title: Closing the access barrier for effective anti-malarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study.
abstract: BACKGROUND
  Artemisinin-based combination therapy (ACT), the treatment of choice for uncomplicated falciparum malaria, is unaffordable and generally inaccessible in the private sector, the first port of call for most malaria treatment across rural Africa. Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to ACT in the private sector could be improved through the provision of a high level supply chain subsidy.
  
  
  METHODS
  Four intervention districts were purposefully selected to receive branded subsidized medicines - "ACT with a leaf", while the fifth district acted as the control. Baseline and evaluation outlet exit surveys and retail audits were conducted at licensed and unlicensed drug outlets in the intervention and control districts. A survey-adjusted, multivariate logistic regression model was used to analyse the intervention's impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial.
  
  
  RESULTS
  At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, "ACT with a leaf" accounted for 69% of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8% at baseline to 26.2% (95% CI: 23.2-29.2%) at evaluation in the intervention districts. In the control district, it rose modestly from 1.8% to 5.6% (95% CI: 4.0-7.3%). The odds of purchasing ACT within 24 hours in the intervention districts compared to the control was 0.46 (95% CI: 0.08-2.68, p=0.4) at baseline and significant increased to 6.11 (95% CI: 4.32-8.62, p<0.0001) at evaluation. Children less than five years of age had "ACT with a leaf" purchased for them more often than those aged above five years. There was no evidence of price gouging.
  
  
  CONCLUSIONS
  These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.
authors.affiliation: Medicines for Malaria Venture-MMV, PO Box 1826 20, rte de Pré-Bois, Geneva 15, 1215, Switzerland. atalisuna@nairobi.kemri-wellcome.org
authors.forename: Ambrose O
authors.initials: AO
authors.lastname: Talisuna
authors.forename: Penny Grewal
authors.initials: PG
authors.lastname: Daumerie
authors.forename: Andrew
authors.initials: A
authors.lastname: Balyeku
authors.forename: Timothy
authors.initials: T
authors.lastname: Egan
authors.forename: Bram
authors.initials: B
authors.lastname: Piot
authors.forename: Renia
authors.initials: R
authors.lastname: Coghlan
authors.forename: Maud
authors.initials: M
authors.lastname: Lugand
authors.forename: Godfrey
authors.initials: G
authors.lastname: Bwire
authors.forename: John Bosco
authors.initials: JB
authors.lastname: Rwakimari
authors.forename: Richard
authors.initials: R
authors.lastname: Ndyomugyenyi
authors.forename: Fred
authors.initials: F
authors.lastname: Kato
authors.forename: Maria
authors.initials: M
authors.lastname: Byangire
authors.forename: Paul
authors.initials: P
authors.lastname: Kagwa
authors.forename: Fred
authors.initials: F
authors.lastname: Sebisubi
authors.forename: David
authors.initials: D
authors.lastname: Nahamya
authors.forename: Angela
authors.initials: A
authors.lastname: Bonabana
authors.forename: Susan
authors.initials: S
authors.lastname: Mpanga-Mukasa
authors.forename: Peter
authors.initials: P
authors.lastname: Buyungo
authors.forename: Julius
authors.initials: J
authors.lastname: Lukwago
authors.forename: Allan
authors.initials: A
authors.lastname: Batte
authors.forename: Grace
authors.initials: G
authors.lastname: Nakanwagi
authors.forename: James
authors.initials: J
authors.lastname: Tibenderana
authors.forename: Kinny
authors.initials: K
authors.lastname: Nayer
authors.forename: Kishore
authors.initials: K
authors.lastname: Reddy
authors.forename: Nilesh
authors.initials: N
authors.lastname: Dokwal
authors.forename: Sylvester
authors.initials: S
authors.lastname: Rugumambaju
authors.forename: Saul
authors.initials: S
authors.lastname: Kidde
authors.forename: Jaya
authors.initials: J
authors.lastname: Banerji
authors.forename: George
authors.initials: G
authors.lastname: Jagoe
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000962:Antimalarials / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use*; D037621:Artemisinins / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use*; D002648:Child; D004359:Drug Therapy, Combination / Q000379:methods; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007783:Lactones / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use*; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D017149:Private Sector; D012424:Rural Population; D014454:Uganda; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D007783:Lactones; C075875:artemisin