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      Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia

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      Malaria Journal
      BioMed Central

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          Abstract

          Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.

          In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme.

          The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.

          The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.

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          Most cited references17

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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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            Access to artemisinin combination therapy for malaria in remote areas of Cambodia

            Background Malaria-endemic countries are switching antimalarial drug policy to artemisinin combination therapies (ACTs) and the global community are considering the setting up of a global subsidy mechanism in order to make them accessible and affordable. However, specific interventions may be needed to reach remote at-risk communities and to ensure that they are used appropriately. This analysis documents the coverage with ACTs versus artemisinin monotherapies, and the effectiveness of malaria outreach teams (MOTs) and Village Malaria Workers (VMWs) in increasing access to appropriate diagnosis and treatment with ACTs in Cambodia, the first country to switch national antimalarial drug policy to an ACT of artesunate and mefloquine (A+M) in 2000. Methods A cross-sectional survey was carried out in three different types of intervention area: with VMWs, MOTs and no specific interventions. Individuals with a history of fever in the last three weeks were included in the study and completed a questionnaire on their treatment seeking and drug usage behaviour. Blood was taken for a rapid diagnostic test (RDT) and data on the household socio-economic status were also obtained. Results In areas without specific interventions, only 17% (42/251) of respondents received a biological diagnosis, 8% (17/206) of respondents who received modern drug did so from a public health facility, and only 8% of them (17/210) received A+M. Worryingly, 78% (102/131) of all artemisinin use in these areas was as a monotherapy. However, both the VMW scheme and MOT scheme significantly increased the likelihood of being seen by a trained provider (Adjusted Odds Ratios (AOR) of 148 and 4 respectively) and of receiving A+M (AORs of 2.7 and 7.7 respectively). Conclusion The coverage rates of appropriate diagnosis and treatment of malaria were disappointingly low and the use of artemisinin monotherapy alarmingly high. This reflects the fragmented nature of Cambodia's health system in remote areas and the reliance placed by these communities on informal vendors from whom artemisinin monotherapies are widely available. However VMWs in particular are an effective means of improving access to malaria diagnosis and treatment. The VMW scheme and the social marketing of RDTS and blister-packaged artesunate and mefloquine have both been scaled up nationally. Case management in the public sector has also reportedly improved. Given recent concerns regarding the development of artemisinin drug resistance on the Thai-Cambodia border, the effectiveness of these measures in reducing the use of artemisinin monotherapy needs to be urgently re-evaluated.
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              Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature

              Background There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor. Methods The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations. Results A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions. Conclusion Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.
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                Author and article information

                Journal
                Malar J
                Malaria Journal
                BioMed Central
                1475-2875
                2011
                18 August 2011
                : 10
                : 243
                Affiliations
                [1 ]Department of Global Health & Development, Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
                [2 ]Population Services International, No. 29, 334 Street, Boeung Keng Kang 1, Khan Chamcar Mon, Phnom Penh, Cambodia
                [3 ]National Center for Parasitology, Entomology and Malaria Control, No 372, Preah Monivong Boulevard, Phnom Penh, Cambodia
                Article
                1475-2875-10-243
                10.1186/1475-2875-10-243
                3173399
                21851625
                b08ff98f-d209-4ce9-a248-8278837cbdbc
                Copyright ©2011 Yeung et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 31 December 2010
                : 18 August 2011
                Categories
                Case Study

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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