Abstract
Substandard and falsified medications are a major threat to public health, directly increasing the risk of treatment failure, antimicrobial resistance, morbidity, mortality and health expenditures. While antimalarial medicines are one of the most common to be of poor quality in low- and middle-income countries, their distributional impact has not been examined. This study assessed the health equity impact of substandard and falsified antimalarials among children under five in Uganda. Using a probabilistic agent-based model of paediatric malaria infection (Substandard and Falsified Antimalarial Research Impact, SAFARI model), we examine the present day distribution of the burden of poor-quality antimalarials by socio-economic status and urban/rural settings, and simulate supply chain, policy and patient education interventions. Patients incur US$26.1 million (7.8%) of the estimated total annual economic burden of substandard and falsified antimalarials, including $2.3 million (9.1%) in direct costs and $23.8 million (7.7%) in productivity losses due to early death. Poor-quality antimalarials annually cost $2.9 million to the government. The burden of the health and economic impact of malaria and poor-quality antimalarials predominantly rests on the poor (concentration index −0.28) and rural populations (98%). The number of deaths among the poorest wealth quintile due to substandard and falsified antimalarials was 12.7 times that of the wealthiest quintile, and the poor paid 12.1 times as much per person in out-of-pocket payments. Rural populations experienced 97.9% of the deaths due to poor-quality antimalarials, and paid 10.7 times as much annually in out-of-pocket expenses compared with urban populations. Our simulations demonstrated that interventions to improve medicine quality could have the greatest impact at reducing inequities, and improving adherence to antimalarials could have the largest economic impact. Substandard and falsified antimalarials have a significant health and economic impact, with greater burden of deaths, disability and costs on poor and rural populations, contributing to health inequities in Uganda.
Highlights
Health equity is defined as everyone having ‘the opportunity to attain their full health potential’ and no one being ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance’ (Brennan Ramirez et al, 2008)
We developed and utilized the SAFARI (Substandard and Falsified Antimalarial Research Impact) model, a dynamic agent-based model built in NetLogo (Version 6.0.2, Wilensky, 1999)
We examined the distribution of health and economic burden of malaria in addition to the distributional impact of substandard and falsified antimalarials in Uganda
Summary
Health equity is defined as everyone having ‘the opportunity to attain their full health potential’ and no one being ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance’ (Brennan Ramirez et al, 2008). The malaria burden disproportionately affects low- and middle-income countries (LMICs), and rests on children, the poor and rural populations (Filmer, 2005; Roca-Feltrer et al, 2008; Uganda Bureau of Statistics (UBOS) and ICF, 2018). The World Health Organization (WHO) estimates that globally, 219 million malaria cases and 435 000 deaths were due to malaria in 2017 (WHO, 2018c) The brunt of this burden rests on countries in Sub-Saharan Africa where 90% of these cases and 91% of these deaths occur (WHO—AFRO, 2017; WHO, 2017c). The 2016 Uganda Demographics and Health Survey (DHS) found that the prevalence of malaria among children in the lowest wealth quintile were over 10 times higher than the prevalence of children in the highest quintile [Uganda Bureau of Statistics (UBOS) and ICF, 2018]. Children in rural households were three times more likely to be infected with malaria than urban children [Uganda Bureau of Statistics (UBOS) and ICF, 2018]
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