Guissou et al. Malaria Journal          (2023) 22:269  Malaria Journal
https://doi.org/10.1186/s12936-023-04705-0
PERSPECTIVE Open Access
The impact of anti-malarial markets 
on artemisinin resistance: perspectives 
from Burkina Faso
Rosemonde M. Guissou1*, Chanaki Amaratunga2,3, Freek de Haan4, Fatoumata Tou5, Phaik Yeong Cheah2,3, 
R. Serge Yerbanga1,5, Ellen H. M. Moors4, Mehul Dhorda2,3, Paulina Tindana6, Wouter P. C. Boon4, 
Arjen M. Dondorp2,3 and Jean Bosco Ouédraogo5 
Abstract 
Background Widespread artemisinin resistance in Africa could be catastrophic when drawing parallels with the fail-
ure of chloroquine in the 1970s and 1980s. This article explores the role of anti-malarial market characteristics 
in the emergence and spread of arteminisin resistance in African countries, drawing on perspectives from Burkina 
Faso.
Methods Data were collected through in-depth interviews and focus group discussions. A representative sample 
of national policy makers, regulators, public and private sector wholesalers, retailers, clinicians, nurses, and commu-
nity members were purposively sampled. Additional information was also sought via review of policy publications 
and grey literature on anti-malarial policies and deployment practices in Burkina Faso.
Results Thirty seven in-depth interviews and 6 focus group discussions were conducted. The study reveals 
that the current operational mode of anti-malarial drug markets in Burkina Faso promotes arteminisin resistance 
emergence and spread. The factors are mainly related to the artemisinin-based combination therapy (ACT) supply 
chain, to ACT quality, ACT prescription monitoring and to ACT access and misuse by patients.
Conclusion Study findings highlight the urgent requirement to reform current characteristics of the anti-malarial 
drug market in order to delay the emergence and spread of artemisinin resistance in Burkina Faso. Four recommenda-
tions for public policy emerged during data analysis: (1) Address the suboptimal prescription of anti-malarial drugs, (2) 
Apply laws that prohibit the sale of anti-malarials without prescription, (3) Restrict the availability of street drugs, (4) 
Sensitize the population on the value of compliance regarding correct acquisition and intake of anti-malarials. Fund-
ing systems for anti-malarial drugs in terms of availability and accessibility must also be stabilized.
Keywords Malaria, ACT , Artemisinin resistance, Antimalarial market, Burkina Faso
*Correspondence:
Rosemonde M. Guissou
rosyguiss@yahoo.fr
Full list of author information is available at the end of the article
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which 
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the 
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Guissou et al. Malaria Journal          (2023) 22:269 Page 2 of 14
Background Socio-economic factors and (un)availability of therapies 
Malaria remains a major cause of mortality and mor- have also been related to resistance along with health 
bidity in African countries including Burkina Faso [1]. system weaknesses and supply chain deficiencies [26, 
Although effective therapies have for long been available 27]. Anti-malarial market characteristics, including sup-
to treat malaria, these treatments are threatened by the ply chain processes, quality control systems, distribution 
emergence and the spread of anti-malarial drug resist- procedures and storage conditions, have previously been 
ance. Historically, the approach to address anti-malarial analysed, showing their impact on the quality, price and/
drug resistance is changing the treatment policy to an or the availability of anti-malarial drugs [6, 28–32].
alternative therapy when treatment failures are observed The link between the anti-malarial market characteris-
[2, 3]. Faced with the emergence of resistance to conven- tics and the emergence and spread of artemisinin resist-
tional monotherapies for the treatment of uncomplicated ance has however been under-investigated, especially 
Plasmodium falciparum malaria, in the early 2000s the in the current context of the emergence of artemisinin 
World Health Organization (WHO) recommended a resistance in African countries. Studying this link in a 
switch from conventional monotherapies to artemisinin- high-transmission country like Burkina Faso can enhance 
based combination therapy (ACT). A first technical con- understanding of factors– global or country-specific—
sultation in 2001 eventually led to recommendations that could contribute to the emergence and spread of 
towards ACT deployment in 2006 [4, 5]. While ACT was resistance to artemisinin and ACT partner drugs, as well 
gradually implemented in affected regions of Southeast as factors that could protect future therapies.
Asia, its introduction was delayed due to financial, politi- This study sought to describe anti-malarial drug mar-
cal and logistical difficulties in most African countries [3, ket structures in Burkina Faso from a systemic perspec-
6, 7]. tive, taking into account a comprehensive set of actors, 
Unfortunately, anti-malarial drug resistance is a con- institutions and networks. It explores characteristics of 
cern once again, with emerging artemisinin and part- the anti-malarial drug markets in Burkina Faso in terms 
ner drug resistance. Artemisinin partial resistance was of policies, distribution, and deployment mechanisms, 
reported in Cambodia in 2009 and has now emerged or and their relationship to potential emergence and spread 
spreaded across several countries in Southeast Asia [8– of artemisinin resistance, in order to define better regula-
12]. Worrisome reports of artemisinin partial resistance tion of market-related processes to preserve current and 
were recently reported in Rwanda and Uganda, although future treatment options.
both countries report that ACT still remains efficacious 
[13, 14]. The consequences of widespread artemisinin Methods
resistance in Africa could be catastrophic when draw- Study setting
ing parallels with the widespread failure of chloroquine Burkina Faso reported over 10 million uncomplicated P. 
in the 1970s and 1980s. While great efforts have been falciparum malaria cases in 2020, and 94.76% of these 
made over the past decades to reduce the global burden cases were treated with artemether-lumefantrine (AL) [1, 
of malaria-related morbidity and mortality, further emer- 33]. This reflects the widespread use of AL in the coun-
gence or spread of artemisinin resistance and subsequent try. Burkina Faso is firmly committed to the fight against 
ACT failures will threaten these recent successes [1, 15]. malaria through the “Programme National de Lutte 
Alternative drug compounds to treat malaria are contre le Paludisme”, the National Malaria Control Pro-
being developed, but they are not yet available [3, 16, gramme (NMCP) created in 1991 and aims to eliminate 
17]. Therefore, new therapeutic regimens and strategies malaria by 2030. Among its main activities are the devel-
should make use of currently available drug compounds opment of national guidelines for the management of 
[18]. In addition to rotating the artemisinin-based combi- malaria, surveillance of the disease, and the management 
nations and extending the duration of treatment of ACT, of the supply of drugs and products against malaria.
