title: A pharmacy too far? Equity and spatial distribution of outcomes in the delivery of subsidized artemisinin-based combination therapies through private drug shops.
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.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN39125414.
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Ave, Boston MA, 02127, USA. jcohen@clintonfoundation.org.
authors.forename: Justin M
authors.initials: JM
authors.lastname: Cohen
authors.forename: Oliver
authors.initials: O
authors.lastname: Sabot
authors.forename: Kate
authors.initials: K
authors.lastname: Sabot
authors.forename: Megumi
authors.initials: M
authors.lastname: Gordon
authors.forename: Isaac
authors.initials: I
authors.lastname: Gross
authors.forename: David
authors.initials: D
authors.lastname: Bishop
authors.forename: Moses
authors.initials: M
authors.lastname: Odhiambo
authors.forename: Yahya
authors.initials: Y
authors.lastname: Ipuge
authors.forename: Lorrayne
authors.initials: L
authors.lastname: Ward
authors.forename: Alex
authors.initials: A
authors.lastname: Mwita
authors.forename: Catherine
authors.initials: C
authors.lastname: Goodman
mesh_terms: D000962:Antimalarials / Q000191:economics / Q000600:supply & distribution*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000191:economics / Q000600:supply & distribution*; D003132:Commerce / Q000458:organization & administration; D003256:Community Participation; D003710:Demography; D004338:Drug Combinations; D016527:Drug Costs; D004983:Ethanolamines / Q000191:economics / Q000600:supply & distribution*; D005380:Financing, Government; D005449:Fluorenes / Q000191:economics / Q000600:supply & distribution*; D006297:Health Services Accessibility / Q000191:economics* / Q000592:standards; D054625:Healthcare Disparities; D006801:Humans; D007407:Interviews as Topic; D010604:Pharmacy / Q000458:organization & administration*; D013636:Tanzania
chemical_list: D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes