title: Impact of introducing subsidized combination treatment with artemether-lumefantrine on sales of anti-malarial monotherapies: a survey of private sector pharmacies in Huambo, Angola.
abstract: Artemisinin-based combination therapies (ACTs) against malaria are subsidized in many African countries, but the impact of subsidy programs in reducing the sales of concomitantly available antimalarial monotherapies is poorly defined.
  
  
  
  Data from The MENTOR initiative, that introduced subsidized artemether-lumefantrine (sAL) in the private sector of Huambo province, Angola, were used. The main response variable was represented by sales of sAL and of monotherapies, measured as number of treatment courses. Sales in private pharmacies of sAL and four antimalarial monotherapies between 2009 and 2013 were organized in four time-periods, and analyzed using generalized linear models for repeated measures. A secondary analysis evaluated changes in relative market share.
  
  
  
  We analyzed data from 34 pharmacies at four time points, taken from a larger survey that involved 165 pharmacies between June 2009 and March 2013. The sAL, following its introduction, became the dominant antimalarial treatment in the private sector, usually exceeding the total sales of all antimalarial monotherapies combined (1480/2800 total treatment courses, 52.8% of all sales in March 2013). Sales of monotherapies decreased significantly, but did not stop, representing 36.7% (1028/2800) of sales at the end of the survey.
  
  
  
  Subsidized ACTs can attain rapidly a high relative market share. Their introduction reduced, but did not eliminate the demand for less effective monotherapies, that might favor parasite resistance.
authors.affiliation: Population Services International, Luanda, Angola clussiana@psi.org.
authors.forename: Cristina
authors.initials: C
authors.lastname: Lussiana
authors.affiliation: Istituto Superiore di Sanitá, Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanità, Rome, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Floridia
authors.affiliation: The MENTOR Initiative, Huambo, Angola.
authors.forename: Joana
authors.initials: J
authors.lastname: Martinho do Rosário
authors.affiliation: National Malaria Control Programme, Ministry of Health, Luanda, Angola.
authors.forename: Filomeno
authors.initials: F
authors.lastname: Fortes
authors.affiliation: The MENTOR Initiative, London, United Kingdom.
authors.forename: Richard
authors.initials: R
authors.lastname: Allan
mesh_terms: D000810:Angola; D000962:Antimalarials / Q000191:economics* / Q000600:supply & distribution; D000077549:Artemether; D037621:Artemisinins / Q000191:economics* / Q000627:therapeutic use; D016527:Drug Costs; D004359:Drug Therapy, Combination; D004983:Ethanolamines / Q000191:economics* / Q000627:therapeutic use; D005380:Financing, Government / Q000191:economics*; D005449:Fluorenes / Q000191:economics* / Q000627:therapeutic use; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D000078102:Lumefantrine; D008288:Malaria / Q000188:drug therapy* / Q000191:economics; D008389:Marketing of Health Services; D010594:Pharmacies / Q000191:economics / Q000706:statistics & numerical data; D017149:Private Sector / Q000191:economics
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004983:Ethanolamines; D005449:Fluorenes; D000077549:Artemether; D000078102:Lumefantrine
keywords: Affordable Medicines Facility-malaria (AMFm); Artemether-lumefantrine; Artemisinin; Malaria; Monotherapies