the introduction of triple artemisinin-based combination 
therapy (TACT) and using multiple first line therapies Supply of anti‑malarial drugs in Burkina Faso
are being explored as strategies making use of current The National Agency for Pharmaceutical Regulation 
anti-malarial drug compounds, which could delay resist- “Agence Nationale de Régulation Pharmaceutique” 
ance [18–22]. (ANRP) oversees regulating drugs in Burkina Faso via 
The link between anti-malarial drug deployment poli- granting a marketing authorization (MA), i.e. a license 
cies and behaviours, and anti-malarial resistance has for any drug to be legally marketed in the country. MA is 
been widely demonstrated [3, 23–26]. Unregulated uti- compulsory for all anti-malarial drugs sold in the coun-
lization of drugs has been identified as the main misuse try and is granted in accordance with recommendations 
behaviour that promotes anti-malarial drug resistance. made by the WHO and the West African Monetary and 
G uissou et al. Malaria Journal          (2023) 22:269 Page 3 of 14
Economic Union (UEMOA). ANRP, in collaboration with WHO recommendations, the country adopted ACT for 
the National Public Health Laboratory (LNSP), moni- the management of uncomplicated malaria.
tors the pharmaceutical market, through quality control Artemether-lumefantrine (AL), dihydroartemisinine-
and pharmacovigilance processes. Similar to other phar- piperaquine (DHA-PPQ) and artesunate-pyronaridine 
maceutical products, supply of anti-malarial drugs is (AP) are the artemisinin-based combinations recom-
ensured through two main channels [34, 35]: mended by the NMCP and Ministry of Health [39]. Anti-
malarial drugs with an MA are not necessarily in the 
• A purchasing center for Essential Generic Medicines NMCP’s guidelines. The public sector solely uses anti-
(EGM), the CAMEG “Centrale d’Achat Médicaments malarial drugs recommended by the NMCP. This sector, 
Essentiels Génériques”, which is a non-profit organi- which is the main health care provider in Burkina Faso, is 
zation with a public service mission, i.e. providing the organized under a pyramidal form at three levels provid-
majority of the population with quality medicines at ing primary, secondary and tertiary health care. Primary 
lower cost. CAMEG is in charge of supplying phar- health care are deliver at local levels mainly by Health 
maceutical depots and pharmacies of all public health and Social Promotion Centres and Medical Centres with 
structures, and also interested private pharmacies, surgical services. Regional and University/National hos-
with EGM and medical consumables. It orders, stores pitals deliver respectively secondary and tertiary health 
and manages all the drugs (generics drugs) purchased care. Burkina Faso also has a private health sector, which 
for government routine activities or for implementa- is mostly concentrated in urban areas, with medical clin-
tion programmes (such as malaria, HIV, tuberculo- ics and nursing offices. This sector also includes denomi-
sis). All the technical and financial partners (TFPs), national structures which are not-for-profit structures 
including the Global Fund to fight Aids, Tuberculosis and therefore offer services at social prices.
and Malaria (GFATM), fundingsgo through CAMEG 
to supply public health centers with EGM and other Access to anti‑malarial drugs by patients in Burkina Faso
essential commodities such as Rapid Diagnostic Test According to regulations, access to anti-malarial drugs is 
(RDTs) for malaria. Through its 10 commercial agen- conditional on the presentation of a prescription. How-
cies, CAMEG supplies approximately 70 dispatchers’ ever, in practice, access to anti-malarial drugs is often 
deposits and 1698 public pharmaceutical depots. independent of a medical prescription and/or a diagnos-
• Private wholesale distributors are both in com- tic test [34]. Patients’ access to medicines, including anti-
petition and complementarity to the activities of malarials, in Burkina Faso’s health system is achieved 
CAMEG. Four of them are prominent: Société de dis- through pharmaceutical depots or pharmacies, which are 
tribution pharmaceutique du Burkina Faso (DPBF), found both in the public and the private sectors.
Laborex, Tedis pharma and Ubiphram. Their head- In the public sector (and often for denominational 
quarters are situated in Ouagadougou, with branches health structures), each structure of the three levels 
located in Bobo-Dioulasso. These private wholesalers has a pharmaceutical depot or a pharmacy in which 
are responsible for supplying private pharmacies with generic anti-malarial drugs are available for purchase. 
brand-name drugs but also with some generic drugs Artemether-lumefantrine (AL), is the main artemisinin-
under license, which are copies of brand names and based combination used in the public health sector for 
called "branded generics". They supply approximately the management of all ages’ uncomplicated malaria [1, 
274 private pharmacies and 527 pharmaceutical 38]. AL is provided for free to pregnant women and chil-
depots. dren under 5 years of age. For the rest of the population, 
it is available at a subsidized price in public health struc-
ture drug shops. This policy, financed by the government 
and its TFPs, make generic versions of artemisinin-based 
Malaria care delivery in Burkina Faso combinations better accessible in comparison with spe-
National malaria management guidelines developed by cialties and their copies.
the NMCP are mainly based on WHO recommenda- Private, for-profit outlets are also important treat-
tions [36–38]. Disease management starts with a biologi- ment sources for malaria in Burkina Faso [34, 35]. There, 
cal diagnostic test (rapid diagnostic test or microscopy) patients have access to all anti-malarials that have an 
followed by anti-malarial treatment: oral treatment for MA, but are not necessarily recommended through 
uncomplicated malaria and an intravenous route for NMCP guidelines. Private pharmaceutical depots are 
severe malaria. Therefore, anti-malarial drug consump- generally located in rural or semi-rural areas and are 
tion should only occur after a consultation and/or a owned by pharmacies that are established in urban areas. 
diagnostic test by a health worker. Since 2005, following Consumer demand, influenced by drug prices and patient 
Guissou et al. Malaria Journal          (2023) 22:269 Page 4 of 14
preferences, is their principal consideration when select- this study [43]. A representative sample of national policy 
ing products to stock [34]. makers and regulators, public and private sector wholesal-
Traditional therapeutics that provide treatment for ers and retailers, clinicians, nurses, and community mem-
malaria through administration of medicinal plants are bers were purposively sampled for semi-structured IDIs 
also available. Burkina Faso has taken efforts to regulate and FGDs and they were asked to answer questions related 
this ancestral practice by setting up a Directorate of Tra- to the market positioning and ethical concerns regarding 
ditional Medicine and Pharmacopoeia in 2022, which potential deployment of triple ACT (Table 1). The details of 
aims to regulate the promotion and enhancement of tra- the methodology have been previously described [43, 44]. 
ditional medicine. This support is manifested by the sale Data collected additionally revealed many aspects of anti-
of some of its traditional pharmacopoeia products in malarial drug market dynamics in Burkina Faso and were 
pharmacies. probed for this study. Added information was obtained 
Pharmaceutical products in Burkina Faso are also sold from a literature review of peer-reviewed manuscripts, pol-
on the stalls of open-air markets as "street drugs"; they icy publications and grey literature on anti-malarial policies 
include both counterfeit drugs and drugs from the nor- and deployment practices in Burkina Faso.
mal circuit [40, 41]. In the latter situation, the storage 
conditions are often considered suboptimal, which causes Data collection
the substance to lose its attributes, therefore its stability Five semi-structured guides were developed for the 
and its effectiveness. Unlike in official pharmacies and different targeted groups [43]. Data collection was 
depots, they are available for retail sale (as individual tab- carried out by two trained and experienced social sci-
lets or full doses) and their prices are negotiable. They are entists, under the supervision of a sociologist (FT) and 
also more easily accessible because the sellers base them- a health economist (RMG). FGDs were conducted with 
selves in the customer’s living environment: in streets or groups of 8–10 participants. Collection sites were Oua-
in market/shops stalls. Lower cost, easy access and avail- gadougou (the capital), Bobo-Dioulasso (the second 
ability are the advantages of these products, and despite largest city in the country) and the village of Santidou-
recognizing the dangers imposed by them, consumers gou, a rural village situated 17  km away from Bobo-
continue to use them [40, 42]. Dioulasso. Data collection was conducted from March 
to April 2020 in Bobo-Dioulasso, and in June 2020 in 
Study design and population Ouagadougou.
This study was conducted under the auspices of the ‘Devel-
opment of Triple Artemisinin-based Combination Thera- Data processing and analysis
pies (DeTACT)’ project. A mixed methods approach using Interviews were transcribed under the supervision of 
in-depth interviews (IDIs) and focus group discussions the team’s sociologist who subsequently analyzed them. 
(FGDs) in combination with a literature review was used for Using NVivo 10 software, each transcript was coded 
Table 1 Respondents in Burkina Faso
Respondent categories N Interview type
Ouaga Bobo
Policy maker National Agency for Pharmaceutical Regulation “Agence Nation- 2 – Interview
ale de la Regulation Pharmaceutique” (ANRP)
National Malaria Control Program (PNLP) 3 – Interview
Regional health authority 2 1 Interview
Malaria researchers 2 1 Interview
Drug wholesaler Public sector wholesalers 3 – Interview
and retailer Private sector wholesalers – 6 Interview
Public sector retailers – 2 Interview
Private sector retailers 1 2 Interview
Drug end user Public sector health care providers 1 3 Interview
Community based health workers – 1 FGD
Private sector health care providers 5 3 Interview
Parents/Caregivers – 5 FGD
Bold values are the number or individual interviews and/or focus discussions groups conducted
G uissou et al. Malaria Journal          (2023) 22:269 Page 5 of 14
according to pre-identified themes. Some themes were but a question of choice.» Supplier 2, Public sector whole-
identified during the study design (inductive) but some saler]. Another CAMEG manager and a respondent from 
themes also emerged during the analysis (deductive). the NMCP explains, indeed, that a large part of generic 
In the study design, the main themes were malaria con- ACTs supply disruptions is due to the late reimburse-
trol strategies in the country and country transition ments of the government to health structures as part of 
from monotherapies to ACT (described previously in its free policies, which impacts the resupplies. [« We say 
part in the methods section because they pertain to the free, but someone pays. […] if that person doesn’t pay on 
study setting), and anti-malarial drugs market operating time, […] it goes without saying that we are now accu-
mode (process for obtaining marketing and importa- mulating what we call receivables and receivables are 
tion authorizations, distribution channels, utilization). reflected in debts vis-à-vis suppliers since we also buy on 
Respondents’ opinions on the threat of artemisinin resist- credit. And when the debts are high it decreases our nego-
ance and strategies to deal with it emerged as a theme tiation capacities to receive the products.» Supplier 1, 
during the analysis. Public sector wholesaler].
Shortages observed in the supply of brand-name drugs 
Results and their copies, are explained by private wholesalers by 
Data from 37 semi-structured in-depth interviews (IDIs) administrative burden in the procurement. [« […], it’s 
and 6 focus group discussions (FGDs) were analyzed to mainly at the customs level: customs negotiations […]. 
explore anti-malarial market characteristics and their Sometimes it’s not so much the product that you don’t find 
potential effect on emergence or spread of artemisinin the product is there, but it is in a container that is sleep-
resistance in Burkina Faso. Policies and processes associ- ing. [….] The problem is the procedure, it’s not so much 
ated with ACT supply process including quality control, the amounts. […] We drag out disruptions not because 
ACT prescription and use practices, and respondents’ the product is lacking at the international level but 
views on their implications to potential artemisinin because there is bureaucracy» Supplier 6, Private sector 
resistance in Burkina Faso were analysed and discussed. wholesaler].
Drug availability is an essential element in disease 
Anti‑malarial drugs supply process in Burkina Faso management. Disruptions in availability provokes inad-
As described previously, there are two main supply chan- equate and incomplete treatment and misuse behaviours. 
nels for authorized anti-malarial medicines, predomi- It also enhance street drugs consumption and self-med-
nately artemisinin-based combinations, in the country: ication behaviours among the population. All of those 
via CAMEG for generics with government as main client, behaviours subsequently promote anti-malarial drug 
and via private wholesale distributors for brand-names resistance.
and branded generics. Disruptions in ACT supply chains, 
weaknesses with regards to the quality control process of Quality control process of ACT 
ACT, and reduced availability of generic ACT were iden- According to respondents, drug quality control systems 
tified as supply-side characteristics that can influence are successfully integrated into the CAMEG supply pro-
emergence and spread of artemisinin/anti-malarial drug cess, but for the private wholesalers, the situation is dif-
resistance in Burkina Faso. ferent. Respondents indicated that there are too many 
ACT brand-names and their copies granted with a mar-
Supply chain of ACT keting authorization (MA). [« It’s true, we’re talking about 
Disruptions in supply chains are observed in both generic competition, but I want the regulations to limit the num-
and brand-named artemisinin-based combinations. For ber of brand-names to 25 or 30» Supplier 5, Private sec-
the generics, private wholesalers assert that the state tor wholesaler]. Respondents from regulatory authorities 
has given the monopoly of the supply and distribu- recognized this issue [« […] otherwise it is a real concern. 
tion to CAMEG, and this leads to frequent disruptions This has led us to try to [actually] limit registrations of the 
in the supply because of it reduced capacities. [«This is same INNs [International Nonproprietary Name]» Policy 
really one of the problems we are currently experiencing. maker 1, ANRP]. Given the limited quality control capac-
CAMEG monopolizes generics [supplying] when it is una- ities of the ANRP, this has an influence on the (perceived 
ble [for it] to respond to the market [demand]» Supplier or real) quality of drugs found in pharmacies. [« What I 
5, Private sector wholesaler]. A manager of the CAMEG have as complaints is the multiplicity of forms existing on 
refuted this idea and affirmed that private wholesalers the ground, […] even if these are the same combinations 
have the right and can import generic ACTs, but they did the sources are multiple and the brands also, so that the 
not do this because they are motivated by profit margins. populations wonder if their quality and effectiveness is 
[«[…] …. So, I would say it’s not a question of monopoly no different. [….]» Supplier 1, Public sector wholesaler]. 
