Role of the private sector in the delivery of ...

Role of the private sector in the delivery of antimalarials and diagnostic testing Stephen Poyer, on behalf of the ACTwatch Group

ACTwatch countries

Nigeria Benin

Cambodia Uganda

DRC

5 year, 7 country project Funded by the BMGF

Objective Zambia Madagascar

Provide policy makers with evidence on trends in availability, price, and use of antimalarials

Partnership

PSI, LSHTM and MoHs www.ACTwatch.info

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Presentation overview • Global policy environment for febrile case management

• Relevance of private sector

• What is currently on offer in the private sector and what are patients getting

www.ACTwatch.info 1/14/2013

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RBM Target: Universal access to malaria diagnostic testing

Prompt parasitological confirmation by microscopy or by RDTs is recommended in all patients suspected of malaria before treatment is started (WHO 2010). Use of RDTs in the private sector recommended.

Antimalarial market is diverse: varying types of outlets Nigeria

(n=2,113)

Madagascar (n=2,414)

Benin

(n=844)

Uganda

(n=2,497)

DRC

(n=1,375)

Zambia (n=435)

Public Health Facility (HF) Community Health Worker Private not-forprofit HF Pharmacy Private for-profit HF Drug Store General Retailer Kiosk / Stall / Informal seller Hawker / Mobile provider

Data from 2009/2010 outlet surveys www.ACTwatch.info

ACTwatch Outlet Survey Results

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Why is the private sector relevant? Role in the antimalarial medicines retail market Relative volume of antimalarials sold in the last 7 days in public/not for profit and private for-profit sectors, 2011 100 90

Percentage of total volume

80 70 60 50 40 30 20 10 0 Public Private Public Private Public Private Public Private Public Private Public Private Public Private Benin

Cambodia

DRC

Madagascar

Nigeria

Uganda

Zambia

DRC data from 2009 www.ACTwatch.info


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The role of the private sector as an initial source of advice/treatment for children under five Distribution of initial sources of advice/tx among children for whom advice was sought Benin

21%

Madagascar

35%

At home Public/NFP Private for-profit

Nigeria

39%

Uganda

26%

Data from 2011/2012 household surveys www.ACTwatch.info

ACTwatch Household Survey Results

page 7

The role of the private sector as a source of antimalarials for children under five Distribution of original antimalarial source among all antimalarials taken by children under five Madagascar N=461

37%

53%

At home Public/NFP Private for-profit

Nigeria N=633

65%

74%

Data from 2011/2012 household surveys www.ACTwatch.info


page 8

Do they stock diagnostic tests? Availability of any test (microscope or RDT) and availability of RDTs in the private sector, 2011 100 90 80 70 60 50 34

40 30 20 10

9

7 1

1

0

0

9

N=1079

N=777

N=1270

N=2035

N=1415

N=2397

N=565

Benin

Cambodia

DRC (2009)

Madagascar

Nigeria

Uganda

Zambia

Any test

RDTs


page 9

Do they stock the most effective treatments? Availability of different antimalarial classes among private-sector outlets stocking antimalarials, 2011 100 90 80

Percentage of outlets

70 60 50 40 30 20 10 0 2011 Benin

2011

2009

Cambodia DRC Non-artemisinin therapy

2011

2011

Madagascar Nigeria Oral artemisinin monotherapy

2011

2011

Uganda Zambia Quality-assured ACT

In Cambodia, the quality assured ACT category shows Any ACT www.ACTwatch.info 1/14/2013


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Do they stock the most effective treatments? Availability of non-artemisinin therapies among private-sector outlets stocking antimalarials, 2011 100 90

Percentage of outlets

80 70 60 50 40 30 20 10 0 2011

2011

2009

2011

2011

2011

2011

Benin

Cambodia

DRC

Madagascar

Nigeria

Uganda

Zambia

Chloroquine www.ACTwatch.info 1/14/2013


Quinine 11

Provider stocking decisions for antimalarials Top reasons mentioned by providers for deciding to stock an antimalarial Benin (2011)

Consumer demand Lowest price

DRC (2009)

Most profitable Easily available

Madagascar (2010)

Gov't recommended

Nigeria (2009)

Uganda (2009)

Zambia (2011) 0 www.ACTwatch.info

10

20

30

40

50

60


70

80

90

100 13

Price Medan private sector price of 1 tablet adult equivalent treatment dose of quality-assured ACT and the most popular non-QAACT antimalarial (either SP or CQ) 7.00

6.00 $4.87

Price, 2010 $USD

5.00

4.00

3.00 $2.00

2.00

$1.96 $1.48

1.00 $0.40

$0.32

$0.60

$0.47

$0.59

$0.49

0.00 Benin

Madagascar

Nigeria

Most popular non-QAACT

Uganda

Zambia

Quality-assured ACT

Data from 2010/2011 outlet surveys www.ACTwatch.info


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What is the private sector selling? 100 90 80

30% CQ 34% SP

60% CQ

70

25% AQ 35% SP 20% QN

60 50 40 30 20 10 0 2011 Benin

2011 Cambodia

2009 DRC

2011 Madagascar

2011 Nigeria

Oral artemisinin monotherapy

Non-oral artemisinin monotherapy

non Quality-assured ACT

Quality-assured ACT

2011 Uganda

2011 Zambia

In Cambodia, the quality assured ACT category shows Any ACT; Data from 2010/2011 outlet surveys www.ACTwatch.info


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What do children receive Distribution of new antimalairal treatments sourced from the private for-profit sector Benin (n=318)

16

37

Madagascar (n=300)

29

17

41

45

Uganda (n=1028)

Nigeria (n=492)

22

22

68

Any ACT CQ Quinine Other

57 Data from 2011/2012 household surveys www.ACTwatch.info


page 16

Conclusions • Although policy is important, alone it will probably have little effect on practices in the private sector.

• Interventions should consider consumer demand and commodity price/availability amongst other factors.

page 18

Acknowledgements Bill and Melinda Gates Foundation Members of the ACTwatch Advisory Committee • • • • • •

Mr. Suprotik Basu Mr. Rik Bosman Ms Renia Coghlan Dr. Thom Eisele Mr. Louis Da Gama Dr. Paul Lalvani

www.ACTwatch.info 1/14/2013

• • • • • • •

Dr. Ramanan Laxminaravan Dr. Matthew Lynch Dr. Bernard Nahlen Dr. Jayesh M. Pandit Dr. Melanie Renshaw Mr. Oliver Sabot Ms Rima Shretta

• • • • • •

Dr. Dr. Dr. Dr. Dr. Dr.

Rick Steketee Warren Stevens Gladys Tetteh Nick White Prashant Yadav Shunmay Yeung

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