Post on 02-Aug-2020
Tanya Shewchuk, on behalf of the ACTwatch group
Antimalarial drugs & diagnostic testing in the era of subsidies: multi-country findings
www.ACTwatch.info 2
Benin
DRC
Zambia
Nigeria
Uganda
Madagascar
Cambodia
ACTwatch: the original countries
2
Objective Provide policy makers with evidence on trends in availability, price, and use of antimalarials
Partnership PSI, LSHTM and MoHs
5 year, 7 country project Funded by the BMGF
www.ACTwatch.info 3
Benin
DRC
Zambia
Nigeria* Uganda*
Madagascar*
Cambodia
ACTwatch methods used in 13 countries
Myanmar
Tanzania*
Kenya*
Zanzibar*
Niger*
Ghana*
As part of Independent Evaluation of the AMFm * Additional funds from Global Fund
Ghana, DNDi/KATH; Niger, CRDH; Tanzania, IHI
Some data presented may appear to differ from those in the Multi-country Baseline Report of the Independent Evaluation of the AMFm, Phase 1. However, the results are complementary as different indicators and denominators are sometimes used.
Presentation Outline
www.ACTwatch.info 4
• Overview of Methods
• Focus on country examples - Nigeria: supply lens - Cambodia: consumer lens - Myanmar: resistance containment
• Future
5
Outlet Survey (PSI) What are the trends in the availability, market share and price of antimalarials? - Trend data over the life of project.
Supply Chain Research (LSHTM) How is the private distribution chain structured? Wholesaler & market characteristics, mark-ups? - Once over life of project
Household Survey (PSI) What are the trends in the levels of use of different antimalarials. What are the determinants of use? - Twice (baseline & endline)
www.ACTwatch.info
3 Research Components – provide a comprehensive picture of the market
6
• Clusters were randomly selected proportional to population size;
• Over-sampling of public health facilities and pharmacies;
• Census conducted of all outlets with the potential to stock antimalarials;
• Audit of all antimalarials in stock: - generic name - brand name – formulation – strength - expiry date – price - volume (quantity) dispensed in the last 7 days
• Availability of diagnostic testing (RDT/Microscopy) captured
• Data were survey set & weighted to provide nationally representative estimates
www.ACTwatch.info
ACTwatch Outlet Survey Methods
www.ACTwatch.info 7
Nigeria: country profile
Population: 158 million
Represents 25% of malaria cases in Africa
Mainly P.falciparum
Oral artemisinin monotherapy controls introduced in 2006
Major external financing: WB, PMI, DFID & GF
AMFm phase 1 pilot
www.ACTwatch.info 8
Nigeria: Timeline & ACTwatch surveys
2008 2009 2010 2011 2012
Outlet Outlet Outlet Household Household Supply
Outlet survey 2009: Sep/Oct 114 Clusters: 6089 outlets approached, 2210 outlets met screening criteria
2011: Oct/Nov 124 Clusters: 8507 outlets approached, 1567 outlets met screening criteria
Household 2009: Aug/Sep 4649 households approached 2734 households met screening criteria
2012: Jun/Jul
Supply chain 2009: Jul/Aug Quantitative: 140 wholesalers interviewed
Qualitative: 9 key informant & 30 in-depth
1st AMFm drugs arrive in-country Jan 2011
www.ACTwatch.info 9
Overview of supply chain: complex & competitive
Maximum number of steps from factory gate/port to retail outlet
5
Employed a member of staff with health qualifications
63% (n=137)
Displayed any up-to-date pharmacy license from the DRA (either wholesale or retail)
8.7% (n=138)
- Antimalarials: key revenue generator - High levels of competition: businesses use diverse marketing/distribution strategies. - Specialized vendors within traditional open-air markets considered important competitors to
conventional traders - Vertically integrated distribution infrastructure & 3rd party logistics used.
