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London School of Hygiene & Tropical Medicine Malaria Centre

Malaria research in social and economic studies

Evaluation of a pilot ACT subsidy programme in two rural districts in Tanzania.

LSHTM investigators:
Catherine Goodman.
External collaborators:
Oliver Sabot, Lorrayne Ward, Justin Cohen, Yahya Ipuge & Megumi Gordon (Clinton Foundation, USA); David Bishop (HLSP, UK); Alex Mwita (National Malaria Control Programme, Tanzania); Moses Odhiambo (Steadman Group).
Funding body:
Clinton Health Access Initiative.

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.

Three districts were assigned to serve as a control or 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-pyramethamine, 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).

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.