Guissou et al. Malaria Journal          (2023) 22:269 Page 6 of 14
[« […] the national laboratory has to carry out checks/ better, when the patient feels that the product is not 
samples before selling but I do not think this is done eve- working or, because of side effects.
rywhere. [……]. I know that there are checks that are done A pediatrician observed: [« … we are the ones who make 
and the results come to find that the selling is finished» parents aware of avoiding self-medication because that is 
Supplier 5, Private sector wholesaler]. what leads to resistance. They go to the pharmacy, they get 
Street drug artemisinin-based combinations that are served, they start the product, it doesn’t work, they stop. 
easily accessible, despite prohibiting laws, exacerbates [….] the product must be given time to act.» User 6, Pri-
this problem [«…. I know what I am talking about, I vate sector health care provider].
assure you that there are counterfeit antimalarials on the However, another respondent nuanced the situation, 
Bobo market: full, overdosed and underdosed» Supplier stating that self-medication is not the main problem 
5, Private sector wholesaler]. A pharmacist in a private given the current state of the health system, the country 
wholesaler company explained that the sales strategy of should rather sensitize the population on good compli-
this street market attracts users: prices can be negotiated, ance. [« If all malaria patients at one time had to go to the 
and drugs can be obtained in retail facilities, which is not prescriber before taking a product, the health service will 
the case in conventional pharmacies. be crowded. So, at the stage where we are, it’s only normal 
Besides patient health and safety threats, non-quality for minor suspicions so that people can treat themselves, 
assured ACT also affect artemisinin efficacy, and sub- whether with medicinal plants or with modern products» 
optimal dosing provides a favourable environment for the Supplier 1, Public sector wholesaler].
emergence and spread of resistance. A pharmacist insisted on the need to sensitize patients 
on correct treatment administration: [«For me it is neces-
Number of generic ACT used in public health sector sary to work so that people respect the dosage, because the 
Only one main artemisinin-based generic combination, resistance comes from the fact that we do not respect the 
AL, is used in the public sector in Burkina Faso, as first times of intake. […], it takes 8 h between the first 2 takes. 
line treatment for the management of uncomplicated After the 8 h […], for sure you will distort your treatment 
malaria. A respondent explains that there are other com- and come and say that it is the drug that is not effective 
binations in national guidelines that work well but they and little by little the parasites will get used to the mol-
are too expensive compared to AL. Extensive use of ecule and develop resistance.…» Supplier 11, Private 
drugs is a factor favouring the emergence or the spread pharmacist].
of resistance and decision-makers are aware of the threat: Self-medication increases the risk of inadequate treat-
[« From the moment that we use the same drugs for mass ment, i.e. non-compliance with correct dosage and/or 
campaigns, SMC and such, we should have in mind the regimen, all of which are recognized as factors that accel-
history of resistance….» Policy maker 3, NMCP]. erate drug resistance. Nevertheless, given the large bur-
Due to wide spread use of a single ACT, selection pres- den of malaria, instead of not providing easy access to 
sure on AL is high and can accelerate the emergence and anti-malarials, it could be important to raise awareness of 
spread of artemisinin resistance in the country. the short-term effects (poor efficacy for current illness) and long-term effects (anti-malarial drug resistance) of 
poor compliance during self-medication.
Anti‑malarial prescription and use practice in Burkina Faso
The malaria treatment guideline is officially defined at 
national levels for both the public and the private health Health worker’s compliance with national guidelines
sector. Compliance by health workers and by patients are Lack of diagnosis and inappropriate treatment pre-
equally important in ensuring good anti-malarial pre- scription are behaviours of health workers commonly 
scription and use practice. observed in Burkina Faso. A researcher stated that the overconfidence of health workers based on their experi-
ence leads them to prescribe anti-malarials without diag-
Accessibility to ACTs, self‑medication, and correct use nostic tests, despite the national guidelines prescribing 
by patient them. An official at the regional level was indignant: [«…
In legislation, availability of anti-malarial drugs in phar- at the level of [public] health facilities, health care provi-
maceutical depots or pharmacies is conditional to sion is criticisable. I have just returned from a supervi-
presenting a prescription. In practice, however, accessi- sion, in certain situations the health workers themselves 
bility is void of this condition. This leads to a strong ten- systematically prescribe in case of fever [without any diag-
dency to self-medicate, which was denounced by many nostic test]» Policy maker 8, Regional Health Authority].
respondents. For them, self-medication is often associ- Both public and private health worker respond-
ated with treatment discontinuity when the patient feels ents in the current study claimed to follow national 
G uissou et al. Malaria Journal          (2023) 22:269 Page 7 of 14
recommendations for malaria management. [« The same poor quality diagnostic/prescription behaviours during 
protocols are applied [in public as in private health sector] supervision visits. An official confessed: [« For private 
whether for severe or uncomplicated malaria» User 4, Pri- health care center, especially large clinics, we can’t man-
vate health care provider]. When asked if there is a differ- age to supervise at their level; we can’t access to ensure, 
ence in anti-malarial prescription behaviour between the for example, that the diagnosis has really been confirmed 
two sectors, they responded affirmatively although with before carrying out the treatment, that the [right] mol-
different points: public sector practitioners believe that ecules have been proposed and respect…» Policy maker 3, 
there are indeed shortcomings at the level of the private NMCP].
sector on the diagnosis which can be explained by their A private pharmacist also insisted on the non-con-
lack of access to rapid diagnostic tests. [«…in the public, formity of several anti-malarial prescriptions for which 
we have access to the RDTs that we use before the anti- she had to correct the dosage: [«When you receive a pre-
malaria prescription, but in the private sector, especially scription where they put [non conform dosage], it is the 
in private practices nursing which we know, most of the duty of the pharmacist to rectify this…» Suppliers 11, Pri-
time they do not have access to the RDTs. They prescribe vate pharmacist].
according to the symptoms described by the patient.» User Inappropriate health care management practices by 
11, Public health care provider]. For private sector prac- health system actors, with overuse and misuse of drugs 
titioners, prescription behaviour differences between the can accelerate the emergence and spread of artemisinin 
two sectors lies mainly in the type of drugs prescribed: resistance.
the public sector favours generic ACT, while the private 
sector prescribes brand-name drugs or branded gener- Artemisinin resistance in Burkina Faso
ics. [«…I think it’s the same efficiency, it’s a question of Despite the absence of scientifically established results 
presentation and also a question of prejudice in relation on the presence of artemisinin resistance in Burkina 
to patients. It is the patients who guide us in our prescrip- Faso, respondents expressed their views on the subject. 
tions because when you prescribe generics, people have a For some, it has already been clearly established in the 
fixed idea. [….] Imagine if someone makes a consultation light of observations of therapeutic failures in the field, 
of 5000 FCFA and in return you give him a prescription of for others the causes of these failures are to be sought 
200 FCFA. It’s weird so that’s mainly why we tend to pre- elsewhere.
scribe brand-name in private sector. Otherwise personally, 
I do not think there is a difference between generic and The case for prevalence of artemisinin resistance 
brand-name drugs.» User 4, Private health care provider]. in Burkina Faso
They did not address the diagnosis aspect, except one Based on their personal observations, complaints from 
of them, who justified patients’ recourse to private sec- clients, patients or relatives, some of the respondents 
tor by their search for a good diagnosis: that is provided believe that therapeutic failures with ACT are prevalent, 
by microscopic examination of a blood film, even though reflecting the emergence of artemisinin resistance. One 
they do not have RDTs. of them questioned: [«  Why before that gave with the 
Several respondents justified the inappropriate treat- same treatments and today, it is necessary to lengthen the 
ment/combination prescription as being the result of treatment or even it is necessary to change treatments? We 
strong patient preferences. A public sector pediatri- do a treatment, it does not work, we change molecules…» 
cian explained that some patients insist on intravenous Policy maker 2, ANRP]. A wholesaler who is also phar-
administration of their medicinal products for treating macist explained: [« […] in pharmacies there are several 
uncomplicated malaria, arguing that this would promote customers who come and ask for another malaria treat-
rapid healing. When they face a refusal in a public health ment. I tell them “dear friend, 4  days ago you were here 
facility, they go to the private sector where they are pro- for an antimalarial.” He says he feels he is not healed. Isn’t 
vided the required service. [« ….They [Patients] are in too there anything else? So the resistance, I don’t know if it’s 
much of a hurry. There is no miracle drug. It takes time for psychological, but it already exists here. It may not be 
it to go.» User 6, Private sector health care provider]. To strong but it exists» Supplier 6, Private sector wholesaler]. 
preserve their customers, practitioners often accede to For them, it is timely to introduce another combination.
these user requests, particularly in the private health sec-
tor. This sector is more prone to non-compliance, which The case against prevalence of artemisinin resistance 
a respondent explained by stressing the almost total in Burkina Faso
absence of quality control within the private sector. In Other respondents were more cautious and link these 
the public sector, regional directorates, sometimes with observations of presumed therapeutic failure to the mis-
NMCP collaboration, has the possibility of identifying use of ACT. According to them, it would be necessary 
Guissou et al. Malaria Journal          (2023) 22:269 Page 8 of 14
above all to invest in sensitization of the population on processes and inadequate funding systems generally 
self-medication as well as in sanitation, the promotion explain disruptions in the public health sector [45, 
of good protection measures against mosquitoes (e.g. 48, 49]. Similar explanations emerge from our results 
mosquito nets) [« Frankly, tell them [decision makers] to and are confirmed by national data that show a dra-
focus on environmental sanitation is the only thing that matic increase in the percentage of pharmaceutical 
can save us from malaria. Medicines are useless, primary depots that have experienced a shortage of generic 
prevention is what we must focus on…let’s make sure there ACT: 9—23% in 2010–2015, increased to 72% in 2016 
are no more mosquitoes…» User 6, Private sector health and 85.5% in 2020 [33, 50, 51]. The numbers from 2016 
care provider]. A researcher stated: [«Never change a correspond to the beginning of implementation of the 
winning team! If ACTs are still effective in Burkina Faso, policy of free healthcare for children under 5 and preg-
I don’t know why the therapeutic relentlessness is neces- nant women, including malaria care. The deficits in 
sary. We cannot leave drugs that are good to jump to other ACT at the beginning of implementation of this policy 
combinations» Policy maker 9, Malaria researcher]. can be explained by the period of adaptation of capaci-
ties, i.e. a steep increase in demand due to care becom-
Discussion ing free. The persistence of this deficit in the following 
Anti-malarial drug market characteristics in Burkina years confirms dysfunctions at the level of logistics and 
Faso were explored to understand how they might accel- financing systems. CAMEG supply chain management 
erate or prevent the emergence and spread of artemisinin capacities must of course be strengthened. However, 
resistance in the country in the context of an imminent the most urgent need according to the present study, is 
threat of artemisinin resistance in African countries. The to secure funding sources for generic ACT, especially 
study shows that the current operational mode of anti- for no-charge policies. For the private sector, strength-
malarial drug markets promotes resistance. This requires ening customs service’s knowledge on pharmaceutical 
rethinking some aspects of current anti-malarial phar- products will contribute to improving administrative 
maceutical policies and health system characteristics. processing times and avoid disruptions observed in 
These aspects are mainly related to (a) ACT supply chain ACT brand-names and their copies.
disruptions, (b) weaknesses in quality and prescription ACT supply disruptions have an influence at several 
monitoring, (c) uncontrolled access to anti-malarials and levels on drug-use behaviours. At the health worker level, 
misuse by patients. if recommended combinations are not available, they will 
prescribe whichever anti-malarials are available, regard-
a) ACT supply chain disruptions less of what national healthcare guidelines recommend. 