Qualitative results:
Nigeria 2009 Supply Chain Research Results
www.ACTwatch.info 10
Outlet surveys capture the structure of the retail market
0
20
40
60
80
100
Public/Not for Profit Sector
Total Private Private for profit facility
Pharmacy Drug store General retailer Itinerant drug vendor
%
- Private health facilities - Pharmacies - Drug shops (PPMVs) - General retailers - Itinerant drug vendors
Market share of AETDs sold/distributed in the past week (7 days), Nigeria 2011
Nigeria 2011 Outlet Survey Results
www.ACTwatch.info 11
What outlets are stocking
0
20
40
60
80
100
2009 2011
%
QAACTs nAT oAMT RDTs
Public Health Facilities
Availability by main antimalarial categories, 2009 and 2011
Nigeria 2009 & 2011 Outlet Survey Results
www.ACTwatch.info 12
What outlets are stocking
0
20
40
60
80
100
2009 2011
%
QAACTs nAT oAMT RDTs
0
20
40
60
80
100
2009 2011
%
Public Health Facilities
Private for-profit*
* Among outlets stocking at least one antimalarial drug
Availability by main antimalarial categories, 2009 and 2011
Nigeria 2009 & 2011 Outlet Survey Results
www.ACTwatch.info 13
0
20
40
60
80
100
2009 2011
%
QAACTs nAT oAMT Diagnostic test
0
20
40
60
80
100
2009 2011
%
$1.48
* Among outlets stocking at least one antimalarial drug
What outlets are stockingAvailability by main antimalarial categories, 2009 and 2011
Public Health Facilities
Private for-profit*
Nigeria 2009 & 2011 Outlet Survey Results
$4.47
14 www.ACTwatch.info
Data can be disaggregated by outlet type – useful for strategic decisions at country level
4.7 1.7 2.6 4.1
52.6
97.1
46.7
34.2
16.5
45.9
14.9
0
33.9
16.8 17.7
99.5
36.2
19.2
1
35
0
10
20
30
40
50
60
70
80
90
100
Public Health Facility
N=228/94
Community Health Worker
N=12/7
Private Not For Profit N=9/9
Total Public/Not for Profit N=249/110
Private For Profit
N=358/88
Pharmacy N=403/37
Drug Store (PPMV)
N=990/1163
General Retailers
N=103/64
Itinerant Drug Vendor
N=10/28
Total Private N=1864/1380
Public/Not for Profit Sector Private Sector
%
2009 2011
* Among outlets stocking at least one antimalarial drug
Nigeria 2009 & 2011 Outlet Survey Results
Availability of oral artemisinin monotherapy*, 2011
15 www.ACTwatch.info
0.7
40.5
5.2
0.1
45.9
0.1 0.2
8.6
30
0.1 0 N/A <0.1
35
0 0.09 0.7 1.4
0
20
40
60
80
100
N=632/914 N=1240/NA N=1433/1367 N=1854/1632 N=1864/1380 N=522/726 N=1583/2337 N=267/490 N=170/216
Benin DRC Kenya Madagascar Nigeria Tanzania Uganda Zambia Zanzibar
%
2009/2010 2011
2009/2010 & 2011 ACTwatch Outlet Survey Results, Independent Evaluation
Results in perspective: cross-country comparisions
* Among outlets stocking at least one antimalarial drug
Availability of oral artemisinin monotherapy in the private sector across 9 studies*, 2011
www.ACTwatch.info 16
Outlet surveys capture the structure of the retail market
0
20
40
60
80
100
Public/Not for Profit Sector
Total Private Private for profit facility
Pharmacy Drug store General retailer Itinerant drug vendor
%
Market share of AETDs sold/distributed in the past week (7 days), Nigeria 2011
Nigeria 2011 Outlet Survey Results
www.ACTwatch.info 17
Impact of AMFm subsidy: - Price of ACTs has gone from $4.5 to $1.8 USD. - Substantial (18%) increase in QAACT market share from 2009. - 67% of all antimalarials in private sector remain either ineffective or are oral
AMT.
