During the lifetime of the ACT Consortium, in many endemic areas only a fraction of those who needed an effective antimalarial would get one.
Barriers existed at every stage of the care pathway, especially for the poorest families in society. Many could not or did not access care of any kind for children with malaria.
Of those who did seek treatment, a high proportion accessed inadequate care through the informal sector. Of those who accessed the informal sector, the majority with malaria frequently received no antimalarial, and of those who did, the antimalarial was often a locally ineffective drug, or was given at inadequate doses. Even where patients reached a formal healthcare facility where free antimalarials existed, only a minority was given effective antimalarials.
For maximum public health impact of ACTs, it was therefore essential that a range of potential strategies for ACT delivery were carefully evaluated to assess where ACTs should be provided, how they should be delivered and who should receive them.
However, the evidence base on ACT delivery strategies was very limited. Most countries were initially deploying ACTs in formal health care facilities only, although in many settings such facilities saw only a minority of febrile cases, with an equal or greater number using shop-bought drugs. There was therefore an urgent need to test interventions to improve the quality of facility care, and to extend ACT availability beyond the formal health care sector.