Trends in access to anti‐malarial treatment in the formal private sector in Uganda: an assessment of availability and affordability of first‐line anti‐malarials and diagnostics between 2007 and 2018

In 2017, the World Health Organization (WHO) African Region contributed 92% of the estimated 219 million cases of malaria that occurred worldwide [1]. Uganda has the third-highest global burden of malaria cases and contributes to 18% of the malaria cases in East and Southern Africa [2]. Malaria is highly endemic in 95% of Uganda and is the third leading cause of mortality in the country, after neonatal disorders and HIV/AIDS [3]. Pregnant women and children under 5 years of age are the most vulnerable population to malaria [4].

Early diagnosis and treatment of malaria contributes to a reduction in malaria transmission, disease burden and prevents deaths. Universal access to anti-malarial treatment is one of the key strategies of the WHO’s Global Technical Strategy for Malaria 2016–30 aiming to reduce malaria mortality rates by at least 90% by 2030 [5].

In 2006, the WHO recommended the use of artemisinin-based combination therapy (ACT) as the first-line treatment for uncomplicated malaria in the effort to address resistance of Plasmodium falciparum to monotherapies and improve treatment outcomes [6]. By 2009, there were concerns about access to quality-assured ACT medicines in many low-income countries (LMICs) that were grappling with a high burden of malaria, especially among the poorest people [7]. Low-cost medicines, for example, chloroquine and sulfadoxine, were widely available and heavily relied on for treatment of uncomplicated malaria, particularly in the private sector outlets [8, 9]. Unfortunately, however, these medicines had gradually become ineffective against malaria parasites. In addition, non-artemisinin-based therapies, artemisinin monotherapies, and low-quality artemisinin-based combinations were widely available [10].

The private sector plays a key role in the fight against malaria [11‐13]. In Uganda, the private sector is the preferred first point of contact for about 61% of households [14]. One of the key barriers of access to quality assured anti-malarial treatment is the high price for ACT medicines and malaria Rapid Diagnostic Tests (RDTs) [15]. Price is a major contributor to limited access to medicines because of its impact on affordability, especially for poor people [16]. By 2009, there were few available brands of ACT medicines in the private sector, most of them unaffordable. For example, it was not uncommon to find a dose of a quality-assured, first-line ACT medicines in private sector outlets retailing at six to 21 times higher than the most commonly sold anti-malarial monotherapy regimens (often non-artemisinin-based in composition) [17].

Furthermore, there were equity concerns; children treated for malaria in the public sector were significantly more likely to receive ACT medicines than those treated in the private sector facilities [7].

As a result, initiatives such as the Global Fund’s (GF) Affordable Medicines Facility-malaria (AMFm) pilot in 2011 and later the private sector co-payment mechanism (CPM) in 2013 were implemented to improve access to ACT in the private sector through subsidies. Subsidies supported by interventions to improve demand are important for improving the availability and affordability of ACT medicines in the private-for-profit sector [18]. The AMFm pilot comprised of three components to promote the appropriate use of ACT in the public, private-for-profit and private-not-for-profit sectors. These components were: price reductions through negotiations with prequalified ACT medicines manufacturers to offer 90% price subsidy to selected importers, support of interventions, such as behaviour change communication and establishment of price monitoring [19]. In December 2013, the AMFm programme was rebranded to the CPM to focus only on the private sector [20] and offered a 70% price subsidy for ACT medicines, but not for RDTs [21]. These efforts were expected to culminate into a trickledown effect of reduced ACT medicines prices in the anti-malarial supply chain to the end user. Details of the CPM are outlined elsewhere [21, 22]. Table 1 lists the interventions conducted.

Whereas the report on the effect of the multi-country (including Uganda) AMFm pilot was published in 2012 under the ACTwatch group [18‐22, 25, 26], there is a paucity of evidence relating to access to anti-malarials prior to and beyond the end of the AMFm pilot. Between 2008 and 2018, the Global Fund disbursed a cumulative total of USD 414,963,377 for strategies to improve access to anti-malarial commodities in Uganda [27]. Despite these continued efforts to support access to anti-malarial commodities in Uganda, there are limited data to show whether the initially observed positive effects were sustained in later years. This paper examines trends in availability and affordability of first-line malaria treatment and diagnostics in Uganda between 2007 and 2018.

A cross-sectional design with quantitative methods was used to assess the availability, price and affordability of ACT medicines and diagnostics using a standardized methodology co-developed by the WHO and Health Action International (HAI), adapted for anti-malarials and diagnostics [28]. This methodology prescribes a minimum of 30 facilities per sector and has been validated and used widely [29‐32].

Annual studies were conducted prior to 2016 and in 2018 while quarterly studies were conducted for the period of October 2016 to Dec 2017. However, the 2007–2010, and 2014–2015 surveys did not measure the availability and prices of RDTs.