title: Has Tanzania embraced the green leaf? Results from outlet and household surveys before and after implementation of the Affordable Medicines Facility-malaria.
abstract: BACKGROUND
  The Affordable Medicines Facility-malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side.
  
  
  METHODS
  Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks.
  
  
  RESULTS
  The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs.
  
  
  CONCLUSIONS
  Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom; Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Thomson
authors.affiliation: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Charles
authors.initials: C
authors.lastname: Festo
authors.affiliation: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Boniface
authors.initials: B
authors.lastname: Johanes
authors.affiliation: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Admirabilis
authors.initials: A
authors.lastname: Kalolella
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom; Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Katia
authors.initials: K
authors.lastname: Bruxvoort
authors.affiliation: Ifakara Health Institute, Dar es Salaam, Tanzania.
authors.forename: Happy
authors.initials: H
authors.lastname: Nchimbi
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Sarah
authors.initials: S
authors.lastname: Tougher
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Matthew
authors.initials: M
authors.lastname: Cairns
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom; Department of Public Health, Trnava University, Trnava, Slovakia.
authors.forename: Mark
authors.initials: M
authors.lastname: Taylor
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Immo
authors.initials: I
authors.lastname: Kleinschmidt
authors.affiliation: International Health Division, ICF International, Calverton, Maryland, United States of America.
authors.forename: Yazoume
authors.initials: Y
authors.lastname: Ye
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mann
authors.affiliation: International Health Division, ICF International, Calverton, Maryland, United States of America.
authors.forename: Ruilin
authors.initials: R
authors.lastname: Ren
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Barbara
authors.initials: B
authors.lastname: Willey
authors.affiliation: International Health Division, ICF International, Calverton, Maryland, United States of America.
authors.forename: Fred
authors.initials: F
authors.lastname: Arnold
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.affiliation: Malaria Branch, Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America.
authors.forename: S Patrick
authors.initials: SP
authors.lastname: Kachur
authors.affiliation: London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Catherine
authors.initials: C
authors.lastname: Goodman
mesh_terms: D000962:Antimalarials / Q000191:economics / Q000627:therapeutic use; D037621:Artemisinins / Q000191:economics / Q000627:therapeutic use*; D016527:Drug Costs; D005191:Family Characteristics; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends; D006306:Health Surveys / Q000379:methods*; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D010594:Pharmacies / Q000191:economics / Q000706:statistics & numerical data; D017149:Private Sector / Q000191:economics / Q000706:statistics & numerical data; D015397:Program Evaluation; D017150:Public Sector / Q000191:economics / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013636:Tanzania
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin