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      Piloting the Global Subsidy: The Impact of Subsidized Artemisinin-Based Combination Therapies Distributed through Private Drug Shops in Rural Tanzania

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          Abstract

          Background

          WHO estimates that only 3% of fever patients use recommended artemisinin-based combination therapies (ACTs), partly reflecting their high prices in the retail sector from where many patients seek treatment. To overcome this challenge, a global ACT subsidy has been proposed. We tested this proposal through a pilot program in rural Tanzania.

          Methods/Principal Findings

          Three districts were assigned to serve either as a control or to receive the subsidy plus a package of supporting interventions. From October 2007, ACTs were sold at a 90% subsidy through the normal private supply chain to intervention district drug shops. Data were collected at baseline and during intervention using interviews with drug shop customers, retail audits, mystery shoppers, and audits of public and NGO facilities.

          The proportion of consumers in the intervention districts purchasing ACTs rose from 1% at baseline to 44.2% one year later (p<0.001), and was significantly higher among consumers purchasing for children under 5 than for adults (p = 0.005). No change in ACT usage was observed in the control district. Consumers paid a mean price of $0.58 for ACTs, which did not differ significantly from the price paid for sulphadoxine-pyrimethamine, the most common alternative. Drug shops in population centers were significantly more likely to stock ACTs than those in more remote areas (p<0.001).

          Conclusions

          A subsidy introduced at the top of the private sector supply chain can significantly increase usage of ACTs and reduce their retail price to the level of common monotherapies. Additional interventions may be needed to ensure access to ACTs in remote areas and for poorer individuals who appear to seek treatment at drug shops less frequently.

          Trial Registration

          Controlled-Trials.com ISRCTN39125414.

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          Most cited references6

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          Treatment seeking for malaria: a review of recent research.

          A review of literature on treatment seeking for malaria was undertaken to identify patterns of care seeking, and to assess what is known about the adequacy of the treatments used. There is considerable variation in treatment seeking patterns, with use of the official sector ranging from 10-99% and self-purchase of drugs ranging from 4-87%. The majority of malaria cases receive some type of treatment, and multiple treatments are common. The response to most episodes begins with self-treatment, and close to half of cases rely exclusively on self-treatment, usually with antimalarials. A little more than half use the official health sector or village health workers at some point, with delays averaging three or more days. Exclusive reliance on traditional methods is extremely rare, although traditional remedies are often combined with modern medicines. Although use of antimalarials is widespread, underdosing is extremely common. Further research is needed to answer the question of what proportion of true malaria cases get appropriate treatment with effective antimalarial drugs, and to identify the best strategies to improve the situation. Interventions for the private and public sector need to be developed and evaluated. More information is needed on the specific drugs used, considering resistance patterns in a particular area. In order to guide future policy development, future studies should define the nature of self-treatment, record multiple treatments and attempt to identify the proportions of all cases who begin treatment with antimalarials at standardized time intervals. Hypothetical questions were found to be of limited usefulness in estimating rates of actual treatments. Whenever possible, studies should focus on actual episodes of illness and consider supplementing retrospective surveys with prospective diary-type methods. In addition, it is important to determine the specificity of local illness terms in identifying true malaria cases and the extent to which local perceptions of severity are consistent with clinical criteria for severity and symptoms of complicated malaria.
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            Is malaria a disease of poverty? A review of the literature.

            To review the evidence on the link between malaria and poverty. Review of the published and grey literature to identify (i) the data available on the socio-economic distribution of malaria incidence and vulnerability, and (ii) the uptake of malaria control interventions. We found mixed evidence on malaria incidence, with a number of studies identifying no relationship between socio-economic status and incidence, although a larger number of studies do find a link. There is strong evidence that uptake of preventive and treatment interventions is closely related to proxies for socio-economic status. More generally, the quality of the literature examining this issue is highly variable, with many different measures of socio-economic status and often inadequate descriptions of methods of data collection and analysis in relation to socio-economic status. Important socio-economic differentials exist in access to malaria interventions, increasing the vulnerability of the poorest. More information is needed about how other methods of delivering malaria treatment and prevention can redress these inequalities.
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              Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities.

              To characterize availability of fever and malaria medicines within the retail sector in rural Tanzania, assess the likely public health implications, and identify opportunities for policy interventions to increase the coverage of effective treatment. A census of retailers selling drugs was undertaken in the areas under demographic surveillance in four Tanzanian districts, using a structured questionnaire. Drugs were stocked by two types of retailer: a large number of general retailers (n = 675) and a relatively small number of drug shops (n = 43). Almost all outlets stocked antipyretics/painkillers. One-third of general retailers stocking drugs had antimalarials, usually chloroquine alone. Almost all drug shops stocked antimalarials (98%): nearly all had chloroquine, 42% stocked quinine, 37% sulphadoxine-pyrimethamine and 30% amodiaquine. A large number of antimalarial brands were available. Population ratios indicate the relative accessibility of retail drug providers compared with health facilities. Drug shop staff generally travelled long distances to buy from drugs wholesalers or pharmacies. General retailers bought mainly from local general wholesalers, with a few general wholesalers accounting for a high proportion of all sources cited. Drugs were widely available from a large number of retail outlets. Potential negative implications include provision of ineffective drugs, confusion over brand names, uncontrolled use of antimalarials, and the availability of components of potential combination therapy regimens as monotherapies. On the other hand, this active and highly accessible retail market provides opportunities for improving the coverage of effective antimalarial treatment. Interventions targeted at all drug retailers are likely to be costly to deliver and difficult to sustain, but two promising points for targeted intervention are drug shops and selected general wholesalers. Retail quality may also be improved through consumer education, and modification of the chemical quality, packaging and price of products entering the retail distribution chain.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2009
                2 September 2009
                : 4
                : 9
                : e6857
                Affiliations
                [1 ]Malaria Control Team, Clinton Foundation HIV/AIDS Initiative, Boston, Massachusetts, United States of America
                [2 ]National Malaria Control Program, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania
                [3 ]Center for Strategic HIV/AIDS Operations Research, Clinton Foundation HIV/AIDS Initiative, Boston, Massachusetts, United States of America
                [4 ]Tanzania Country Office, Clinton Foundation HIV/AIDS Initiative, Dar es Salaam, Tanzania
                [5 ]Mott MacDonald Group Limited, Croydon, United Kingdom
                [6 ]Social Research Division, Steadman Group, Nairobi, Kenya
                [7 ]Kennedy School of Government and Harvard Business School, Harvard University, Cambridge, Massachusetts, United States of America
                [8 ]Health Policy Unit, London School of Hygiene and Tropical Medicine and Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya
                BMSI-A*STAR, Singapore
                Author notes

                Conceived and designed the experiments: OS AM YAI LW CG. Performed the experiments: YAI MG DPB MBO LW. Analyzed the data: OS JMC MG DPB LW CG. Contributed reagents/materials/analysis tools: OS AM JMC MBO CG. Wrote the paper: OS.

                Article
                09-PONE-RA-10096R1
                10.1371/journal.pone.0006857
                2730578
                19724644
                94c1faae-a4be-4fd3-9e02-a045704b1d86
                Sabot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                : 2 May 2009
                : 21 July 2009
                Page count
                Pages: 7
                Categories
                Research Article
                Infectious Diseases
                Public Health and Epidemiology/Global Health
                Public Health and Epidemiology/Infectious Diseases

                Uncategorized
                Uncategorized

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