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Malaria Journal

, 16:219

ACT now: anti-malarial market complexity one decade after the introduction of artemisinin combination therapy – evidence from sub-Saharan Africa and the Greater Mekong Sub-region


BackgroundSeveral 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.

MethodsThe 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.

ResultsA 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.

ConclusionThe 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.

KeywordsPrivate sector Case management Anti-malarial ACT Diagnostics RDT AbbreviationsACTartemisinin-based combination therapy

ALartemether lumefantrine

AETDadult equivalent treatment dose

AMFmaffordable medicines facility for malaria

BCCbehaviour change communications

CHWcommunity health worker

CPMco-payment mechanism

EMAEuropean Medicines Agency

IQRinterquartile range

IPTpintermittent preventive treatment in pregnancy

mRTDmalaria rapid diagnostic test

PACEProgramme for Accessible Communication and Education

QAACTquality assured artemisinin combination therapy

SPsulfadoxine pyrimethamine

WHOWorld Health Organization

Electronic supplementary materialThe online version of this article doi:10.1186-s12936-017-1824-x contains supplementary material, which is available to authorized users.

Autor: ACTwatch Group - Henry Kaula - Peter Buyungo - Jimmy Opigo


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