title: Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries.
abstract: BACKGROUND
  Artemisinin-based combination therapy (ACT) is the first-line malaria treatment throughout most of the malaria-endemic world. Data on ACT availability, price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality-assured ACT supply. This paper presents supply side data from ACTwatch outlet surveys in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia.
  
  
  METHODS
  Between March 2009 and June 2010, nationally representative surveys of outlets providing anti-malarials to consumers were conducted. A census of all outlets with the potential to provide anti-malarials was conducted in clusters sampled randomly.
  
  
  RESULTS
  28,263 outlets were censused, 51,158 anti-malarials were audited, and 9,118 providers interviewed. The proportion of public health facilities with at least one first-line quality-assured ACT in stock ranged between 43% and 85%. Among private sector outlets stocking at least one anti-malarial, non-artemisinin therapies, such as chloroquine and sulphadoxine-pyrimethamine, were widely available (> 95% of outlets) as compared to first-line quality-assured ACT (< 25%). In the public/not-for-profit sector, first-line quality-assured ACT was available for free in all countries except Benin and the DRC (US$1.29 [Inter Quartile Range (IQR): $1.29-$1.29] and $0.52[IQR: $0.00-$1.29] per adult equivalent dose respectively). In the private sector, first-line quality-assured ACT was 5-24 times more expensive than non-artemisinin therapies. The exception was Madagascar where, due to national social marketing of subsidized ACT, the price of first-line quality-assured ACT ($0.14 [IQR: $0.10, $0.57]) was significantly lower than the most popular treatment (chloroquine, $0.36 [IQR: $0.36, $0.36]). Quality-assured ACT accounted for less than 25% of total anti-malarial volumes; private-sector quality-assured ACT volumes represented less than 6% of the total market share. Most anti-malarials were distributed through the private sector, but often comprised non-artemisinin therapies, and in the DRC and Nigeria, oral artemisinin monotherapies. Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector.
  
  
  CONCLUSIONS
  These standardized, nationally representative results demonstrate the typically low availability, low market share and high prices of ACT, in the private sector where most anti-malarials are accessed, with some exceptions. The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries. The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria.
authors: Population Services International, Malaria & Child Survival Department, P.O. Box 43640, Nairobi, Kenya. koconnell@psi.org
authors: Kathryn A
authors: KA
authors: O'Connell
authors: Hellen
authors: H
authors: Gatakaa
authors: Stephen
authors: S
authors: Poyer
authors: Julius
authors: J
authors: Njogu
authors: Illah
authors: I
authors: Evance
authors: Erik
authors: E
authors: Munroe
authors: Tsione
authors: T
authors: Solomon
authors: Catherine
authors: C
authors: Goodman
authors: Kara
authors: K
authors: Hanson
authors: Cyprien
authors: C
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: Chérifatou 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: Steven
authors: S
authors: Chapman
authors: Tanya
authors: T
authors: Shewchuk
authors: Desmond
authors: D
authors: Chavasse
mesh_terms: D000349:Africa; D000962:Antimalarials / Q000191:economics* / Q000600:supply & distribution*; D037621:Artemisinins / Q000191:economics* / Q000600:supply & distribution*; D003132:Commerce / Q000706:statistics & numerical data; D004338:Drug Combinations; D019353:Endemic Diseases; D006801:Humans; D007783:Lactones / Q000191:economics* / Q000600:supply & distribution*; D008288:Malaria / Q000188:drug therapy / Q000453:epidemiology*; D017149:Private Sector; D017150:Public Sector
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; D007783:Lactones; C075875:artemisin