Replacement of continuous-use medicines by unregu-
A robust structure of the anti-malarial market supply in lated drugs may compromise the control of the disease 
Burkina Faso prevails, with two mains official channels: and/or the adherence to therapy, affecting the treatment 
a central purchasing with a public mission (CAMEG) in effectiveness [47]. At the patient level, disruptions can 
charge of generic ACT procurement mainly for public impact adherence to treatment or lead to renunciation. 
health structures, and approved wholesalers who sup- This can also enhance the use of street drugs, which are 
ply private markets with brand-name ACT and branded cheaper than those obtained at private pharmacies [30]. 
generics. All these misuse behaviours, generated by disruption of 
Centralization of procurement has proven to reduce ACT supply can accelerate the emergence and spread of 
drug stock-outs and increase drug availability for pop- artemisinin resistance.
ulations [45]. Large quantities ordered at central loca-
tions offers economies of scale and leads to affordable b) Weaknesses in quality and prescription monitoring.
acquisition and sale prices. However, centralization 
has its limitations, given the problems in ACT avail- To ensure drug safety, it is important that drug quality 
ability, highlighted by respondents especially in the and proper prescription are safeguarded at the national 
public health sector. Supply disruptions seem to be a level. In Burkina Faso, shortcomings in the quality con-
trend in low- and middle-income countries (LMICs). trol process have been observed regarding the quality of 
An evaluation of availability rates of generic drugs drugs and their prescription practice, particularly in the 
for acute conditions in basic health structures of 40 private sector which provides a significant part of the 
LMICs revealed a mean availability of 53.5% in the country’s supply of medicines. Additionally, there is pres-
public sector and 66.2% in the private sector [46]. In sure exerted on the main ACT used at the national level, 
Brazil, this rate was estimated at 52.9% in 2017 [47]. due to lack of other affordable ACTs and the policy of a 
Weaknesses in purchasing and/or supply management single first-line treatment.
G uissou et al. Malaria Journal          (2023) 22:269 Page 9 of 14
Weaknesses in quality control of ACT imported by private on these products [29]. Prescribers and patients should 
sector wholesalers also be informed about the risks of the emergence of 
According to the WHO, 1 out of 10 medical products artemisinin resistance and its consequences and the sub-
was reportedly counterfeit or substandard in LMICs and sequent importance of adhering to recommended prod-
most of them were anti-malarials or antibiotics [52]. A ucts, insofar as their choice is one of the main factors that 
study conducted in eight African countries showed that guides ACT purchases by private wholesalers [29].
non-quality assured ACT accounted for 8–40% of the Anti-malarial market actors in Burkina Faso recom-
market share in the private sector drug stores, and this mended strengthening the fight against street drugs by 
trend was much weaker in the public sector [30]. Burkina the government, even though literature review suggested 
Faso government’s weak ability to control the quality of that artemisinin-based combinations were not present 
imported ACT is highlighted by study results and is all among street drugs in the country [41, 56]. Nevertheless, 
the more worrying as their quality is often questionable, the timeline of previous reports (2006–08), the exist-
especially in the case of street drugs. Tinto and Rouamba ence of counterfeit ACT in neighbouring countries [30] 
(2020) explained that many drugs of questionable qual- and the high rate of access of this market by the popula-
ity or counterfeit drugs are circulating on the Burkinabe tion [40, 41] compels us to conclude that there is a strong 
market and the country does not have the technical plat- probability that ACT of poor quality are available in the 
form to address this critical health problem [53]. streets of the country. Financial and geographical acces-
Availability and use of poor quality anti-malarials have sibility as well as the possibility of unit purchase and 
historically been linked to treatment failure and in some price negotiation are the main explanatory reasons for 
cases, have coincided with the emergence or spread of the recourse to street drugs according to our study and 
resistance [54]. There have been alarms of anti-malarial this is confirmed by other studies in the African context 
resistance that were in reality due to poor-quality anti- [26, 40, 42, 57]. Increased and—above all—continuous 
malarials and not due to parasite resistance [16]. Effica- repression of supply and sales circuits (including mar-
cious anti-malarials are crucial for malaria control and kets, street vendors) would certainly reduce availability 
it is essential to monitor their efficacy in order to inform of street drugs. Numerous repression operations have 
treatment policies and detect, as early as possible, emerg- been carried out, yet a lack of continuous follow-up 
ing drug resistance [3]. Drug quality control and phar- seems to suggest an absence of political will. At the same 
macovigilance systems for private sector are important time, the Burkinabe government tried to strengthen the 
issues to address to delay the emergence or the spread alternative to street drugs more appealing by providing 
of artemisinin resistance in Burkina Faso. ANRP appears stable and secure funding system in the form of a policy 
to be moving towards reducing the number of ACT for better access to quality-assured ACT. This has been 
imported by wholesalers in order to allow concentrated shown in 8 countries of sub-Saharan Africa, demonstrat-
and more effective controls. Indeed, the multiplicity of ing increased accessibility to ACT especially in hard-to-
supply sources for private wholesalers, denounced even reach areas [58].
by Burkinabe private pharmacies owners [34], makes 
control more difficult. The same observation was made in Weaknesses in quality control of ACT prescription
several other African countries with a listing of 92 differ- Apart from the quality of the drug, its proper use is nec-
ent suppliers in Nigeria [30]. essary for an effective and efficient result. Even if health 
While waiting to be able to set up an effective quality workers, being from public or private health sectors, 
control system, ANRP could rely on the WHO prequali- claim to follow national recommendations, respondents 
fication programme which ensures the quality of drugs in in this study raise questions about the quality of malaria 
the public sector. This programme certifies non-toxicity management and anti-malarial prescriptions. They 
and efficacy of drugs and is mandatory for any transac- highlighted a lack of diagnosis before treatment admin-
tion carried out with international funding, as is the case istration and prescription of inappropriate treatment/
for a large part of generics ACT purchase in Burkina Faso combination as well as the lack in the control of prac-
[6, 55]. With the centralization of purchases by CAMEG, tice, particularly in private sector. The study results are 
a sufficient level of quality control of generic medicines is consistent with several studies that have reported sub-
ensured. If some brand-names and their copies are in this optimal health worker compliance with ‘test and treat’ 
prequalification list, they may be prioritized by the gov- malaria guidelines in endemic sub-Saharan African coun-
ernment as the quality label is already assured. Restrict- tries including Burkina Faso [26, 59–63]. Malaria treat-
ing the import of brand-names and their copies will ment is still largely presumptive despite the recognition 
require an effective campaign to sensitize private sector of the usefulness of diagnostics tests and their increasing 
vendors, as it is likely to influence their profit margin availability, particularly in public health sectors [58–61]. 
