Understanding private sector demand for malaria medications in developing countries

In 2010, there were more than 200 million malaria infections around the world and it was estimated that less than half of these cases received the type of treatment recommended by both the World Health Organization and the governments in countries where malaria is a major health problem, called artemisinin-based combination therapy (ACT). Malaria infections that are not properly treated can lead to serious health consequences, including permanent disability and even death, with young children in developing countries particularly at risk.

Part of the reason why so many individuals do not get optimally treated with ACTs is because that due to problems of access, availability of drugs, convenience and cost in the public sector, patients in malaria-endemic countries often turn to private clinics, hospitals and even retail shops in order to obtain treatment. And although ACTs are available on the market, these patients are unlikely to receive them as treatment and instead are likely to be treated with an older, less effective medicine.

The aim of this study is to help to answer the questions of why malaria patients who turn to the private sector for treatment are less likely to receive an ACT drug, and what factors act as facilitators and barriers to receiving an ACT. There will be a particular focus on the responsiveness of demand for ACTs to price, and the potential effects of interventions to reduce the price of antimalarial medicines. It is hoped that by generating better understanding of these factors, this new knowledge will help all of those working to ensure that malaria infections are optimally treated to design more successful interventions and better predict the impact of these interventions.

To do this, we propose to analyse data collected in Benin, Madagascar, Uganda and Zambia during surveys of households that experienced a recent malaria infection and complementary surveys of all sources of antimalarial medicines in the vicinity of these households, including private retailers, clinics and hospitals. During the first stage of the analysis, we will investigate patterns of treatment seeking behaviour by describing whether or not treatment for the malaria episode was sought, where treatment was sought, what antimalarial was received and in what quantity, whether an ACT was received, the price paid for the medicines, and total costs of treatment. We will also investigate if these patterns differ across selected groupings, such as age and income groups, household size/composition, and by urban and rural locations.

The second stage of the analysis will use statistical models to ascertain which factors are important facilitators and barriers to patients receiving an ACT to treat malaria, and we may also investigate how these factors affect the quantity of medicines purchased. Because of the complexity of both the behaviour we are attempting to analyse and the data we are using to do so, there are a number of issues that must be considered to ensure these analyses are conducted in a valid way. For example, the decision-making processes that lead to the final event of acquiring an ACT could involve a number of choices: one is the decision of whether or not to seek treatment; another involves choosing where to procure the treatment; while another decision involves whether or not an antimalarial is obtained, the choice of antimalarial, and in what quantity. Models must allow for these decisions to be made simultaneously, separately, or sequentially (with subsequent choices being dependent on previous ones). Finally, using these models, we will attempt to predict how changes in the price of ACTs, household income, and distance to outlets, among others, might affect the number of patients treated with ACTs and quantity of ACTs consumed.

The treatment of malaria in developing countries takes place in a complex and pluralistic environment, we believe that a better understanding of treatment seeking behaviour and demand for antimalarials will benefit a wide range of stakeholders, from people in communities where malaria poses a substantial risk to well-being to the many national and international agencies working to improve access to treatment in endemic countries.

The research findings have the potential to benefit people suffering from malaria (~250 million cases per year worldwide, of which 86% occur in Africa) by strengthening policies to improve access to antimalarials. Better information about the factors influencing demand will help to identify key barriers to access in different settings and to adapt policies to maximise their impact.

In the study countries, government bodies active in setting malaria case management policies and in regulating the pharmaceutical sector will benefit from having access to high quality data on the health seeking behaviour of their constituent populations. This will assist the identification of targets for action, and the design of evidence-based interventions to increase access to treatment. For example, better information on the elasticity of demand for ACTs, could lead to better predictions of demand response to subsidy programmes, thereby improving demand forecasting and reducing risks of under- and over-supply by national procurement agencies. This, in turn, will lead to fewer treatment stock-outs at health facilities and more efficient use of scarce government resources for health.

This research should also improve understanding of the role of the private commercial sector in supplying antimalarials in endemic settings and, where this is found to have potential for public health impact, lead to greater involvement of this sector in medicines distribution.

The UK Department for International Development has identified malaria as a key priority, and developed a business case for investing in malaria control based on the high burden of the disease in terms of mortality, health care cost and impact on economic growth and development. DFID is an important funder of the Affordable Medicines Facility-malaria, a global initiative to subsidise ACTs. Improved evidence about the characteristics of demand for antimalarial medicines will be used by DFID and other agencies to shape malarial control interventions.

Other bilateral and multilateral agencies (eg. the Global Fund, UNITAID and the WHO) and civil society organisations (eg. Malaria Consortium and Population Services International) engaged in the procurement and distribution of antimalarials may similarly benefit from the output of this research. As these organisations commonly provide funding to improve access to antimalarials, project outputs may also contribute to the better targeting of funding, the design of more effective interventions and also of more informed evaluations (eg. setting benchmarks for success).

Our work on ACTwatch has also put us in close contact with organisations involved in antimalarial market shaping and demand management activities, such as the Clinton Health Access Initiative (conducting global ACT demand forecasts and research on maximising the impact of subsidies for ACTs) and the Medicines for Malaria Venture (a public-private partnership developing new antimalarials also engaged in action research to improve ACT access). While the project outputs will directly benefit these organisations by providing them with crucial market intelligence, they may also lead to the development of better tools to predict market behaviour. Similarly, ACT manufacturers will benefit from stronger evidence on which to forecast demand, allowing them to better plan to meet demand when there are important market changes, such as subsidy programmes or large increases in donor funding to purchase ACTs, leading to a more reliable supply of medicines.