market share in the private sector in Kenya, followed by Benin and Uganda (19%), Nigeria (12%) and Zambia (8%); this figure was 27% in Katanga and 40% in Kinshasa. Public sector non-QAACT availability and distribution was much lower, with the exception of Zambia (availability, 85%; market share, 32%). Diverse generics and formulations were available, but non-QAACT were most commonly artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DHA PPQ), in tablet formulation, imported, and distributed in urban areas at either pharmacies or drug stores. The number of unique manufacturers supplying non-QAACT to each country ranged from 9 in Uganda to 92 in Nigeria. CONCLUSIONS Addressing the availability and distribution of non-QAACT will require effective private sector engagement and evidence-based strategies to address provider and consumer demand for these products. Given the variation in non-QAACT markets observed across the eight study countries, active efforts to limit registration, importation and distribution of non-QAACT must be tailored to the country context, and will involve addressing complex and challenging aspects of medicine registration, private sector pharmaceutical regulation, local manufacturing and drug importation. These efforts may be critical not only to patient health and safety, but also to effective malaria control and protection of artemisinin drug efficacy in the face of spreading resistance.
Collapse
Affiliation(s)
- Paul N. Newton
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH UK
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH UK
| |
Collapse
|
9
|
Zinsou C, Cherifath AB. The malaria testing and treatment landscape in Benin. Malar J 2017; 16:174. [PMID: 28446236 PMCID: PMC5405537 DOI: 10.1186/s12936-017-1808-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/06/2017] [Indexed: 11/20/2022] Open
Abstract
Background Since 2004, artemisinin-based combination therapy (ACT) has been the first-line treatment for uncomplicated malaria in Benin. In 2016, a medicine outlet survey was implemented to investigate the availability, price, and market share of anti-malarial treatment and malaria diagnostics. Results provide a timely and important benchmark to measure future interventions aimed at increasing access to quality malaria case management services. Methods Between July 5th to August 6th 2016, a cross sectional, nationally-representative malaria outlet survey was conducted in Benin. A census of all public and private outlets with potential to distribute malaria testing and/or treatment was implemented among 30 clusters (arrondissements). Outlets were eligible for inclusion in the study if they met at least one of three study criteria: (1) one or more anti-malarials reportedly in stock on the day of the survey; (2) one or more anti-malarials reportedly in stock within the 3 months preceding the survey; and/or (3) provided malaria blood testing. An audit was completed for all anti-malarials, malaria rapid diagnostic tests (RDT) and microscopy. Results 7260 outlets with the potential to sell or distribute anti-malarials were included in the census and 2966 were eligible and interviewed. A total of 17,669 anti-malarial and 494 RDT products were audited. Quality-assured ACT was available in 95.0% of all screened public health facilities and 59.4% of community health workers (CHW), and availability of malaria blood testing was 94.7 and 68.4% respectively. Sulfadoxine–pyrimethamine (SP) was available in 73.9% of public health facilities and not found among CHWs. Among private-sector outlets stocking at least one anti-malarial, non-artemisinin therapies were most commonly available (94.0% of outlets) as compared to quality-assured ACT (36.1%). 31.3% of the ACTs were marked with a “green leaf” logo, suggesting leakage of a co-paid ACT into Benin’s unsubsidized ACT market from another country. 78.5% of the anti-malarials distributed were through the private sector, typically through general retailers (47.6% of all anti-malarial distribution). ACT comprised 44% of the private anti-malarial market share. Private-sector price of quality-assured ACT ($1.35) was three times more expensive than SP ($0.42) or chloroquine ($0.41). Non-artemisinin therapies were cited as the most effective treatment for uncomplicated malaria among general retailers and itinerant drug vendors. Conclusions The ACTwatch data has shown the importance of the private sector in terms of access to malaria treatment for the majority of the population in Benin. These findings highlight the need for increased engagement with the private sector to improve malaria case management and an immediate need for a national ACT subsidy. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1808-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Cyprien Zinsou
- Association Beninoise pour le Marketing Social, Lot 919 Immeuble Montcho, Sikecodji, Cotonou, Republic of Benin.
| | | |
Collapse
|
10
|
Tougher S, Hanson K, Goodman C. What happened to anti-malarial markets after the Affordable Medicines Facility-malaria pilot? Trends in ACT availability, price and market share from five African countries under continuation of the private sector co-payment mechanism. Malar J 2017; 16:173. [PMID: 28441956 PMCID: PMC5405529 DOI: 10.1186/s12936-017-1814-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/09/2017] [Indexed: 12/02/2022] Open
Abstract
Background The private sector supplies anti-malarial treatment for large proportions of patients in sub-Saharan Africa. Following the large-scale piloting of the Affordable Medicines Facility-malaria (AMFm) from 2010 to 2011, a private sector co-payment mechanism (CPM) provided continuation of private sector subsidies for quality-assured artemisinin combination therapies (QAACT). This article analyses for the first time the extent to which improvements in private sector QAACT supply and distribution observed during the AMFm were maintained or intensified during continuation of the CPM through 2015 in Kenya, Madagascar, Nigeria, Tanzania and Uganda using repeat cross-sectional outlet survey data. Results QAACT market share in all five countries increased during the AMFm period (p < 0.001). According to the data from the last ACTwatch survey round, in all study countries except Madagascar, AMFm levels of private sector QAACT availability were maintained or improved. In 2014/15, private sector QAACT availability was greater than 70% in Nigeria (84.3%), Kenya (70.5%), Tanzania (83.0%) and Uganda (77.1%), but only 11.2% in Madagascar. QAACT market share was maintained or improved post-AMFm in Nigeria, Tanzania and Uganda, but statistically significant declines were observed in Kenya and Madagascar. In 2014/5, QAACT market share was highest in Kenya and Uganda (48.2 and 47.5%, respectively) followed by Tanzania (39.2%), Nigeria (35.0%), and Madagascar (7.0%). Four of the five countries experienced significant decreases in median QAACT price during the AMFm period. Private sector QAACT prices were maintained or further reduced in Tanzania, Nigeria and Uganda, but prices increased significantly in Kenya and Madagascar. SP prices were consistently lower than those of QAACT in the AMFm period, with the exception of Kenya and Tanzania in 2011, where they were equal. In 2014/5 QAACT remained two to three times more expensive than the most popular non-artemisinin therapy in all countries except Tanzania. Conclusions Results suggest that a private sector co-payment mechanism for QAACT implemented at national scale for 5 years was associated with positive and sustained improvements in QAACT availability, price and market share in Nigeria, Tanzania and Uganda, with more mixed results in Kenya, and few improvements in Madagascar. The subsidy mechanism as implemented over time across countries was not sufficient on its own to achieve optimal QAACT uptake. Supporting interventions to address continued availability and distribution of non-artemisinin therapies, and to create demand for QAACT among providers and consumers need to be effectively implemented to realize the full potential of this subsidy mechanism. Furthermore, there is need for comprehensive market assessments to identify contemporary market barriers to high coverage with both confirmatory testing and appropriate treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1814-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Sarah Tougher
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH, UK
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WCH 9SH, UK
| |
Collapse
|
11
|
Michael D, Mkunde SP. The malaria testing and treatment landscape in mainland Tanzania, 2016. Malar J 2017; 16:202. [PMID: 28521811 PMCID: PMC5437635 DOI: 10.1186/s12936-017-1819-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/11/2017] [Indexed: 11/10/2022] Open
Abstract
Background Understanding the key characteristics of malaria testing and treatment is essential to the control of a disease that continues to pose a major risk of morbidity and mortality in mainland Tanzania, with evidence of a resurgence of the disease in recent years. The introduction of artemisinin combination therapy (ACT) as the first-line treatment for malaria, alongside policies to promote rational case management following testing, highlights the need for evidence of anti-malarial and testing markets in the country. The results of the most recent mainland Tanzania ACTwatch outlet survey are presented here, including data on the availability, market share and price of anti-malarials and malaria diagnosis in 2016. Methods A nationally-representative malaria outlet survey was conducted between 18th May and 2nd July, 2016. A census of public and private outlets with potential to distribute malaria testing and/or treatment was conducted among a representative sample of administrative units. An audit was completed for all anti-malarials, malaria rapid (RDT) diagnostic tests and microscopy. Results A total of 5867 outlets were included in the nationally representative survey, across both public and private sectors. In the public sector, availability of malaria testing was 92.3% and quality-assured (QA) ACT was 89.1% among all screened outlets. Sulfadoxine–pyrimethamine (SP) was stocked by 51.8% of the public sector and injectable artesunate was found in 71.4% of all screened public health facilities. Among anti-malarial private-sector stockists, availability of testing was 15.7, and 65.1% had QA ACT available. The public sector accounted for 83.4% of the total market share for malaria diagnostics. The private sector accounted for 63.9% of the total anti-malarial market, and anti-malarials were most commonly distributed through accredited drug dispensing outlets (ADDOs) (39.0%), duka la dawa baridi (DLDBs) (13.3%) and pharmacies (6.7%). QA ACT comprised 33.1% of the national market share (12.2% public sector and 20.9% private sector). SP accounted for 53.3% of the total market for anti-malarials across both private and public sectors (31.3 and 22.0% of the total market, respectively). The median price per adult equivalent treatment dose (AETD) of QA ACT in the private sector was $1.40, almost 1.5 times more expensive than the median price per AETD of SP ($1.05). In the private sector, 79.3% of providers perceived ACT to be the most effective treatment for uncomplicated malaria for adults and 88.4% perceived this for children. Conclusions While public sector preparedness for appropriate malaria testing and case management is showing encouraging signs, QA ACT availability and market share in the private sector continues to be sub-optimal for most outlet types. Furthermore, it is concerning that SP continues to predominate in the anti-malarial market. The reasons for this remain unclear, but are likely to be in part related to price, availability and provider knowledge or preferences. Continued efforts to implement government policy around malaria diagnosis and case management should be encouraged. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1819-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
| | - Daniel Michael
- PSI/Tanzania, Plot # 1347/48 Masaki, Msasani Peninsula, Haile Selassie Road, PO Box 33500, Dar es Salaam, Tanzania.
| | | |
Collapse
|
12
|
Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
Collapse
Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
13
|
Ansah EK, Whitty CJ, Bart-Plange C, Gyapong M. Changes in the availability and affordability of subsidised artemisinin combination therapy in the private drug retail sector in rural Ghana: before and after the introduction of the AMFm subsidy. Int Health 2016; 8:427-432. [PMID: 27744327 PMCID: PMC5181550 DOI: 10.1093/inthealth/ihw041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/24/2016] [Accepted: 08/09/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Most people with febrile illness are treated in the private drug retail sector. Ghana was among nine countries piloting the Global Fund Affordable Medicines Facility - malaria (AMFm). AMFm aimed to: increase artemisinin combination therapy (ACT) affordability; increase ACT availability; increase ACT use; and 'crowd out' artemisinin monotherapies. METHODS Three censuses were carried out 2 months before (2010), 2 months after and 2.5 years after (2013) the first co-paid ACTs to assess changes in antimalarial (AM) availability and price in private retail shops in a Ghanaian rural district to assess the sustainability of the initial gains. Supply, stock-out and cost were explored. RESULTS Of 62 shops in the district, 56 participated with 398, 388 and 442 brands of AMs in the shops during the 3 censuses. The proportion of ACTs increased over the period while monotherapies reduced. Herbal-based AM preparations comprised 40-45% of AMs in stock with minimal variation over the period. ACTs were the most sold AM type for all ages but overall buying and selling prices of Quality Assured-ACTs increased by 40-100%. CONCLUSIONS Initial gains in ACT availability were sustained, but not improved on 2.5 years after AMFm. Widespread availability of unproven herbal medicines is a concern; AMFm had little impact on this.
Collapse
Affiliation(s)
- Evelyn K Ansah
- Dangme West District Health Directorate, Ghana Health Service, P.O. Box DD1, Dodowa, Ghana
| | | | - Constance Bart-Plange
- National Malaria Control Programme, Ghana Health Service, P.O. Box KB493, Korle-Bu, Accra, Ghana
| | - Margaret Gyapong
- Dodowa Health Research Center, Ghana Health Service, P.O. Box DD1, Dodowa, Ghana
| |
Collapse
|
14
|
Lussiana C. Towards subsidized malaria rapid diagnostic tests. Lessons learned from programmes to subsidise artemisinin-based combination therapies in the private sector: a review. Health Policy Plan 2016; 31:928-39. [PMID: 25862732 PMCID: PMC4977424 DOI: 10.1093/heapol/czv028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2015] [Indexed: 11/14/2022] Open
Abstract
The idea of a private sector subsidy programme of artemisinin-based combination therapies (ACTs) was first proposed in 2004. Since then, several countries around the world have hosted pilot projects or programmes on subsidized ACTs and/or the Affordable Medicines Facility-malaria programme (AMFm). Overall the private sector subsidy programmes of ACTs have been effective in increasing availability of ACTs in the private sector and driving down average prices but struggled to crowd out antimalarial monotherapies. The results obtained from this ambitious strategy should inform policy makers in the designing of future interventions aimed to control malaria morbidity and mortality. Among the interventions recently proposed, a subsidy of rapid diagnostic tests (RDTs) in the private sector has been recommended by governments and international donors to cope with over-treatment with ACTs and to delay the emergence of resistance to artemisinin. In order to improve the cost-effectiveness of co-paid RDTs, we should build on the lessons we learned from almost 10 years of private sector subsidy programmes of ACTs in malaria-endemic countries.
Collapse
|
15
|
Wiysonge CS, Abdullahi LH, Ndze VN, Hussey GD. Public stewardship of private for-profit healthcare providers in low- and middle-income countries. Cochrane Database Syst Rev 2016; 2016:CD009855. [PMID: 27510030 PMCID: PMC5014877 DOI: 10.1002/14651858.cd009855.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Governments use different approaches to ensure that private for-profit healthcare services meet certain quality standards. Such government guidance, referred to as public stewardship, encompasses government policies, regulatory mechanisms, and implementation strategies for ensuring accountability in the delivery of services. However, the effectiveness of these strategies in low- and middle-income countries (LMICs) have not been the subject of a systematic review. OBJECTIVES To assess the effects of public sector regulation, training, or co-ordination of the private for-profit health sector in low- and middle-income countries. SEARCH METHODS For related systematic reviews, we searched the Cochrane Database of Systematic Reviews (CDSR) 2015, Issue 4; Database of Abstracts of Reviews of Effectiveness (DARE) 2015, Issue 1; Health Technology Assessment Database (HTA) 2015, Issue 1; all part of The Cochrane Library, and searched 28 April 2015. For primary studies, we searched MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 16 June 2016); Science Citation Index and Social Sciences Citation Index 1987 to present, and Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 3 May 2016 for papers citing included studies); Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 3, part of The Cochrane Library (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 28 April 2015); Embase 1980 to 2015 Week 17, OvidSP (searched 28 April 2015); Global Health 1973 to 2015 Week 16, OvidSP (searched 30 April 2015); WHOLIS, WHO (searched 30 April 2015); Science Citation Index and Social Sciences Citation Index 1975 to present, ISI Web of Science (searched 30 April 2015); Health Management, ProQuest (searched 22 November 2013). In addition, in April 2016, we searched the reference lists of relevant articles, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and various electronic databases of grey literature. SELECTION CRITERIA Randomised trials, non-randomised trials, interrupted time series studies, or controlled before-after studies. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and extracted data, comparing their results and resolving discrepancies by consensus. We expressed study results as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI), where appropriate, and assessed the certainty of the evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). We did not conduct meta-analysis because of heterogeneity of interventions and study designs. MAIN RESULTS We identified 20,177 records, 50 of them potentially eligible. We excluded 39 potentially eligible studies because they did not involve a rigorous evaluation of training, regulation, or co-ordination of private for-profit healthcare providers in LMICs; five studies identified after the review was submitted are awaiting assessment; and six studies met our inclusion criteria. Two included studies assessed training alone; one assessed regulation alone; three assessed a multifaceted intervention involving training and regulation; and none assessed co-ordination. All six included studies targeted private for-profit pharmacy workers in Africa and Asia.Three studies found that training probably increases sale of oral rehydration solution (one trial in Kenya, 106 pharmacies: RR 3.04, 95% CI 1.37 to 6.75; and one trial in Indonesia, 87 pharmacies: RR 1.41, 95% CI 1.03 to 1.93) and dispensing of anti-malarial drugs (one trial in Kenya, 293 pharmacies: RR 8.76, 95% CI 0.94 to 81.81); moderate-certainty evidence.One study conducted in the Lao People's Democratic Republic shows that regulation of the distribution and sale of registered pharmaceutical products may improve composite pharmacy indicators (one trial, 115 pharmacies: improvements in four of six pharmacy indicators; low-certainty evidence).The outcome in three multifaceted intervention studies was the quality of pharmacy practice; including the ability to ask questions, give advice, and provide appropriate treatment. The trials applied regulation, training, and peer influence in sequence; and the study design does not permit separation of the effects of the different interventions. Two trials conducted among 136 pharmacies in Vietnam found that the multifaceted intervention may improve the quality of pharmacy practice; but the third study, involving 146 pharmacies in Vietnam and Thailand, found that the intervention may have little or no effects on the quality of pharmacy practice (low-certainty evidence).Only two studies (both conducted in Vietnam) reported cost data, with no rigorous assessment of the economic implications of implementing the interventions in resource-constrained settings. No study reported data on equity, mortality, morbidity, adverse effects, satisfaction, or attitudes. AUTHORS' CONCLUSIONS Training probably improves quality of care (i.e. adherence to recommended practice), regulation may improve quality of care, and we are uncertain about the effects of co-ordination on quality of private for-profit healthcare services in LMICs. The likelihood that further research will find the effect of training to be substantially different from the results of this review is moderate; implying that monitoring of the impact is likely to be needed if training is implemented. The low certainty of the evidence for regulation implies that the likelihood of further research finding the effect of regulation to be substantially different from the results of this review is high. Therefore, an impact evaluation is warranted if government regulation of private for-profit providers is implemented in LMICs. Rigorous evaluations of these interventions should also assess other outcomes such as impacts on equity, cost implications, mortality, morbidity, and adverse effects.
Collapse
Affiliation(s)
- Charles S Wiysonge
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
- South African Medical Research CouncilCochrane South AfricaCape TownSouth Africa
| | - Leila H Abdullahi
- University of Cape TownVaccines for Africa Initiative, Institute of Infectious Disease and Molecular MedicineAnzio RoadCape TownSouth Africa7925
| | - Valantine N Ndze
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
| | - Gregory D Hussey
- University of Cape TownVaccines for Africa Initiative, Institute of Infectious Disease and Molecular MedicineAnzio RoadCape TownSouth Africa7925
| | | |
Collapse
|
16
|
Khin HSS, Aung T, Thi A, White C. Oral artemisinin monotherapy removal from the private sector in Eastern Myanmar between 2012 and 2014. Malar J 2016; 15:286. [PMID: 27216408 PMCID: PMC4877749 DOI: 10.1186/s12936-016-1292-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/13/2016] [Indexed: 11/19/2022] Open
Abstract
Background In 2012 the Artemisinin Monotherapy Therapy Replacement (AMTR) project was implemented in Eastern Myanmar to increase access to subsidized, quality-assured artemisinin combination therapy (ACT) and to remove oral artemisinin monotherapy (AMT) from the private sector. The aim of this paper is to examine changes over time in the private sector anti-malarial landscape and to illustrate the value of complementary interventions in the context of a national ACT subsidy. Methods Three rounds of cross-sectional malaria medicine outlet surveys were conducted, in 2012, 2013 and 2014. Project intervention areas were selected from the Myanmar Artemisinin Resistance Containment (MARC) area. Provider detailing was implemented in these selected areas. Comparison areas were