Guissou et al. Malaria Journal          (2023) 22:269 Page 10 of 14
The findings also show an absence of health care prac- spread of resistance to artemisinin [20, 68, 69]. Beyond 
titioners’ quality control by Burkinabe government’s, questions of efficacy, cost and cost-effectiveness must 
despite it being in the texts, especially in the private sec- also be considered; our study confirms that it is this fac-
tor. Even training on compliance to national guidelines tor that determines the choice of AL combination among 
is scarce, the government usually contenting itself with the other combinations recommended by the WHO for 
sending them paper versions of national directives, while uncomplicated malaria management.
this sector is the most indexed in the literature for is ina- The Burkina Faso government also encourages and 
bility to diagnose and treat non-malarial fevers, and an supports the development of traditional medicine, which 
innate motive to over-prescribe malaria treatment [64]. is widely used by the populations and even medicine 
Weak financial capacity is put forward by regulators as practitioners [70–72]. The country’s weak pharmacovigi-
one of the reason for the lack of quality control of health lance capacities explains the low number of traditional 
care practitioners with regards to malaria diagnosis and drugs available in pharmacies given the large number of 
treatment. However, given the preponderant role of the medicinal plants used in the management of malaria [70, 
private sector in the provision of care, it is more than 73–75]. Continued support for pharmacovigilance activi-
necessary to undertake effective and efficient training ties is required to have safe products that will diversify 
and control activities in order to ensure that private sec- the medicines offered and reduce the selection pressure 
tor acts in line with state priorities. RDTs should also be on modern anti-malarial combinations.
available at their level to enhance their use and improve 
malaria case management. c) Uncontrolled access to anti-malarials and misuse by 
The quality of prescription is partially determined by patients.
the quality of prescribers. The Burkinabe health system 
delegates prescribing medication to nurses, community- Despite clear regulations, anti-malarials are accessi-
based health workers and often less qualified health ble without prescription at all drug sales outlets in Bur-
workers in peripheral health centers. This practice aims kina Faso, similar to many malaria-endemic countries 
to facilitate access to care for populations, especially [29]. Free access to anti-malarials leads to high rates of 
those in rural areas due to lack of doctors. Inappropri- self-medication according to the study respondents. 
ate prescriptions observed in the management of malaria This situation is common in endemic countries since the 
is partially explained by this delegation of prescription, population has a relatively good knowledge of symptoms, 
without providing adequate training or lack of retrain- causes, mode of transmission, etc. related to malaria [76, 
ning [34, 53, 65]. The country is currently in the trend of 77]. A survey conducted in Burkina Faso urban private 
increasing the availability of doctors at the level of basic pharmacies among 1,467 people who came to buy an 
public health structures, and this will undoubtedly con- anti-malarial, revealed that 2/3 had come directly, with-
tribute to improve the quality of prescriptions. out a prescription [34]. A high rate of self-medication has 
Prescribers’ skill level and experience, together with also been observed in the Democratic Republic of Congo 
training and supervision are a necessity to ensure with 96 to 98% of respondents in studies admitting to 
implementation and maintenance of good prescription self-medicate with anti-malarials [78, 79]. In contrast, 
practices [66, 67]. Inappropriate malaria health care man- a study in Ghana reports a lower proportion (16.8%) of 
agement practices by health system actors result in over- non-prescribed anti-malarial use, and explains it by the 
use and misuse of ACT [3, 23, 24]. existence of National Health Insurance Scheme [77]. The 
direct recourse to treatment is generally not carried out 
Pressure due to limited ACTs used in the country following a diagnostic test. Therefore, there is a risk of 
A study in Burkina Faso of private pharmacies showed treating the wrong disease since diseases highly preva-
that AL was the main anti-malarial dispensed, both lent in countries with high malaria endemicity, such as 
with and without a medical prescription, over several dengue fever or typhoid fever, have symptoms very simi-
years [34]. Our results also highlighted the strong use of lar to malaria [76]. In addition to inappropriate malaria 
generic versions of this combination in the public health treatment‐seeking behaviours, this open access also 
sector. The intense utilization of this ACT places selective enhances anti-malarial misuse behaviours: use of non-
pressure on artemisinin and the partner drug [20, 24, 68]. recommended molecules, failure to respect intake inter-
Development of new combinations such as triple arte- vals, failure to complete the treatment. Several studies 
misinin-based combination therapies (TACTs) are being have highlighted these types of behaviours in anti-malar-
explored as a possible alternative [43, 44]. Multiple first- ial use and have shown their link with the emergence or 
line therapies (MFTs) are also proposed to mitigate the the spread of resistance: anti-malarial drug resistance has 
effects of this pressure and thus delay the emergence and been accelerated by the way drugs are used (or misused) 
G uissou et al. Malaria Journal          (2023) 22:269 Page 11 of 14
and by the social and economic conditions in which they and ACT represents a significant barrier to patients in 
are used [3, 25, 53, 77, 80, 81]. This is similar to the case the community, especially in rural areas [85].
of antibiotics misuse, which is widespread with conse-
quences of resistance emergence or spread [82, 83]. Study limitations
The main limitation of this study is absence of deep 
Could requiring a prescription for access to ACT curb these investigation into the role of ACT costs and price on 
misuse behaviours? anti-malarial market dynamics. Indeed this variable was 
Many study respondents think it could and they sug- found important in securing the generic ACT supply 
gest it should be regulated. It is also the conclusion of chain, on the choice of artemisinin-based combinations 
studies on pervasive drug misuses in the same context for national policies and on anti-malarials use behaviours 
[79, 82]. However, one interview respondent stated that by community members. These community members are 
open access and self-medication is not the problem given end users of ACT and their support is essential for the 
country health system organization and access difficul- successful implementation of an efficient pharmaceuti-
ties: the prevalence of malaria in Burkina Faso is such cal policy. Given the widespread poverty in Burkina Faso, 
that if all patients visit the health centers, the already similar to most African sub-Saharan countries, knowl-
insufficient health centers would be even more over- edge of price impact on their choices is important. A 
whelmed. This difficult physical access to health services system that relies on community members’ ability to pay 
due to their insufficient geographical coverage is a real- for appropriate treatments risks a repeat of events asso-
ity shared by LMIC populations. In addition, the aspect ciated with chloroquine resistance, where an effective 
of increased financial burden must be considered. If ideal and cheap anti-malarial drug was rendered useless partly 
health services were available, this would imply the pay- due to under-treatment [64]. Also, the impact of storage 
ment for consultation, diagnostic examination (in the conditions on the quality of ACT, highlighted by the lit-
event of recourse to the private sector), and treatment. erature, was not investigated in this study. The cumber-
Burkina Faso, similar to many other LMICs, has a low someness of customs administrative procedures on brand 
rate of coverage by health insurance and, therefore, the supply shortages that emerged in the results, was also 
majority of the populations would bear this burden from not taken into account in the identification of the main 
their families budgets [82, 84]. Poverty affects integral respondents.
aspects of malaria treatment-seeking behaviours, includ-
ing adherence to treatment [23]. Conclusion
Given the structural barriers to anti-malarial access This study presents a compilation of important informa-
and to proper use behaviour, which cannot be resolved tion regarding anti-malarial market characteristics and 
immediately, and with the threat of resistance to arte- their possible influence on the emergence and spread of 
misinin, Burkina Faso, like other LMICs, should consider artemisinin resistance in Burkina Faso. Many character-
strong sensitization campaigns on good compliance in istics of the current anti-malarial market in Burkina Faso 
malaria treatment administration and use. Awareness are accelerating factors to this effect. These include the 
should also focus on compliance with national recom- ongoing disruptions in ACT supply chain at both pub-
mendations for care with the use of quality-assured mol- lic and private wholesalers’ level, weaknesses in quality 
ecules in order to fight against the use of street drugs. control systems for ACT, selection pressure on ACT that 
Community members in Burkina Faso generally have a are used for malaria management, uncontrolled access to 
good knowledge of malaria. However, their knowledge ACT by patients, and misuse of ACT by both prescribers 
of anti-malarial drug resistance is poor [81]. Increasing and community members. Most of these dysfunctions are 
their knowledge regarding the consequences of the mis- structural barriers that cannot be resolved in the short 
use of ACT, on their current illness and at a more holistic to medium term even though the threat of artemisinin 
level, on the emergence or spread of resistance and their resistance looms. Malaria control in African malaria 
implications such as the cost of a change in treatment at endemic countries is mainly based on treatment interven-
the national level, could promote safe behaviour. Official tions. Therefore, it is necessary to have an effective and 
drug sellers should also be made aware of those aspects efficient drug policy design that takes into account local 
with the addition of RDTs being made available to them constraints. The malaria research community is work-
[34, 59]. The mean cost of RDTs in private Burkina Faso ing on the modification of existing treatments, as well 
pharmacies was estimated at 1,523 FCFA (2.412 USD), a as the discovery and development of new drugs to coun-
higher cost than generic ACT in these stores [34]. Sup- ter resistance to current drugs. While waiting for these 
plying RDTs free for the populations would be ideal. innovations, solutions that can be quickly implemented 
Indeed, the combined healthcare costs of both the RDTs must be considered. The majority of study respondents 
Guissou et al. Malaria Journal          (2023) 22:269 Page 12 of 14
recognized an increase in therapeutic failures. They are tropm edres. ac/ units/ moru- bangk ok/b ioeth ics-e ngage ment/ data-s hari ng). 
aware of the risk of the emergence and spread of arte- Most interviews are directly traceable to individual identities and therefore 
we cannot share the interview data without releasing the identities of the 
misinin resistance in Burkina Faso and associate this respondents. In each interview, respondents introduced themselves and 
with factors related to anti-malarial markets and subse- spoke about their direct (working) environment. Moreover, the topics dis-
quent (mis) use of anti-malarials. To address this threat, cussed and responses to questions, could be directly linked to their job posi-
tions and affiliation, especially with higher level policy and regulatory officials. 
four recommendations for public policy emerged during We guaranteed full anonymity to the respondents prior to data collection and 
data analysis: (1) Address the suboptimal prescription of therefore sharing the dataset without restrictions would be unethical.
anti-malarial drugs, (2) Apply laws that prohibit the sale 
of anti-malarials without prescription, (3) Restrict the Declarations
availability of street drugs, (4) Sensitize the population 
Ethics approval and consent to participate
on the value of compliance regarding correct acquisition Ethical approval from Institutional Review Board (IRB) was obtained from the 
and intake of anti-malarials. Funding systems for malaria National Health Ethics Committee of Burkina Faso (83-2019/CEIRES in addition 
treatment facilitate the availability and accessibility of to ethical approval from Oxford Tropical Medicine Research Ethics Committee 
(OxTREC Ref: 552-19). Prior to entering the research sites, permission to carry 
appropriate therapies for the maximum number of peo- out the study was obtained from relevant community gate keepers, and the 
ple and must, therefore, be stabilized. The dramatic con- respondents before commencement of the interview session. Before admin-
sequences, both in terms of economic and public health istration of the questionnaire, the nature, purpose and process of the study 
were explained to the participants after which informed written consent was 
outcomes, of the emergence and the spread of chloro- obtained. Necessary steps were taken to ensure confidentiality. Participants 
quine resistance must not be repeated with ACT. were continuously reminded of their right to withdraw from the study at any 
time. After each session, the participants were consulted to ensure that study 
findings reflected their voices and perceptions.
Abbreviations
Consent for publication
ACT  Artemisinin-based Combination Therapy
For the purpose of Open Access, the author has applied a CC BY public 
AL  Artemether-Lumefantrine
copyright license to any Author Accepted Manuscript version arising from this 
ANRP  National Agency for Pharmaceutical Regulation / Agence Nation-
submission.
ale de Régulation Pharmaceutique
ASAQ  Artesunate-amodiaquine
Competing interests
CAMEG  Centrale d’Achat Médicaments Essentiels Génériques
We declare that no competing interests exist.
DeTACT D evelopment of Triple Artemisinin-based Combination Therapies
EGM E ssential Generic Medicines
Author details
FGDs F ocus Group Discussions 1 Institut de Recherche en Sciences de la Sante, Centre National de la 
IDIs  In-depth Interviews
Recherche Scientifique et Technologique, Ouagadougou, Burkina Faso. 
LMICs L ow- and Middle-Income Countries 2 Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medi-
LNSP N ational Public Health Laboratory / Laboratoire National de Santé 
cine, Mahidol University, Bangkok, Thailand. 3 Center for Tropical Medicine 
Publique
and Global Health, Nuffield Department of Medicine, University of Oxford, 
MA  Marketing Authorization
Oxford, UK. 4 Copernicus Institute of Sustainable Development, Utrecht 
NMCP N ational Malaria Control Programme / Programme National de 
University, Utrecht, The Netherlands. 5 Institut des Sciences et Techniques, 
Lutte contre le Paludisme
Bobo-Dioulasso, Burkina Faso. 6 School of Public Health, College of Health Sci-
RDTs  Rapid Diagnostics Tests
ences, University of Ghana, Accra, Ghana. 
SMC S easonal Malaria Chemoprevention
TACTs T riple Artemisinin-based Combination Therapies
Received: 23 June 2023   Accepted: 5 September 2023
TFPs  Technical and Financial Partners
UEMOA  West African Monetary and Economic Union /Union Economique 
et Monetaire Ouest Africaine
WHO W orld Health Organization
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