Myanmar 2015 Reference Document

www.ACTwatch.info

Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document

The Republic of the Union of Myanmar

2015

http://www.actwatch.info/

www.ACTwatch.info Page 1

Released November 2016 Suggested citation ACTwatch Group and Population Services International Myanmar (PSI MM). (2016). ACTwatch Study Reference Document: Myanmar Outlet Survey 2015. Washington DC: PSI. Contact Dr. Megan Littrell ACTwatch Principal Investigator PSI | 1120 19th St NW Suite 600 Washington DC 20036 [email protected]

Dr. Si Thu Thein PSI/Myanmar, Deputy Director of Strategic Information 16 West Shwe Gone Dine 4th St Bahan Township, Yangon, Myanmar Phone: +951 375 854 Fax: +951 527 668 Email: [email protected]

Dr. Hnin Su Su Khin PSI/Myanmar, Director of Malaria Programs 16 West Shwe Gone Dine 4th St Bahan Township, Yangon, Myanmar Phone: +951 375 854 Fax: +951 527 668 Email: [email protected]

Acknowledgements This study was jointly conducted under the ACTwatch Program, funded by the Bill and Melinda Gates Foundation and the PSI Myanmar Artemisinin Monotherapy Replacement Project (AMTR), funded by the Bill and Melinda Gates Foundation, the UK Department for International Development, and Good Ventures. This study was implemented by Population Services International (PSI).

PSI Myanmar PSI Myanmar Field Team Myanmar Survey Research Dr. Si Thu Thein Ye Kyaw Aung Patrick Meza Hein Ko Ko Htet Dr. Hnin Su Su Khin Eh Thi Paw Sanyu Aung Bwai Htan Lyan Dr. Tin Aung Sandar Oo Paing Swan Khaing Zaw Zaw Pyae Sone Barry Whittle Dr. Ei Ei Khaing Nay Min Thu Kyaw Zeya Leah Valencia Dr. Nan Yu Wai Min Aung Su Nandar Hlaing Daniel Crapper Dr. Aung Min Htut Chit Ko Lwin Thein Than Tun Saw Win Aye Myat Mon Wai Yan Ko Ko ACTwatch Team Hlaing Myint Tun Ant Min Nyo Tin Tin Aye Andrew Andrada Thet Swe Khin Zaw Yan Naing Aung Erick Auko Nay Lin Tun Thura Win May Thazin Oo Dr. Katie Bates Zaw Min Htet Bo Than Htike Soe Nyi Nyi Lwin Dr. Paul Bouanchaud Lel Pwe Htoo Hnin Thandar Bo Kyaw Naing Htwe Dr. Desmond Chavasse Kyaw Soe Linn Thet Thet Robyn Cyr Chit Oo Maung Tun Tun Win Kevin Duff Haymar Zin Myint Thazin Tin Win Keith Esch Hein Ko Ko Thant Than Myat Soe Anna Fulton Yu Hlaing Hnin Htet Arkar Kyaw Tarryn Haslam Toe Toe Catherine Hurley Whitney Isenhower Focus Point Research Services Co., LTD. Dr. Beth Kangwana May Khalar Win Daw Marlar Khine U Thein Htike Aung Gloria Kigo Daw Soe Ei San U Tin Lin Aung U Kaung Htet Aliza Lailari U Myo Zaw Nyein U Kaday Kyaw U Htet Naing Win Dr. Megan Littrell Daw Nant Aye Aye Than Daw Tun Ei Ei Aung Daw Aye Myo Myo Win Julius Ngigi U San Lin Soe U Aye Min Zaw Daw Lwin Mar Thant Dr. Kathryn O’Connell Daw Khin Sandar Htun U Soe Min Than Daw Aye Aye Maw Ricki Orford U Tun Yar Zar Kyaw U Aung Zaw Win U Ye Ko Ko Stephen Poyer Daw Thin Thin Hlaing U Ko Ko Paing U Than Aung Htay Dr. Justin Rahariniaina Daw Yin Yin Nu U Kyi Zin Ko U Pyae Phyo Christina Riley Daw Cho Lin Hlaing U Ye Htet Aung U Aung Soe Moe Dr. Andria Rusk U Min Nyan Htet Aung U Hein Min Htun U Zam Zo Taung Julianna Smith U Tin Tun Naing U Pyae Thu Naing U Kyaw Min Thu Rachel Thompson U Zay Yar Aung U Htun Naung Naung Oo Daw Pan Ei Phyu Cynthia Whitman Daw Kyi Pyar Win U Kyaw Thet Khine U Win Htun


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Table of Contents

LIST OF TABLES ................................................................................................................................................... 3

LIST OF FIGURES ................................................................................................................................................. 5

LIST OF ABBREVIATION ...................................................................................................................................... 9

DEFINITIONS ..................................................................................................................................................... 10

INTRODUCTION ................................................................................................................................................ 12

SUMMARY OF METHODS AND DATA COLLECTION ......................................................................................... 14

SUMMARY OF KEY FINDINGS ........................................................................................................................... 17

RESULTS SECTION A: CORE INDICATOR NATIONAL ESTIMATES ...................................................................... 77

RESULTS SECTION B: CORE INDICATORS ACROSS DOMAINS........................................................................... 96

RESULTS SECTION C: ORAL ARTEMISININ MONOTHERAPY INDICATOR NATIONAL ESTIMATES ................... 150

RESULTS SECTION D: ORAL ARTEMISININ MONOTHERAPY INDICATORS ACROSS DOMAINS ...................... 155

ANNEX 1: ACTWATCH BACKGROUND ............................................................................................................ 172

ANNEX 2: COUNTRY BACKGROUND............................................................................................................... 175

ANNEX 3: ARTEMISININ MONOTHERAPY REPLACEMENT PROJECT .............................................................. 183

ANNEX 4: OUTLET SURVEY METHODS ........................................................................................................... 184

ANNEX 5: SAMPLED TOWNSHIPS .................................................................................................................. 187

ANNEX 6: DETAILED SAMPLE DESCRIPTION .................................................................................................. 189

ANNEX 7: QUESTIONNAIRE ............................................................................................................................ 191

ANNEX 8: ANTIMALARIAL PRODUCT INFORMATION .................................................................................... 221

ANNEX 9: RDT REFERENCE ............................................................................................................................. 226

ANNEX 10. SAMPLING WEIGHTS ................................................................................................................... 227

ANNEX 11: INDICATOR DEFINITIONS ............................................................................................................. 228

ANNEX 12. ADULT EQUIVALENT TREATMENT DOSE (AETD) ......................................................................... 242



List of Tables

Summary of Key Findings

Table S1: Key results, by outlet type ............................................................................................................................... 17

Table S2: Key results, by outlet type, across domain ..................................................................................................... 20

Results Section A: Core Indicator National Estimates

Table A1: Availability of antimalarials, among all screened outlets, by outlet type ....................................................... 77

Table A2: Availability of antimalarials, among antimalarial-stocking outlets, by outlet type ........................................ 79

Table A3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type ....................................................................................................... 81

Table A4: Types of quality-assured and non-quality-assured ACTs audited in the public and private sector ............... 83

Table A5: Antimalarial market composition ................................................................................................................... 84

Table A6a: Price of tablet formulation antimalarials, by outlet type ............................................................................. 85

Table A6b: Price of pre-packaged antimalarials, by outlet type ..................................................................................... 86

Table A7: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type .......................... 87

Table A8: Malaria blood testing market composition .................................................................................................... 88

Table A9: Price of malaria blood testing for adults, by outlet type ................................................................................ 89

Table A10: Antimalarial market share ............................................................................................................................ 90

Table A11: Antimalarial market share within outlet type .............................................................................................. 91

Table A12: Malaria blood testing market share ............................................................................................................. 92

Table A13: Malaria blood testing market share, across outlet type ............................................................................... 93

Table A14: Private sector case management training, supervision, support and surveillance, by outlet type ............. 94

Table A15: Provider antimalarial treatment knowledge and practices, by outlet type ................................................. 95

Results Section B: Core Indicators Across Domains

Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across domain ............................. 96

Table B2: Availability of antimalarials, among antimalarial-stocking outlets, by outlet type, across domain ............. 103

Table B3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type, across domain ........................................................................... 109

Table B4: Types of quality-assured and non-quality-assured ACTs audited in the public and private sector, across domain .................................................................................................................................................................. 115

Table B5: Antimalarial market composition, across domain ........................................................................................ 116

Table B6a: Price of tablet formulation antimalarials, by outlet type, across domain .................................................. 117

Table B6b: Price of pre-packaged antimalarials, by outlet type, across domain .......................................................... 121

Table B7: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across domain .............................................................................................................................................................................. 123

Table B8: Malaria blood testing market composition, across domain ......................................................................... 125

Table B9: Price of malaria blood testing for adults, by outlet type, across domain ..................................................... 126

Table B10.1: Antimalarial market share, Eastern (AMTR intervention) Domain .......................................................... 127

Table B10.2: Antimalarial market share, Central (AMTR comparison) Domain ........................................................... 128

Table B10.3: Antimalarial market share, Western Domain .......................................................................................... 129

Table B10.4: Antimalarial market share, Bangladesh border / Rakhine Domain ......................................................... 130



Table B11.1: Antimalarial market share within outlet type, Eastern (AMTR intervention) Domain ............................ 131

Table B11.2: Antimalarial market share within outlet type, Central (AMTR comparison) Domain ............................. 132

Table B11.3: Antimalarial market share within outlet type, Western Domain ............................................................ 133

Table B11.4: Antimalarial market share within outlet type, Bangladesh border / Rakhine Domain ........................... 134

Table B12.1: Malaria blood testing market share, Eastern (AMTR intervention) Domain ........................................... 135

Table B12.2: Malaria blood testing market share, Central (AMTR comparison) Domain ............................................ 136

Table B12.3: Malaria blood testing market share, Western Domain ........................................................................... 137

Table B12.4: Malaria blood testing market share, Bangladesh border / Rakhine Domain .......................................... 138

Table B13.1: Malaria blood testing market share, Eastern (AMTR intervention) Domain ........................................... 139

Table B13.2: Malaria blood testing market share, Central (AMTR comparison) Domain ............................................ 140

Table B13.3: Malaria blood testing market share, Western Domain ........................................................................... 141

Table B13.4: Malaria blood testing market share, Bangladesh border / Rakhine Domain .......................................... 142

Table B14: Private sector case management training, supervision, support and surveillance, by outlet type ............ 143

Table B15: Provider antimalarial treatment knowledge and practices, by outlet type, across domains ..................... 147

Results Section C: Oral AMT Indicator National Estimates

Table C1: Availability of oral artemisinin monotherapy, by outlet type ....................................................................... 150

Table C2: Characteristics of oral AMT supply & demand, among oral AMT stockists*, by outlet type ....................... 151

Table C3: Distribution of oral AMT, among outlets stocking oral AMT, by outlet type................................................ 152

Table C4: Characteristics of oral AMT products, by outlet type ................................................................................... 153

Results Section D: Oral AMT Indicators Across Domains

Table D1: Availability of oral artemisinin monotherapy, by outlet type ...................................................................... 155

Table D2: Characteristics of oral AMT supply & demand, among oral AMT stockists*, by outlet type ....................... 159

Table D3: Distribution of oral AMT, among outlets stocking oral AMT, by outlet type ............................................... 162

Table D4: Characteristics of oral AMT products, by outlet type ................................................................................... 165

Annex Tables

Table X1. Sampled Townships ....................................................................................................................................... 187

Table X2: Detailed sample description ......................................................................................................................... 189

Table X3: Number of antimalarials audited .................................................................................................................. 221

Table X4: Quality-Assured (QAACT) and Non-Quality Assured ACTs ............................................................................ 222

Table X5: Nationally Registered ACTs ........................................................................................................................... 223

Table X6: Oral Artemisinin Monotherapies .................................................................................................................. 224

Table X7: Oral AMT Manufacturers and Country of Manufacture* ............................................................................. 224

Table X8: Severe Malaria Treatment ............................................................................................................................ 225

Table X9: Number of RDTs audited ............................................................................................................................... 226

Table X10: RDT Brand Names and Manufacturers* ..................................................................................................... 226

Table X11: Adult Equivalent Treatment Dose Definitions ............................................................................................ 243



List of Figures

Figure 1: Timeline of Key Events and Policies in Myanmar ............................................................................................ 13

Figure 2: Map of the selected areas, Myanmar 2015 ..................................................................................................... 15

Figure 3: Survey flow diagram, Myanmar, 2015 ............................................................................................................. 16

[AMTR Intervention, AMTR Comparison, Western / India border, Bangladesh border /Rakhine] ................................ 16

Market Composition

Figure 4. Antimalarial market composition: outlet type distribution, 2015 ................................................................... 30

Figure 5. Antimalarial market composition: outlet type distribution by strata, 2015 .................................................... 30

Figure 6. Malaria blood testing market composition: outlet type distribution, 2015 .................................................... 31

Figure 7. Malaria blood testing market composition: outlet type distribution by strata, 2015 ..................................... 31

Antimalarial Availability

Figure 8. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2015 ....................... 32

Figure 9. Percentage of outlets with at least one antimalarial in stock on the day of the survey, by strata, 2015 ....... 32

Figure 10. Percentage of antimalarial-stocking outlets with any ACT in stock on the day of the survey, 2015 ............ 33

Figure 11. Percentage of antimalarial-stocking outlets with any ACT in stock on the day of the survey, by strata, 2015 ................................................................................................................................................................................ 33

Figure 12. Percentage of antimalarial-stocking outlets with any AL in stock on the day of the survey, 2015 ............... 34

Figure 13. Percentage of antimalarial-stocking outlets with any AL in stock on the day of the survey, by strata, 2015 ................................................................................................................................................................................ 34

Figure 14. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2015 ........................................................................................................................................................................ 35

Figure 15. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, by strata, 2015 ............................................................................................................................................................ 35

Figure 16. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2015 ........................................................................................................................................................................ 36

Figure 17. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, by strata, 2015 ........................................................................................................................................................ 36

Figure 18. Types of non-quality assured ACT audited among health workers and private sector outlets, 2015 .......... 37

Figure 19. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2015 ........................................................................................................................................................................ 38

Figure 20. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, by strata, 2015 ........................................................................................................................................................ 38

Figure 21. Percentage of antimalarial-stocking outlets with CQ (first-line Pv treatment) in stock on the day of the survey, 2015 ........................................................................................................................................................... 39

Figure 22. Percentage of antimalarial-stocking outlets with CQ (first-line Pv treatment) in stock on the day of the survey, by strata, 2015 ........................................................................................................................................... 39

Figure 23. Percentage of antimalarial-stocking outlets with primaquine in stock on the day of the survey, 2015 ....... 40

Figure 24. Percentage of antimalarial-stocking outlets with primaquine in stock on the day of the survey, by strata, 2015 ........................................................................................................................................................................ 40

Figure 25. Percentage of antimalarial-stocking outlets with oral artemisinin monotherapy in stock on the day of the survey, 2015 ........................................................................................................................................................... 41



Figure 26. Percentage of antimalarial-stocking outlets with oral artemisinin monotherapy in stock on the day of the survey, by strata, 2015 ........................................................................................................................................... 41

Figure 27. Percentage of antimalarial-stocking outlets with treatment for severe malaria in stock on the day of the survey, 2015 ........................................................................................................................................................... 42

Figure 28. Percentage of antimalarial-stocking outlets with treatment for severe malaria in stock on the day of the survey, by strata, 2015 ........................................................................................................................................... 42

Figure 29. Percentage of antimalarial-stocking outlets with any antimalarial that is not in the national treatment guidelines in stock on the day of the survey, 2015 ................................................................................................ 43

Figure 30. Percentage of antimalarial-stocking outlets with any antimalarial that is not in the national treatment guidelines in stock on the day of the survey, by strata, 2015 ................................................................................ 43

Antimalarial Market Share

Figure 31. Total antimalarial market share, 2015 ..................................................................................................... 44

Figure 32. Antimalarial market share, AMTR Intervention, 2015 ............................................................................. 45

Figure 33. Antimalarial market share, AMTR Comparison, 2015 .............................................................................. 45

Figure 34. Antimalarial market share, Western / India border, 2015 ....................................................................... 46

Figure 35. Antimalarial market share, Bangladesh border / Rakhine, 2015 ............................................................. 46

Figure 36. Antimalarial market share among health workers and private sector outlets, by strata, 2015 .................... 47

Malaria Blood Testing Availability

Figure 37. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2015 ............................. 48

Figure 38. Percentage of antimalarial-stocking outlets with malaria blood testing available, by strata, 2015 ............. 48

Figure 39. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2015 ................................ 49

Figure 40. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2015 ........................................... 50

Figure 41. Percentage of antimalarial-stocking outlets with malaria RDTs available, by strata, 2015 ........................... 50

Malaria Blood Testing Market Share

Figure 42. Malaria blood testing market share, 2015 ............................................................................................... 51

Figure 43. Malaria RDT market share among health workers and private sector outlets, 2015 .............................. 51

Figure 44. Malaria RDT market share within community health workers and private sector outlets, 2015 ................. 52

Sale and Distribution of Antimalarials and Malaria Blood Tests

Figure 45. Percentage of outlets with blood testing available that sold or distributed malaria tests in the previous week, and percentage of antimalarial-stocking outlets that sold or distributed an antimalarial in the previous week, by outlet type, 2015 ..................................................................................................................................... 53

Figure 46. Percentage of antimalarial-specific-stocking outlets that sold or distributed the specific antimalarial in the previous week, by outlet type, 2015 ...................................................................................................................... 53

Figure 47. Percentage of antimalarial-specific-stocking outlets that sold or distributed the specified antimalarial in the previous week, by strata, 2015 ........................................................................................................................ 54

Price

Figure 48. Private sector median price of RDTs and pre-packaged adult artemether lumefantrine, across outlet type, 2015 ........................................................................................................................................................................ 55

Figure 49. Private sector median price of RDTs and pre-packaged adult artemether lumefantrine, across strata, 2015 ................................................................................................................................................................................ 55



Figure 50. Private sector median price of one adult equivalent treatment dose of tablet AL, CQ, and oral AMT, 2015 ................................................................................................................................................................................ 56

Figure 51. Private sector median price of tablet AL, CQ, and oral AMT, across strata, 2015 ......................................... 56

Provider Knowledge

Figure 52. Percentage of providers who correctly state the first-line treatment for uncomplicated P. falciparum malaria (AL, DHA-PPQ, or ASMQ), 2015 ................................................................................................................. 57

Figure 53. Percentage of providers who correctly state the first-line treatment for uncomplicated P. falciparum malaria (AL, DHA-PPQ, or ASMQ), by strata, 2015 ................................................................................................. 57

Figure 54. Percentage of providers who correctly state the adult dosing regimen for artemether lumefantrine, 2015 ................................................................................................................................................................................ 58

Figure 55. Percentage of providers who correctly state the adult dosing regimen for artemether lumefantrine, by strata, 2015 ............................................................................................................................................................ 58

Figure 56. Percentage of providers who correctly state the first-line treatment for uncomplicated P. vivax malaria (chloroquine plus primaquine), 2015 ..................................................................................................................... 59

Figure 57. Percentage of providers who correctly state the first-line treatment for uncomplicated P. vivax malaria (chloroquine plus primaquine), by strata, 2015 ..................................................................................................... 59

Provider Reported Supervision, Training, and Case Load Reporting

Figure 58. Percentage of providers who reportedly received training on malaria diagnosis (RDT or microscopy) by outlet type, 2015 .................................................................................................................................................... 60

Figure 59. Percentage of providers who reportedly received training on malaria diagnosis (RDT or microscopy) by strata, 2015 ............................................................................................................................................................ 60

Figure 60. Percentage of providers who reportedly received training on national malaria treatment guidelines (RDT or microscopy) by outlet type, 2015 ...................................................................................................................... 61

Figure 61. Percentage of providers who reportedly received training on national malaria treatment guidelines (RDT or microscopy) by strata, 2015 ............................................................................................................................... 61

Figure 62. Percentage of providers who reportedly received a supervisory or regulatory visit in the past year, by outlet type, 2015 .................................................................................................................................................... 62

Figure 63. Percentage of providers who reportedly received a supervisory or regulatory visit in the past year, by strata, 2015 ............................................................................................................................................................ 62

Figure 64. Percentage of providers who reportedly keep records on the number of patients tested and treated for malaria, by outlet type, 2015 ................................................................................................................................. 63

Figure 65. Percentage of providers who reportedly keep records on the number of patients tested and treated for malaria, by strata, 2015 .......................................................................................................................................... 63

Figure 66. Percentage of providers who reportedly report on the numbers of patients tested/treated to the government or non-government organizations, by outlet type, 2015 .................................................................. 64

Figure 67. Percentage of providers who reportedly report on the numbers of patients tested/treated to the government or non-government organizations, by strata, 2015 ........................................................................... 64

Figure 68. Percentage of providers who reportedly: receive provider training and supervision and keep records on malaria case load data and report on those records and have both national first-line ACT and malaria blood testing in stock, 2015 ............................................................................................................................................. 65

Oral Artemisinin Monotherapy Availability, Distribution, and Supply Characteristics

Figure 69. Percentage of antimalarial-stocking outlets with any Oral AMT in stock in the past three months but not in stock on the day of the survey, by outlet type, 2015 ............................................................................................. 66

Figure 70. Source of oral AMT among oral AMT-stocking outlets, 2015 ........................................................................ 67



Figure 71. Source of oral AMT among oral AMT-stocking outlets, by strata, 2015 ........................................................ 67

Figure 72. Percentage of oral AMT-stocking outlets that reportedly obtained oral AMT from a supplier within the past three months, by outlet type, 2015 ....................................................................................................................... 68

Figure 73. Median number of oral AMT packages in stock on the day of the survey among oral AMT-stocking outlets, by strata, 2015 ........................................................................................................................................................ 68

Figure 74. Median number of oral AMT packages in stock on the day of the survey among oral AMT-stocking outlets, by strata, 2015 ........................................................................................................................................................ 69

Figure 75. Percentage of oral AMT-stocking outlets that report artesunate and/or artemether tablets are requested by name by customers, by strata, 2015 ................................................................................................................. 69

Figure 76. Oral AMT distribution over the past week among oral AMT-stocking outlets, 2015 .................................... 70

Figure 77. Oral AMT distribution over the past week among oral AMT-stocking outlets, by strata, 2015 .................... 70

Figure 78. Median number of 50mg oral AMT tablets distributed in the past week, by strata, 2015 ........................... 71

Figure 79. Outlet type, among oral AMT products audited, 2015 .................................................................................. 72

Figure 80. Proportion of oral AMT products audited within each sector, by strata, 2015 ............................................. 72

Figure 81. Active ingredient, among all oral AMT products audited, 2015 .................................................................... 73

Figure 82. Percentage of active ingredient-specific oral AMT products among all oral AMT products audited, by strata, 2015 ............................................................................................................................................................ 73

Figure 83. Oral AMT time-to-expiry, among all oral AMT products audited, 2015 ........................................................ 74

Figure 84. Oral AMT time-to-expiry among all oral AMT products audited, by strata, 2015 ......................................... 74

Figure 85. Manufacturers, among all oral AMT products audited, 2015 ....................................................................... 75

Figure 86. Oral AMT manufacturers among all oral AMT products audited, by strata, 2015 ........................................ 75

Figure 87. Median number of 50mg oral AMT tablets reportedly typically dispensed to treat malaria in an adult, by outlet type, 2015 .................................................................................................................................................... 76

Figure 88. Private sector median wholesale and retail price per oral AMT tablet, across outlet type, 2015 ................ 76



List of Abbreviation ACT Artemisinin combination therapy

AETD Adult equivalent treatment dose

AL Artemether lumefantrine

AMFm Affordable Medicines Facility – malaria

AMTR Artemisinin Monotherapy Replacement Project

ASMQ Artesunate mefloquine

BMGF The Bill and Melinda Gates Foundation

CHW Community Health Worker

DFID Department for International Development

DHA-PPQ Dihydroartemisinin piperaquine

EMA European Medicines Agency

GFATM Global Fund to Fight AIDS, TB, and Malaria

G6PD Glucose-6-phosphate-deydrogenase deficiency

GMS Greater Mekong Subregion

GPS Global Positioning System

IM Intramuscular injection

IV Intravenous injection

Kg Kilogram

Mg Milligram

MMW Mobile Malaria Worker

MARC Myanmar Artemisinin Resistance Containment Project

MMK

MOH

Myanmar Kyats

Ministry of Health

Oral AMT Ministry of Health Oral artemisinin monotherapy

n Number

NGO Non-governmental Organization

Pf Plasmodium falciparum

Pv Plasmodium vivax

QA ACT Quality-assured artemisinin combination therapy

RDT Rapid diagnostic test

UK United Kingdom

USAID United States Agency for International Development

VMV Village Malaria Volunteer



Definitions

Survey Methods Definitions

Outlet Any service delivery point or point of sale for commodities. Outlets are not restricted to

stationary points of sale and may include mobile units or individuals.

Outlets eligible for

inclusion in the

study

Outlets were administered a full questionnaire if they met at least one of three inclusion

criteria: (1) had one or more antimalarials in stock at the time of the survey visit; (2)

reportedly had one or more antimalarials in stock in the previous three months; or (3)

provide malaria blood testing (microscopy or rapid diagnostic tests) but do not provide

antimalarial treatment. Government health facilities were excluded from the study.

Cluster The primary sampling unit, or cluster, for the outlet survey. In Myanmar, they were defined

as wards in urban areas and village tracts in rural areas.

Censused cluster A ward/village tract where field teams conducted a full census of all outlets with the

potential to sell antimalarials.

Antimalarial Indicator Definitions Antimalarial Any medicine recognized by the WHO for the treatment of malaria. Medicines used solely

for the prevention of malaria were excluded from analysis of key indicators in this report.

Dosing/treatment

regimen

The posology or timing and number of doses of an antimalarial used to treat malaria. This

schedule often varies by patient weight.

Adult Equivalent

Treatment Dose

(AETD)

An AETD is the number of milligrams (mg) of an antimalarial drug required to treat a 60 kg

adult (see Annex 8).

Monotherapy An antimalarial medicine that has a single mode of action. This may be a medicine with a

single active compound or a synergistic combination of two compounds with related

mechanisms of action.

Artemisinin and its

derivatives

Artemisinin is a plant extract or synthetic plant extract used in the treatment of malaria.

The most common derivatives of artemisinin used to treat malaria are artemether,

artesunate, and dihydroartemisinin.

Artemisinin-based

Combination Therapy

(ACT)

An antimalarial that combines artemisinin or one of its derivatives with an antimalarial or

antimalarials of a different class.

Artemisinin

monotherapy

An antimalarial medicine that has a single active compound, where this active compound

is artemisinin or one of its derivatives.

Oral artemisinin

monotherapy

Artemisinin or one of its derivatives in a dosage form with an oral route of administration.

These include tablets, suspensions, and syrups and exclude suppositories and injections.

Non-artemisinin

therapy

An antimalarial medicine that does not contain artemisinin or any of its derivatives.

First-line treatment for

Plasmodium

falciparum

The government recommended treatment for uncomplicated Plasmodium falciparum

malaria. At the time of the 2015 survey, Myanmar's first-line treatment for uncomplicated

Pf malaria was artemether lumefantrine (AL), dihydroartemisinin piperaquine, or

artesunate mefloquine. Subsequent updates to national guidelines stipulate AL plus single

low-dose primaquine as the first-line.

First-line treatment for

Plasmodium vivax

The government recommended treatment for Plasmodium vivax malaria. Myanmar's first-

line treatment for Pv malaria is chloroquine plus primaquine.



Second-line treatment The government recommended second-line treatment for uncomplicated malaria. At the

time of the survey, Myanmar's second-line treatments for uncomplicated malaria

included oral formulations of artesunate doxycycline, artesunate tetracycline and

artesunate clindamycin.

Nationally registered

ACTs

ACTs registered with a country’s national drug regulatory authority and permitted for sale

or distribution in country. Each country determines its own criteria for placing a drug on

its nationally registered listing.

Quality-assured

Artemisinin-Based

Combination Therapies

(QAACTs)

QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and

Malaria’s Quality Assurance Policy. A QAACT is any ACT that appeared on the Global

Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy

prior to data collection (see

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/), or that

previously had C-status in an earlier Global Fund quality assurance policy and was used in

a program supplying subsidized ACTs. QAACTs also include ACTs that have been granted

regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim®

and Pyramax®.

Quality-assured ACT

with the “padonma”

logo

The “padonma” logo is a quality-assurance seal that has been used

to promote the use of quality-assured AL. Provider and consumer

communications promote the use of antimalarial treatment bearing

the padonma logo.

Severe malaria

treatment

The government recommends intravenous or intramuscular artesunate as first-line

treatment in the management of severe falciparum malaria. If artesunate is not available,

intramuscular artemether or quinine dihydrochloride injections should be used for

treating severe malaria cases. Rectal artesunate is suitable for pre-referral treatment

when the above parenteral treatments are not immediately available.1

1 World Health Organization. (2015). Guidelines for the treatment of malaria, 3rd edition. Geneva: WHO.


http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/


Introduction ACTwatch is a multi-country research project implemented by Population Services International (PSI) (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence. The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID and the Department for International Development (DFID) See Annex 1 for more information about the ACTwatch project. Project scale-up in the Greater Mekong sub-Region (GMS) in 2015 was designed to deliver key indicators for informing and monitoring strategies and policies for malaria elimination. PSI/Myanmar implemented annual market monitoring surveys modeled after the ACTwatch study design and methods as part of the evaluation of the Artemisinin Monotherapy Replacement Project (AMTR). The AMTR project was specifically designed to rapidly replace the widespread availability and use of oral artemisinin monotherapy (oral AMT) with quality-assured ACT (see annex 3 for more information on the AMTR project. The 2015 ACTwatch outlet survey was implemented to continue providing market information for the AMTR project, and was expanded to cover new research domains to inform program and policy at national level. The newly drafted 2016-2020 National Strategic Plan for Malaria Control and Elimination aims to improve upon the strategies currently in place for malaria control and move towards malaria elimination. Specific strategies include:

Achieve universal coverage of case management services to ensure 100% parasitological diagnosis of all

suspected cases and effective treatment of all confirmed cases

o Specific targeting of mobile and migrant populations and populations in hard to reach areas through

preemptive supply of commodities

Implement active case detection through enhancement of the surveillance system to detect, immediately

notify, investigate, classify and respond to all cases and foci to move toward malaria elimination

o Specific targeting of mobile and migrant populations and populations in hard to reach areas with

support from public, private, and PPM partners

Implementing comprehensive IEC/BCC approach that facilitates treatment seeking behavior for fever within

24 hours at a health facility or with a qualified care provider and usage of LLINs

Supply Chain Strengthening

The 2015 outlet survey was the fourth round of ACTwatch-style outlet surveys conducted in Myanmar and the first official ACTwatch outlet survey. This report presents data points from four distinct domains across Myanmar for 2015. The selected areas in the eastern half of Myanmar for 2015 outlet survey are in line with the 2012-2014 AMTR intervention and comparison domains that were based on the Myanmar Artemisinin Resistance Containment (MARC) Tier classification system and WHO 2-tier stratification system for addressing drug resistance. The expansion into the western half of Myanmar for 2015 outlet survey included newly selected areas from the Western/India border region and Bangladesh border/Rakhine region. All study areas were selected from either Tier 1 (areas prioritized for immediate response to contain resistance or eliminate malaria) or Tier 2 (areas targeted for intensified malaria control to reduce transmission and/or limit the risk of emergence or spread of resistant parasites). These surveys are designed to monitor key antimalarial market indicators within each of the four domains. ACTwatch outlet survey findings can inform ongoing monitoring, evaluation, and adjustment to policy, strategy, and funding decisions to strengthen malaria case management. Data points comparing 2015 estimates to previous survey rounds (2012, 2013, 2014) can be found in the 2015 AMTR report.


http://www.psi.org/


Report notes

This document is a complete reference for the 2015 outlet survey and includes key indicators for all four domains: a) AMTR Intervention, b) AMTR Comparison, c) Western/India border, and d) Bangladesh border/Rakhine. Please see annexes for information about the study context, design, implementation and data analysis.

The “all private” column within tables and figures refers to all outlets except community health workers, which are considered public sector.

Grey text for data appearing in report tables indicates that the estimate provided was derived from a small sample size. Specifically, grey text is used to indicate point estimates derived from a number (n) of less than 50 and median prices derived from an n of less than 5.

All results are rounded to one decimal point. Market composition and market share totals may not always sum to 100% due to rounding.

Malaria testing and treatment prices are reported in US dollars. Price information is captured in local currency and converted to US dollars based on exchange rates available from www.oanda.com using the historical exchange rates tool. The average exchange rate over the entire data collection period is used for converting local currency captured during data collection to US dollars.

Figure 1: Timeline of Key Events and Policies in Myanmar


http://www.oanda.com/


Summary of Methods and Data Collection A representative antimalarial outlet survey was conducted at a national level in Myanmar between 18 August 2015 and 4 January 2016 across four regional domains: AMTR Intervention domain (east), AMTR Comparison domain (central), Western / India border region, and Bangladesh border / Rakhine region. A full description of the research design and methods is provided in Annex 4. The sampling strategy differed between the AMTR domains and the western domains due to lack of a published national sampling frame with population sizes at the desired cluster level (ward / village tract) at the time that sampling was completed for AMTR domains, and availability of a new national frame for sampling of the western domains. Briefly, a representative sample of townships was selected with probability of selection proportionate to population size (PPS) within AMTR intervention areas and AMTR comparison areas. Cluster population estimates were calculated within each township based on the population distribution of urban wards and rural village tracts per township. Sixteen clusters were then selected using PPS in each township reflecting the respective urban/rural population distributions. Within both the Western / India border domain, and the Bangladesh border / Rakhine domain, 180 clusters (wards/village tracts) were selected using PPS sampling (see sampled townships in Annex 5 and the detailed sampling description in Annex 6). Within selected wards and village tracts, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was completed. The census did not include screening government health facilities due to lack of approvals, but did include community-based health workers (CHWs), and these health workers are often currently or previously employed within government health facilities, or were formally trained as CHWs by government or non-governmental organizations. These CHWs are therefore considered public sector, while all other outlet types are considered private sector.



Figure 2: Map of the selected areas, Myanmar 2015

Outlets were screened to determine eligibility. Outlets eligible for the survey met at least one of three criteria: 1) one or more antimalarials were in stock on the day of the survey; 2) one or more antimalarials were in stock in the three months preceding the survey; and/or 3) malaria blood testing (microscopy or RDT) was available. The results of the census are summarized in figure 3.

A structured questionnaire was used to complete an audit of all antimalarials and RDTs as well as a provider interview (see Annex 7). See Annexes 8 and 9 for detailed summaries of antimalarials and RDTs audited. Where oral artemisinin monotherapy (oral AMT) such as artesunate tablets was found, additional questions were administered to gather information about the oral AMT in stock including the supplier. Data collection was paper-based and the data were entered using CSPro. All data cleaning and analysis was performed using Stata 13.1 (©StataCorp, College Station, TX). Data were weighted to account for variation in probability of outlet selection (see Annex 10), and standard error calculation reflected clustering of outlets at township and urban ward/rural village tract levels. Standard indicators were constructed according to definitions applied across ACTwatch project countries (see Annex 11).



Outlets that did not meet screening criteria 23,851

[6,708; 6,683; 4,449; 6,011]

Figure 3: Survey flow diagram, Myanmar, 2015 [AMTR Intervention, AMTR Comparison, Western / India border, Bangladesh border /Rakhine]

A

Outlets enumerated* [28,664]

[8,432; 7,481; 5,666; 7,085]

B Outlets screened**

[28,267] [8,271; 7,393; 5,598; 7,005]

D Outlets interviewed***

[4,395] [1,554; 702; 1,147; 992] 1 = 3,859 [1,330; 594; 1,065; 870] 2= 413 [171; 81; 69, 92] 3= 123 [53; 27; 13; 30]

Outlets not screened [397]

[161; 88; 68; 80]

Outlets not interviewed [22]

[9; 8; 2; 3]

Outlet closed at time of visit 256

[116; 60; 49; 31]

Outlet closed permanently 53 [13; 18; 11; 11]

Refused 88 [32; 10; 8; 38]

Interview interrupted 1 [0; 1; 0; 0] Respondent not available 10 [6; 2; 1; 1] Refused 10 [3; 5; 0; 2] Other 1 [0; 0; 1; 0]

1: Antimalarials in stock on day of visit 2: Antimalarials reportedly in stock during the previous 3 months but not on the day of the visit 3: Malaria blood testing available but no antimalarials in stock * Identified as outlets with potential to sell or distribute antimalarials and/or provide malaria blood testing during the census ** Administered questions to assess current or recent (previous 3 months) availability of antimalarials and malaria blood testing *** A partial or complete interview was conducted with an outlet representative

C Outlets that met screening criteria

[4,416] [1,563; 710; 1,149; 994]

1 = 3,881 [1,339; 602; 1,067; 873] 2 = 413 [171; 81; 69; 92] 3 = 122 [53; 27; 13; 29]



Summary of Key Findings

Table S1: Key results, by outlet type

Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer

Itinerant Drug Vendor

ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Readiness for malaria case management Proportion of all screened outlets outlets* with:

N=2,737 N=610 N=970 N=22,733 N=1,217 N=25,530 N=28,267

Availability of malaria blood testing 41.9 34.5 9.5 0.2 7.8 1.6 6.1

(38.9, 45.0) (28.9, 40.2) (6.6, 12.4) (0.1, 0.3) (5.5, 10.1) (1.3, 1.9) (5.6, 6.6)

Availability of national first-line ACT for Pf malaria

AL, DHA-PPQ, ASMQ 37.9 38.4 22.7 1.5 12.2 3.4 7.3

(35.1, 40.8) (31.8, 45.0) (18.4, 27.1) (1.2, 1.8) (8.8, 15.7) (3.0, 3.9) (6.7, 7.9)

AL, DHA-PPQ, ASMQ and primaquine 26.4 16.5 0.7 0.0 1.2 0.4 3.4

(23.8, 28.9) (10.4, 22.5) (0.0, 1.5) (0.0, 0.1) (0.3, 2.1) (0.3, 0.6) (3.0, 3.7)

Availability of first-line ACT for Pf malaria (AL, DHA-PPQ, ASMQ) and blood testing available

34.1 24.6 5.2 0.2 4.5 1.1 4.8

(31.3, 37.0) (19.0, 30.3) (3.2, 7.3) (0.1, 0.3) (2.8, 6.1) (0.8, 1.3) (4.3, 5.2)

Availability of first-line ACT for Pf malaria (AL, DHA-PPQ, ASMQ) and blood testing not available

3.8 13.8 17.5 1.3 7.8 2.4 2.5

(3.0, 4.6) (10.9, 16.6) (13.6, 21.4) (1.0, 1.6) (5.1, 10.4) (2.1, 2.7) (2.2, 2.8)

Availability of national first-line treatment for Pv malaria

Chloroquine 30.3 24.9 18.1 1.9 14.3 3.4 6.4

(27.6, 32.9) (18.9, 30.9) (14.5, 21.7) (1.6, 2.3) (11.5, 17.1) (3.0, 3.8) (5.9, 6.9)

Chloroquine and primaquine 24.9 17.1 0.9 0.0 1.5 0.5 3.2

(22.3, 27.5) (11.0, 23.3) (0.2, 1.7) (0.0, 0.1) (0.5, 2.4) (0.3, 0.6) (2.9, 3.6)

Availability of primaquine 28.1 18.6 1.0 0.0 1.7 0.5 3.6

(25.3, 30.8) (12.5, 24.8) (0.2, 1.8) (0.0, 0.1) (0.7, 2.7) (0.4, 0.7) (3.3, 4.0)

Availability of national first-line severe malaria treatment (artesunate IV/IM) 1.3 7.6 3.9 0.0 0.8 0.4 0.5

(0.8, 1.8) (5.1, 10.1) (1.9, 5.9) (0.0, 0.1) (0.0, 1.7) (0.2, 0.5) (0.3, 0.6)

Readiness for malaria case management

Proportion of antimalarial-stocking outlets with: N=1,263 N=314 N=522 N=1,341 N=419 N=2,596 N=3,859

Availability of malaria blood testing 81.6 58.0 15.6 3.2 17.9 16.2 42.9

(78.4, 84.8) (50.8, 65.3) (10.8, 20.4) (1.5, 5.0) (13.1, 22.7) (13.3, 19.1) (40.1, 45.7)


AL, DHA-PPQ, ASMQ 83.1 76.4 49.0 29.6 35.0 41.7 58.1

(80.1, 86.1) (68.4, 84.5) (42.2, 55.7) (25.2, 34.1) (28.0, 42.0) (36.9, 46.6) (55.0, 61.1)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

AL, DHA-PPQ, ASMQ and primaquine 58.8 32.6 1.6 0.8 3.1 6.3 27.6

(55.0, 62.6) (23.0, 42.2) (0.0, 3.2) (0.0, 1.9) (1.0, 5.2) (3.5, 9.0) (25.0, 30.2)


75.4 48.4 11.0 3.0 12.8 12.9 38.4

(71.9, 78.8) (40.5, 56.2) (7.2, 14.9) (1.3, 4.8) (8.5, 17.2) (10.1, 15.7) (35.7, 41.2)


7.8 28.1 37.9 26.6 22.2 28.8 19.6

(5.9, 9.6) (22.2, 34.0) (30.8, 45.0) (22.2, 31.0) (16.4, 28.0) (25.3, 32.3) (17.2, 22.0)


Chloroquine 67.0 49.7 38.0 39.2 42.5 41.8 52.9

(63.5, 70.5) (41.5, 58.0) (31.7, 44.4) (32.8, 45.7) (35.6, 49.5) (38.4, 45.3) (50.0, 55.7)


(51.0, 59.0) (24.4, 43.1) (0.3, 3.7) (0.0, 2.2) (1.6, 6.2) (4.0, 9.5) (23.8, 29.1)

Availability of primaquine 62.6 36.8 2.2 1.7 4.8 7.7 30.0

(58.6, 66.5) (27.6, 46.0) (0.4, 3.9) (0.1, 3.2) (2.3, 7.2) (4.9, 10.4) (27.2, 32.7)

Availability of national first-line severe malaria treatment (artesunate IV/IM) 3.1 14.8 8.3 1.3 2.2 4.6 4.0

(1.8, 4.4) (10.2, 19.5) (4.6, 12.1) (0.0, 2.7) (0.0, 4.4) (3.2, 6.1) (2.9, 5.0)

Oral artemisinin monotherapy

Availability among all screened outlets* 1.2 7.2 17.3 1.5 6.2 2.3 2.1

(0.7, 1.8) (5.0, 9.4) (13.5, 21.0) (1.2, 1.8) (3.9, 8.5) (1.9, 2.7) (1.8, 2.5)

Availability among antimalarial-stocking outlets 2.9 13.8 36.5 34.6 18.9 27.7 17.3

(1.6, 4.2) (9.3, 18.2) (29.9, 43.2) (28.5, 40.7) (13.1, 24.7) (23.8, 31.7) (14.8, 19.8)

Recent availability among all screened outlets*: Reportedly available in the past 3 months, not available on the day of the survey

1.1 0.7 3.5 0.3 3.5 0.6 0.6

(0.5, 1.7) (0.1, 1.4) (1.7, 5.2) (0.2, 0.4) (2.2, 4.9) (0.5, 0.7) (0.5, 0.8)

Antimalarial market share within outlet/sector type ^

% % % % % % %

% National first-line ACT for Pf malaria (AL, DHA-PPQ, ASMQ) market share 70.8 60.0 39.4 37.0 44.0 43.7 51.9

% National first-line treatment for Pv malaria (chloroquine) market share

22.3 16.5 28.3 28.0 31.4 26.6 25.3

% Oral artemisinin monotherapy market share

3.8 13.3 20.0 29.2 14.2 19.6 14.8




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Private sector price Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median price for one artemether lumefantrine (a first-line Pf malaria ACT) Adult Equivalent Treatment Dose (AETD)

$0.00 $0.15 $0.30 $0.35 $0.37 $0.33 $0.00

[0.00-0.00] (1,065) [0.01-0.47] (163) [0.24-0.44] (215) [0.21-0.68] (284) [0.00-0.70] (92) [1.62-0.51] (754) [0.00-0.10] (1,819)

Median price for one first-line Pv malaria (chloroquine) Adult Equivalent Treatment Dose (AETD)

$0.00 $0.09 $0.16 $0.29 $0.27 $0.20 $0.03

[0.0-0.0] (627) [0.01-0.65] (45) [0.11-0.32] (161) [0.15-0.39] (328) [0.10-0.98] (78) [0.12-0.39] (612) [0.0-0.16] (1,239)

Median price for one oral AMT Adult Equivalent Treatment Dose (AETD) $2.66 $2.15 $2.34 $3.06 $2.86 $3.06 $3.06

[1.13-3.66] (53) [1.05-3.11] (52) [2.06-2.90] (232) [2.69-3.78] (555) [2.74-4.32] (65) [2.33-3.31] (904) [2.33-3.36] (957)

Median price for an RDT # $0.00 $0.13 $0.24 $0.08 $0.00 $0.10 $0.00

[0.0-0.0] (1,169) [0.00-0.81] (190) [0.24-1.05] (68) [0.00-0.08] (37) [0.00-0.81] (80) [1.62-0.63] (375) [0.0-0.0] (1,544)

Median price for malaria microscopy # $0.00 $1.05 $0.39 - - $0.60 $0.33

[0.00-0.00] (3) [0.51-3.84] (19) [0.39-0.70] (3) - - [0.09-3.49] (22) [0.07-1.39] (25)

* The denominator includes 564 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).

Outlets with at least one antimalarial in stock on the day of the survey. ^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by national first-line treatment for P. falciparum malaria (AL, DHA-PPQ, ASMQ), national

first-line treatment for P. vivax malaria (chloroquine) and by oral artemisinin monotherapy. # Price inclusive of consultation / service fees for an adult.

Source: ACTwatch Outlet Survey, Myanmar, 2015.



