Jan 14, 2013 - Dr. Warren Stevens. â¢. Dr. Gladys Tetteh. â¢. Dr. Nick White. â¢. Dr. Prashant Yadav. â¢. Dr. Shunmay Yeung. Bill and Melinda Gates Foundation.
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
2
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
3
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
5
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
ACTwatch Outlet Survey Results
6
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
ACTwatch Household Survey Results
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
ACTwatch Outlet Survey Results
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
ACTwatch Outlet Survey Results
10
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
ACTwatch Outlet Survey Results
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
ACTwatch Outlet Survey Results
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
ACTwatch Outlet Survey Results
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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
ACTwatch Outlet Survey Results
15
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
ACTwatch Household Survey Results
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