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Fever, Parasitemia and Access to Subsidized ACTs –
Evidence from Uganda’s Eastern Province
Jessica Cohen
Bill Dickens
Günther Fink
AFFORDABLE MEDICINES FACILITY-MALARIA REVIEW AND THE
FINANCING OF FEBRILE ILLNESS MANAGEMENT
September 17-18 2012
The National Academies, Washington, DC 20037
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Uganda
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RDT Study Districts
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92 Study Villages:
May 2011 to April 2012
•2500 Households
•15,000 Individuals
> 30,000 Illness reports> 30,000 Illness reports
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Endemicity
• At the end of the trial, free testing was offered to all
household members
• About 66% of members were present and consented to
testing, for a total of 9887 tests (96% consented)testing, for a total of 9887 tests (96% consented)
• About 50% of children and 30% of adults (all without acute
health problems) were found to test positive � highly
endemic area
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Most Common Morbidity Symptoms
50%
60%
70%
80%
90%
100%
Pe
rce
nta
ge
of
res
po
nd
en
ts r
ep
ort
ing
sym
pto
m
Mean: 1.1 cases per household and month
0%
10%
20%
30%
40%
Pe
rce
nta
ge
of
res
po
nd
en
ts r
ep
ort
ing
sym
pto
m
Please do not cite without permission of authors.
Where Do Fever Patients Seek Treatment?
Clinic11%
Other3%
Unknown20%
Note: 23% of fevers don’t seek treatment at all.
Drug shop39%
Health Center22%
Hospital5%
3%
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Most Common Drug Treatment
59.0%
33.8%35.5%
0.4
0.5
0.6
0.7F
rac
tio
n o
f fe
ve
r p
ati
en
ts g
ett
ing
…
27.7%
0
0.1
0.2
0.3
Antibiotic Painkiller ACT Other antimalarial
Fra
cti
on
of fe
ve
r p
ati
en
ts g
ett
ing
…
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Other Antimalarials
Artenam7%
Chloroquine9%
SP/Fansidar6%
Other1%
Quinine77%
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Change in Treatment over Time
0.3
0.35
0.4
Fra
cti
on
of fe
ve
rs s
ee
kin
g tr
ea
tme
nt g
ett
ing
tre
ate
d w
ith
C
oa
rte
m a
nd
Qu
inin
e
0.15
0.2
0.25
1 2 3 4 5 6 7 8 9 10
Fra
cti
on
of fe
ve
rs s
ee
kin
g tr
ea
tme
nt g
ett
ing
tre
ate
d w
ith
C
oa
rte
m a
nd
Qu
inin
e
FB Round
Fraction of fevers treated with quinine
Fraction of fevers treated with Coartem
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15
20
25
30
Millio
n D
os
es
of A
MF
m A
CT
s
Cumulative AMFm ACTs Arriving in Public Facilities
Cumulative AMFm ACTs Arriving in Private Facilities
Timing of the AMFm
0
5
10
15
Millio
n D
os
es
of A
MF
m A
CT
s
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ACT Distribution in Retail Sector:
How Many Shops Stock ACTs?
85.1%
0.6
0.7
0.8
0.9
1
Fra
cti
on
of L
ice
ns
ed
Dru
g S
ho
ps S
tockin
g C
oart
em
32.5%
0
0.1
0.2
0.3
0.4
0.5
Baseline Endline
Fra
cti
on
of L
ice
ns
ed
Dru
g S
ho
ps S
tockin
g C
oart
em
Please do not cite without permission of authors.
2000
2500
3000
3500
Me
an
re
po
rte
d p
ric
e in
US
HACT Pricing in the Retail Sector
0
500
1000
1500
June July August September October November December January February March
Me
an
re
po
rte
d p
ric
e in
US
H
Mean Price for Coartem
95% CI
95% CI
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Malaria Testing (28% overall)
50.5% 51.5%
63.1%
0.4
0.5
0.6
0.7
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
te
ste
d a
t..
8.9%
0
0.1
0.2
0.3
Drug shop Clinic Health Center Hospital
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
te
ste
d a
t..
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Self-reported Test Results (N=23,849)
0.4
0.5
0.6
0.7
Fra
cti
on
of
pa
tie
nts
ge
ttin
g…
Not tested
Report to have tested positive
Report to have tested negative
0
0.1
0.2
0.3
0.4
Antibiotic Painkiller ACT Other antimalarial
Fra
cti
on
of
pa
tie
nts
ge
ttin
g…
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Treatment of Confirmed Malaria Tests (N=1800)
0.4
0.5
0.6
0.7
Fra
cti
on
of
pa
tie
nts
ge
ttin
g…
Positive Negative
0
0.1
0.2
0.3
Antibiotic Painkiller ACT Other antimalarial
Fra
cti
on
of
pa
tie
nts
ge
ttin
g…
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Trends in ACT Treatment by Age Group
0.25
0.30
0.35
0.40
0.45
0.50
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
0.00
0.05
0.10
0.15
0.20
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Ages 0-4 Ages 5-19 Ages 20+
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Trends in ACT Treatment by Wealth Quintile (All)
0.25
0.30
0.35
0.40
0.45
0.50
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
0.00
0.05
0.10
0.15
0.20
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Poorest
Asset Quintile 3
Richest
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Trends in ACT Treatment by Wealth Quintile (Untested)
0.20
0.25
0.30
0.35
0.40
0.45
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
0.00
0.05
0.10
0.15
0.20
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Poorest
Asset Quintile 3
Richest
Please do not cite without permission of authors.
Trends in ACT Treatment by Wealth Quintile (Tested Positive)
0.5909091
0.40
0.50
0.60
0.70
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T 59.1%
0.00
0.10
0.20
0.30
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Poorest
Asset Quintile 3
Richest
Please do not cite without permission of authors.
Trends in ACT Treatment by Wealth Quintile
(Tested Negative)
0.40
0.50
0.60
0.70
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Poorest
Asset Quintile 3
Richest
0.00
0.10
0.20
0.30
Fra
cti
on
of
feve
r p
ati
en
ts g
ett
ing
an
AC
T
Please do not cite without permission of authors.
Main Findings
• The percentage of fever patients getting an ACT has increased
from about 30% in June 2011 to 40% in April 2012 (and the
quinine share has fallen by about the same amount)
• Increases in ACT access are particularly large for low SES
householdshouseholds
• Testing affects but no necessarily determines treatment choice:
– about 50% don’t get an ACT even when tested positive
– about 25% get an ACT even when the test result is negative
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Backup Slides
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Positivity by Age Group
0.5
0.6
0.7
0.8F
ract
ion
of
RD
Ts p
osi
tiv
e
Overall, 49% of asymptomatic
patients tested positive
0
0.1
0.2
0.3
0.4
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
Fra
ctio
n o
f R
DTs
po
siti
ve
Age Group
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Parasitemia by Sex
50%
60%
70%
80%
Pe
rce
nta
ge
of
po
siti
ve
RD
Ts
0%
10%
20%
30%
40%
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64
Pe
rce
nta
ge
of
po
siti
ve
RD
Ts
Age group
Male Female
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Malaria Seasonality
60%
65%
70%
75%
Pe
rce
nta
ge
of a
dm
inis
tere
d S
lid
es
Po
sit
ive
35%
40%
45%
50%
55%
July August September October November December January February March
Pe
rce
nta
ge
of a
dm
inis
tere
d S
lid
es
Po
sit
ive
Note: 95% confidence intervals need to be adjusted for spatial clustering
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