Measure impact of system-based interventions
Nigeria 2009 & 2011 Outlet Survey Results
Market share of AETDs dispensed over previous 7 days across outlet types, 2011
0
20
40
60
80
100
Public/Not for Profit Sector
Total Private Private for profit facility
Pharmacy Drug store General retailer Itinerant drug vendor
QAACTs with logo QAACTs Non-QAACTs SP in public sector Non-artemisinin therapy Non-oral artemisinin monotherapy
www.ACTwatch.info 18
Impact of AMFm subsidy: - Substantial (18%) increase in QAACT market share from 2009 data. - 67% of all antimalarials in private sector remain either ineffective or are oral
AMT.
Measure impact of system-based interventions
Nigeria 2009 & 2011 Outlet Survey Results
Market share of AETDs dispensed over previous 7 days across outlet types, 2011
0
20
40
60
80
100
Public/Not for Profit Sector
Total Private Private for profit facility
Pharmacy Drug store General retailer Itinerant drug vendor
QAACTs with logo QAACTs Non-QAACTs SP in public sector Non-artemisinin therapy Non-oral artemisinin monotherapy
www.actwatch.info
19
Very low transmission P.f. 1st line: DHA-Pip (zone 1), AS+MQ ACT & RDT private sector subsidy since 2004 CNM – Designated Three Zones:
• Zone 1 Containment Program
• Zone 2 [2½ years – BMGF]
• Zone 3 & “No Zone” Dynamic policy/strategy environment aimed at containing drug resistance
Cambodia: country profile (at time of 2011 survey)
www.ACTwatch.info 20
Cambodia: Timeline & ACTwatch surveys
2008 2009 2010 2011 2012
Outlet Outlet Household Household Supply
Outlet survey 2009: Jun/Jul 7833 outlets approached 1019 outlets met screening criteria
2011: Jun/Aug 18584 outlets approached 1529 outlets met screening criteria
Household 2009: Oct/Nov 22371 households approached 1465 households met screening criteria
2011: Nov/Dec 20895 households approached 1013 households met screening criteria
Supply chain 2009: Aug/Nov Quantitative: 95 wholesaler interviews
Qualitative: 19 semi-structured interviews
ACT and RDT subsidy since 2004
What do people initially do when they think they have malaria?
www.ACTwatch.info 21
Take some ac*on at Home 54% Or Do nothing 4%
Public Facility, 9%
Village Malaria Worker, <1%
Private Sector 38% 80% of people who seek
treatment go to private sector
Cambodia 2011 Household Survey Results
www.ACTwatch.info 22
6 2.2
Private Sector 31%
Zone2 (n=317)
PHF9%
Private Sector 33%
Zone 3 (n=202)
Where do people initially go when they think they have malaria?
Took some action at home or did nothing
Private Sector
Village Malaria Worker
Public Health Facility
8.7
Private Sector 32%
TOTAL (n=1,010)
3.3
6.9
19.6
Zone 1 (n=491)
Cambodia 2011 Household Survey Results
www.ACTwatch.info 23
0
20
40
60
80
100
Any
ACT
Non
-ar
tem
isin
in
ther
apy
Ora
l ar
tem
isin
in
mon
othe
rap
y
Any
ACT
Non
-ar
tem
isin
in
ther
apy
Ora
l ar
tem
isin
in
mon
othe
rap
y
Total PHF/VMW Total private
0
20
40
60
80
100
Any ACT Non-artemisinin therapy
Oral artemisinin monotherapy
Any ACT Non-artemisinin therapy
Oral artemisinin monotherapy
Total PHF/VMW Total private
%
Public Sector (PHF&VMW)
Private Sector
When they arrive, are drugs available?
www.ACTwatch.info 24
When they arrive – are tests available?
