title: Monitoring fever treatment behaviour and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries.
abstract: BACKGROUND
  Access to artemisinin-based combination therapy (ACT) remains limited in high malaria-burden countries, and there are concerns that the poorest people are particularly disadvantaged. This paper presents new evidence on household treatment-seeking behaviour in six African countries. These data provide a baseline for monitoring interventions to increase ACT coverage, such as the Affordable Medicines Facility for malaria (AMFm).
  
  
  METHODS
  Nationally representative household surveys were conducted in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia between 2008 and 2010. Caregivers responded to questions about management of recent fevers in children under five. Treatment indicators were tabulated across countries, and differences in case management provided by the public versus private sector were examined using chi-square tests. Logistic regression was used to test for association between socioeconomic status and 1) malaria blood testing, and 2) ACT treatment.
  
  
  RESULTS
  Fever treatment with an ACT is low in Benin (10%), the DRC (5%), Madagascar (3%) and Nigeria (5%), but higher in Uganda (21%) and Zambia (21%). The wealthiest children are significantly more likely to receive ACT compared to the poorest children in Benin (OR = 2.68, 95% CI = 1.12-6.42); the DRC (OR = 2.18, 95% CI = 1.12-4.24); Madagascar (OR = 5.37, 95% CI = 1.58-18.24); and Nigeria (OR = 6.59, 95% CI = 2.73-15.89). Most caregivers seek treatment outside of the home, and private sector outlets are commonly the sole external source of treatment (except in Zambia). However, children treated in the public sector are significantly more likely to receive ACT treatment than those treated in the private sector (except in Madagascar). Nonetheless, levels of testing and ACT treatment in the public sector are low. Few caregivers name the national first-line drug as most effective for treating malaria in Madagascar (2%), the DRC (2%), Nigeria (4%) and Benin (10%). Awareness is higher in Zambia (49%) and Uganda (33%).
  
  
  CONCLUSIONS
  Levels of effective fever treatment are low and inequitable in many contexts. The private sector is frequently accessed however case management practices are relatively poor in comparison with the public sector. Supporting interventions to inform caregiver demand for ACT and to improve provider behaviour in both the public and private sectors are needed to achieve maximum gains in the context of improved access to effective treatment.
authors: Population Services International, Malaria & Child Survival Department, PO Box 43640, Nairobi, Kenya, Africa. mlittrell@psi.org
authors: Megan
authors: M
authors: Littrell
authors: Hellen
authors: H
authors: Gatakaa
authors: Illah
authors: I
authors: Evance
authors: Stephen
authors: S
authors: Poyer
authors: Julius
authors: J
authors: Njogu
authors: Tsione
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authors: Solomon
authors: Erik
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authors: Munroe
authors: Steven
authors: S
authors: Chapman
authors: Catherine
authors: C
authors: Goodman
authors: Kara
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authors: Hanson
authors: Cyprien
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authors: Zinsou
authors: Louis
authors: L
authors: Akulayi
authors: Jacky
authors: J
authors: Raharinjatovo
authors: Ekundayo
authors: E
authors: Arogundade
authors: Peter
authors: P
authors: Buyungo
authors: Felton
authors: F
authors: Mpasela
authors: Cherifatou Bello
authors: CB
authors: Adjibabi
authors: Jean Angbalu
authors: JA
authors: Agbango
authors: Benjamin Fanomezana
authors: BF
authors: Ramarosandratana
authors: Babajide
authors: B
authors: Coker
authors: Denis
authors: D
authors: Rubahika
authors: Busiku
authors: B
authors: Hamainza
authors: Tanya
authors: T
authors: Shewchuk
authors: Desmond
authors: D
authors: Chavasse
authors: Kathryn A
authors: KA
authors: O'Connell
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use*; D002675:Child, Preschool; D004359:Drug Therapy, Combination / Q000379:methods; D005335:Fever of Unknown Origin / Q000188:drug therapy*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007783:Lactones / Q000627:therapeutic use*; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D007783:Lactones; C075875:artemisin