antimalarial drugs & diagnostic testing in the era of ...€¦ · 1567 outlets met screening...

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

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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


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


What outlets are stocking

0

20

40

60

80

100

2009 2011

%

QAACTs nAT oAMT RDTs

0

20

40

60

80

100

2009 2011

%


Private for-profit*

* Among outlets stocking at least one antimalarial drug

Availability by main antimalarial categories, 2009 and 2011



0

20

40

60

80

100

2009 2011

%

QAACTs nAT oAMT Diagnostic test

0

20

40

60

80

100

2009 2011

%

$1.48


What outlets are stockingAvailability by main antimalarial categories, 2009 and 2011


Private for-profit*


$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



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


Availability of oral artemisinin monotherapy in the private sector across 9 studies*, 2011


Outlet surveys capture the structure of the retail market

0

20

40

60

80

100




%

Market share of AETDs sold/distributed in the past week (7 days), Nigeria 2011

Nigeria 2011 Outlet Survey Results


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


Market share of AETDs dispensed over previous 7 days across outlet types, 2011

0

20

40

60

80

100




QAACTs with logo QAACTs Non-QAACTs SP in public sector Non-artemisinin therapy Non-oral artemisinin monotherapy


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


Market share of AETDs dispensed over previous 7 days across outlet types, 2011

0

20

40

60

80

100




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)


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?


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


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


8.7

Private Sector 32%

TOTAL (n=1,010)

3.3

6.9

19.6

Zone 1 (n=491)



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?


When they arrive – are tests available?

0

20

40

60

80

100


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


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


What does the patient take?

0

20

40

60

80

100

Cocktail ACT Non-artemisinin monotherapy

Artemisinin monotherapy

%


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.


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


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


•  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

antimalarial drugs & diagnostic testing in the era of ...€¦ · 1567 outlets met screening...

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