0
20
40
60
80
100
Public Health Facility
VMW Total PHF/VMW
Pharmacy/ Clinic
Drug Store Retail Outlet Mobile Provider Total Private
Public / Not for Profit Sector Private Sector
%
Availability of diagnostic testing services (RDT or microscopy), Public & Private Sectors*
Cambodia 2011 Outlet Survey Results
* Out of outlets stocking at least one antimalarial
Market Share by Sector – 2009 & 2011
www.ACTwatch.info 25
0
10
20
30
40
50
60
70
80
90
100
Total PHF/VMW Total private Total PHF/VMW Total private
2009 20092 2011 2011
Any ASMQ DHA+PPQ Other ACT Non-artemisinin therapy Oral artemisinin monotherapy Non-oral artemisinin monotherapy
Cambodia 2009 & 2011 Outlet Survey Results
www.ACTwatch.info 26
What does the patient take?
0
20
40
60
80
100
Cocktail ACT Non-artemisinin monotherapy
Artemisinin monotherapy
%
Cambodia 2011 Household Survey Results
27
What is in a Cocktail?
Made to order / wholesale Patients often do not know contents “Multiple symptoms require multiple medicines”
GUARD/ ACT Consortium 311 treatments containing 866 tablets bought by mystery clients. Very common elements (chemical analysis): • Antipyretics, vitamins, antihistamine, caffeine • Some antimalarials – mainly chloroquine • Also antibiotics and steroids
ACTwatch Outlet Survey 2011 – Cocktails bought by interviewers from 1,133 outlets. – On visual inspection, contents looks similar to those
from GUARD study.
www.ACTwatch.info 28
Myanmar: country profile Population 48 million
~70% P. Falciparum
Imprecise estimates of cases per year due to lack of data (range from 1-8 million)
National health authority still allows marketing of oral AMT for uncomplicated malaria, as reported by WHO 4/2012
Artemisinin resistance suspected from 2009 in eastern Myanmar
www.ACTwatch.info 29
Myanmar: Outlet Survey
• Difference from the standard ACTwatch methodology:
- public health facilities not included - a number of areas not including in sampling frame as inaccessible.
• Preliminary findings being presented today.
Data Collec4on March to May, 2012 3476 potential outlets approached 1274 met screening criteria
0
20
40
60
80
100
Private health facility N=200
Pharmacy N=340
I4nerant drug vendor N=146
General retailer N=273
Health worker N=200
Private Sector Health worker
First-‐line quality assured ACT (FAACT) Non artemisinin therapy Oral artemisinin monotherapy
%
Availability of antimalarial drug by outlet type, Myanmar 2012, Preliminary findings
Quality assured ACT
0%
20%
40%
60%
80%
100%
Private facility Pharmacy Itinerant drug vendor
General Retailer Health Worker TOTAL MARKET
Quality assured ACT (QAACT) Other ACT
Chloroquine Other non-artemisinin therapy
Oral artemisinin monotherapy Non-oral artemisinin monotherapy
Market share within each outlet type Myanmar 2012, Preliminary findings
TOTAL
Future: ACTwatch2
www.ACTwatch.info 32
• Outlet Surveys. RDTs – full audit • Household Surveys -> Mystery Clients, Exit Interviews,
Observational research
…Recruiting a PI.
33
www.ACTwatch.info 11/2/12
• Mr. Suprotik Basu • Mr. Rik Bosman • Ms Renia Coghlan • Dr. Thom Eisele • Mr. Louis Da Gama • Dr. Paul Lalvani
• Dr. Ramanan Laxminaravan
• Dr. Matthew Lynch • Dr. Bernard Nahlen • Dr. Jayesh M. Pandit • Dr. Melanie Renshaw • Mr. Oliver Sabot • Ms Rima Shretta
• Dr. Rick Steketee • Dr. Warren Stevens • Dr. Gladys Tetteh • Dr. Nick White • Dr. Prashant Yadav • Dr. Shunmay Yeung
Bill and Melinda Gates Foundation DFID The Global Fund to Fight AIDS, Tuberculosis and Malaria Members of the ACTwatch Advisory Committee
Acknowledgements