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

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

Anti-malarial landscape in Myanmar: results from a nationally representative survey among community health workers and the private sector outlets in 2015/2016

Abstract Background In 2015/2016, an ACTwatch outlet survey was implemented to assess the anti-malarial and malaria testing landscape in Myanmar across four domains (Eastern, Central, Coastal, Western regions). Indicators provide an important benchmark to guide Myanmar’s new National Strategic Plan to eliminate malaria by 2030. Methods This was a cross-sectional survey, which employed stratified cluster-random sampling across four regions in Myanmar. A census of community health workers (CHWs) and private outlets with potential to distribute malaria testing and/or treatment was conducted. An audit was completed for all anti-malarials, malaria rapid diagnostic tests. Results A total of 28,664 outlets were approached and 4416 met the screening criteria. The anti-malarial market composition comprised CHWs (41.5%), general retailers (27.9%), itinerant drug vendors (11.8%), pharmacies (10.9%), and private for-profit facilities (7.9%). Availability of different anti-malarials and diagnostic testing among anti-malarial-stocking CHWs was as follows: artemisinin-based combination therapy (ACT) (81.3%), chloroquine (67.0%), confirmatory malaria test (77.7%). Less than half of the anti-malarial-stocking private sector had first-line treatment in stock: ACT (41.7%) chloroquine (41.8%), and malaria diagnostic testing was rare (15.4%). Oral artemisinin monotherapy (AMT) was available in 27.7% of private sector outlets (Western, 54.1%; Central, 31.4%; Eastern; 25.0%, Coastal; 15.4%). The private-sector anti-malarial market share comprised ACT (44.0%), chloroquine (26.6%), and oral AMT (19.6%). Among CHW the market share was ACT (71.6%), chloroquine (22.3%); oral AMT (3.8%). More than half of CHWs could correctly state the national first-line treatment for uncomplicated falciparum and vivax malaria (59.2 and 56.9%, respectively) compared to the private sector (15.8 and 13.2%, respectively). Indicators on support and engagement were as follows for CHWs: reportedly received training on malaria diagnosis (60.7%) or national malaria treatment guidelines (59.6%), received a supervisory or regulatory visit within 12 months (39.1%), kept records on number of patients tested or treated for malaria (77.3%). These indicators were less than 20% across the private sector. Conclusion CHWs have a strong foundation for achieving malaria goals and their scale-up is merited, however gaps in malaria commodities and supplies must be addressed. Intensified private sector strategies are urgently needed and must be scaled up to improve access and coverage of first-line treatments and malaria diagnosis, and remove oral AMT from the market place. Future policies and interventions on malaria control and elimination in Myanmar should take these findings into consideration across all phases of implementation

Towards achieving Abuja targets: identifying and addressing barriers to access and use of insecticides treated nets among the poorest populations in Kenya

<p>Abstract</p> <p>Background</p> <p>Ensuring that the poor and vulnerable population benefit from malaria control interventions remains a challenge for malaria endemic countries. Until recently, ownership and use of insecticides treated nets (ITNs) in most countries was low and inequitable, although coverage has increased in countries where free ITN distribution is integrated into mass vaccination campaigns. In Kenya, free ITNs were distributed to children aged below five years in 2006 through two mass campaigns. High and equitable coverage were reported after the campaigns in some districts, although national level coverage remained low, suggesting that understanding barriers to access remains important. This study was conducted to explore barriers to ownership and use of ITNs among the poorest populations before and after the mass campaigns, to identify strategies for improving coverage, and to make recommendations on how increased coverage levels can be sustained.</p> <p>Methods</p> <p>The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: cross-sectional surveys (n = 708 households), 24 focus group discussions and semi-structured interviews with 70 ITN suppliers.</p> <p>Results</p> <p>Affordability was reported as a major barrier to access but non-financial barriers were also shown to be important determinants. On the demand side key barriers to access included: mismatch between the types of ITNs supplied through interventions and community preferences; perceptions and beliefs on illness causes; physical location of suppliers and; distrust in free delivery and in the distribution agencies. Key barriers on the supply side included: distance from manufacturers; limited acceptability of ITNs provided through interventions; crowding out of the commercial sector and the price. Infrastructure, information and communication played a central role in promoting or hindering access.</p> <p>Conclusions</p> <p>Significant resources have been directed towards addressing affordability barriers through providing free ITNs to vulnerable groups, but the success of these interventions depends largely on the degree to which other barriers to access are addressed. Only if additional efforts are directed towards addressing non-financial barriers to access, will high coverage levels be achieved and sustained.</p

Action to protect the independence and integrity of global health research

Storeng KT, Abimbola S, Balabanova D, et al. Action to protect the independence and integrity of global health research. BMJ GLOBAL HEALTH. 2019;4(3): e001746

The economic costs of malaria in four Kenyan districts: do household costs differ by disease endemicity?

Background: Malaria inflicts significant costs on households and on the economy of malaria endemic countries. There is also evidence that the economic burden is higher among the poorest in a population, and that cost burdens differ significantly between wet and dry seasons. What is not clear is whether, and how, the economic burden of malaria differs by disease endemicity. The need to account for geographical and epidemiological differences in the estimation of the social and economic burden of malaria is well recognized, but there is limited data, if any, to support this argument. This study sought to contribute towards filling this gap by comparing malaria cost burdens in four Kenyan districts of different endemicity. Methods: A cross-sectional household survey was conducted during the peak malaria transmission season in the poorest areas in four Kenyan districts with differing malaria transmission patterns (n = 179 households in Bondo; 205 Gucha; 184 Kwale; 141 Makueni). Findings: There were significant differences in duration of fever, perception of fever severity and cost burdens. Fever episodes among adults and children over five years in Gucha and Makueni districts (highland endemic and low acute transmission districts respectively) lasted significantly longer than episodes reported in Bondo and Kwale districts (high perennial transmission and seasonal, intense transmission, respectively). Perceptions of illness severity also differed between districts: fevers reported among older children and adults in Gucha and Makueni districts were reported as severe compared to those reported in the other districts. Indirect and total costs differed significantly between districts but differences in direct costs were not significant. Total household costs were highest in Makueni (US$19.6 per month) and lowest in Bondo (US$ 9.2 per month). Conclusions: Cost burdens are the product of complex relationships between social, economic and epidemiological factors. The cost data presented in this study reflect transmission patterns in the four districts, suggesting that a relationship between costs burdens and the nature of transmission might exist, and that the same warrants more attention from researchers and policy makers