Distribution of ACTs in the private sector in Angola

Gilda Encarnação, known as Shakira among her 8 brothers and sisters, is a happy, active three year-old girl who normally loves to run around and play with her older friends. In the morning her mom noticed she wasn't smiling as usual and when she helped her to get dressed she realized she had a high temperature. Shakira lives with her large family in a rural area in Huambo where the nearest public health facility is 10 kms away and this morning she was in no condition to make the journey.

Shakira's father buying Coartem on his local private pharmacy for her daughter treatment.

Her father heard on the radio that the most effective treatment for malaria was now available in their local pharmacy for a low price. He bought Coartem, a combination of Arthemether and Lumefantrine, and within 15 minutes she was able to take her first dose. Her father described a quick improvement. The antimalarial tablets had started to work quickly and he was surprised with how soon after taking COARTEM that she started eating and playing tag. He was relieved that this time Shakira was 100% cured after taking the three day treatment.

Since 2006 Coartem has been procured by President’s Malaria Initiative (PMI) for distribution in Angola via the public sector. Two years in, the results of the Angola Malaria Indicator Survey 2006-2007 (MIS) suggest that little had changed with regards to prescription practices of anti-malarials and confirm that the majority of under-fives presenting with fever continue to receive either chloroquine or amodiaquine monotherapies. Huambo, however, is a success story to date in comparison with the national picture. After almost two years of intensive technical training support from The MENTOR Initiative with an ongoing USAID funded programme, over 85% of existing provincial health facilities are receiving strong technical support to introduce the national malaria case management protocols, which include artemisinin-based combination treatments (ACTs) as first-line malaria treatment. Routine surveillance visits have revealed that over 60% are now using the new ACT protocol for uncomplicated malaria effectively.  Until October of 2008, however, little information was known about private sector practices regarding malaria treatment both in Huambo and nationally. Provincial and national health authorities recognize that the private sector plays a very significant role in providing treatment for malaria cases in Angola, suspecting that the private sector is responsible for treating at least 40-60% of febrile cases.  Given that the last national resistance studies published estimated over 50% resistance to chloroquine, 25% to Fansidar and 10% do amodiaquine, lack of availability of ACTs in the private sector poses a great challenge for many communities to access effective treatment for malaria. At the same time, the private sector presents a very important opportunity through which access to effective ACTs for malaria might be significantly expanded.

Shakira holding her teddy bear with her friends and family after being treated and cured of malaria.
Source: The Mentor Initiative.

In October of 2008 The MENTOR Initiative received funding from USAID/PMI to assist the National Malaria Control Program (NMCP), the National Essential Drugs Programme (NEDP) and provincial health authorities, in the pilot of distribution and effective use of ACT at private sector outlets in two municipalities in Huambo province and to ensure the correct implementation and adherence to national strategies and protocols.

The initial assessment of the private sector in Huambo undertaken by The MENTOR Initiative last November 2008, showed that the majority of anti-malarial drugs being sold were monotherapies of chloroquine, quinine, fansidar and amodiaquine.  The same study reported a large range in prices with 60 % of pediatric malarial treatments being sold between 50 and 200 Kwanzas.  At the same time, a survey of knowledge, attitudes and practices showed that half of people interviewed knew that Coartem or another ACT was the best medicine to use in the treatment of malaria.  Reported high price of Coartem, with a cost of up to 1500 kwanzas in the private sector, and low availability, however, limit access to effective treatment even for those who know to seek ACTs.

Dr. Filomeno Fortes (Director of NMCP) launching the distribution of Coartem in the private sector in Huambo.

On the 17th of July 2009, the distribution of ACTs to private outlets was launched and to date 97 pharmacies of the two intervention municipalities of Huambo and Caala are already providing Coartem at the price of 75 Kwanzas ($1USD) for children under five years of age.  This price, established by the NMCP, is competitive if not cheaper than the alternative monotherapies, ensuring that people have access to affordable and effective malaria treatment. Ongoing supervision has indicated that initial results on the key outcomes of the pilot, uptake and adherence to price of subsidized ACTs, are promising.

Now other children like Shakira have the opportunity to access effective treatment for malaria in their own communities.