title: Price subsidies increase the use of private sector ACTs: evidence from a systematic review.
abstract: BACKGROUND
  Although artemisinin combination therapies (ACTs) are the recommended first-line treatment for uncomplicated malaria in most endemic countries, they have been prohibitively expensive in the retail sector where many suspected malaria cases purchase treatment. ACT subsidies seek to stimulate consumer demand for the drugs over cheaper but often ineffective alternatives by reducing their prices. Recent evidence from eight regions implementing such subsidies suggests that they are generally successful in improving availability of the drugs and decreasing their retail prices, but it remains unclear whether these outcomes translate to improved use by patients with suspected malaria.
  
  
  METHODS
  A systematic literature review was conducted to identify reports of experimental or programmatic ACT subsidies to assess the impact of subsidies on consumer use. Relationships between price, use and potential confounding factors were examined using logistic and repeated measures binomial regression models, and approximate magnitudes of associations were assessed with linear regression. In total, 40 studies, 14 peer-reviewed and 26 non-peer-reviewed, were eligible for inclusion in the analysis. The reviewed studies found a substantial increase in private sector ACT use following the introduction of a subsidy. Overall, each $1 decrease in price was linked to a 24 percentage point increase in the fraction of suspected malaria cases purchasing ACTs (R(2) = 0.302). No significant differences were evident in this relationship when comparing the poorest and richest groups, rural vs urban populations or children vs adults.
  
  
  CONCLUSIONS
  These findings suggest that ACT price reductions can increase their use for suspected malaria, even within poorer, more remote populations that may be most at risk of malaria mortality. Whether a subsidy is appropriate will depend upon local context, including treatment-seeking behaviours and malaria prevalence. This review provides an initial foundation for policymakers to make evidence-based decisions regarding ACT price reductions to increase use of potentially life-saving drugs.
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Suite 400, Boston, MA, USA and Slingshot, 67 Riverside Dr. Nairobi Kenya 00100 London, UK alix.morris@gmail.com.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Morris
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Suite 400, Boston, MA, USA and Slingshot, 67 Riverside Dr. Nairobi Kenya 00100 London, UK.
authors.forename: Abigail
authors.initials: A
authors.lastname: Ward
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Suite 400, Boston, MA, USA and Slingshot, 67 Riverside Dr. Nairobi Kenya 00100 London, UK.
authors.forename: Bruno
authors.initials: B
authors.lastname: Moonen
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Suite 400, Boston, MA, USA and Slingshot, 67 Riverside Dr. Nairobi Kenya 00100 London, UK.
authors.forename: Oliver
authors.initials: O
authors.lastname: Sabot
authors.affiliation: Clinton Health Access Initiative, 383 Dorchester Avenue, Suite 400, Boston, MA, USA and Slingshot, 67 Riverside Dr. Nairobi Kenya 00100 London, UK.
authors.forename: Justin M
authors.initials: JM
authors.lastname: Cohen
mesh_terms: D000349:Africa; D000962:Antimalarials / Q000191:economics* / Q000627:therapeutic use; D037621:Artemisinins / Q000191:economics* / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006297:Health Services Accessibility; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D011306:Prescription Fees; D017149:Private Sector; D012424:Rural Population; D014505:Urban Population
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin
keywords: Subsidy; artemisinin combination therapies; malaria; systematic review