Availability, market share and price of quality assured artemisinin-based combination therapies in private drug outlets after over a decade of Copayment mechanism in Uganda.

Background Malaria remains one of the leading causes of morbidity, and mortality in Uganda. A large proportion of malaria symptomatic patients seek healthcare in the private sector. However, availability and affordability are major barriers to access to effective treatment. The private sector copayment mechanism in Uganda aims to increase availability and affordability of antimalarial agents. Our study assessed the availability, price, and market share of quality assured artemisinin-based combination therapies (QAACTs) in private drug outlets after over a decade of copayment mechanism in the private sector in Uganda. Methods This was a cross-sectional survey of anti-malarial agents in private drug outlets in high (Tororo, and Apac districts) and low (Kabale and Mbarara districts) malaria transmission settings. Following the WHO/HAI criteria, an audit of the antimalarial agents was done using a checklist to determine availability, price, and market share of QAACTs. Data was entered in Epi-data and analyzed in STATA ver 14.0 at 95% confidence level. Results A total of twenty-eight (28) private drug outlets (pharmacies and drug shops) were included in the survey. One in seven Artemisinin-based combination therapies (ACTs) in the drug outlets were quality assured (QAACTs). Artemether-lumefantrine (AL), 8.9% (11/124) and Artesunate-Amodiaquine (AQ), 7.3% (9/124) were the only QAACTs present in the drug outlets at the time of the survey. The majority, 86.1%% (124/144) of antimalarial agents present in stock in the drug outlets were artemisinin based. The most common, 38.9% (56/144) ACT in the drug outlets was Dihydroartemisinin-Piperaquine (DHP). Most, 69.4% (100/144) of the antimalarial agents were in high malaria transmission settings. The cost of ACT antimalarial agents is high in the country, USD 1.4 (Artemether-Lumefantrine, AL), USD 2.4 (Dihydroartemisinin-Piperaquine, DP), the first line and second-line agents respectively for treatment of uncomplicated malaria in Uganda. There was a statistically significant difference between the dispensing price of the ‘Green leaf’ ACTs and the recommended price (p<0.001). Conclusion Quality assured artemisinin-based combination therapies (QAACTs) are not common in private drug outlets in low and high malaria transmission settings. All the drug outlets had at least one ACT antimalarial agent present on the day of the survey. The dispensing price of QAACTs was significantly higher than the recommended markup price. There is need for awareness creation, surveillance, and monitoring of the implementation of Copayment mechanism in the country. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was reviewed and approved by Makerere University School of Biomedical Sciences Research Ethics Committee (SBS 803). The protocol was further reviewed and cleared by Uganda National Council of Science and Technology (UNCST), (HS1169ES). Administrative clearance was also obtained from the local authorities in the study settings. In each drug outlet, a written informed consent was obtained from the pharmacist prior to data collection and for all the participants who consented, the drug outlets were included in the study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All relevant data are within the manuscript and its Supporting Information files.