Improving estimation of ACT treatment coverage in Africa
Authors: John Humphrey Amuasi
Journal: The Lancet Global Health (2017)

In a study in The Lancet Global Health, Adam Bennet and colleagues1Bennett A Bisanzio D Yukich JO et al.Population coverage of artemisinin-based combination treatment in children younger than 5 years with fever and Plasmodium falciparum malaria in Africa, 2003–2015: a modelling study using data from national surveys.Lancet Glob Health. 2017; 5: e418-e427Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar have applied innovative methods to do an analysis of household survey data providing evidence that artemisinin combination therapy (ACT) treatment coverage for children younger than 5 years with malaria remains very low despite huge efforts at increasing ACT availability across the continent. Although the authors bemoan the low ACT treatment coverage, particularly in the private sector, it is important to scrutinise treatment coverage further to identify possible solutions to the problem. Examination of table 2 of the appendix shows several instances in which the proportion of children with fever and Plasmodium falciparum infection who received treatment with any antimalarial was considerably higher than the proportion of children with fever and P falciparum infection who received an ACT. For instance, in Uganda, which has the highest ACT treatment coverage, the proportion of children with fever and P falciparum infection who received an ACT was 10 percentage points lower than the proportion of children with fever and P falciparum infection who received treatment with any antimalarial, according to survey UG20141. Therefore, increasing the availability of ACTs as emphasised by the authors is unlikely to achieve the desired effect on ACT treatment coverage as long as non-policy-recommended antimalarial therapies remain available, particularly in the private sector. Emphasis is being placed on the private sector because procurement is largely driven by anticipated sales volumes and profit margins.2Shretta R Yadav P Stabilizing supply of artemisinin and artemisinin-based combination therapy in an era of wide-spread scale-up.Malar J. 2012; 11: 399Crossref PubMed Scopus (27) Google Scholar Unlike the public sector, where the centralised nature of commodity procurement and service delivery mechanisms makes it simpler to achieve adherence to antimalarial policy with respect to not stocking artemisinin monotherapies and non-artemisinin therapies. Although increasing availability of ACTs has been shown to outcompete inappropriate therapies,3Ye Y et al.Tougher S1 ACTwatch GroupEffect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data.Lancet. 2012; 380: 1916-1926Summary Full Text Full Text PDF PubMed Scopus (122) Google Scholar deliberate actions need to be taken to reduce the availability of undesirable antimalarial treatments. Examples include imposing outright importation bans or other severe penalties on importation of non-policy-recommended antimalarial treatments and vigorous negative campaigns against their use. Negative campaigning has the potential to modify demand and supply patterns and has been effective in a number of health interventions.4Emery SL Szczypka G Powell LM Chaloupka FJ Public health obesity-related TV advertising: lessons learned from tobacco.Am J Prevent Med. 2007; 33: S257-S263Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 5Orleans CT Increasing the demand for and use of effective smoking-cessation treatments: reaping the full health benefits of tobacco-control science and policy gains—in our lifetime.Am J Prevent Med. 2007; 33: S340-S348Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 6Wakefield MA Loken B Hornik RC Use of mass media campaigns to change health behaviour.Lancet. 2010; 376: 1261-1271Summary Full Text Full Text PDF PubMed Scopus (1362) Google Scholar Important differences in factors influencing commodity procurement and service delivery among healthcare providers, and health seeking behaviour, exist between the public and private health sectors in countries.7Amfm Independent Evaluation TeamIndependent Evaluation of Phase 1 of the Affordable Medicines Facility - malaria (AMFm), Multi-Country Independent Evaluation Report: Final Report. ICF International and London School of Hygiene and Tropical Medicine, Calverton, Maryland and London2012Google Scholar, 8Amuasi JH Diap G Nguah SB et al.Access to artemisinin-combination therapy (ACT) and other anti-malarials: national policy and markets in Sierra Leone.PLoS ONE. 2012; 7: e47733Crossref PubMed Scopus (11) Google Scholar, 9Kangwana BB Njogu J Wasunna B et al.Malaria drug shortages in Kenya: a major failure to provide access to effective treatment.Am J Trop Med Hyg. 2009; 80: 737-738Crossref PubMed Scopus (72) Google Scholar The authors show that even though ACT treatment coverage was generally low, those who sought treatment in the public sector were twice as likely to receive an ACT than those in the private sector. Thus, in analysing malaria treatment survey data to inform policy action, two issues require careful consideration. First, the way a malaria treatment facility operates should inform its classification into either a public or a private treatment source. For example, it is well known that non-governmental, or so-called mission, facilities function largely as quasi-public in several malaria endemic countries. In fact, in some countries, mission hospitals double as the main district secondary health facility. In such cases, it becomes relevant whether or not they are classified along with governmental sources as public sector, even though they are really not owned by the government. Second, policy interventions often include elements aimed at modifying factors that influence outcomes differently between public and private sectors. As such, there is better policy-actionable information to be derived, when results for survey analysis are presented stratified by public and private sectors at country level. Bennet and colleagues also make an important addition to the literature on the Affordable Medicines Facility—malaria (AMFm) intervention, since a comparison of ACT treatment coverage for countries that had the AMFm intervention is made with those for countries that did not have the AMFm intervention. However, the authors acknowledge that the higher ACT treatment coverage in those countries that had the AMFm intervention cannot be directly linked to the intervention itself. The authors' consideration that other related factors could have accounted for this is supported by figure 2C; in which this disparity is shown to emerge as early as 2007, even though the first AMFm ACTs reached some countries in August 2010 (p 53).7Amfm Independent Evaluation TeamIndependent Evaluation of Phase 1 of the Affordable Medicines Facility - malaria (AMFm), Multi-Country Independent Evaluation Report: Final Report. ICF International and London School of Hygiene and Tropical Medicine, Calverton, Maryland and London2012Google Scholar The decline in malaria incidence and mortality observed in Africa has been attributed to multiple interventions; including vector control activities, and widespread deployment of insecticide treated nets (ITNs), rapid diagnostic tests, and ACTs.10Gething PW Casey DC Weiss DJ et al.Mapping Plasmodium falciparum mortality in Africa between 1990 and 2015.N Engl J Med. 2016; 375: 2435-2445Crossref PubMed Scopus (177) Google Scholar Increasing the low ACT treatment coverage and scaling-up diagnostics, particularly in the private sector, has the potential to further reduce malaria mortality. The predictive modelling, data imputation, and assumptions that went into producing the estimates presented in this paper show the need for more robust indices of ACT treatment coverage. Achieving this will require more detail to be included in routine household surveys, along with the introduction of health facility surveys and exit interviews for people seeking treatment for fever. This additional data collection will have important cost implications, but hold great potential benefit for informing the planning and implementation of large-scale interventions, and measuring their effect at both country and continental levels, ultimately saving cost. I declare no competing interests. Population coverage of artemisinin-based combination treatment in children younger than 5 years with fever and Plasmodium falciparum infection in Africa, 2003–2015: a modelling study using data from national surveysDespite progress during the 2003–15 malaria programme, ACT treatment for children with malaria remains unacceptably low. More work is needed at the country level to understand how health-care access, service delivery, and ACT supply might be improved to ensure appropriate treatment for all children with malaria. Full-Text PDF Open Access