selected outside of this catchment area, from townships in close proximity to the MARC framework. Within each domain, multi-staged sampling was used to select areas for the survey. Outlets with the potential to sell or distribute anti-malarials in the private sector were screened for eligibility. Results The total number of outlets approached for an interview was as follows in the intervention and comparison areas, respectively: 2012, N = 2046 and 1612; 2013, N = 1636 and 1884; 2014, N = 2939 and 2941. The percentage of pharmacies, general retailers and mobile providers (classed as ‘priority outlets’) with oral AMT in stock on the day of the survey decreased over time in the intervention areas (2012 = 68 %; 2013 = 48 %; 2014 = 10 %). Conversely, quality-assured ACT availability increased among these outlets (2012 = 4 %; 2013 = 62 %; 2014 = 79 %). Relative oral AMT market share among priority outlets also decreased over time (2012 = 44 %; 2013 = 18 %; 2014 = 14 %), while market share of quality-assured ACT increased (2012 = 3 %; 2013 = 59 %; 2014 = 51 %). Among priority outlets in the comparison area, similar trends were observed, though changes over time were less substantial compared to the intervention area. Other outlet types (community health workers and health facilities) performed relatively well over time though modest improvements were also observed. Conclusion The findings point to the successful design and implementation of a strategy to rapidly remove oral AMT from pharmacies, general retailers and mobile providers and to replace its use with quality-assured ACT. The evidence also highlights the importance of supporting interventions in the context of a high-level subsidy. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1292-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Hnin Su Su Khin
- Population Services International Myanmar, No. 16, Shwe Gon Taing Street 4, Yangon, Myanmar.
| | - Tin Aung
- Population Services International Myanmar, No. 16, Shwe Gon Taing Street 4, Yangon, Myanmar
| | - Aung Thi
- National Malaria Control Program, Department of Public Health, Ministry of Health, Naypyidaw, Myanmar
| | - Chris White
- Division of Global Policy & Advocacy, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | | |
Collapse
|
17
|
Hargreaves JRM, Goodman C, Davey C, Willey BA, Avan BI, Schellenberg JRA. Measuring implementation strength: lessons from the evaluation of public health strategies in low- and middle-income settings. Health Policy Plan 2016; 31:860-7. [PMID: 26965038 PMCID: PMC4977426 DOI: 10.1093/heapol/czw001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 11/28/2022] Open
Abstract
Evaluation of strategies to ensure evidence-based, low-cost interventions reach those in need is critical. One approach is to measure the strength, or intensity, with which packages of interventions are delivered, in order to explore the association between implementation strength and public health gains. A recent systematic review suggested methodological guidance was needed. We described the approaches used in three examples of measures of implementation strength in evaluation. These addressed important public health topics with a substantial disease burden in low-and middle-income countries; they involved large-scale implementation; and featured evaluation designs without comparison areas. Strengths and weaknesses of the approaches were discussed. In the evaluation of Ethiopia’s Health Extension Programme, implementation strength scoring for each kebele (ward) was based on aggregated data from interviews with mothers of children aged 12–23 months, reflecting their reports of contact with four elements of the programme. An evaluation of the Avahan HIV prevention programme in India used the cumulative amount of Avahan funding per HIV-infected person spent each year in each district. In these cases, a single measure was developed and the association with hypothesised programme outcomes presented. In the evaluation of the Affordable Medicines Facility—malaria, several implementation strength measures were developed based on the duration of activity of the programme and the level of implementation of supporting interventions. Measuring the strength of programme implementation and assessing its association with outcomes is a promising approach to strengthen pragmatic impact evaluation. Five key aspects of developing an implementation strength measure are to: (a) develop a logic model; (b) identify aspects of implementation to be assessed; (c) design and implement data collection from a range of data sources; (d) decide whether and how to combine data into a single measure; and, (e) plan whether and how to use the measure(s) in outcome analysis.
Collapse
Affiliation(s)
| | | | | | | | - Bilal Iqbal Avan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | |
Collapse
|