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.
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.
Alba
Sandra
S
Dept. Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland. sandra.alba@unibas.ch
Hetzel
Manuel W
MW
Goodman
Catherine
C
Dillip
Angel
A
Liana
Jafari
J
Mshinda
Hassan
H
Lengeler
Christian
C
D000962:Antimalarials / Q000600:supply & distribution* / Q000627:therapeutic use; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000600:supply & distribution* / Q000627:therapeutic use; D003132:Commerce / Q000379:methods*; D004338:Drug Combinations; D004983:Ethanolamines / Q000600:supply & distribution* / Q000627:therapeutic use; D005449:Fluorenes / Q000600:supply & distribution* / Q000627:therapeutic use; D006297:Health Services Accessibility; D006801:Humans; D008137:Longitudinal Studies; D008288:Malaria / Q000188:drug therapy*; D017149:Private Sector / Q000458:organization & administration; D019035:Rural Health Services / Q000600:supply & distribution; D012424:Rural Population; D013636:Tanzania / Q000453:epidemiology
D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes