Price subsidies increase the use of private sector ACTs: evidence from a systematic review

Abstract

Background: Although artemisinin combination therapies (ACTs) are the recommended first-line treatment for uncomplicated malaria in most endemic countries, they have been prohibitively expensive in the retail sector where many suspected malaria cases purchase treatment. ACT subsidies seek to stimulate consumer demand for the drugs over cheaper but often ineffective alternatives by reducing their prices. Recent evidence from eight regions implementing such subsidies suggests that they are generally successful in improving availability of the drugs and decreasing their retail prices, but it remains unclear whether these outcomes translate to improved use by patients with suspected malaria.

Methods: A systematic literature review was conducted to identify reports of experimental or programmatic ACT subsidies to assess the impact of subsidies on consumer use. Relationships between price, use and potential confounding factors were examined using logistic and repeated measures binomial regression models, and approximate magnitudes of associations were assessed with linear regression. In total, 40 studies, 14 peer-reviewed and 26 non-peer-reviewed, were eligible for inclusion in the analysis. The reviewed studies found a substantial increase in private sector ACT use following the introduction of a subsidy. Overall, each $1 decrease in price was linked to a 24 percentage point increase in the fraction of suspected malaria cases purchasing ACTs (R(2) = 0.302). No significant differences were evident in this relationship when comparing the poorest and richest groups, rural vs urban populations or children vs adults.

Conclusions: These findings suggest that ACT price reductions can increase their use for suspected malaria, even within poorer, more remote populations that may be most at risk of malaria mortality. Whether a subsidy is appropriate will depend upon local context, including treatment-seeking behaviours and malaria prevalence. This review provides an initial foundation for policymakers to make evidence-based decisions regarding ACT price reductions to increase use of potentially life-saving drugs.

Keywords: Subsidy; artemisinin combination therapies; malaria; systematic review.

Figure 1

Literature flowchart of ACT subsidies measuring use.

Figure 2

Summary of experimental studies with controlled use data. The fraction of suspected malaria patients receiving ACTs over time in the subsidized and non-subsidized study groups are shown according to (A) household surveys of all febrile household members in the rural districts of Busia, Mumias and Samia Kenya (dashed), and febrile children under five in rural Busia, Butere-Mumias and Teso Districts, Kenya (solid). (B) Exit interviews with anti-malarial purchasers for children under five in three districts of Tanzania (dashed) and five districts of Uganda (solid). Studies in (A) represent the combined private and public sectors (B) received them in private outlets only.

Figure 3

Of those obtaining anti-malarials from the private sector, the proportion that obtained an ACT by country before and during implementation of the AMFm. Data are from ACTwatch surveys in Madagascar, Nigeria, and Uganda and contemporary surveys in Tanzania and Ghana. The timing of each survey with respect to the beginning of the ACT subsidy is given in months in the numbers above each bar. All results are from household surveys except in Tanzania and Ghana, where figures represent the results of exit interviews with anti-malarial purchasers.

Figure 4

Changes in ACT use in AMFm countries by rurality and SES. (A) Increases in use of ACTs in the private sector by children under five in the lowest and highest SES groups reported in ACTwatch household surveys before and after implementation of the AMFm in Madagascar, Nigeria and Uganda. (B) Increases in use of ACTs by children under five in urban and rural areas as reported in ACTwatch household surveys before and after implementation of the AMFm in Madagascar, Nigeria and Uganda.

Figure 5

ACT prices and stocking in the private sector. The dashed curve line is the logistic trend for all ages, and the solid line is the logistic trend for under-fives only. Both lines represent the trend without the outlier point, a region in Madagascar with high-ACT stocking and prices.

Figure 6

ACT stocking and use in the private sector. Relationship between stocking of ACTs in private sector or outlets and the fraction of anti-malarial users that receive ACTs, by all ages and by children under five only. The dashed line is the trend for all ages, and the solid line is the trend for under-fives only.

Figure 7

ACT prices and use in the private sector. The dashed line is the logistic curve for all ages, and the solid line is the logistic trend for children under 5 years of age. Both trend lines do not include the high-priced region of Madagascar.