title: The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention?
abstract: BACKGROUND
  To assess the availability, price and market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention.
  
  
  METHODS
  Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country.
  
  
  RESULTS
  QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001).
  
  
  CONCLUSIONS
  The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.
authors.affiliation: ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA. yazoume.ye@icfi.com.
authors.forename: Yazoume
authors.initials: Y
authors.lastname: Ye
authors.affiliation: ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA. fred.arnold@icfi.com.
authors.forename: Fred
authors.initials: F
authors.lastname: Arnold
authors.affiliation: KEMRI/Wellcome Trust, Nairobi, Kenya. anoor@nairobi.kemri-wellcome.org.
authors.forename: Abdisalan
authors.initials: A
authors.lastname: Noor
authors.affiliation: African Population and Health Research Center, Nairobi, Kenya. mwamukoya@aphrc.org.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Wamukoya
authors.affiliation: Kumasi Centre for Collaborative Research in Tropical Medicine, Kumasi, Ghana. amuas001@umn.edu.
authors.forename: John
authors.initials: J
authors.lastname: Amuasi
authors.affiliation: Komfo Anokye Teaching Hospital, Kumasi, Ghana. sbnguah@gmail.com.
authors.forename: Samuel
authors.initials: S
authors.lastname: Blay
authors.affiliation: African Population and Health Research Center, Nairobi, Kenya. bmberu@aphrc.org.
authors.forename: Blessing
authors.initials: B
authors.lastname: Mberu
authors.affiliation: ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA. Ruilin.Ren@icfi.com.
authors.forename: Ruilin
authors.initials: R
authors.lastname: Ren
authors.affiliation: African Population and Health Research Center, Nairobi, Kenya. ckyobutungi@aphrc.org.
authors.forename: Catherine
authors.initials: C
authors.lastname: Kyobutungi
authors.affiliation: African Population and Health Research Center, Nairobi, Kenya. fwekesah@aphrc.org.
authors.forename: Frederick
authors.initials: F
authors.lastname: Wekesah
authors.affiliation: ICF International, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA. Hellen.Gatakaa@icfi.com.
authors.forename: Hellen
authors.initials: H
authors.lastname: Gatakaa
authors.affiliation: Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan. mitsuru.toda@gmail.com.
authors.forename: Mitsuru
authors.initials: M
authors.lastname: Toda
authors.affiliation: The ACTwatch project (Population Services International), Nairobi, Kenya. jngigi@psi.org.
authors.forename: Julius
authors.initials: J
authors.lastname: Njogu
authors.affiliation: The ACTwatch project (Population Services International), Nairobi, Kenya. illah@psi.org.
authors.forename: Illah
authors.initials: I
authors.lastname: Evance
authors.affiliation: The ACTwatch project (Population Services International), Nairobi, Kenya. kaoconnell@hotmail.com.
authors.forename: Kathryn
authors.initials: K
authors.lastname: O'Connell
authors.affiliation: The ACTwatch project (Population Services International), Nairobi, Kenya. shewchuktanya@yahoo.com.
authors.forename: Tanya
authors.initials: T
authors.lastname: Shewchuk
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. Sarah.Tougher@lshtm.ac.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Thougher
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. Andrea.Mann@lshtm.ac.uk.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mann
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. Barbara.Willey@lshtm.ac.uk.
authors.forename: Barbara
authors.initials: B
authors.lastname: Willey
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. Catherine.Goodman@lshtm.ac.uk.
authors.forename: Catherine
authors.initials: C
authors.lastname: Goodman
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK. Kara.Hanson@lshtm.ac.uk.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
mesh_terms: D000962:Antimalarials / Q000627:therapeutic use*; D037621:Artemisinins / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D004359:Drug Therapy, Combination / Q000379:methods; D005843:Geography; D005869:Ghana; D006297:Health Services Accessibility; D006801:Humans; D007630:Kenya; D007783:Lactones / Q000627:therapeutic use*; D008288:Malaria / Q000188:drug therapy*
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D007783:Lactones; C075875:artemisin