Table S2: Key results, by outlet type, across domain

Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Readiness for malaria case management Proportion of all screened outlets outlets* with:

1. N=847 2. N=724 3. N=536 4. N=630

1. N=226 2. N=152 3. N=126 4. N=106

1. N=363 2. N=211 3. N=217 4. N=179

1. N=6,638 2. N=5,972 3. N=4,408 4. N=5,715

1. N=197 2. N=334 3. N=311 4. N=375

1. N=7,424 2. N=6,669 3. N=5,062 4. N=6,375

1. N=8,271 2. N=7,393 3. N=5,598 4. N=7,005

Availability of malaria blood testing

1. Eastern (AMTR intervention) 59.3 47.3 14.7 0.6 13.5 2.8 9.0

(54.8, 63.7) (38.3, 56.5) (10.1, 20.9) (0.3, 1.1) (8.8, 20.2) (2.2, 3.5) (8.1, 9.9)

2. Central (AMTR comparison) 31.4 29.4 4.4 0.0 4.1 0.9 4.2

(26.4, 36.8) (20.8, 39.9) (1.9, 9.6) (0.0, 0.2) (2.3, 7.3) (0.6, 1.3) (3.6, 5.0)

3. Western / India border 36.1 38.4 5.8 0.1 7.8 1.5 7.5

(29.4, 43.3) (25.8, 52.7) (3.3, 9.8) (0.1, 0.4) (4.7, 12.6) (1.2, 2.0) (6.4, 8.8)

4. Bangladesh border / Rakhine 38.1 22.7 13.9 0.1 6.7 1.2 5.2

(31.5, 45.2) (14.3, 34.1) (7.0, 25.6) (0.0, 0.3) (3.3, 13.2) (0.8, 1.7) (4.2, 6.4)


AL, DHA-PPQ, ASMQ


(51.9, 60.5) (38.8, 52.8) (26.1, 40.0) (2.9, 4.8) (12.8, 29.9) (5.6, 7.6) (10.8, 13.3)


(21.8, 31.1) (26.5, 51.1) (12.3, 26.9) (0.2, 0.5) (5.4, 13.5) (1.4, 2.7) (3.9, 5.3)


(27.0, 40.9) (26.6, 48.2) (11.0, 22.0) (0.4, 1.0) (4.1, 11.6) (1.8, 2.7) (6.6, 8.8)


(28.5, 42.3) (14.9, 42.6) (9.7, 28.6) (0.4, 1.0) (4.9, 15.3) (1.4, 2.6) (4.5, 6.7)

AL, DHA-PPQ, ASMQ and primaquine


(32.2, 40.5) (14.6, 26.4) (0.0, 1.7) (0.0, 0.2) (1.1, 6.2) (0.5, 0.9) (4.0, 5.2)


(14.9, 23.2) (10.0, 35.4) (0.2, 4.3) (0.0, 0.2) (0.1, 2.6) (0.2, 1.0) (2.0, 3.0)


(20.9, 33.9) (2.9, 10.6) (0.8, 6.0) - (0.3, 8.4) (0.1, 0.7) (3.9, 6.1)


(21.5, 33.8) (2.2, 12.4) (0.1, 4.1) - - (0.0, 0.2) (2.3, 4.0)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets



(44.7, 53.3) (26.3, 41.6) (5.8, 14.9) (0.2, 0.8) (4.6, 11.7) (1.4, 2.4) (6.3, 7.9)


(19.6, 29.1) (13.5, 34.5) (0.9, 6.3) (0.0, 0.2) (0.9, 5.3) (0.4, 1.0) (2.6, 3.8)


(25.8, 39.1) (15.4, 32.5) (1.4, 7.0) (0.0, 0.1) (1.0, 7.5) (0.5, 1.1) (5.1, 7.3)


(26.3, 39.7) (7.1, 27.8) (2.2, 12.7) (0.0, 0.2) (2.2, 12.4) (0.4, 1.3) (3.3, 5.3)



(5.7, 9.2) (8.9, 16.5) (18.6, 28.7) (2.5, 4.3) (7.2, 21.2) (3.9, 5.5) (4.2, 5.8)


(1.2, 3.6) (11.4, 21.1) (10.2, 24.6) (0.2, 0.5) (4.0, 10.2) (1.0, 1.7) (1.1, 1.8)


(0.9, 2.8) (8.2, 22.6) (8.7, 18.0) (0.4, 1.0) (2.5, 6.9) (1.2, 1.9) (1.2, 1.9)


(1.3, 4.7) (6.4, 21.0) (5.7, 22.7) (0.4, 0.9) (1.8, 6.3) (0.9, 1.6) (1.0, 1.8)


Chloroquine


(38.9, 47.7) (18.8, 33.0) (8.1, 18.9) (0.5, 1.1) (13.6, 24.0) (1.9, 3.0) (6.1, 7.7)


(18.4, 27.1) (17.2, 40.4) (11.5, 23.0) (0.5, 1.3) (8.6, 17.9) (1.8, 2.9) (3.8, 5.3)


(24.7, 37.4) (18.6, 48.5) (20.7, 39.3) (4.3, 7.8) (8.5, 17.8) (6.0, 9.2) (10.0, 13.1)


(20.2, 32.2) (10.5, 25.1) (20.2, 39.6) (4.6, 7.4) (8.4, 17.1) (5.7, 8.4) (7.6, 10.5)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Chloroquine and primaquine


(31.5, 40.4) (14.3, 26.8) (0.0, 1.7) (0.0, 0.1) (1.4, 7.0) (0.5, 0.9) (3.9, 5.2)


(13.8, 22.0) (11.4, 36.9) (0.3, 4.3) (0.0, 0.1) (0.2, 2.6) (0.3, 1.0) (1.9, 3.0)


(19.7, 31.8) (3.7, 15.0) (1.2, 5.2) (0.0, 0.1) (0.6, 7.9) (0.2, 0.8) (3.8, 5.8)


(18.1, 29.4) (1.8, 9.1) (0.2, 3.9) - - (0.0, 0.1) (1.9, 3.5)

Availability of primaquine


(34.2, 43.2) (16.3, 29.7) (0.1, 1.8) (0.0, 0.2) (1.4, 7.0) (0.5, 1.0) (4.3, 5.6)


(15.8, 24.8) (12.1, 37.1) (0.3, 4.3) (0.0, 0.2) (0.6, 3.0) (0.3, 1.0) (2.2, 3.3)


(23.2, 36.3) (4.0, 15.7) (1.3, 6.8) (0.0, 0.1) (0.7, 7.8) (0.2, 0.8) (4.4, 6.6)


(22.9, 35.1) (2.9, 13.3) (0.2, 3.9) - - (0.0, 0.2) (2.4, 4.2)

Availability of national first-line severe malaria treatment (artesunate IV/IM)


(0.8, 2.7) (6.0, 15.0) (3.9, 14.1) (0.0, 0.1) (0.4, 6.8) (0.4, 1.1) (0.4, 1.2)


(0.9, 2.9) (3.6, 12.1) (0.7, 6.6) (0.0, 0.2) (0.1, 2.9) (0.2, 0.4) (0.3, 0.6)


(0.2, 1.4) (5.7, 20.7) (3.4, 11.0) (0.1, 0.5) (0.4, 5.0) (0.4, 1.3) (0.4, 1.2)


(0.1, 1.4) (1.9, 12.2) (0.2, 2.1) - - (0.0, 0.2) (0.1, 0.2)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Readiness for malaria case management

Proportion of antimalarial-stocking outlets with:

1. N=545 2. N=244 3. N=242 4. N=232

1. N=129 2. N=65 3. N=80 4. N=40

1. N=185 2. N=88

3. N=144 4. N=105

1. N=381 2. N=104 3. N=462 4. N=394

1. N=90 2. N=93

3. N=137 4. N=99

1. N=785 2. N=350 3. N=823 4. N=638

1. N=1,330 2. N=594

3. N=1,065 4. N=870

Availability of malaria blood testing


(78.1, 85.3) (60.7, 76.3) (17.4, 34.4) (4.2, 13.1) (18.2, 34.0) (18.5, 27.0) (45.1, 52.5)


(70.3, 83.0) (43.6, 68.1) (4.6, 21.2) (0.2, 7.6) (6.0, 20.1) (10.9, 21.8) (38.0, 48.0)


(80.0, 89.6) (34.5, 67.4) (5.1, 15.8) (0.3, 1.6) (10.9, 29.1) (6.1, 12.0) (29.6, 41.8)


(84.8, 94.1) (25.9, 64.6) (7.0, 24.6) (0.5, 3.9) (10.2, 38.6) (5.5, 13.5) (28.8, 40.9)


AL, DHA-PPQ, ASMQ


(83.9, 90.9) (72.9, 85.1) (61.4, 76.1) (54.3, 73.1) (35.7, 59.6) (59.5, 71.2) (70.6, 79.7)


(69.8, 81.6) (63.0, 90.2) (31.4, 56.5) (9.6, 23.7) (19.0, 41.4) (27.6, 46.8) (48.8, 59.5)


(76.1, 88.6) (34.7, 68.9) (19.8, 36.1) (3.9, 8.6) (11.7, 29.3) (11.2, 17.5) (32.9, 43.9)


(86.2, 95.1) (39.6, 88.6) (19.8, 47.3) (6.1, 13.3) (19.7, 47.3) (14.2, 25.0) (35.9, 48.3)

AL, DHA-PPQ, ASMQ and primaquine


(51.7, 61.3) (26.3, 43.9) (0.1, 3.5) (0.3, 2.6) (2.8, 13.1) (4.7, 9.0) (25.2, 32.4)


(47.4, 61.3) (24.0, 61.6) (0.5, 9.7) (0.2, 7.6) (0.5, 8.4) (4.4, 16.7) (24.5, 33.9)


(56.8, 75.3) (4.0, 15.3) (1.4, 10.0) - (0.7, 20.5) (0.8, 4.2) (19.6, 30.2)


(63.3, 77.8) (5.9, 29.7) (0.2, 7.4) - - (0.3, 1.7) (18.0, 29.0)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets



(72.1, 80.4) (50.2, 66.3) (13.2, 28.9) (4.1, 13.0) (12.0, 25.0) (15.4, 22.9) (40.6, 48.2)


(63.0, 76.3) (33.3, 61.0) (2.1, 14.1) (0.2, 7.6) (3.0, 16.4) (7.5, 18.3) (32.9, 42.6)


(72.4, 85.1) (20.7, 46.6) (2.4, 11.8) (0.0, 0.6) (2.7, 19.0) (2.9, 6.8) (25.4, 36.5)


(78.4, 90.1) (21.0, 59.2) (4.2, 21.9) (0.2, 2.6) (9.0, 37.7) (4.3, 12.1) (26.2, 38.2)



(8.9, 14.3) (14.8, 29.5) (41.1, 57.6) (47.1, 66.1) (19.5, 43.1) (40.0, 53.6) (27.4, 35.0)


(3.6, 10.4) (24.1, 43.2) (25.7, 52.0) (8.7, 22.4) (14.1, 32.0) (19.6, 30.9) (12.6, 21.4)


(2.2, 6.6) (11.1, 32.5) (15.7, 29.4) (3.7, 8.5) (7.1, 17.9) (7.5, 12.2) (6.0, 9.6)


(3.4, 12.0) (16.8, 50.0) (11.3, 38.2) (5.6, 12.4) (6.4, 22.2) (8.6, 15.8) (7.5, 13.4)


Chloroquine


(63.0, 71.8) (35.1, 53.2) (18.6, 36.4) (9.1, 18.0) (33.1, 54.3) (20.1, 28.3) (39.8, 46.8)


(58.8, 71.4) (41.9, 71.3) (27.7, 51.0) (27.6, 54.5) (31.0, 54.4) (37.0, 50.2) (47.8, 58.5)


(68.4, 82.3) (28.0, 62.9) (39.6, 60.8) (43.0, 60.5) (24.8, 44.1) (41.6, 53.8) (52.5, 62.5)


(59.0, 74.6) (25.7, 62.6) (43.9, 63.4) (74.6, 85.7) (31.0, 58.5) (62.4, 74.2) (63.4, 72.7)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets



(50.9, 60.9) (26.1, 44.2) (0.1, 3.5) (0.2, 2.3) (3.7, 14.9) (4.7, 9.1) (24.8, 32.3)


(43.8, 58.2) (27.4, 64.3) (0.8, 9.8) (0.4, 7.3) (0.7, 8.3) (5.4, 17.6) (23.6, 33.2)


(53.8, 70.6) (5.1, 21.2) (2.1, 8.8) (0.0, 0.5) (1.6, 19.5) (1.2, 4.8) (18.8, 28.9)


(52.2, 68.8) (4.5, 23.9) (0.4, 6.9) - - (0.3, 1.4) (15.0, 25.5)

Availability of primaquine


(55.3, 65.2) (29.6, 48.9) (0.2, 3.7) (0.4, 2.8) (3.7, 14.9) (5.4, 10.4) (27.2, 34.9)


(50.4, 65.3) (29.3, 64.7) (0.8, 9.8) (0.9, 8.8) (1.9, 9.9) (6.4, 18.4) (27.1, 37.0)


(64.2, 79.8) (5.6, 22.1) (2.3, 11.4) (0.1, 1.2) (1.9, 19.4) (1.6, 5.2) (22.2, 33.0)


(67.5, 80.8) (7.6, 32.6) (0.4, 6.9) - - (0.5, 1.9) (19.3, 30.2)

Availability of national first-line severe malaria treatment (artesunate IV/IM)


(1.3, 4.2) (11.2, 24.4) (9.3, 26.1) (0.2, 1.9) (1.1, 14.3) (4.0, 10.5) (2.9, 7.5)


(2.7, 8.2) (7.9, 23.7) (1.7, 14.6) (0.6, 8.1) (0.2, 9.4) (3.0, 7.6) (3.3, 6.8)


(0.5, 3.5) (8.0, 28.8) (6.0, 18.6) (1.0, 4.1) (1.1, 12.7) (2.4, 8.0) (1.9, 5.7)


(0.2, 3.6) (5.1, 29.5) (0.5, 3.8) - - (0.3, 1.7) (0.4, 1.7)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets


Availability among all screened outlets*


(0.8, 3.0) (4.4, 12.9) (9.2, 22.0) (1.1, 2.5) (3.1, 12.8) (1.7, 3.6) (1.6, 3.5)


(0.7, 2.6) (3.3, 10.5) (11.0, 22.2) (0.5, 1.4) (3.8, 11.3) (1.3, 2.2) (1.3, 2.1)


(1.0, 3.3) (16.6, 35.5) (28.0, 46.8) (5.9, 9.3) (3.5, 8.6) (7.1, 10.1) (6.1, 8.8)


(0.1, 0.8) (1.8, 9.6) (11.9, 31.9) (0.6, 1.1) (2.8, 8.7) (1.2, 2.0) (1.1, 1.8)

Availability among antimalarial-stocking outlets


(1.2, 4.7) (8.0, 21.4) (22.4, 40.5) (20.1, 38.6) (8.3, 26.4) (18.9, 32.4) (10.8, 20.5)


(2.1, 7.5) (6.8, 22.2) (26.4, 49.4) (33.7, 56.3) (13.7, 34.4) (24.8, 38.9) (15.5, 23.7)


(2.6, 7.9) (22.4, 50.5) (52.9, 73.1) (60.2, 72.1) (9.7, 22.4) (49.4, 58.7) (32.1, 41.6)


(0.2, 2.2) (4.4, 24.9) (24.3, 52.8) (7.7, 15.6) (10.1, 30.3) (11.7, 20.2) (8.2, 14.0)

Recent availability among all screened outlets*: Reportedly available in the past 3 months, not available on the day of the survey


(0.3, 1.4) (0.2, 3.2) (0.4, 2.4) (0.2, 0.5) (0.3, 5.6) (0.3, 0.6) (0.3, 0.6)


(0.9, 3.5) (0.1, 2.6) (2.8, 10.4) (0.1, 0.3) (1.6, 5.9) (0.3, 0.6) (0.4, 0.8)


(0.1, 0.5) (0.4, 4.6) (1.3, 6.6) (1.0, 2.3) (4.5, 11.6) (1.3, 2.9) (1.1, 2.5)


(0.2, 1.5) (0.2, 8.8) (1.4, 7.7) (0.1, 0.7) (4.4, 12.8) (0.6, 1.4) (0.6, 1.3)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Antimalarial market share within outlet/sector type ^

% % % % % % %

% National first-line ACT for Pf malaria (AL, DHA-PPQ, ASMQ) market share

Eastern (AMTR intervention) 65.2 68.4 52.7 67.0 41.0 58.4 60.5

Central (AMTR comparison) 75.4 33.1 27.3 17.3 54.8 33.4 48.1

Western 36.6 43.2 16.8 14.2 18.9 17.6 21.8

Bangladesh border / Rakhine 76.6 86.6 30.5 27.0 39.5 38.8 48.5

% National first-line treatment for Pv malaria (chloroquine) market share



Western 56.6 6.0 45.3 44.6 28.2 40.5 44.0


% Oral artemisinin monotherapy market share



Western 4.6 22.7 30.5 38.9 38.2 34.5 27.9


Private sector price Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median

[IQR] (N)

Median price for one artemether lumefantrine (a first-line Pf malaria ACT) Adult Equivalent Treatment Dose (AETD)

Eastern (AMTR intervention) $0.00 $0.24 $0.31 $0.31 $0.39 $0.31 $0.00

[0.00-0.00] (490) [0.00-0.55] (69) [0.24-0.39] (115) [0.00-0.39] (217) [0.00-0.79] (39) [0.00-0.39] (440) [0.00-0.31] (930)

Central (AMTR comparison) $0.00 $0.00 $0.28 $0.31 $0.39 $0.31 $0.00

[0.00-0.00] (190) [0.00-0.39] (34) [0.24-0.39] (22) [0.28-0.39] (13) [0.00-0.55] (15) [0.00-0.39] (84) [0.00-0.00] (274)

Western $0.00 $0.39 $0.31 $0.47 $0.00 $0.39 $0.00

[0.00-0.00] (176) [0.24-0.79] (35) [0.24-0.79] (36) [0.39-1.89] (24) [0.00-0.55] (18) [0.24-0.79] (113) [0.00-0.00] (289)

Bangladesh border / Rakhine $0.00 $0.28 $0.31 $0.47 $0.39 $0.39 $0.00

[0.00-0.00] (209) [0.00-0.39] (25) [0.24-0.55] (42) [0.39-1.57] (30) [0.00-0.94] (20) [0.22-0.94] (117) [0.00-0.00] (326)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Median price for Pv malaria (chloroquine) Adult Equivalent Treatment Dose (AETD)


[0.00-0.00] (253) [0.00-1.18] (13) [0.08-0.39] (31) [0.16-0.39] (18) [0.20-1.97] (13) [0.08-0.39] (75) [0.00-0.08] (328)


[0.00-0.00] (120) [0.00-0.39] (10) [0.12-0.24] (33) [0.12-0.39] (16) [0.00-0.39] (19) [0.12-0.39] (78) [0.00-0.16] (198)

Western $0.00 $0.39 $0.20 $0.39 $0.20 $0.39 $0.20

[0.00-0.00] (126) [0.16-0.39] (8) [0.16-0.39] (51) [0.20-0.39] (171) [0.00-0.39] (26) [0.20-0.39] (256) [0.00-0.39] (382)


[0.00-0.00] (128) [0.00-0.39] (14) [0.13-0.39] (46) [0.20-0.39] (123) [0.20-0.79] (20) [0.16-0.39] (203) [0.00-0.24] (331)

Median price for one oral AMT Adult Equivalent Treatment Dose (AETD)


[1.26-3.78] (19) [0.00-2.77] (9) [2.27-3.15] (61) [3.02-3.78] (115) [2.52-6.29] (15) [2.52-3.78] (200) [2.52-3.78] (219)


[0.00-3.78] (9) [1.26-3.02] (6) [1.95-2.96] (30) [2.27-3.78] (46) [3.02-3.15] (16) [2.14-3.02] (98) [2.14-3.15] (107)

Western $3.02 $3.15 $2.52 $3.78 $3.17 $3.78 $3.78

[3.02-3.78] (23) [2.52-3.78] (32) [2.27-3.02] (102) [3.02-3.78] (344) [3.02-3.78] (22) [3.02-3.78] (500) [3.02-3.78] (523)


[3.15-3.15] (2) [2.01-3.78] (5) [1.89-2.27] (39) [3.02-3.78] (50) [2.39-3.78] (12) [2.27-3.02] (106) [2.27-3.02] (108)

Median price for an RDT #


[0.00-0.00] (506) [0.00-0.79] (99) [0.00-0.79] (44) [0.00-0.00] (30) [0.00-0.47] (28) [0.00-0.39] (201) [0.00-0.00] (707)


[0.00-0.00] (225) [0.00-0.79] (30) [0.39-1.57] (3) (1) [0.00-1.18] (10) [0.00-0.79] (44) [0.00-0.00] (269)

Western $0.00 $0.39 $0.00 $0.16 $0.00 $0.00 $0.00

[0.00-0.00] (203) [0.00-1.18] (37) [0.00-0.00] (6) [0.00-0.16] (3) [0.00-0.39] (23) [0.00-0.79] (69) [0.00-0.00] (272)


[0.00-0.00] (235) [0.00-0.79] (24) [0.39-0.55] (15) [0.00-0.39] (3) [0.00-0.63] (19) [0.00-0.63] (61) [0.00-0.00] (296)




Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

Median price for malaria microscopy #

Eastern (AMTR intervention) $0.00 $1.57 - - - $1.57 $0.79

(1) [0.00-2.36] (7) - - - [0.00-2.36] (7) [0.00-1.57] (8)

Central (AMTR comparison) $0.00 $0.00 - - - $0.00 $0.00

(1) [0.00-5.74] (3) - - - [0.00-5.74] (3) [0.00-1.57] (4)

Western $0.00 $0.79 $0.39 - - $0.39 $0.00

(1) [0.39-0.79] (8) (1) - - [0.39-0.79] (9) [0.00-0.79] (10)

Bangladesh border / Rakhine - $2.75 $0.39 - - $0.39 $0.39

- (1) [0.39-0.79] (2) - - [0.39-0.79] (3) [0.39-0.79] (3)


Outlets with at least one antimalarial in stock on the day of the survey. ^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by national first-line treatment for P. falciparum malaria (AL, DHA-PPQ, ASMQ), national

first-line treatment for P. vivax malaria (chloroquine) and by oral artemisinin monotherapy. # Price inclusive of consultation / service fees for an adult.




Community health worker

Private for-profit health facility

Pharmacy

General retailer

Itinerant drug vendor

AMTR Intervention AMTR Comparison Western/India border

Bangladesh/Rakhine

Market Composition

Figure 4. Antimalarial market composition: outlet type distribution, 2015 Among all outlets with at least one antimalarial in stock (See Table A5 for full data)

Community health workers accounted for the majority of outlets with antimalarials in stock (41.5%). However, private-sector outlets accounted for over half of antimalarial-stocking outlets (58.5%), including general retailers (27.9%), itinerant drug vendors (11.8%), pharmacies (10.9%), and private for-profit facilities (7.9%).

Figure 5. Antimalarial market composition: outlet type distribution by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B5 for full data)

Antimalarial stocking outlets in the Western and Bangladesh/Rakhine regions were commonly private sector outlets (65.0%, 68.4%), and over 40% were general retailers. General retailers were also a common outlet type for antimalarials in the AMTR intervention area (30%), but accounted for only 19% of antimalarial-stocking outlets in the AMTR comparison area. Public sector community health workers accounted for about 32% of antimalarial stocking outlets in Bangladesh/Rakhine areas and 35% in Western/India areas as compared with 44% in both AMTR intervention and comparison areas.



Community Health Worker

Private For-Profit Facility

Pharmacy

General Retailer


AMTR Intervention AMTR Comparison Western/India border

Bangladesh/Rakhine

Figure 6. Malaria blood testing market composition: outlet type distribution, 2015 Among all outlets with at least one malaria diagnostic test in stock (See Table A8 for full data)

Public sector community health workers accounted for the majority of outlets with blood testing available (78.0%). Private-sector outlets accounted for only 22.0% of outlets with malaria testing, including private for-profit facilities (10.6%), pharmacies (4.1%), general retailers (2.3%), and itinerant drug vendors (4.9%).

Figure 7. Malaria blood testing market composition: outlet type distribution by strata, 2015 Among all outlets with at least one malaria diagnostic test in stock (See Table B8 for full data)

Public sector community health workers accounted for a large proportion of blood test-stocking outlets at greater than 70% across all domains. The private sector accouted for a larger proportion of outlets with malaria testing in the AMTR Intervention areas (28%) as compared to other domains (Comparison, 19%; Western/India, 17%; Balgladesh/Rakhine, 20%).



Antimalarial Availability

Figure 8. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2015 Among all screened outlets (See Table A1 for full data)

Among all screened outlets, private for-profit health facilities were the most likely to be stocking antimalarials (50.4%), and nearly half of health workers and pharmacies screened were also found to be stocking antimalarials (45.0% and 46.9%, respectively). One in three itinerant drug vendors screened were stocking antimalarials (33.7%), while only 4.6% of general retailers were stocking antimalarials.

Figure 9. Percentage of outlets with at least one antimalarial in stock on the day of the survey, by strata, 2015 Among all screened outlets (See Table B1 for full data)

Overall, outlets were more likely to stock antimalarials in the AMTR Intervention (15.8%) or Western/India areas (19.9%) as compared to AMTR Comparison (8.4%) and Bangladesh/Rakhine areas (13.1%). Differences were particularly notable among health workers screened, where those in the AMTR Intervention domain were more likely to be stocking antimalarials (64.0%) as compared to the other domains (AMTR Comparison, 34.3%; Western/India, 40.4%; Bangladesh/Rakhine, 38.3%). Additionally, among private for-profit health facilities, 70.6% in the Western/India domain were stocking antimalarials as compared to lower availability in other domains (AMTR Intervention, 57.4%; AMTR Comparison, 47.6%; Bangladesh/Rakhine, 38.2%).

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AMTR Intervention AMTR Comparison Western/India border Bangladesh border/Rakhine



Figure 10. Percentage of antimalarial-stocking outlets with any ACT in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Over three-fourths of antimalarial-stocking health workers and private for-profit health facilities were stocking any ACT (83.1% and 76.4%, respectively), while nearly half of antimalarial-stocking pharmacies were stocking any ACT (49.0%). Approximately one in three antimalarial-stocking general retailers and itinerant drug vendors had any ACT available (29.6% and 35.0%, respectively). Nearly all ACTs audited in the Myanmar outlet survey were national first-line ACTs (artemether lumefantrine or dihydroartemisinin piperaquine).

Figure 11. Percentage of antimalarial-stocking outlets with any ACT in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Among antimalarial-stocking outlets, 75.4% of all outlets in AMTR Intervention areas had ACT in stock as compared with 54.2% in Comparison areas, and less than 50% in Western/India (38.3%) and Bangladesh/Rakhine areas (42.0%). These domain differences were due to differences in availability within private sector outlets, where availability was highest in AMTR Intervention areas among pharmacies, general retailers, and itinerant drug vendors.

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Figure 12. Percentage of antimalarial-stocking outlets with any AL in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Availability of any AL was highest among community health workers (82.9%) and private for-profit health facilities (70.9%). Less than half of antimalarial-stocking pharmacies had any AL available (44.8%), and approximately one in three general retailers and itinerant drug vendors were stocking any AL (29.6% and 33.7%, respectively).

Figure 13. Percentage of antimalarial-stocking outlets with any AL in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Among antimalarial-stocking outlets, 74.0% of all outlets in AMTR Intervention areas had AL in stock as compared with 52.7% in Comparison areas, and less than 50% in Western/India (37.5%) and Bangladesh/Rakhine areas (41.6%). These domain differences were due to differences in availability within private sector outlets, where availability was highest in AMTR Intervention areas among pharmacies, general retailers, and itinerant drug vendors.

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Figure 14. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Availability of quality-assured ACT was highest among community health workers (80.2%) and private for-profit health facilities (68.0%). Less than half of antimalarial-stocking pharmacies had any AL available (44.1%), and less than one in three general retailers and itinerant drug vendors were stocking a quality-assured ACT (27.8% and 29.0%, respectively).

Figure 15. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Among antimalarial-stocking outlets, 73.0% of all outlets in AMTR Intervention areas had quality-assured ACT in stock as compared with 48.8% in Comparison areas, and less than 50% in Western/India (35.5%) and Bangladesh/Rakhine areas (39.8%). These domain differences were due to differences in availability within private sector outlets, where availability was highest in AMTR Intervention areas among pharmacies, general retailers, and itinerant drug vendors.

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Figure 16. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Availability of non-quality-assured ACT was low across all antimalarial-stocking outlet types (6.3%), with the highest availability among private for-profit health facilities at 12.8%.

Figure 17. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Among private sector antimalarial-stocking outlets, availability of non-quality-assured ACTs was lowest in Balgladesh/Rakhine (2.3%) and highest in AMTR Comparison areas (8.2%). Among public sector CHWs, availability was highest in the Bangladesh/Rakhine domain (19.0%) followed by the Western / India border domain (13.7%), AMTR Comparison domain (5.9%) and AMTR Intervention domain (4.2%).

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Figure 18. Types of non-quality assured ACT audited among health workers and private sector outlets, 2015 Among all non QA ACT medicines audited (See Table A4 for full data)

All QA ACTs audited were artemether lumefantrine tablets. Among non-quality-assured ACT medicines audited in the public sector, the primary medicine audited was artemether lumefantrine tablets (94.6%). However, in the private sector, most of the non-quality-assured ACT medicines audited were dihydroartemisinin piperaquine tablets (52.6%), with artemether lumefantrine tablets comprising just 42.4%. Other non-quality-assured ACT medicines audited included artesunate amodiaquine tablets in both sectors, and artemisinin napthoquine tablets in the private sector.

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Figure 19. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Among antimalarial-stocking outlets, availability of non-artemisinins (e.g. chloroquine, primaquine) was highest among community health workers (78.9%) and itinerant drug vendors (70.5%). Over half of private for-profit health facilities (59.6%) and nearly half of pharmacies and general retailers were stocking non-artemisinin monotherapy (48.5%, and 48.5%, respectively).

Figure 20. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Availability of non-artemisinins among antimalarial-stocking outlets was 50.9% in AMTR Intervention areas as compared to 68.6% in AMTR Comparison areas, 73.9% in Western/India areas, and 81.9% in Bangladesh/Rakhine areas. Data trends suggest lowest availability of non-artemisinins in AMTR Intervention areas across all outlet types. Particularly notable differences were observed among general retailers: AMTR Intervention, 18.3%; AMTR Comparison, 51.6%; Western/India, 62.6%; and Bangladesh/Rakhine, 91.6%. In addition, only about one-third of pharmacies in AMTR Intervention areas were stocking non-artemisinin therapy (35.2%) as compared to greater than 60% in Western/India (63.9%) and Bangladesh/Rakhine (62.5%)

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Figure 21. Percentage of antimalarial-stocking outlets with CQ (first-line Pv treatment) in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Availability of the first-line treatment for Pv malaria, chloroquine, was highest among community health workers (67%) and similar across private sector outlet types. About half of antimalarial-stocking private for-profit health facilities had chloroquine available (49.7%), while availability was slightly lower among pharmacies (38%), general retailers (39.2%), and itinerant drug vendors (42.5%).

Figure 22. Percentage of antimalarial-stocking outlets with CQ (first-line Pv treatment) in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Availability of chloroquine among antimalarial-stocking outlets was 43.3% in AMTR Intervention areas as compared to 53.2% in AMTR Comparison areas, 57.6% in Western/India areas, and 68.2% in Bangladesh/Rakhine areas. Data trends suggest lowest availability of chloroquine in AMTR Intervention areas across all outlet types with the exception of private health facilities. Particularly notable differences were observed among general retailers: AMTR Intervention, 12.9%; AMTR Comparison, 40.3%; Western/India, 51.8%; and Bangladesh/Rakhine, 80.7%. In addition, only about one-quarter of pharmacies in AMTR Intervention areas were stocking non-artemisinin therapy (26.5%) as compared to about half in Western/India (50.2%) and Bangladesh/Rakhine (53.8%)

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Figure 23. Percentage of antimalarial-stocking outlets with primaquine in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Availability of primaquine, used for radical cure of Pv malaria and as a gametocytic agent, was highest among community health workers (62.6%) and slightly lower in private for-profit health facilities (36.8%). Less than one in ten of antimalarial-stocking private outlets had primaquine available (7.7%), while availability was especially low among pharmacies (2.2%), general retailers (1.7%), and itinerant drug vendors (4.8%).

Figure 24. Percentage of antimalarial-stocking outlets with primaquine in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

Availability of primaquine among antimalarial-stocking outlets was similar across domains at 30.9% in AMTR Intervention areas, 31.9% in AMTR Comparison areas, 27.3% in Western/India areas, and 24.3% in Bangladesh/Rakhine areas. Primaquine availability was highest among community health workers at 60.3% in AMTR Intervention, 58.1% in AMTR Comparison, 72.7% in Western/India border, and 74.7% in Bangladesh border/Rakhine. However, availability is quite low in the private sector. Data shows that primaquine availability is lowest at less than 7% across all domains in pharmacies, general retailers, and itinerant drug vendors. Availability in private for-profit facilities is much higher in the AMTR areas at 38% in AMTR Intervention, and 46.6% in AMTR Comparison versus the western domains (Western/India border, 11.5%; Bangladesh border/Rakhine, 16.6%).

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Figure 25. Percentage of antimalarial-stocking outlets with oral artemisinin monotherapy in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Approximately one in four private sector antimalarial-stocking outlets had oral artemisinin monotherapy in stock (27.7%). Availability was highest among pharmacies (36.5%) and general retailers (34.6%), and about 1in 5 itinerant drug vendors were stocking oral AMT (18.9%). Availability was relatively lower in private health facilities (13.8%), and only 2.9% of community health workers were stocking oral AMT.

Figure 26. Percentage of antimalarial-stocking outlets with oral artemisinin monotherapy in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

More than half of all antimalarial-stocking private sector outlets in Western/India border areas had oral AMT in stock (54.1%). Availability was much lower in AMTR Intervention (25.0%), Comparison (31.4%), and Bangladesh/Rakhine areas (15.4%). Availability was highest in Western/India areas within all outlet types with the exception of similar availability across domains among itinerant drug vendors and CHWs.

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Figure 27. Percentage of antimalarial-stocking outlets with treatment for severe malaria in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Treatments for severe malaria available in Myanmar included injectable quinine, arteether, artemether, and artesunate. Only about one in four antimalarial-stocking private for-profit health facilities had treatment for severe malaria available (27.3%). Although they would not be expected to manage severe cases, severe malaria treatments were available among nearly half of itinerant drug vendors (48.0%).

Figure 28. Percentage of antimalarial-stocking outlets with treatment for severe malaria in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

More than half of private for-profit health facilities in Western/India had severe malaria treatment available (57.9%) as compared to less than 30% in all other domains (AMTR Intervention, 27.3%; AMTR Comparison, 25.5%; Bangladesh/Rakhine, 22.7%).

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Figure 29. Percentage of antimalarial-stocking outlets with any antimalarial that is not in the national treatment guidelines in stock on the day of the survey, 2015 Among all outlets with at least one antimalarial in stock (See Table A2 for full data)

Approximately one-third of antimalarial-stocking private sector outlets were stocking an antimalarial that was not indicated in the national treatment guidelines. These medicines were most commonly artesunate tablets, but also included nonartemisinin therapies such as mefloquine and SP. Availability of any antimalarial that is not in the national treatment guidelines was highest among antimalarial-stocking pharmacies and general retailers (40.6% and 38.2%, respectively). Availability was low among community health workers at just 3.5%.

Figure 30. Percentage of antimalarial-stocking outlets with any antimalarial that is not in the national treatment guidelines in stock on the day of the survey, by strata, 2015 Among all outlets with at least one antimalarial in stock (See Table B2 for full data)

More than half of all antimalarial-stocking private sector outlets in Western/India areas had antimalarials in stock that were not indicated in the national treatment guidelines (56.0%). Availability was much lower in AMTR Intervention (26.7%), Comparison (36.3%), and Bangladesh border/Rakhine areas (23.9%). Availability was highest in Western/India areas within all outlet types with the exception of similar availability across domains among itinerant drug vendors and CHWs.

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Antimalarial Market Share Figure 31. Total antimalarial market share, 2015

Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type (See table A10 for full data)

Private sector outlets accounted for 70% of antimalarial distribution while CHWs accounted for 30%. Note that government health facilities were not included in the study, and market share therefore excludes distribution by these facilities. Private sector market share included market share private facilities (13.3%), pharmacies (27.4%), general retailers (15.2%) and itinerant drug vendors (14.0%). ACTs accounted for about half of all antimalarials distributed (52%), and one-third of all antimalarials distributed were quality-assured ACTs with the Padonma logo (32.4%). Chloroquine market share was 25.3%. Oral AMT market share was 14.8%.

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Figure 32. Antimalarial market share, AMTR Intervention, 2015 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type (See table B10.1 for full data)

In the AMTR Intervention domain, private sector outlets accounted for 69% of antimalarial distribution while CHWs accounted for 31%. Note that government health facilities were not included in the study, and market share therefore excludes distribution by these facilities. Private sector market share included market share private facilities (16.3%), pharmacies (33.6%), general retailers (13.7%) and itinerant drug vendors (5.3%). ACTs accounted for 61% of all antimalarials distributed, and half of all antimalarials distributed were quality-assured ACTs with the Padonma logo (50.2%). Chloroquine market share was 15.3%. Oral AMT market share was 17.0%.

Figure 33. Antimalarial market share, AMTR Comparison, 2015

Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type (See table B10.2 for full data)

In the AMTR Comparison domain, private sector outlets accounted for 65% of antimalarial distribution while CHWs accounted for 35%. Note that government health facilities were not included in the study, and market share therefore excludes distribution by these facilities. Private sector market share included market share private facilities (16.0%), pharmacies 19.9%), general retailers (13.2%) and itinerant drug vendors (16.0%). ACTs accounted for almost half of all antimalarials distributed (48.1%), with only 17.6% of all antimalarials distributed were quality-assured ACTs with the Padonma logo. Chloroquine market share was 27.6%. Oral AMT market share was 15.0%.

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Figure 34. Antimalarial market share, Western / India border, 2015 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type (See table B10.3 for full data)

In the Western / India border domain, private sector outlets accounted for 78% of antimalarial distribution while CHWs accounted for 22%. Note that government health facilities were not included in the study, and market share therefore excludes distribution by these facilities. Private sector market share included market share private facilities (4.8%), pharmacies (31.4%), general retailers (32.6%) and itinerant drug vendors (9.4%). ACTs accounted for only 22% of all antimalarials distributed, and only 11.2% of all antimalarials distributed were quality-assured ACTs with the Padonma logo. Chloroquine market share was 44.0%. Oral AMT market share was 27.9%.

Figure 35. Antimalarial market share, Bangladesh border / Rakhine, 2015

Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type (See table B10.4 for full data)

In the Bangladesh border / Rakhine domain, private sector outlets accounted for 74% of antimalarial distribution while CHWs accounted for 26%. Note that government health facilities were not included in the study, and market share therefore excludes distribution by these facilities. Private sector market share included market share private facilities (8.3%), pharmacies (26.0%), general retailers (16.7%) and itinerant drug vendors (23.2%). ACTs accounted for almost half of all antimalarials distributed (48.5%), and more than one-quarter of all antimalarials distributed were quality-assured ACTs with the Padonma logo (26.7%). Chloroquine market share was 32.9%. Oral AMT market share was 10.6%.

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Figure 36. Antimalarial market share among health workers and private sector outlets, by strata, 2015 Relative market volume (sale/distribution) of antimalarial AETDs, by target outlet types in intervention and comparison areas (See table B11 for full data)

Across domains, ACTs accounted for 60.0% of all antimalarials distributed by CHWs and 44.0% of all antimalarial distributed in the private sector. ACT market share among CHWs was similar across domains with the exception of low market share in the Western/India areas (36.6%). In this domain, chloroquine accounted for more than half of all antimalarials distributed by CHWs. Within the private sector, ACTs accounted for more than half of all antimalarials distributed in AMTR Intervention areas (59.1%), but ACT market share was less than half in the private sector in all other domains: AMTR Comparison, 33.4%; Western/India, 17.6%; and Bangladesh/Rakhine, 38.8% Across domains, oral AMT accounted for 1 in 5 of all antimalarials distributed in the private sector (19.6%). Oral AMT market share was highest in Western/India areas (34.5%) as compared to AMTR Intervention (23.0%) and Comparison areas (20.8%), and Bangladesh/Rakhine (13.1%).

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Malaria Blood Testing Availability Figure 37. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2015

Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See table A7 for full data)

Over three-fourths of health workers and over half of private for-profit health facilities had a malaria blood test available (77.7% and 58.2%, respectively). Availability of malaria blood testing was much lower among other private sector outlet types, and overall only 15.4% of private sector antimalarial-stocking outlets had testing available.

Figure 38. Percentage of antimalarial-stocking outlets with malaria blood testing available, by strata, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See table B7 for full data)

Availability of malaria blood testing did not differ significantly by domain among health workers. Within the private sector, data trends suggest higher availability in AMTR Intervention areas as compared with other domains across all outlet types. Overall private sector availability of testing was availability of testing was 21.0% in AMTR Intervention areas compared to 14.8% in AMTR Comparison areas, and less than 10% in Western/India (8.4%) and Bangladesh/Rakhine areas (8.7%).

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Figure 39. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2015


Availability of malaria microscopy was generally low and only 4.0% of private health facilities had malaria microscopy available.

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Figure 40. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2015


Over three-fourths of health workers and over half of private for-profit health facilities had malaria RDTs available (77.7% and 55.4%, respectively). Availability of mRDTs was much lower among other private sector outlet types, and overall only 14.9% of private sector antimalarial-stocking outlets had mRDTs available.

Figure 41. Percentage of antimalarial-stocking outlets with malaria RDTs available, by strata, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See table B7 for full data)

Availability of malaria RDTs did not vary significantly across domains among health workers. Within the private sector, data trends suggest higher availability in AMTR Intervention areas as compared with other domains across all outlet types. Overall private sector availability of mRDTs was availability of testing was 20.5% in AMTR Intervention areas compared to 14.2% in AMTR Comparison areas, and less than 10% in Western/India (8.2%) and Bangladesh/Rakhine areas (8.7%).

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Malaria Diagnostic Market Share Figure 42. Malaria blood testing market share, 2015

Relative market volume (sale/distribution) of blood tests, by outlet type (See Table A12 for full data)

The majority of malaria blood tests were provided by health workers (78.6%), with malaria RDTs comprising the majority of the malaria blood testing market share (98.3%). The private sector testing market share was 21.3%, including 10.9% of tests provided by private for-profit health facilities.

Figure 43. Malaria RDT market share among health workers and private sector outlets, 2015

Relative market volume (sale/distribution) of manufacturer-specific RDTs, by outlet type (See Table A13 for full data)

Most of the malaria RDTs provided were manufactured by Standard Diagnostics (94.4%). Among health workers, nearly all tests provided were Standard Diagnostics test (98.0%) as compared with 80.4% in the private sector.

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Figure 44. Malaria RDT market share within community health workers and private sector outlets, 2015 Relative market volume (sale/distribution) of manufacturer-specific RDTs, by strata (See Table A13 for full data)

Most of the malaria RDTs provided were manufactured by Standard Diagnostics (94.4%). Among community health workers, nearly all tests provided were Standard Diagnostics test (98.0%) as compared with 80.4% in the private sector.

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Distribution and Sales of Antimalarials

Figure 45. Percentage of outlets with blood testing available that sold or distributed malaria tests in the previous week, and percentage of antimalarial-stocking outlets that sold or distributed an antimalarial in the previous week, by outlet type, 2015 Among all outlets with at least one antimalarial or/and diagnostic test in stock on the day of the survey (See Table A3 for full data)

Overall, fewer than half of outlets providing malaria blood testing reported performing a test in the previous week (44.5%). While 40% or more of health workers (45.2%), private health facilities (46.2%) and itinerant drug vendors 40.4%) reported performing a testing in the previous week, only 21.2% of general retailers reported performing a test. Among outlets with antimalarials in stock, about 1 in 5 reported distributed an antimalarial in the previous week (19.5%). About one-third of pharmacies reported distributing antimalarials in the past week (33.6%) as compared to less than 20% of health workers (14.0%), private facilities (17.6%), and general retailers (19.3%).

Figure 46. Percentage of antimalarial-specific-stocking outlets that sold or distributed the specific

antimalarial in the previous week, by outlet type, 2015 Among antimalarial-specific-stocking outlets with at least one specified in stock on the day of the survey (See Table A3 for full data)

Among outlets with oral AMT in stock, 25.3% reported distributed oral AMT in the previous week. In comparison, among outlets with the first-line ACT in stock, only 12.9% reported distributing ACT in the previous week, and among outlets with chloroquine in stock, only 9.7% reported distributing chloroquine in the previous week. More common recent distribution of oral AMT as compared to ACTs and chloroquine was observed across outlet types, with the exception of similar distribution of each drug type in pharmacies and itinerant drug vendors.

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Figure 47. Percentage of antimalarial-specific-stocking outlets that sold or distributed the specified antimalarial in the previous week, by strata, 2015 Among antimalarial-stocking outlets with at least one of the specified antimalarials in stock on the day of the survey (See Table B3 for full data)

Distribution of any antimalarial, when available, was approximately between 15-25% across domains. When available, oral AMT was more likely to be distributed than the first-line ACT or chloroquine across all domains except for the Bangladesh border/Rakhine domain where the percent distribution of oral AMT and first-line ACT were comparable (20.6% and 20.8%, respectively). Oral AMT had been sold or distributed in the past week at 20% of outlets or more across domains. Distribution/sale of a first-line ACT or chloroquine was generally between 10-15% across domains.

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First-line ACT Chloroquine Oral artemisinin monotherapy



Antimalarial and Malaria Diagnostic Price in the Private Sector Figure 48. Private sector median price of RDTs and pre-packaged adult artemether lumefantrine, across

outlet type, 2015 Among all RDTs and adult pre-packaged AL available in the private sector (See Tables A6b & A9 for full data)

The median price of adult pre-packaged AL was higher than the median price of malaria RDTs in pharmacies ($0.35 vs. $0.24), general retailers ($0.39 vs. $0.08), and itinerant drug vendors ($0.20 vs. $0.0). Overall in the private sector, the median price of adult pre-packaged artemether lumefantrine was higher at $0.35 versus the median price of a malaria RDT at $0.10. However, the median price of a malaria RDT in private for-profit facilities was higher ($0.13) than the median price of pre-packaged adult AL ($0.09). This may be because general retailer and itinerant drug vendor providers are more likely to receive RDTs for free and therefore do not charge for the tests. Fees associated with testing may also be included in the overall health package service fee and may therefore not be reported when asked about RDT pricing specifically.

Figure 49. Private sector median price of RDTs and pre-packaged adult artemether lumefantrine, across strata, 2015 Among all RDTs and adult pre-packaged AL available in the private sector (See Tables B6b & B9 for full data)

Overall in the private sector across all strata, the median price of adult pre-packaged artemether lumefantrine was higher versus the median price of a malaria RDT. Most notably, the median private sector price of a malaria RDT was free in the AMTR Intervention area, Western/India border, and Bangladesh border/Rakhine domains. The median price of adult pre-packaged artemether lumefantrine was slightly lower in the AMTR Intervention and Comparison areas in the east ($0.31) versus the Western/India border and Bangladesh border/Rakhine domains in the western part of Myanmar ($0.39).

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Figure 50. Private sector median price of one adult equivalent treatment dose of tablet AL, CQ, and oral AMT, 2015 Among all tablet-formulation artemether lumefantrine, chloroquine, and oral artemisinin monotherapy available in the private sector (See Tables A6a for full data)

Across all private sector outlet types, median price of one oral artemisinin monotherapy adult equivalent treatment dose (AETD) was significantly higher at $3.06 than the median prices of one AETD of artemether lumefantrine ($0.35), and chloroquine ($0.20). However, as noted in figure 88 below, the amount of oral AMT most often distributed to treat adult customers is 2 tablets, which is just a fraction of a full AETD. At this point the prices become much more comparable and the resulting cost to the consumer is $0.32 for oral AMT, versus $0.35 for artemether lumefantrine. It is therefore about 10% cheaper for the consumer to buy 2 tablets of oral AMT at $0.32 versus a full AETD of quality assured artemether lumefantrine at $0.35.

Figure 51. Private sector median price of tablet AL, CQ, and oral AMT, across strata, 2015 Among all tablet artemether lumefantrine, chloroquine, and oral artemisinin monotherapy available in the private sector (See Tables B6a for full data)

Across all domains, median private sector price of oral artemisinin monotherapy was significantly higher than the median prices of artemether lumefantrine and chloroquine. There was little variability between median private sector prices for each specific antimalarial across domains, though prices were lowest for all medicines in the AMTR Comparison domain and highest in the Western/India border domain. Artemether lumefantrine ranged from $0.31 to $ 0.39, chloroquine ranged from $0.16 to $0.39, and oral AMT ranged from $3.02 to $3.78. The low prices of AL across domains are likely a result of subsidized AL from the AMTR project and other entities.

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Provider Knowledge and Characteristics Figure 52. Percentage of providers who correctly state the first-line treatment for uncomplicated P.

falciparum malaria (AL, DHA-PPQ, or ASMQ), 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table A15 for full data)

Provider knowledge of the first-line treatment for Pf malaria was highest among health workers and private for-profit health facilities (59.2% and 58.8%, respectively). Provider knowledge was lower among other private sector outlet types; only 15.1% of pharmacy providers and 15.4% of itinerant drug vendors correctly stated the first-line treatment for Pf malaria, and knowledge among general retailers was even lower at 4.5%. Among pharmacies, itinerant drug vendors, and general retailers, more than 4 out of 5 providers stated that they did not know the first-line treatment for uncomplicated Pf malaria.

Figure 53. Percentage of providers who correctly state the first-line treatment for uncomplicated P. falciparum malaria (AL, DHA-PPQ, or ASMQ), by strata, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table B15 for full data)

Provider knowledge of the first-line treatment for Pf malaria did not differ significantly across domains among health workers. Among providers in the private sector, knowledge was higher in AMTR Intervention (19.8%) and AMTR Comparison areas (18.3%) as compared to Western/India (3.9%) and Bangladesh/Rakhine areas (4.9%).

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Figure 54. Percentage of providers who correctly state the adult dosing regimen for artemether lumefantrine, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table A15 for full data)

Provider knowledge of the adult dosing regimen for AL was highest among health workers and private for-profit health facilities (49.5% and 50.5%, respectively). Provider knowledge was lower among other private sector outlet types; only 10.5% of pharmacy providers and 10.3% of itinerant drug vendors correctly stated the correct adult dosing regimen, and knowledge among general retailers was even lower at 2.8%.

Figure 55. Percentage of providers who correctly state the adult dosing regimen for artemether lumefantrine, by strata, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table B15 for full data)

Provider knowledge of the adult dosing regimen for AL did not differ significantly across domains among health workers. Among providers in the private sector, knowledge was higher in AMTR Intervention (14.8%) and AMTR Comparison areas (13.9%) as compared to Western/India (3.5%) and Bangladesh/Rakhine areas (4.4%).

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Figure 56. Percentage of providers who correctly state the first-line treatment for uncomplicated P. vivax malaria (chloroquine plus primaquine), 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table A15 for full data)

Provider knowledge of the first-line treatment for Pv malaria was highest among health workers and private for-profit health facilities (36.0% and 30.8%, respectively). Provider knowledge was lower among other private sector outlet types; less than one in ten itinerant drug vendors correctly stated the first-line treatment regimen for Pv malaria (7.4%), and knowledge was even lower among pharmacies and general retailers (1.8% and 0.9%, respectively).

Figure 57. Percentage of providers who correctly state the first-line treatment for uncomplicated P. vivax malaria (chloroquine plus primaquine), by strata, 2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months (See Table B15 for full data)

Provider knowledge of the first-line treatment for Pv malaria did not differ significantly across domains among community health workers, where it was highest (29.3%-43.1%). However, among private sector outlets for-profit health facilities, provider knowledge was much lower in the Western/India border (1.7%) and Bangladesh border/Rakhine (1.1%) domains compared to the AMTR Intervention (8.8%) and AMTR Comparison (7.0%) domains. Among pharmacies and general retailers, provider knowledge was particularly abysmal at 3.0% or less across all domains.

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Training, Supervision, and Reporting Figure 58. Percentage of providers who reportedly received training on malaria diagnosis (RDT or

microscopy) by outlet type, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

Community health workers were much more likely to report having received training on malaria diagnosis (60.7%) then private sector providers (8.0%). Strictly among the private sector, private for-profit health facilities reported receiving training on malaria diagnosis (22.6%) than pharmacies (12.1%), general retailers (3.2%), and itinerant drug vendors (4.4%).

Figure 59. Percentage of providers who reportedly received training on malaria diagnosis (RDT or

microscopy) by strata, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table B14 for full data)

The percentage of community health workers reportedly receiving training on malaria diagnosis was comparable across domains, ranging from 56.55 in the AMTR Comparison domain to 66.4% in the Western/India border domain. In the private sector, providers were more likely to report having received training on malaria diagnosis in the AMTR Intervention domain versus all other domains. Overall, 34.2% providers in the AMTR Intervention domain reported having received training on national malaria treatment guidelines versus 30.5% in the AMTR Comparison domain, 26.1% in Western/India border domain, and 21.7% in the Bangladesh border/Rakhine domain.

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Figure 60. Percentage of providers who reportedly received training on national malaria treatment guidelines (RDT or microscopy) by outlet type, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

Community health workers were much more likely to report having received training on national malaria treatment guidelines (59.6%) then private sector providers (9.6%). Strictly among the private sector, private for-profit health facilities reported receiving training on the national malaria treatment guidelines (23.6%) than pharmacies (9.3%), general retailers (6.4%), and itinerant drug vendors (6.7%).

Figure 61. Percentage of providers who reportedly received training on national malaria treatment

guidelines (RDT or microscopy) by strata, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table B14 for full data)

Providers were slightly more likely to report having received training on national malaria treatment guidelines in the AMTR Intervention domain versus all other domains, regardless of sector. Overall, 34.2% providers in the AMTR Intervention domain reported having received training on national malaria treatment guidelines versus 31.4% in the AMTR Comparison domain, 24.3% in Western/India border domain, and 22.8% in the Bangladesh border/Rakhine domain.

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Figure 62. Percentage of providers who reportedly received a supervisory or regulatory visit in the past year, by outlet type, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

Community health workers were slightly more likely to report having received a supervisory or regulatory visit in the past year (39.1%) then private sector providers (19.9%). Strictly among the private sector, private for-profit health facilities reported receiving a supervisory or regulatory visit in the past year (32.0%) than pharmacies (16.7%), general retailers (19.2%), and itinerant drug vendors (12.5%).

Figure 63. Percentage of providers who reportedly received a supervisory or regulatory visit in the past

year, by strata, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table B14 for full data)

Providers in the AMTR Intervention domain were much more likely to report having received a supervisory or regulatory visit in the past year across all sectors at 52.8% compared to AMTR Comparison (17.8%), Western/India border (15.1%), and Bangladesh border/Rakhine (10.6%) domains. Supervisory or regulatory visits were reportedly less common in other domains, particularly in the private sector where all other domains other than AMTR Intervention (47.8%) had supervisory visit rates of less than 10%.

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Figure 64. Percentage of providers who reportedly keep records on the number of patients tested and treated for malaria, by outlet type, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

Again, community health workers were much more likely to report keeping records on the number of patients tested and treated (77.3%) then private sector providers (12.2%). Strictly among the private sector, private for-profit health facilities reported keeping records on the number of patients tested and treated (52.0%) than pharmacies (5.4%), general retailers (2.5%), and itinerant drug vendors (11.6%).

Figure 65. Percentage of providers who reportedly keep records on the number of patients tested and

treated for malaria, by strata, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table B14 for full data)

Record keeping was reportedly more common in the AMTR Intervention and Comparison domains among private sector facilities (16.3% and 13.3%, respectively) compared to Western/India border (6.4%) and Bangladesh border/Rakhine (3.9%) domains. Differences were comparable across domains among community health workers, ranging from 74.8% to 83.7%.

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Figure 66. Percentage of providers who reportedly report on the numbers of patients tested/treated to the government or non-government organizations, by outlet type, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

Community health workers were once again much more likely to report on the number of patients tested and treated (76.0%) then private sector providers (9.4%). Strictly among the private sector, private for-profit health facilities reported records to the government or non-government organizations on the number of patients tested and treated (40.3%) than pharmacies (4.7%), general retailers (2.4%), and itinerant drug vendors (7.7%).

Figure 67. Percentage of providers who reportedly report on the numbers of patients tested/treated to

the government or non-government organizations, by strata, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table B14 for full data)

Reporting was reportedly slightly more common in the AMTR Intervention and Comparison domains among private sector facilities (13.2% and 9.7%, respectively) compared to the domains along the western border that were each less than 5%. The differences across domains were again comparable among community health workers, ranging from 73.4% to 81.4%.

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Figure 68. Percentage of providers who reportedly: receive provider training and supervision and keep records on malaria case load data and report on those records and have both national first-line ACT and malaria blood testing in stock, 2015 Among providers in outlets stocking antimalarials or blood testing (See Table A14 for full data)

One in four health workers (23.2%) and only 3.1% of private sector outlets with malaria testing or treatment available reported recent malaria case management training, supervision, availability of national first-line ACT and malaria blood testing, and reportedly keep and report caseload data to government or non-governmental organizations.

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(1) Training and supervision, &(2) National first-line ACT and Malaria blood testing, &(3) Keeps and Reports on Case Load



Oral Artemisinin Monotherapy Availability, Distribution, and Supply Characteristics Figure 69. Percentage of antimalarial-stocking outlets with any Oral AMT in stock in the past three

months but not in stock on the day of the survey, by outlet type, 2015 Among all outlets with at least one antimalarial in stock (See Table C1 for full data)

Very few antimalarial-stocking outlets reported stocking oral AMT recently (in the past three months) but not on the day of the survey (2.9%)

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Figure 70. Source of oral AMT among oral AMT-stocking outlets, 2015 Among all outlets with at least one oral AMT in stock or reportedly in stock in the past three months (See Table C2 for full data)

The majority of oral AMT stocking outlets obtained oral AMT from a pharmacy (53.5%), followed by a fixed-location retailer 39.5%. Other oral AMT supplier types included mobile distributors, village-buyers, rural health centers, and ‘floating shops’ (i.e. shops on boats that travel local rivers).

Figure 71. Source of oral AMT among oral AMT-stocking outlets, by strata, 2015 Among all outlets with at least one oral AMT in stock or reportedly in stock in the past three months (See Table D2 for full data)

Over half of oral AMT stocking outlets in AMTR Intervention, Comparison, and the Western/India Border domains obtained oral AMT from a pharmacy, with fixed-location retailers being the second most popular choice. Oral AMT stocking outlets in the Bangladesh/Rakhine domain obtained oral AMT from fixed-location shops 62.3% of the time, followed by pharmacies (34.6%). Other oral AMT supplier types included mobile distributors, village-buyers, rural health centers, and ‘floating shops’ (i.e. shops on boats that travel local rivers).

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Figure 72. Percentage of oral AMT-stocking outlets that reportedly obtained oral AMT from a supplier within the past three months, by outlet type, 2015 Among all outlets with at least one oral AMT in stock or reportedly in stock in the past three months (See Table C2 for full data)

Approximately half of outlets stocking oral AMT reportedly obtained oral AMT from a supplier within the past three months (53.1%).

Figure 73. Median number of oral AMT packages in stock on the day of the survey among oral AMT-

stocking outlets, by strata, 2015 Among all outlets with at least one oral AMT in stock or reportedly in stock in the past three months (See Table C2 for full data)

Oral AMT-stocking outlets had a median of 1 oral AMT package in stock on the day of the survey. The median number of packages in stock ranged from less than 1 package among community health workers (0.4) to nearly 2 packages (1.8) among pharmacies.

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Figure 74. Median number of oral AMT packages in stock on the day of the survey among oral AMT-stocking outlets, by strata, 2015 Among all outlets with at least one oral AMT in stock on the day of the survey (See Table C3 for full data)

Most oral AMT-stocking outlets 1 – 2 oral AMT package in stock on the day of the survey. Health workers, private for-profit facilities, and pharmacies were more likely to have a greater stock of oral AMT (~ 3 – 6 packages). Outlets in the AMTR intervention, Western/India border, and Bangladesh/Rakhine domains were more likely to have a slightly greater stock than outlets in the AMTR comparison domain, with the exception of health worker and private for-profit facility types. The denominator includes only outlets that had oral AMT in stock on the day of the survey.

Figure 75. Percentage of oral AMT-stocking outlets that report artesunate and/or artemether tablets are requested by name by customers, by strata, 2015 Among all outlets with at least one oral AMT in stock or reportedly in stock in the past three months (See Table C2 for full data)

70% of oral AMT-stocking outlets reported that artesunate and/or artemether tablets were requested by name by customers. Providers were particularly likely to report consumer demand among pharmacies (83.4%) and general retailers (93.3%) as compared with health workers (28.3%), private facilities (28.5%), and itinerant drug vendors (2.9%).

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None distributed Distributed < 1 AETD Distributed >= 1 AETD

None distributed

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AMTR Intervention Western/India Bangladesh/Rakhine

Figure 76. Oral AMT distribution over the past week among oral AMT-stocking outlets, 2015 Among all outlets with at least one oral AMT in stock on the day of the survey (See Table C3 for full data)

Approximately three-fourths of oral-AMT stocking outlets reported no oral AMT distribution in the past week (74.7%). 13.5% of oral-AMT stocking outlets reported total distribution of less than one adult equivalent treatment dose (AETD) in the past week and 11.8% reported distributed 1 or more adult equivalent treatment doses.

Figure 77. Oral AMT distribution over the past week among oral AMT-stocking outlets, by strata, 2015 Among all outlets with at least one oral AMT in stock on the day of the survey (See Table D3 for full data)

Across domains, 70-80% of oral-AMT stocking outlets reported no oral AMT distribution in the past week. In the AMTR Comparison and Western/India Border domain, a higher percentage of those distributing oral-AMT were distributing at less than one adult equivalent treatment dose (AETD) in the past week versus one or more AETDs. Again, while this is a low amount of oral AMT being distributed, this finding highlights the problem of sub-optimal dosing or oral AMT in Myanmar.



Figure 78. Median number of 50mg oral AMT tablets distributed in the past week, by strata, 2015 Among outlets that distributed oral AMT in the past week (See Table C3 for full data)

Among providers who reported distributing oral AMT in the past week, the median number of tablets distributed to individual customers was 18.0. Distribution was considerably higher among private facilities (100.6) as compared with health workers (56.2), pharmacies (26.6), general retailers (10.4) and itinerant drug vendors (41.8).

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AMTR Intervention Western/India border Bangladesh border

Oral AMT Product Characteristics Figure 79. Outlet type, among oral AMT products audited, 2015

Outlet type, among all oral AMT products in stock on the day of the survey (See Table C4 for full data)

A total of 1,036 oral AMT products were audited and half of these (49.4%) were audited in general retail outlets. About one-quarter of oral AMT products were found in pharmacies (23.6%) and 14.6% were audited within itinerant drug vendors.

Figure 80. Proportion of oral AMT products audited within each sector, by strata, 2015

Among all oral AMT products in stock on the day of the survey (See Table D4 for full data)

In the AMTR Intervention area, more than half of all oral AMT products were audited in general retail outlets (54.5%). A quarter of products were found in pharmacies, with the remainder products being found across private for-profit facilities, with health workers, or itinerant drug vendors (all less than 10%). In the AMTR comparison domain, general retailers had the greatest proportion of oral AMT products (44.7%) followed by pharmacies (23.3%). Itinerant drug vendors did have a slightly larger proportion of the oral AMT market at 17%. Health workers and private for-profit facilities rounded out the rest of the market with less than 10% each. Of all oral AMT products audited in the Western/India border domain, over 75% were found in general retail outlets. A small proportion was found in pharmacies (13%), whereas health workers, private for-profit facilities, and itinerant drug vendors each comprised less than 5% of the oral AMT market. While the greatest proportion of oral AMT products were again audited in general retail outlets in the Bangladesh/Rakhine domain (45%), pharmacies and itinerant drug vendors also made up a large share of the oral AMT market at 27% and 23%, respectively. Oral AMT products audited within private for-profit facilities and health workers were minimal.



AMTR Comparison

Artesunate Artemether

Artesunate

Artemether

AMTR Intervention Western/India border

Bangladesh border

Figure 81. Active ingredient, among all oral AMT products audited, 2015 Active ingredient, among all oral AMT products in stock on the day of the survey (See Table C4 for full data)

Over 90% of all oral AMT products audited were artesunate tablets (91.9%).

Figure 82. Percentage of active ingredient-specific oral AMT products among all oral AMT products audited, by strata, 2015 Among all oral AMT products in stock on the day of the survey (See Table D4 for full data)

Artesunate products comprised over 90% of all oral AMT products found in the AMTR Comparison domain, Western/India border domain, and Bangladesh/Rakhine domain. Artemether had a slightly larger presence in the AMTR Intervention domain at 14%, with artesunate still making up the majority at 86%.



AMTR Comparison

Expired Less than 1 year 1-2 years Greater than 2 years

Expired

Less than 1 year

1-2 years

Greater than 2 years


Bangladesh border

Figure 83. Oral AMT time-to-expiry, among all oral AMT products audited, 2015 Among all oral AMT products in stock on the day of the survey (See Table C4 for full data)

Oral AMT has a shelf life of four years from the time of production. At the time of the survey, 14.4% of all oral AMT products audited were expired. 60.4% of products still had a shelf life of greater than 2 years, indicating that these products had been manufactured in mid-2013 at the earliest.

Figure 84. Oral AMT time-to-expiry among all oral AMT products audited, by strata, 2015 Among all oral AMT products in stock on the day of the survey (See Table D4 for full data)

The majority of oral AMT products audited still had greater than a 2-year shelf life across all domains, including over 75% in the Western/India border domain. Products were more likely to be expired in the AMTR Intervention and Comparison domains, though proportion of products expired was less than 18% in each.



AMTR Comparison

Mediplantex AA Medical Kunming Pharma Other

Mediplantex

AA Medical

Kunming Pharma

Other


Bangladesh border

Figure 85. Manufacturers, among all oral AMT products audited, 2015 Among all oral AMT products in stock on the day of the survey (See Table C4 for full data)

In total, oral AMT products from more than 10 manufacturers were found in Myanmar (see Annex 8). Three-quarters of all oral AMT found in Myanmar was manufactured by Mediplantex (Vietnam). Other manufacturers of audited oral AMT were AA Medical (Vietnam) (8.0%) and Kunming Pharmaceutical Corporation (China) (2.6%).

Figure 86. Oral AMT manufacturers among all oral AMT products audited, by strata, 2015 Among all oral AMT products in stock on the day of the survey (See Table D4 for full data)

Oral AMT products manufactured by Mediplantex were found in large amounts across all domains. The Western/India border and Bangladesh/Rakhine domains had particularly large proportions of Mediplantex-manufactured oral AMT products at 84% and 83%, respectively.



Figure 87. Median number of 50mg oral AMT tablets reportedly typically dispensed to treat malaria in

an adult, by outlet type, 2015 Among all oral AMT products in stock on the day of the survey (See Table C4 & D4 for full data)

According to WHO treatment guidelines, a full adult equivalent treatment dose of oral AMT is approximately 20 tablets and includes a loading dose. Typically oral AMT is sold in packages of 12 tablets. The median number of tablets typically dispensed to treat an adult with malaria was reportedly 2 tablets. Health workers reported typically dispensing a median number of 9.7 tablets, and private facilities a median number of 8.9 tablets. The median was much lower among providers in pharmacies (1.9), general retailers (1.2), and itinerant drug vendors (3.5).

Figure 88. Private sector median wholesale and retail price per oral AMT tablet, across outlet type, 2015 Among all oral AMT available in the private sector (See Tables C4 for full data)

The median private sector wholesale price of one oral AMT tablet was $0.11 versus a retail price for one tablet of $0.16. This constitutes a 30.2% markup. With a typical oral AMT dose of 2 tablets to treat an adult the resulting cost to the consumer is $0.32. The median private sector retail price of one AETD of quality-assured artemether lumefantrine is $0.35. It is therefore about 10% cheaper for the consumer to buy 2 tablets of oral AMT at $0.32 versus a full AETD of quality assured artemether lumefantrine at $0.35.

0

2

4

6

8

10

12

14



Facility



All Private Total

Private Sector

Me

dia

n n

o. t

able

ts

0.10 0.100.12 0.11 0.11

0.110.12

0.160.20

0.16

$0.00

$0.10

$0.20

$0.30

Private for-ProfitHealth Facility

Pharmacy General Retailer Itinerant Drug Vendor All Private

Private Sector

Me

dia

n P

rice

Oral AMT Wholesale - 1 tablet Oral AMT Retail - 1 tablet



Results Section A: Core Indicator National Estimates

Table A1: Availability of antimalarials, among all screened outlets, by outlet type

Community Health

Worker

Private For-Profit

Facility Pharmacy General Retailer


ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: N=2,737 N=610 N=970 N=22,733 N=1,217 N=25,530 N=28,267

Any antimalarial at the time of survey visit 45.0 50.4 46.9 4.6 33.7 8.2 12.3

(42.0, 48.0) (44.1, 56.6) (41.2, 52.5) (4.1, 5.2) (29.4, 38.0) (7.5, 8.9) (11.5, 13.1)

Any ACT 37.9 38.4 22.7 1.5 12.2 3.4 7.3

(35.1, 40.8) (31.8, 45.0) (18.4, 27.1) (1.2, 1.8) (8.8, 15.7) (3.0, 3.9) (6.7, 7.9)

First-line ACT 37.9 38.4 22.7 1.5 12.2 3.4 7.3

(35.1, 40.8) (31.8, 45.0) (18.4, 27.1) (1.2, 1.8) (8.8, 15.7) (3.0, 3.9) (6.7, 7.9)

Artemether Lumefantrine (AL) 37.8 35.5 20.9 1.5 11.9 3.3 7.2

(34.9, 40.7) (28.8, 42.2) (17.0, 24.9) (1.2, 1.8) (8.4, 15.3) (2.9, 3.7) (6.6, 7.7)

Dihydroartemisinin Piperaquine (DHA PPQ) 0.2 5.1 2.3 <0.1 0.6 0.2 0.2

(0.0, 0.3) (3.3, 6.9) (0.8, 3.7) (0.0, <0.1) (0.0, 1.3) (0.1, 0.3) (0.1, 0.3)

First-line ACT and primaquine 26.4 16.5 0.7 <0.1 1.2 0.4 3.4

(23.8, 28.9) (10.4, 22.5) (0.0, 1.5) (0.0, 0.1) (0.3, 2.1) (0.3, 0.6) (3.0, 3.7)

Quality Assured ACT (QA ACT) 36.7 34.1 20.5 1.4 10.5 3.1 6.9

(33.9, 39.5) (27.4, 40.8) (16.6, 24.5) (1.1, 1.8) (7.3, 13.6) (2.7, 3.5) (6.4, 7.4)

QAACT with the “padonma” logo 11.2 23.9 17.8 1.4 7.6 2.7 3.6

(9.6, 12.7) (18.4, 29.4) (14.6, 20.9) (1.1, 1.7) (4.9, 10.3) (2.3, 3.0) (3.2, 4.0)

QAACT without the “padonma” logo 28.3 10.7 2.9 <0.1 3.0 0.5 3.6

(25.5, 31.0) (7.4, 14.0) (0.2, 5.7) (0.0, 0.1) (1.6, 4.5) (0.4, 0.6) (3.2, 4.0)

Non-quality-assured ACT (non-QA ACT) 3.4 6.6 2.9 0.1 2.6 0.4 0.7

(2.3, 4.4) (4.5, 8.6) (1.4, 4.4) (0.0, 0.1) (0.9, 4.2) (0.3, 0.5) (0.6, 0.9)

Nationally Registered ACT 35.8 37.7 22.7 1.5 11.4 3.4 7.0

(33.0, 38.6) (31.2, 44.2) (18.4, 27.1) (1.2, 1.8) (8.0, 14.7) (2.9, 3.8) (6.4, 7.5)

Any non-artemisinin therapy 35.1 29.7 22.9 2.3 23.7 4.5 7.9

(32.3, 38.0) (23.6, 35.9) (18.6, 27.3) (2.0, 2.7) (20.5, 26.9) (4.0, 4.9) (7.3, 8.5)

Chloroquine € 30.3 24.9 18.1 1.9 14.3 3.4 6.4

(27.6, 32.9) (18.9, 30.9) (14.5, 21.7) (1.6, 2.3) (11.5, 17.1) (3.0, 3.8) (5.9, 6.9)

Primaquine 28.1 18.6 1.0 <0.1 1.7 0.5 3.6

(25.3, 30.8) (12.5, 24.8) (0.2, 1.8) (0.0, 0.1) (0.7, 2.7) (0.4, 0.7) (3.3, 4.0)

Other non-artemisinin therapy ^ 2.9 6.7 9.6 0.7 15.2 1.7 1.8

(2.1, 3.7) (3.7, 9.8) (6.7, 12.5) (0.5, 0.8) (12.6, 17.8) (1.4, 1.9) (1.6, 2.1)

Chloroquine and primaquine 24.9 17.1 0.9 <0.1 1.5 0.5 3.2

(22.3, 27.5) (11.0, 23.3) (0.2, 1.7) (0.0, 0.1) (0.5, 2.4) (0.3, 0.6) (2.9, 3.6)



Table A1: Availability of antimalarials, among all screened outlets, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Oral artemisinin monotherapy 1.2 7.2 17.3 1.5 6.2 2.3 2.1

(0.7, 1.8) (5.0, 9.4) (13.5, 21.0) (1.2, 1.8) (3.9, 8.5) (1.9, 2.7) (1.8, 2.5)

Non-oral artemisinin monotherapy 3.7 12.7 9.6 0.2 4.4 0.9 1.2

(2.7, 4.8) (9.3, 16.2) (6.6, 12.7) (0.1, 0.2) (2.2, 6.5) (0.7, 1.1) (1.0, 1.5)

Any treatment for severe malaria 6.0 14.2 14.5 0.3 16.1 1.8 2.2

(4.8, 7.2) (10.6, 17.8) (10.7, 18.4) (0.2, 0.4) (13.2, 19.0) (1.5, 2.1) (1.9, 2.6)

Artesunate IV/IM # 1.3 7.6 3.9 <0.1 0.8 0.4 0.5

(0.8, 1.8) (5.1, 10.1) (1.9, 5.9) (0.0, 0.1) (0.0, 1.7) (0.2, 0.5) (0.3, 0.6)

Artemether IV/IM 2.8 6.7 7.7 0.1 3.9 0.7 0.9

(1.9, 3.6) (3.9, 9.6) (5.1, 10.2) (0.1, 0.2) (1.9, 5.8) (0.5, 0.8) (0.7, 1.1)

Quinine IV/IM 2.5 3.5 6.5 0.2 12.8 1.0 1.2

(1.8, 3.3) (1.5, 5.5) (4.4, 8.7) (0.1, 0.3) (10.4, 15.2) (0.9, 1.2) (1.0, 1.4)

Any antimalarial that is not in the Myanmar National Treatment Guidelines £

1.5 10.2 19.3 1.6 7.9 2.6 2.5

(1.0, 2.1) (7.0, 13.3) (15.4, 23.2) (1.3, 2.0) (5.5, 10.4) (2.2, 3.0) (2.1, 2.8)


At the time of the 2015 Myanmar ACTwatch outlet survey, artemether lumefantrine, dihydroartemisinin piperaquine and artesunate mefloquine were the first-line treatments for uncomplicated P. falciparum malaria. There was no artesunate mefloquine audited during the 2015 survey.

€ At the time of the 2015 Myanmar ACTwatch outlet survey, chloroquine was the first-line treatment for uncomplicated P. vivax malaria. Includes outlets that stock chloroquine monotherapy or chloroquine co-packaged in a Vivax Treatment Kit with primaquine.

^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. # At the time of the 2015 Myanmar ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. £ See Annex 2.




Table A2: Availability of antimalarials, among antimalarial-stocking outlets, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: N=1,263 N=314 N=522 N=1,341 N=419 N=2,596 N=3,859

Any ACT 83.1 76.4 49.0 29.6 35.0 41.7 58.1

(80.1, 86.1) (68.4, 84.5) (42.2, 55.7) (25.2, 34.1) (28.0, 42.0) (36.9, 46.6) (55.0, 61.1)

First-line ACT 83.1 76.4 49.0 29.6 35.0 41.7 58.1

(80.1, 86.1) (68.4, 84.5) (42.2, 55.7) (25.2, 34.1) (28.0, 42.0) (36.9, 46.6) (55.0, 61.1)


(79.9, 85.9) (62.1, 79.7) (38.6, 51.1) (25.1, 34.1) (26.8, 40.6) (35.2, 44.2) (53.8, 59.8)

Dihydroartemisinin Piperaquine (DHA PPQ) 0.3 9.6 5.0 0.1 1.8 2.9 1.8

(0.1, 0.5) (6.3, 13.0) (1.8, 8.2) (0.0, 0.2) (0.0, 4.0) (1.7, 4.1) (1.0, 2.5)

First-line ACT and primaquine 58.8 32.6 1.6 0.8 3.1 6.3 27.6

(55.0, 62.6) (23.0, 42.2) (0.0, 3.2) (0.0, 1.9) (1.0, 5.2) (3.5, 9.0) (25.0, 30.2)


(77.1, 83.3) (59.0, 77.0) (37.9, 50.3) (23.6, 32.1) (23.0, 35.1) (32.9, 41.7) (51.4, 57.3)

QAACT with the “padonma” logo 22.2 47.5 37.8 27.0 20.2 30.7 27.2

(18.8, 25.6) (38.5, 56.6) (32.4, 43.3) (22.8, 31.2) (15.2, 25.2) (27.0, 34.4) (24.6, 29.8)

QAACT without the “padonma” logo 63.9 21.4 6.7 1.0 9.2 7.0 29.9

(60.1, 67.7) (15.6, 27.1) (0.7, 12.6) (0.0, 2.0) (5.1, 13.4) (4.9, 9.0) (27.1, 32.7)

Non-quality-assured ACT (non-QA ACT) 8.1 12.8 6.3 1.9 8.0 5.7 6.3

(5.8, 10.4) (8.8, 16.8) (3.0, 9.6) (0.0, 3.9) (3.1, 12.9) (4.0, 7.4) (5.1, 7.6)


(74.1, 81.0) (66.9, 82.9) (42.2, 55.7) (24.6, 33.8) (25.2, 39.0) (35.8, 45.6) (52.0, 58.2)

Any non-artemisinin therapy 78.9 59.6 48.5 48.5 70.5 55.1 65.5

(75.8, 81.9) (51.3, 68.0) (40.8, 56.2) (41.6, 55.3) (64.4, 76.6) (51.6, 58.7) (62.7, 68.3)

Chloroquine € 67.0 49.7 38.0 39.2 42.5 41.8 52.9

(63.5, 70.5) (41.5, 58.0) (31.7, 44.4) (32.8, 45.7) (35.6, 49.5) (38.4, 45.3) (50.0, 55.7)

Primaquine 62.6 36.8 2.2 1.7 4.8 7.7 30.0

(58.6, 66.5) (27.6, 46.0) (0.4, 3.9) (0.1, 3.2) (2.3, 7.2) (4.9, 10.4) (27.2, 32.7)


(5.0, 8.9) (7.0, 20.5) (14.4, 26.4) (10.4, 18.6) (39.4, 51.4) (18.4, 25.5) (13.7, 17.8)


(51.0, 59.0) (24.4, 43.1) (0.3, 3.7) (0.0, 2.2) (1.6, 6.2) (4.0, 9.5) (23.8, 29.1)

Oral artemisinin monotherapy 2.9 13.8 36.5 34.6 18.9 27.7 17.3

(1.6, 4.2) (9.3, 18.2) (29.9, 43.2) (28.5, 40.7) (13.1, 24.7) (23.8, 31.7) (14.8, 19.8)

Non-oral artemisinin monotherapy 8.9 24.5 20.1 3.6 12.5 11.0 10.1

(6.5, 11.3) (18.1, 30.9) (14.5, 25.7) (1.7, 5.6) (7.3, 17.7) (8.6, 13.4) (8.2, 12.0)



Table A2: Availability of antimalarials, among antimalarial-stocking outlets, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Any treatment for severe malaria 14.3 27.3 30.7 7.3 48.0 22.8 19.3

(11.4, 17.2) (20.4, 34.2) (23.7, 37.7) (4.4, 10.2) (41.9, 54.2) (19.4, 26.3) (16.7, 21.8)

Artesunate IV/IM # 3.1 14.8 8.3 1.3 2.2 4.6 4.0

(1.8, 4.4) (10.2, 19.5) (4.6, 12.1) (0.0, 2.7) (0.0, 4.4) (3.2, 6.1) (2.9, 5.0)

Artemether IV/IM 6.5 12.4 15.8 2.4 11.1 7.7 7.3

(4.3, 8.7) (6.8, 18.1) (11.1, 20.5) (0.9, 4.0) (6.3, 15.9) (5.8, 9.7) (5.6, 8.9)

Quinine IV/IM 6.1 6.7 14.0 4.1 38.4 13.8 10.6

(4.3, 8.0) (2.3, 11.1) (9.6, 18.4) (1.4, 6.7) (32.5, 44.3) (10.9, 16.6) (8.7, 12.4)


3.5 20.3 40.6 38.2 24.2 32.0 20.2

(2.2, 4.9) (13.7, 26.8) (33.7, 47.6) (32.1, 44.2) (18.2, 30.2) (28.1, 35.9) (17.7, 22.7)

* Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 135 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).







Table A3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type

Community Health

Worker Private For-Profit



ALL Private

ALL Outlets

Proportion of outlets with any antimalarial in stock that:

N=1,249 N=305 N=501 N=1,200 N=397 N=2,403 N=3,652

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed antimalarials in the past week 14.0 17.6 33.6 19.3 28.0 23.7 19.4

(11.2, 16.7) (10.9, 24.3) (27.7, 39.4) (15.1, 23.5) (22.0, 34.1) (20.6, 26.8) (17.2, 21.6)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]

Number of AETDs distributed in the past week 0.0 0.0 0.0 0.0 0.0 0.0 0.0

[0.0-0.0] [0.0-0.0] [0.0-1.2] [0.0-0.0] [0.0-0.1] [0.0-0.0] [0.0-0.0]

Proportion of outlets with first-line ACT in stock that:

N=1,053 N=228 N=242 N=301 N=118 N=889 N=1,942

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed first-line ACT in the past week 10.2 13.1 24.9 16.9 17.7 17.4 12.9

(7.7, 12.6) (7.4, 18.8) (18.4, 31.3) (9.0, 24.8) (7.8, 27.5) (12.8, 21.9) (10.6, 15.3)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]


[0.0-0.0] [0.0-0.0] [0.0-1.2] [0.0-0.1] [0.0-0.0] [0.0-0.0] [0.0-0.0]

Proportion of outlets with chloroquine € in stock that:

N=826 N=120 N=168 N=490 N=132 N=910 N=1,736

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed chloroquine in the past week 5.2 9.0 28.6 8.7 19.2 15.0 9.7

(3.3, 7.0) (1.0, 17.0) (18.6, 38.5) (3.1, 14.3) (11.3, 27.1) (11.7, 18.4) (7.8, 11.5)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]


[0.0-0.0] [0.0-0.0] [0.0-1.1] [0.0-0.0] [0.0-0.2] [0.0-0.0] [0.0-0.0]

Proportion of outlets with primaquine in stock that:

N=773 N=89 N=11 N=8 N=14 N=122 N=895

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed primaquine in the past week 5.6 9.8 1.4 2.0 <0.1 8.3 6.3

(3.5, 7.6) (0.1, 19.5) (0.0, 3.7) (0.0, 5.2) (0.0, <0.1) (0.9, 15.8) (4.0, 8.5)



Table A3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type

Community Health




ALL Private

ALL Outlets

Proportion of outlets with oral artemisinin monotherapy in stock that:

N=56 N=66 N=219 N=526 N=78 N=889 N=945

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed oral artemisinin monotherapy in the the past week 27.2 23.6 30.2 27.6 16.5 26.1 25.3

(18.9, 35.5) (8.2, 39.0) (20.5, 39.9) (19.9, 35.4) (7.1, 26.0) (20.1, 32.2) (19.5, 31.1)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]


[0.2-0.6] [0.0-0.0] [0.0-0.5] [0.0-0.3] [0.0-0.1] [0.0-0.1] [0.0-0.0]

Proportion of outlets with any antimalarial that is not indicated within national treatment guidelines £ in stock that:

N=64 N=77 N=236 N=560 N=100 N=973 N=1,037

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed antimalarial that is not indicated within national treatment guidelines in the past week

14.6 20.9 30.6 26.1 16.6 25.0 23.9

(5.1, 24.1) (7.4, 34.5) (21.0, 40.2) (18.8, 33.5) (8.0, 25.2) (19.3, 30.7) (18.5, 29.3)

Median

[IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]


[0.0-0.2] [0.0-0.0] [0.0-0.5] [0.0-0.2] [0.0-0.1] [0.0-0.1] [0.0-0.1]

Proportion of outlets with malaria blood testing available (microscopy or RDT) that:

N=1,147 N=201 N=89 N=50 N=82 N=422 N=1,569

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Provided/performed a malaria test in the past week 45.2 46.2 28.6 21.2 40.4 42.3 44.5

(41.0, 49.4) (36.3, 56.2) (20.9, 36.3) (10.2, 32.1) (25.8, 54.9) (32.8, 51.9) (40.6, 48.3)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]

Number of malaria tests provided/performed in the past week 0.3 0.4 0.4 0.0 0.5 0.2 0.3

[0.0-2.8] [0.0-2.6] [0.0-1.5] [0.0-3.5] [0.0-1.2] [0.0-1.7] [0.0-2.8]


€ At the time of the 2015 Myanmar ACTwatch outlet survey, chloroquine was the first-line treatment for uncomplicated P. vivax malaria. Includes chloroquine monotherapy or chloroquine co-packaged in a Vivax Treatment Kit with primaquine.

£ See Annex 2.




Table A4: Types of quality-assured and non-quality-assured ACTs audited in the public and private sector

ACT generic name Quality-assured ACT Non-quality-assured ACT

Community Health Worker Private sector Community Health Worker Private Sector

% (95% CI) % (95% CI) % (95% CI) % (95% CI)

Proportion of all audited antimalarials*: N audited=2,134 N audited=1,124 N audited=137 N audited=152

Artemether lumefantrine 100.0 100.0 94.6 42.4

- - (90.3, 98.9) (29.3, 55.4)

Artesunate amodiaquine 0.0 0.0 0.3 4.0

- - (0.0, 0.9) (0.0, 8.3)

Dihydroartemisinin piperaquine 0.0 0.0 5.1 52.6

- - (0.9, 9.3) (39.1, 66.2)

Artemisinin napthoquine 0.0 0.0 <0.1 1.0

- - (0.0, <0.1) (0.0, 3.0)

* All ACTs found in Myanmar were tablet formulation.




Table A5: Antimalarial market composition

Outlet type, among outlets with at least 1 antimalarial in stock on the day of the survey:*


Private For-Profit



ALL Private

% % % % % %

N=3,859 outlets 41.5 7.9 10.9 27.9 11.8 58.5

(37.8, 45.2) (5.6, 10.2) (8.8, 13.0) (24.9, 30.9) (9.8, 13.8) (54.8, 62.2)

*Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.




Table A6a: Price of tablet formulation antimalarials, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Median price of a tablet AETD*: Median [IQR]

(N of Antimalarials)

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Any ACT $0.00 $0.17 $0.39 $0.39 $0.24 $0.36 $0.00

[0.00-0.00] (2,254) [0.01-0.83] (241) [0.26-0.75] (345) [0.29-0.84] (404) [0.00-0.77] (146) [0.11-0.73] (1,136) [0.00-0.10] (3,390)

Artemether lumefantrine (AL) $0.00 $0.09 $0.35 $0.39 $0.20 $0.35 $0.00

[0.00-0.00] (2,243) [0.01-0.61] (213) [0.26-0.51] (316) [0.29-0.84] (400) [0.00-0.72] (139) [1.06-0.61] (1,068) [0.00-0.10] (3,311)

Dihydroartemisinin Piperaquine (DHA PPQ) $1.69 $2.36 $1.62 $1.43 $0.92 $1.56 $1.54

[0.24-2.02] (9) [1.37-2.61] (28) [1.49-1.85] (26) [1.35-1.51] (3) [0.64-1.01] (6) [1.06-2.02] (63) [0.95-2.00] (72)

Quality Assured ACT (QA ACT) $0.0 $0.09 $0.34 $0.37 $0.13 $0.33 $0.00

[0.0-0.00] (2,123) [0.01-0.54] (202) [0.26-0.50] (301) [0.29-0.63] (387) [0.00-0.70] (131) [0.05-0.54] (1,021) [0.00-0.10] (3,144)

QAACT with the “Padonma” logo $0.14 $0.23 $0.34 $0.39 $0.56 $0.38 $0.17

[0.07-0.58] (431) [0.07-0.58] (145) [0.26-0.44] (286) [0.29-0.53] (377) [0.42-0.91] (88) [0.22-0.54] (896) [0.07-0.45] (1,327)

QAACT without the “Padonma” logo $0.00 $0.00 $0.17 $1.07 $0.00 $0.00 $0.00

[0.00-0.00] (1,692) [0.00-0.38] (57) [0.00-2.06] (15) [0.91-1.09] (10) [0.00-0.00] (43) [0.00-0.31] (125) [0.00-0.00] (1,817)

Non-quality-assured ACT (non-QA ACT) $0.00 $1.52 $1.46 $1.44 $1.25 $1.38 $0.26

[0.00-0.00] (131) [0.67-2.41] (39) [1.23-1.94] (44) [0.56-6.56] (17) [0.60-1.53] (15) [0.82-1.79] (115) [0.00-1.16] (246)

Chloroquine $0.00 $0.09 $0.16 $0.29 $0.27 $0.20 $0.03

[0.00-0.00] (627) [0.01-0.65] (45) [0.11-0.32] (161) [0.15-0.39] (328) [0.10-0.98] (78) [0.12-0.39] (612) [0.00-0.16] (1,239)

Primaquine $0.00 $0.04 $0.08 $0.03 $0.00 $0.00 $0.00

[0.00-0.00] (571) [0.00-0.05] (27) [0.08-0.08] (4) [0.03-0.03] (2) [0.00-0.16] (7) [0.00-0.05] (40) [0.00-0.00] (611)

Vivax Treatment Kit $0.00 $0.15 - - $0.88 $0.15 $0.00

[0.00-0.00] (88) [0.02-0.55] (30) - - [0.88-0.88] (1) [0.02-0.55] (31) [0.00-0.00] (119)

Oral Artemisinin Monotherapy $2.66 $2.15 $2.34 $3.06 $2.86 $3.06 $3.06

[1.13-3.66] (53) [1.05-3.11] (52) [2.06-2.90] (232) [2.69-3.78] (555) [2.74-4.32] (65) [2.33-3.31] (904) [2.33-3.36] (957)

* AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.

Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 157 any ACT, 127 artemether lumefantrine, 29 dihydroartemisinin piperaquine, 91 QA ACT with the 'padonma' logo, 23 QA ACT without the 'padonma logo', 43 non-quality assured ACT, 628 chloroquine, 201 primaquine, 14 vivax treatment kit, 79 oral artemisinin monotherapy.




Table A6b: Price of pre-packaged antimalarials, by outlet type

Health Worker Private

For-Profit Facility

Pharmacy General Retailer Itinerant

Drug Vendor ALL

Private ALL

Outlets

Median price of one pre-packaged* therapy:

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Adult first-line ACT $0.00 $0.21 $0.34 $0.36 $0.37 $0.33 $0.00

[0.00-0.00] (1,073) [0.01-0.82] (188) [0.24-0.81] (239) [0.21-0.71] (287) [0.00-0.70] (95) [0.06-0.67] (809) [0.00-0.13] (1,882)

Adult Artemether Lumefantrine $0.00 $0.15 $0.30 $0.35 $0.37 $0.33 $0.00

[0.00-0.00] (1,065) [0.01-0.47] (163) [0.24-0.44] (215) [0.21-0.68] (284) [0.00-0.70] (92) [1.62-0.51] (754) [0.00-0.10] (1,819)

Adult Dihydroartemisinin Piperaquine $2.02 $1.94 $1.70 $1.43 $1.65 $1.72 $1.70

[1.69-2.02] (8) [1.68-2.36] (25) [1.61-1.85] (24) [1.35-1.51] (3) [1.15-1.65] (3) [1.62-2.10] (55) [1.51-2.08] (63)

Pediatric Artemether Lumefantrine $0.0 $0.08 $0.55 $0.27 $0.09 $0.13 $0.00

[0.0-0.00] (353) [0.07-0.14] (16) [0.17-0.58] (21) [0.23-0.35] (30) [0.00-0.31] (15) [0.07-0.32] (82) [0.00-0.00] (435)

* Adult pre-packaged therapy is the package size intended for a 60kg adult. Pediatric pre-packaged therapy is the package size intended for a 10kg child.

At the time of the 2015 Myanmar ACTwatch outlet survey, artemether lumefantrine, dihydroartemisinin piperaquine and artesunate meflooquine were the first-line treatments for uncomplicated P. falciparum malaria. There was no artesunate mefloquine audited during the 2015 survey.

Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 84 adult artemether lumefantrine, 25 adult dihydroartemisinin piperaquine, 9 pediatric artemether lumefantrine




Table A7: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets** stocking N=1,382 N=338 N=569 N=1,483 N=500 N=2,890 N=4,272

Any malaria blood testing 77.7 58.2 15.2 3.0 16.4 15.4 40.5

(74.4, 81.0) (51.4, 65.0) (10.7, 19.7) (1.4, 4.6) (12.2, 20.6) (12.6, 18.1) (37.8, 43.2)

N=1,382 N=338 N=569 N=1,483 N=500 N=2,890 N=4,272

Malaria microscopy 0.2 4.0 0.3 0.0 0.0 0.6 0.4

(0.0, 0.5) (1.6, 6.4) (0.0, 0.7) - - (0.2, 0.9) (0.2, 0.7)

N=1,382 N=338 N=569 N=1,483 N=500 N=2,890 N=4,272

Rapid diagnostic tests (RDTs) 77.7 55.4 15.1 3.0 16.4 14.9 40.2

(74.4, 81.0) (48.7, 62.2) (10.6, 19.6) (1.4, 4.6) (12.2, 20.6) (12.3, 17.6) (37.6, 42.9)

Quality-assured RDT Ω 67.8 42.8 7.4 1.0 12.2 9.8 33.1

(64.0, 71.5) (34.7, 50.9) (3.9, 10.9) (0.0, 2.1) (8.2, 16.2) (7.6, 12.0) (30.4, 35.8)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. No antimalarial-stocking outlets were missing information about both availability of microscopy and availability

of RDTs. 18 antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.” Ω QA RDT status could not be determined for 55 RDTs because of missing product information.




Table A8: Malaria blood testing market composition

Outlet type, among outlets with malaria blood testing available on the day of the survey:*


Private For-Profit



ALL Private

% % % % % %

N=1,595 outlets 78.0 10.6 4.1 2.3 4.9 22.0

(73.8, 82.2) (7.1, 14.1) (2.8, 5.4) (1.2, 3.4) (3.4, 6.5) (17.8, 26.2)

* Outlets with malaria blood testing available on the day of the survey, verified by presence of at least one RDT recorded in the RDT audit sheet and/or reported availability of malaria microscopy.




Table A9: Price of malaria blood testing for adults, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Total median price to consumers:* Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Microscopy $0.00 $1.05 $0.39 - - $0.60 $0.33

[0.00-0.00] (3) [0.51-3.84] (19) [0.39-0.70] (3) - - [0.09-3.49] (22) [0.07-1.39] (25)

Rapid diagnostic test (RDT) $0.00 $0.13 $0.24 $0.08 $0.00 $0.10 $0.00

[0.00-0.00] (1,169) [0.00-0.81] (190) [0.24-1.05] (68) [0.00-0.08] (37) [0.00-0.81] (80) [1.62-0.63] (375) [0.00-0.00] (1,544)

* Total price to the consumer including consultation and/or service fees. Malaria blood testing price information was not available (missing or “don’t know” response) for:

91 RDTs, 8 microscopy tests




Table A10: Antimalarial market share

AETDs sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold / distributed:*


Private For-Profit



TOTAL Private

ANTI-MALARIAL TOTAL**

% % % % % % %

Any antimalarial that is indicated in the national treatment guidelines £ 28.9 10.3 20.4 10.3 11.1 52.1 81.0

1. Any ACT 21.3 8.0 11.0 5.6 6.2 30.7 52.0

Any first-line ACT 21.3 8.0 10.8 5.6 6.2 30.6 51.9



QA ACT with the “Padonma” logo 6.2 6.8 9.5 5.3 4.7 26.2 32.4

QA ACT without the “Padonma” logo 14.7 0.1 0.5 0.0 1.0 1.6 16.3

Non-quality-assured ACT 0.5 1.1 0.9 0.4 0.5 2.9 3.4


2. Any non-artemisinin therapy 6.9 3.5 9.4 4.9 5.5 23.2 30.2

Chloroquine € 6.7 2.2 7.7 4.3 4.4 18.6 25.3


3. Oral artemisinin monotherapy 1.1 1.8 5.5 4.5 2.0 13.7 14.8

4. Non-oral artemisinin monotherapy 0.7 0.1 1.5 0.2 0.4 2.3 3.0

OUTLET TYPE TOTAL*** 30.1 13.3 27.4 15.2 14.0 69.9 100.0

* A total of 2,129.3 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type. £ See Annex 2.

At the time of the 2015 Myanmar ACTwatch outlet survey, artemether lumefantrine, dihydroartemisinin piperaquine and artesunate mefloquine were the first-line treatments for uncomplicated P. falciparum malaria. There was no artesunate mefloquine audited during the 2015 survey. Distribution of dihydroartemisinin piperaquine was minimal and is not included in the market share table.


^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 8,735 antimalarials were audited. Of these, 1,246 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.

Source: ACTwatch Outlet Survey, Myanamar, 2015.



Table A11: Antimalarial market share within outlet type



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 70.8 60.0 40.1 37.1 44.0 44.0 52.0









Chloroquine € 22.3 16.5 28.3 28.0 31.4 26.6 25.3




* A total of 2,129.3 AETDs were reportedly sold or distributed in the previous seven days: 518.9 health workers; 260.4 private for-profit health facilities; 711.6 pharmacies; 413.1 general retailers; 225.3 itinerant drug vendors. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

£ See Annex 2.



^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. Categories 1 through 4 sum to 100% within each column. A total of 8,735 antimalarials were audited. Of these, 1,246 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 773 health worker, 82 private for-profit health facilities; 93 pharmacy; 241 general retailers; 57 itinerant drug vendors.

Source: ACTwatch Outlet Survey, Myanamar, 2015.



\

Table A12: Malaria blood testing market share

Number of malaria blood tests provided in the previous week by outlet type and blood test type as a percentage of all blood tests provided:*


Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %

1. Malaria microscopy <0.1 1.7 0.0 0.0 0.0 1.7 1.7

2. RDT 78.6 9.2 2.5 1.7 6.2 19.6 98.3


* A total of 3,912 malaria blood tests were reportedly administered in the previous seven days. ** Row sum – market share for the specified type of blood testing medicine. *** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 1,668 malaria blood tests were audited. Of these, 34 audited tests were not included in market share calculations due to incomplete or inconsistent information.




Table A13: Malaria blood testing market share, across outlet type

Number of malaria blood tests provided in the previous week by blood test type as a percentage of all blood tests provided within each outlet type:*


Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %

Total blood testing market

1. Malaria microscopy 0.0 15.6 1.2 0.0 0.0 8.1 1.7

2. RDT 100.0 84.4 98.8 100.0 100.0 91.9 98.3

Malaria RDT market

Manufacturer

Standard Diagnostics Inc. 98.0 76.5 71.6 66.8 93.5 80.4 94.4

Premier Medical Corporation LTD 1.4 2.9 20.5 33.2 5.5 8.7 2.8

Nantongegens Biotechnology Co., LTD 0.0 2.8 3.2 0.0 0.0 1.7 0.4

Other 0.4 15.5 0.8 0.0 1.0 7.7 1.9

Unknown 0.2 2.3 3.9 0.0 0.0 1.6 0.5

Quality-assured RDT 80.5 66.5 67.7 66.8 87.2 73.2 79.0

* 3,912 malaria blood tests reportedly administered in the previous seven days: 2,831 community health workers; 629 private for-profit health facilities; 158 pharmacies; 85 general retailers, 209 itinerant drug vendors Categories 1 through 2 sum to 100% in within each column. A total of 1,668 malaria blood tests were audited. Of these, 34 audited tests were not included in market share calculations due to incomplete or inconsistent information.

Manufacturer was not captured for 22 RDTs audited. Ω QA RDT status could not be determined for 55 RDTs because of missing product information.




Table A14: Private sector case management training, supervision, support and surveillance, by outlet type

Community

Health Worker Private For-Profit



ALL Private

Proportion of outlets that: %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Have a provider who reportedly received training in the past year on: N=1,461 N=354 N=576 N=1,487 N=508 N=2,925

(1) Malaria diagnosis (RDT and/or microscopy) 60.7 22.6

(17.4, 27.7)

12.1 3.2 4.4 8.0

(57.0, 64.4) (7.1, 17.0) (1.4, 5.0) (2.3, 6.4) (5.9, 10.2)

N=1,461 N=354 N=576 N=1,486 N=508 N=2,924

(2) National malaria treatment guidelines 59.6 23.6 9.3 6.4 6.7 9.4

(55.8, 63.4) (18.1, 29.1) (4.9, 13.7) (3.6, 9.3) (3.4, 9.9) (6.9, 11.8)

Supervision/regulation N=1,458 N=351 N=573 N=1,485 N=508 N=2,917

(3) Report receiving a supervisory or regulatory visit within the past year 39.1 32.0 16.7 19.2 12.5 19.9

(35.8, 42.4) (25.5, 38.6) (12.7, 20.8) (16.0, 22.3) (8.6, 16.3) (17.1, 22.7)

Passive surveillance N=1,461 N=354 N=574 N=1,484 N=508 N=2,920

(4) Keep records on number of patients tested/treated for malaria 77.3 52.0 5.4 2.5 11.6 12.2

(74.1, 80.6) (42.9, 61.0) (3.2, 7.6) (1.1, 4.0) (7.6, 15.6) (9.3, 15.2)

N=1,459 N=351 N=574 N=1,482 N=508 N=2,915

(5) Report numbers of patients tested/treated for malaria to government or non-government organization

76.0 40.3 4.7 2.4 7.7 9.4

(72.6, 79.3) (31.0, 49.6) (2.6, 6.9) (1.0, 3.8) (4.3, 11.1) (6.7, 12.1)

Among outlets reporting numbers of patients tested/treated to any organization: N=1,459 N=351 N=574 N=1,482 N=508 N=2,915

Report numbers to government 51.8 10.3 1.2 0.7 4.5 2.9

(48.1, 55.5) (5.3, 15.3) (0.3, 2.2) (0.0, 1.7) (1.5, 7.6) (1.7, 4.2)

N=1,459 N=351 N=574 N=1,482 N=508 N=2,915

Report numbers of to a non-governmental organization 26.2 30.8 3.5 1.7 3.1 6.6

(22.6, 29.9) (23.7, 37.9) (1.5, 5.5) (0.6, 2.8) (1.5, 4.8) (4.6, 8.6)

Composite indicators * N=1,457 N=349 N=573 N=1,483 N=508 N=2,913

Reportedly have a trained provider (1 or 2) and receive supervision (2) 30.8 15.4 4.4 4.1 2.2 5.6

(27.6, 34.1) (10.7, 20.1) (1.9, 6.9) (2.1, 6.2) (0.6, 3.8) (4.1, 7.2)

N=1,457 N=349 N=573 N=1,483 N=508 N=2,913

Reportedly have a trained provider (1 or 2), receive supervision (3), have national first-line treatment for Pf and Pv in stock, and provide malaria blood testing (RDT or microscopy)

24.8 12.3 1.9 1.7 1.7 3.4

(21.7, 27.8) (8.4, 16.3) (0.4, 3.4) (0.4, 3.1) (0.3, 3.1) (2.3, 4.4) N=1,453 N=346 N=571 N=1,476 N=508 N=2,901

Reportedly have a trained provider (1 or 2), receive supervision (3), have national first-line treatment for Pf and Pv in stock, provide malaria blood testing (RDT or microscopy), keep records on numbers of patients tested/treatment for malaria (4), and report these numbers to a government or non-governmental organization (5)

23.2 (20.2, 26.2)

10.8 (6.9, 14.6)

1.3 (0.2, 2.5)

1.7 (0.4, 3.1)

1.7 (0.3, 3.1)

3.1 (2.0, 4.1)

Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). There were no missing responses. The number of providers who reported “don’t know” included: 7 diagnosis training, 8 case management training, 15 supervision, 12 record keeping, and 5 reporting. * Among outlets with responses for all relevant questions.




Table A15: Provider antimalarial treatment knowledge and practices, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: N=1,382 N=338 N=569 N=1,483 N=500 N=2,890 N=4,272 Correctly state the national first-line treatment for uncomplicated P. falciparum malaria

AL 57.8 53.1 13.3 4.5 11.7 13.9 31.7

(53.8, 61.8) (45.1, 61.1) (9.5, 17.1) (2.1, 6.9) (7.3, 16.1) (10.8, 16.9) (29.2, 34.2)

AL, ASMQ, or DHA PPQ 59.2 58.8 15.1 4.5 15.4 15.8 33.4

(55.1, 63.2) (51.6, 66.1) (10.3, 19.8) (2.2, 6.9) (10.6, 20.3) (12.6, 19.0) (30.7, 36.0)

AL, ASMQ, or DHA PPQ and primaquine 6.5 (4.9, 8.1)

4.3 0.8 0.5 1.1 1.2 3.3

(1.2, 7.5) (0.0, 2.0) (0.0, 1.4) (0.0, 2.3) (0.2, 2.2) (2.4, 4.2)

Correctly state the national first-line treatment for uncomplicated P. vivax malaria

Chloroquine 56.9 52.6 7.0 2.5 20.0 13.2 31.3

(52.9, 60.9) (44.4, 60.8) (4.3, 9.6) (1.0, 4.0) (14.8, 25.3) (10.5, 15.9) (28.8, 33.8)


(32.4, 39.6) (23.5, 38.1) (0.5, 3.1) (0.0, 1.9) (4.4, 10.4) (4.2, 8.3) (16.5, 20.3)

Proportion of providers who:

Correctly state the first-line dosing regimen for uncompliated P. falciparum malaria

AL 49.5 50.5 10.5 2.8 10.3 12.0 27.2

(45.4, 53.6) (41.6, 59.4) (6.9, 14.1) (1.2, 4.4) (5.9, 14.7) (9.0, 14.9) (24.8, 29.7)


For uncomplicated P. falciparum malaria in adults, report an ACT as the:

Most effective treatment 71.8 64.4 19.8 8.5 19.7 20.2 41.1

(68.1, 75.6) (57.8, 71.0) (15.5, 24.1) (6.2, 10.9) (14.7, 24.6) (17.3, 23.2) (38.5, 43.7)

Treatment he/she most commonly recommends 66.2 59.3 18.7 9.3 21.3 20.1 38.9

(62.2, 70.2) (53.3, 65.3) (14.5, 23.0) (6.8, 11.8) (16.1, 26.5) (17.3, 23.0) (36.2, 41.5)

Numbers of providers (N) in this table are the total number of providers eligible for table indicators. No providers were missing information.




Results Section B: Core Indicators across domains

Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking:

1. N=847 2. N=724 3. N=536 4. N=630

1. N=226 2. N=152 3. N=126 4. N=106

1. N=363 2. N=211 3. N=217 4. N=179

1. N=6,638 2. N=5,972 3. N=4,408 4. N=5,715

1. N=197 2. N=334 3. N=311 4. N=375

1. N=7,424 2. N=6,669 3. N=5,062 4. N=6,375

1. N=8,271 2. N=7,393 3. N=5,598 4. N=7,005

Any antimalarial at the time of survey visit


(59.5, 68.3) (48.6, 65.7) (38.0, 56.5) (4.7, 7.2) (32.7, 52.0) (8.5, 11.6) (14.3, 17.6)


(29.4, 39.6) (37.1, 58.4) (34.5, 51.0) (1.4, 2.7) (24.2, 35.8) (4.5, 6.1) (7.5, 9.5)


(33.1, 48.1) (60.4, 79.2) (45.6, 69.4) (9.1, 13.7) (29.2, 44.8) (13.4, 18.2) (17.9, 22.1)


(31.6, 45.4) (25.4, 52.9) (38.2, 68.6) (5.8, 8.9) (21.7, 34.0) (8.6, 11.7) (11.5, 14.9)

Any ACT


(51.9, 60.5) (38.8, 52.8) (26.1, 40.0) (2.9, 4.8) (12.8, 29.9) (5.6, 7.6) (10.8, 13.3)


(21.8, 31.1) (26.5, 51.1) (12.3, 26.9) (0.2, 0.5) (5.4, 13.5) (1.4, 2.7) (3.9, 5.3)


(27.0, 40.9) (26.6, 48.2) (11.0, 22.0) (0.4, 1.0) (4.1, 11.6) (1.8, 2.7) (6.6, 8.8)


(28.5, 42.3) (14.9, 42.6) (9.7, 28.6) (0.4, 1.0) (4.9, 15.3) (1.4, 2.6) (4.5, 6.7)

First-line ACT


(51.9, 60.5) (38.8, 52.8) (26.1, 40.0) (2.9, 4.8) (12.8, 29.9) (5.6, 7.6) (10.8, 13.3)


(21.8, 31.1) (26.5, 51.1) (12.3, 26.9) (0.2, 0.5) (5.4, 13.5) (1.4, 2.7) (3.9, 5.3)


(27.0, 40.9) (26.6, 48.2) (11.0, 22.0) (0.4, 1.0) (4.1, 11.6) (1.8, 2.7) (6.6, 8.8)


(28.5, 42.3) (14.9, 42.6) (9.7, 28.6) (0.4, 1.0) (4.9, 15.3) (1.4, 2.6) (4.5, 6.7)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Artemether Lumefantrine (AL)


(51.4, 60.1) (34.5, 47.4) (24.7, 37.9) (2.9, 4.8) (12.8, 29.9) (5.4, 7.3) (10.6, 13.0)


(21.8, 31.1) (24.5, 49.9) (10.6, 23.2) (0.2, 0.5) (4.8, 12.7) (1.3, 2.5) (3.8, 5.1)


(26.9, 40.7) (22.8, 41.8) (10.5, 21.1) (0.4, 1.0) (3.7, 11.2) (1.6, 2.6) (6.4, 8.7)


(28.5, 42.3) (13.8, 41.3) (9.4, 28.3) (0.4, 1.0) (4.5, 14.9) (1.4, 2.5) (4.4, 6.7)

Dihydroartemisinin Piperaquine (DHA PPQ)

1. Eastern (AMTR intervention) 0.5 7.2 3.0 <0.1 0.6 0.3 0.4

(0.2, 1.1) (4.3, 11.8) (1.4, 6.2) (0.0, 0.1) (0.1, 3.9) (0.2, 0.6) (0.2, 0.6)


- (2.4, 8.1) (0.9, 7.7) - (0.1, 4.3) (0.1, 0.4) (0.1, 0.3)

3. Western / India border 0.2 9.6 1.2 <0.1 0.7 0.3 0.3

(0.0, 0.7) (5.5, 16.3) (0.4, 3.3) (0.0, 0.2) (0.3, 1.8) (0.2, 0.4) (0.2, 0.4)


- (0.2, 8.8) (0.0, 2.2) - (0.1, 2.1) (0.0, 0.2) (0.0, 0.2)

First-line ACT and primaquine


(32.2, 40.5) (14.6, 26.4) (0.0, 1.7) (0.0, 0.2) (1.1, 6.2) (0.5, 0.9) (4.0, 5.2)

2. Central (AMTR comparison) 18.7 19.8 1.0 <0.1 0.6 0.5 2.4

(14.9, 23.2) (10.0, 35.4) (0.2, 4.3) (0.0, 0.2) (0.1, 2.6) (0.2, 1.0) (2.0, 3.0)


(20.9, 33.9) (2.9, 10.6) (0.8, 6.0) - (0.3, 8.4) (0.1, 0.7) (3.9, 6.1)


(21.5, 33.8) (2.2, 12.4) (0.1, 4.1) - - (0.0, 0.2) (2.3, 4.0)

Quality Assured ACT (QA ACT)


(50.5, 59.2) (33.9, 46.7) (24.7, 37.9) (2.8, 4.8) (12.6, 29.5) (5.4, 7.2) (10.4, 12.9)


(20.8, 29.6) (22.7, 48.1) (10.4, 22.9) (0.1, 0.4) (3.3, 8.7) (1.1, 2.2) (3.5, 4.8)


(25.6, 39.3) (21.1, 40.1) (8.3, 18.2) (0.3, 0.8) (3.7, 11.2) (1.5, 2.4) (6.0, 8.3)


(27.7, 41.4) (12.9, 40.2) (9.0, 27.5) (0.4, 0.9) (3.7, 14.0) (1.2, 2.4) (4.2, 6.4)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

QAACT with the “padonma” logo


(20.3, 26.6) (24.5, 36.2) (24.7, 37.9) (2.8, 4.8) (10.7, 25.9) (5.0, 6.9) (6.8, 8.9)


(5.5, 10.6) (12.5, 33.1) (7.1, 15.1) (0.1, 0.4) (1.6, 5.6) (0.7, 1.5) (1.4, 2.2)


(0.6, 2.7) (17.1, 36.0) (7.5, 16.8) (0.3, 0.7) (1.6, 5.6) (1.1, 1.8) (1.1, 1.8)


(0.2, 1.9) (9.6, 35.2) (8.0, 23.4) (0.3, 0.9) (1.8, 6.2) (0.9, 1.7) (0.9, 1.6)

QAACT without the “padonma” logo


(32.0, 40.5) (7.4, 17.2) - (0.0, 0.2) (1.5, 7.0) (0.3, 0.6) (3.7, 5.1)


(16.0, 24.5) (8.2, 20.5) (1.7, 15.9) (0.0, 0.2) (1.1, 5.0) (0.3, 0.8) (2.1, 3.3)


(24.4, 38.1) (3.2, 11.2) (0.2, 6.0) (0.0, 0.3) (1.5, 8.4) (0.3, 0.9) (4.7, 7.0)


(27.2, 41.0) (1.7, 12.3) (1.0, 6.8) (0.0, 0.3) (1.3, 11.8) (0.2, 1.0) (3.2, 5.2)

Non-quality-assured ACT (non-QA ACT)


(1.7, 4.1) (4.8, 12.6) (1.9, 6.6) (0.0, 0.1) (0.7, 5.4) (0.3, 0.7) (0.5, 1.0)


(1.1, 3.6) (3.9, 10.6) (1.0, 7.7) (0.0, 0.3) (1.5, 8.6) (0.3, 0.7) (0.4, 0.9)


(3.4, 8.9) (6.5, 18.0) (2.1, 7.0) (0.1, 0.3) (0.5, 2.4) (0.3, 0.7) (1.0, 1.9)


(3.9, 13.1) (1.0, 9.6) (0.4, 4.3) (0.0, 0.2) (0.5, 4.3) (0.1, 0.4) (0.6, 1.7)

Nationally Registered ACT


(50.7, 59.2) (38.4, 52.4) (26.1, 40.0) (2.9, 4.8) (12.6, 29.5) (5.6, 7.5) (10.6, 13.1)


(19.1, 28.1) (25.8, 49.9) (12.3, 26.9) (0.2, 0.5) (4.4, 12.1) (1.3, 2.6) (3.5, 4.9)


(23.5, 36.6) (25.7, 47.0) (10.7, 21.7) (0.4, 0.9) (2.7, 9.7) (1.6, 2.5) (5.8, 7.9)


(26.9, 40.7) (14.4, 42.1) (9.7, 28.6) (0.4, 1.0) (4.0, 14.4) (1.3, 2.5) (4.2, 6.5)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Any non-artemisinin therapy


(43.2, 51.8) (22.0, 37.7) (11.1, 24.1) (0.8, 1.5) (22.5, 34.5) (2.6, 4.0) (7.2, 9.1)


(22.8, 32.3) (21.2, 43.6) (15.4, 29.4) (0.7, 1.5) (17.3, 27.7) (2.6, 3.8) (5.0, 6.7)


(28.9, 42.7) (28.9, 56.2) (28.0, 47.2) (5.4, 9.1) (23.8, 37.7) (8.6, 12.5) (13.0, 16.6)


(25.7, 38.7) (13.3, 37.1) (23.4, 45.7) (5.2, 8.3) (13.5, 22.6) (6.9, 9.7) (9.2, 12.5)

Chloroquine €


(38.9, 47.7) (18.8, 33.0) (8.1, 18.9) (0.5, 1.1) (13.6, 24.0) (1.9, 3.0) (6.1, 7.7)


(18.4, 27.1) (17.2, 40.4) (11.5, 23.0) (0.5, 1.3) (8.6, 17.9) (1.8, 2.9) (3.8, 5.3)


(24.7, 37.4) (18.6, 48.5) (20.7, 39.3) (4.3, 7.8) (8.5, 17.8) (6.0, 9.2) (10.0, 13.1)


(20.2, 32.2) (10.5, 25.1) (20.2, 39.6) (4.6, 7.4) (8.4, 17.1) (5.7, 8.4) (7.6, 10.5)

Primaquine


(34.2, 43.2) (16.3, 29.7) (0.1, 1.8) (0.0, 0.2) (1.4, 7.0) (0.5, 1.0) (4.3, 5.6)


(15.8, 24.8) (12.1, 37.1) (0.3, 4.3) (0.0, 0.2) (0.6, 3.0) (0.3, 1.0) (2.2, 3.3)


(23.2, 36.3) (4.0, 15.7) (1.3, 6.8) (0.0, 0.1) (0.7, 7.8) (0.2, 0.8) (4.4, 6.6)


(22.9, 35.1) (2.9, 13.3) (0.2, 3.9) - - (0.0, 0.2) (2.4, 4.2)

Other non-artemisinin therapy ^


(1.9, 5.0) (1.2, 5.3) (4.3, 12.0) (0.2, 0.6) (12.4, 22.2) (0.8, 1.6) (1.0, 1.9)


(2.0, 4.7) (4.5, 17.2) (5.4, 16.3) (0.2, 0.6) (12.2, 20.8) (1.2, 1.9) (1.3, 2.1)


(1.9, 5.2) (10.1, 26.6) (13.1, 27.9) (1.9, 3.3) (18.4, 30.6) (4.1, 6.0) (3.9, 5.6)


(1.1, 3.8) (2.1, 15.3) (6.4, 18.8) (0.9, 2.1) (5.4, 11.1) (1.7, 2.7) (1.7, 2.7)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)



(31.5, 40.4) (14.3, 26.8) (0.0, 1.7) (0.0, 0.1) (1.4, 7.0) (0.5, 0.9) (3.9, 5.2)


(13.8, 22.0) (11.4, 36.9) (0.3, 4.3) (0.0, 0.1) (0.2, 2.6) (0.3, 1.0) (1.9, 3.0)


(19.7, 31.8) (3.7, 15.0) (1.2, 5.2) (0.0, 0.1) (0.6, 7.9) (0.2, 0.8) (3.8, 5.8)


(18.1, 29.4) (1.8, 9.1) (0.2, 3.9) - - (0.0, 0.1) (1.9, 3.5)



(0.8, 3.0) (4.4, 12.9) (9.2, 22.0) (1.1, 2.5) (3.1, 12.8) (1.7, 3.6) (1.6, 3.5)


(0.7, 2.6) (3.3, 10.5) (11.0, 22.2) (0.5, 1.4) (3.8, 11.3) (1.3, 2.2) (1.3, 2.1)


(1.0, 3.3) (16.6, 35.5) (28.0, 46.8) (5.9, 9.3) (3.5, 8.6) (7.1, 10.1) (6.1, 8.8)


(0.1, 0.8) (1.8, 9.6) (11.9, 31.9) (0.6, 1.1) (2.8, 8.7) (1.2, 2.0) (1.1, 1.8)

Non-oral artemisinin monotherapy


(2.6, 6.6) (9.1, 23.0) (7.0, 18.4) (0.1, 0.2) (2.4, 15.1) (0.7, 1.9) (1.0, 2.3)


(2.8, 6.3) (6.5, 16.6) (3.3, 11.4) (0.0, 0.3) (1.7, 6.3) (0.4, 0.9) (0.8, 1.3)


(2.0, 4.9) (23.5, 48.5) (15.9, 29.2) (0.7, 1.6) (5.3, 13.2) (2.2, 3.7) (2.3, 3.7)


(0.9, 4.0) (4.0, 15.3) (4.6, 24.0) (0.0, 0.2) (0.9, 5.5) (0.3, 0.9) (0.5, 1.1)

Any treatment for severe malaria


(4.6, 8.9) (9.7, 24.3) (9.2, 22.9) (0.1, 0.3) (12.1, 24.1) (1.1, 2.5) (1.5, 3.1)


(5.0, 9.1) (7.8, 18.5) (7.3, 19.0) (0.1, 0.4) (13.0, 22.0) (1.2, 2.0) (1.7, 2.6)


(3.6, 7.7) (28.6, 54.5) (21.2, 38.5) (1.3, 2.6) (21.5, 34.6) (4.4, 6.6) (4.4, 6.5)


(2.1, 6.2) (4.6, 16.0) (8.5, 28.0) (0.3, 0.8) (5.5, 11.5) (1.1, 1.9) (1.3, 2.1)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Artesunate IV/IM #


(0.8, 2.7) (6.0, 15.0) (3.9, 14.1) (0.0, 0.1) (0.4, 6.8) (0.4, 1.1) (0.4, 1.2)


(0.9, 2.9) (3.6, 12.1) (0.7, 6.6) (0.0, 0.2) (0.1, 2.9) (0.2, 0.4) (0.3, 0.6)


(0.2, 1.4) (5.7, 20.7) (3.4, 11.0) (0.1, 0.5) (0.4, 5.0) (0.4, 1.3) (0.4, 1.2)


(0.1, 1.4) (1.9, 12.2) (0.2, 2.1) - - (0.0, 0.2) (0.1, 0.2)

Artemether IV/IM


(1.8, 5.1) (3.3, 16.0) (5.2, 13.2) (0.0, 0.2) (2.0, 13.5) (0.4, 1.4) (0.6, 1.7)


(1.8, 4.9) (2.1, 11.0) (2.3, 8.8) (0.0, 0.2) (1.5, 5.7) (0.3, 0.6) (0.5, 1.0)


(1.7, 4.4) (19.9, 43.2) (14.1, 26.8) (0.6, 1.4) (4.6, 11.9) (2.0, 3.2) (2.0, 3.2)


(0.8, 3.7) (0.9, 9.5) (4.2, 23.8) (0.0, 0.2) (0.9, 5.5) (0.3, 0.8) (0.4, 1.0)

Quinine IV/IM


(1.4, 4.1) (0.4, 3.5) (3.0, 9.6) (0.0, 0.1) (9.4, 18.1) (0.4, 1.0) (0.6, 1.3)


(1.8, 4.4) (2.0, 11.3) (3.9, 11.9) (0.0, 0.3) (10.5, 18.8) (0.8, 1.4) (0.9, 1.6)


(1.6, 4.8) (8.7, 25.2) (8.7, 23.0) (0.9, 1.9) (18.2, 30.4) (3.0, 4.7) (2.9, 4.4)


(0.9, 3.6) (0.1, 4.6) (2.6, 10.1) (0.2, 0.7) (3.8, 8.5) (0.7, 1.2) (0.8, 1.3)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)



(1.0, 3.4) (4.9, 13.6) (10.3, 23.9) (1.1, 2.5) (4.6, 15.2) (1.8, 3.8) (1.8, 3.7)


(0.9, 2.8) (5.5, 17.0) (12.3, 23.2) (0.6, 1.5) (5.1, 13.0) (1.5, 2.4) (1.5, 2.3)


(1.1, 3.4) (17.8, 37.0) (28.4, 47.2) (6.2, 9.6) (3.7, 8.9) (7.4, 10.4) (6.3, 9.1)


(0.3, 1.6) (4.7, 18.2) (16.1, 37.7) (1.0, 1.9) (4.3, 10.8) (1.9, 3.0) (1.8, 2.7)








Table B2: Availability of antimalarials, among antimalarial-stocking outlets, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking:

1. N=545 2. N=244 3. N=242 4. N=232

1. N=129 2. N=65 3. N=80 4. N=40

1. N=185 2. N=88

3. N=144 4. N=105

1. N=381 2. N=104 3. N=462 4. N=394

1. N=90 2. N=93

3. N=137 4. N=99

1. N=785 2. N=350 3. N=823 4. N=638

1. N=1,330 2. N=594

3. N=1,065 4. N=870

Any ACT


(83.9, 90.9) (72.9, 85.1) (61.4, 76.1) (54.3, 73.1) (35.7, 59.6) (59.5, 71.2) (70.6, 79.7)


(69.8, 81.6) (63.0, 90.2) (31.4, 56.5) (9.6, 23.7) (19.0, 41.4) (27.6, 46.8) (48.8, 59.5)


(76.1, 88.6) (34.7, 68.9) (19.8, 36.1) (3.9, 8.6) (11.7, 29.3) (11.2, 17.5) (32.9, 43.9)


(86.2, 95.1) (39.6, 88.6) (19.8, 47.3) (6.1, 13.3) (19.7, 47.3) (14.2, 25.0) (35.9, 48.3)

First-line ACT


(83.9, 90.9) (72.9, 85.1) (61.4, 76.1) (54.3, 73.1) (35.7, 59.6) (59.5, 71.2) (70.6, 79.7)


(69.8, 81.6) (63.0, 90.2) (31.4, 56.5) (9.6, 23.7) (19.0, 41.4) (27.6, 46.8) (48.8, 59.5)


(76.1, 88.6) (34.7, 68.9) (19.8, 36.1) (3.9, 8.6) (11.7, 29.3) (11.2, 17.5) (32.9, 43.9)


(86.2, 95.1) (39.6, 88.6) (19.8, 47.3) (6.1, 13.3) (19.7, 47.3) (14.2, 25.0) (35.9, 48.3)

Artemether Lumefantrine (AL)


(83.1, 90.4) (62.7, 78.2) (57.1, 73.0) (54.1, 72.9) (35.7, 59.6) (57.1, 69.3) (68.8, 78.5)


(69.8, 81.6) (57.8, 88.1) (27.0, 49.1) (9.6, 23.7) (17.2, 39.0) (25.9, 43.3) (47.7, 57.6)


(75.7, 88.2) (30.1, 60.1) (18.9, 34.5) (3.8, 8.4) (10.7, 28.3) (10.4, 16.4) (32.1, 43.2)


(86.2, 95.1) (37.2, 86.2) (19.2, 46.8) (6.1, 13.3) (18.1, 46.4) (13.7, 24.4) (35.6, 48.0)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)



(0.3, 1.7) (7.8, 19.5) (3.2, 12.0) (0.0, 1.1) (0.2, 8.9) (2.1, 5.4) (1.4, 3.6)


- (5.2, 16.4) (2.1, 16.8) - (0.3, 13.8) (1.8, 7.0) (1.0, 4.1)


(0.1, 1.7) (7.6, 23.3) (0.8, 5.6) (0.0, 1.5) (0.8, 4.9) (1.1, 2.8) (0.8, 2.2)


- (0.5, 21.3) (0.1, 4.1) - (0.3, 7.4) (0.2, 1.7) (0.1, 1.2)

First-line ACT and primaquine


(51.7, 61.3) (26.3, 43.9) (0.1, 3.5) (0.3, 2.6) (2.8, 13.1) (4.7, 9.0) (25.2, 32.4)


(47.4, 61.3) (24.0, 61.6) (0.5, 9.7) (0.2, 7.6) (0.5, 8.4) (4.4, 16.7) (24.5, 33.9)


(56.8, 75.3) (4.0, 15.3) (1.4, 10.0) - (0.7, 20.5) (0.8, 4.2) (19.6, 30.2)


(63.3, 77.8) (5.9, 29.7) (0.2, 7.4) - - (0.3, 1.7) (18.0, 29.0)



(81.6, 89.1) (61.5, 77.2) (57.1, 73.0) (53.7, 72.5) (35.2, 58.8) (56.7, 68.8) (67.8, 77.7)


(66.2, 78.1) (54.0, 84.8) (26.4, 48.5) (7.2, 20.0) (11.5, 27.6) (22.1, 38.9) (43.9, 53.7)


(72.1, 85.1) (27.9, 57.7) (14.8, 30.0) (3.1, 7.5) (10.6, 28.2) (9.3, 15.0) (30.2, 41.1)


(83.4, 93.3) (35.0, 84.0) (18.2, 45.5) (5.3, 12.4) (14.5, 44.0) (12.3, 22.7) (33.8, 46.2)

QAACT with the “padonma” logo


(32.0, 41.1) (42.8, 61.7) (57.1, 73.0) (52.9, 72.1) (29.2, 52.6) (52.9, 65.2) (45.0, 53.2)


(16.2, 29.8) (29.4, 60.0) (16.2, 35.2) (6.4, 18.5) (5.4, 17.9) (13.8, 27.1) (16.4, 26.0)


(1.6, 6.7) (22.9, 51.5) (13.4, 27.7) (2.8, 6.4) (4.5, 14.6) (7.0, 11.6) (5.4, 9.0)


(0.6, 5.0) (27.0, 74.0) (16.1, 39.1) (4.7, 11.7) (6.7, 21.4) (9.2, 16.8) (6.8, 12.3)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

QAACT without the “padonma” logo


(51.4, 61.5) (13.4, 28.5) - (0.3, 2.5) (3.8, 14.9) (3.0, 6.3) (23.6, 31.6)


(50.6, 65.1) (18.6, 39.2) (4.4, 32.4) (0.2, 7.6) (3.9, 16.4) (6.8, 15.4) (26.8, 36.4)


(68.8, 82.4) (4.4, 16.2) (0.3, 10.1) (0.1, 2.8) (4.2, 21.4) (1.7, 5.4) (23.4, 34.5)


(81.5, 92.7) (4.2, 30.0) (1.9, 11.6) (0.2, 3.5) (4.9, 36.0) (2.1, 9.6) (25.1, 37.6)



(2.7, 6.3) (8.7, 20.8) (4.5, 12.8) (0.3, 2.1) (1.7, 12.2) (3.1, 6.8) (3.2, 6.0)


(3.5, 9.8) (8.2, 21.8) (2.5, 16.9) (0.7, 12.5) (5.1, 26.3) (5.3, 12.4) (5.3, 9.8)


(8.5, 21.1) (8.9, 25.8) (3.6, 11.7) (0.5, 2.6) (1.3, 6.4) (2.1, 4.6) (4.7, 9.6)


(11.2, 30.4) (2.4, 23.9) (0.8, 7.8) (0.3, 2.3) (1.8, 14.5) (1.2, 4.2) (4.7, 12.0)

Nationally Registered ACT


(81.7, 89.2) (72.2, 84.5) (61.4, 76.1) (54.3, 73.1) (35.1, 58.9) (59.4, 71.0) (69.6, 78.8)


(60.8, 74.2) (61.6, 88.4) (31.4, 56.5) (8.6, 23.6) (15.6, 37.3) (25.9, 45.2) (44.1, 55.0)


(63.7, 81.4) (33.6, 67.2) (19.2, 35.6) (3.7, 8.4) (7.8, 24.6) (10.0, 16.3) (28.7, 39.8)


(80.9, 91.9) (38.7, 87.5) (19.8, 47.3) (5.8, 13.1) (16.0, 44.9) (13.3, 24.0) (33.9, 46.5)

Any non-artemisinin therapy


(69.8, 78.2) (41.1, 60.9) (25.9, 45.8) (13.4, 24.4) (55.2, 76.6) (27.6, 37.7) (46.9, 55.0)


(73.4, 84.4) (52.1, 77.1) (36.3, 65.0) (37.3, 65.7) (64.1, 82.5) (53.2, 66.3) (63.2, 73.5)


(81.5, 92.4) (44.0, 73.1) (54.6, 72.4) (54.8, 69.9) (75.6, 88.0) (60.7, 71.5) (69.5, 77.8)


(76.1, 88.4) (32.4, 83.0) (50.5, 73.2) (86.9, 94.7) (48.9, 77.1) (75.7, 85.9) (77.4, 85.7)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Chloroquine €


(63.0, 71.8) (35.1, 53.2) (18.6, 36.4) (9.1, 18.0) (33.1, 54.3) (20.1, 28.3) (39.8, 46.8)


(58.8, 71.4) (41.9, 71.3) (27.7, 51.0) (27.6, 54.5) (31.0, 54.4) (37.0, 50.2) (47.8, 58.5)


(68.4, 82.3) (28.0, 62.9) (39.6, 60.8) (43.0, 60.5) (24.8, 44.1) (41.6, 53.8) (52.5, 62.5)


(59.0, 74.6) (25.7, 62.6) (43.9, 63.4) (74.6, 85.7) (31.0, 58.5) (62.4, 74.2) (63.4, 72.7)

Primaquine


(55.3, 65.2) (29.6, 48.9) (0.2, 3.7) (0.4, 2.8) (3.7, 14.9) (5.4, 10.4) (27.2, 34.9)


(50.4, 65.3) (29.3, 64.7) (0.8, 9.8) (0.9, 8.8) (1.9, 9.9) (6.4, 18.4) (27.1, 37.0)


(64.2, 79.8) (5.6, 22.1) (2.3, 11.4) (0.1, 1.2) (1.9, 19.4) (1.6, 5.2) (22.2, 33.0)


(67.5, 80.8) (7.6, 32.6) (0.4, 6.9) - - (0.5, 1.9) (19.3, 30.2)

Other non-artemisinin therapy ^


(2.9, 7.9) (2.1, 8.8) (10.3, 22.6) (3.5, 10.0) (29.9, 50.4) (8.9, 15.1) (6.6, 11.2)


(5.9, 13.4) (8.7, 36.1) (12.7, 36.3) (10.9, 27.7) (43.8, 63.8) (21.9, 36.3) (16.1, 24.3)


(4.8, 12.7) (14.0, 37.4) (23.6, 45.3) (17.9, 27.2) (54.9, 74.7) (28.5, 35.4) (20.4, 26.8)


(2.8, 9.9) (5.4, 35.7) (12.3, 33.0) (14.1, 26.4) (19.4, 39.7) (17.1, 26.1) (13.2, 19.8)



(50.9, 60.9) (26.1, 44.2) (0.1, 3.5) (0.2, 2.3) (3.7, 14.9) (4.7, 9.1) (24.8, 32.3)


(43.8, 58.2) (27.4, 64.3) (0.8, 9.8) (0.4, 7.3) (0.7, 8.3) (5.4, 17.6) (23.6, 33.2)


(53.8, 70.6) (5.1, 21.2) (2.1, 8.8) (0.0, 0.5) (1.6, 19.5) (1.2, 4.8) (18.8, 28.9)


(52.2, 68.8) (4.5, 23.9) (0.4, 6.9) - - (0.3, 1.4) (15.0, 25.5)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)



(1.2, 4.7) (8.0, 21.4) (22.4, 40.5) (20.1, 38.6) (8.3, 26.4) (18.9, 32.4) (10.8, 20.5)


(2.1, 7.5) (6.8, 22.2) (26.4, 49.4) (33.7, 56.3) (13.7, 34.4) (24.8, 38.9) (15.5, 23.7)


(2.6, 7.9) (22.4, 50.5) (52.9, 73.1) (60.2, 72.1) (9.7, 22.4) (49.4, 58.7) (32.1, 41.6)


(0.2, 2.2) (4.4, 24.9) (24.3, 52.8) (7.7, 15.6) (10.1, 30.3) (11.7, 20.2) (8.2, 14.0)

Non-oral artemisinin monotherapy


(4.1, 10.2) (16.9, 37.1) (16.7, 34.3) (1.0, 4.1) (6.3, 30.8) (7.7, 17.3) (6.3, 13.6)


(8.3, 17.8) (13.4, 34.0) (8.0, 25.3) (2.2, 11.3) (5.9, 20.4) (8.6, 16.2) (9.2, 15.7)


(5.1, 12.0) (32.9, 66.3) (28.4, 47.9) (6.9, 13.4) (15.2, 33.4) (15.0, 22.2) (12.0, 17.8)


(2.4, 10.2) (9.5, 40.0) (9.1, 39.6) (0.4, 2.3) (3.3, 18.6) (3.3, 9.0) (3.5, 8.0)

Any treatment for severe malaria


(7.1, 13.8) (18.0, 39.1) (22.1, 42.4) (1.3, 4.4) (30.0, 53.1) (12.0, 22.5) (10.2, 18.1)


(14.7, 25.9) (15.8, 38.4) (17.7, 41.9) (5.5, 18.3) (47.5, 66.8) (23.4, 36.3) (20.7, 30.1)


(9.0, 18.5) (39.4, 74.3) (38.6, 61.8) (12.4, 21.3) (65.5, 83.1) (30.4, 38.6) (23.2, 31.0)


(5.4, 15.9) (10.7, 42.0) (17.3, 46.1) (3.8, 10.4) (19.9, 40.5) (11.0, 18.4) (10.2, 15.8)

Artesunate IV/IM #


(1.3, 4.2) (11.2, 24.4) (9.3, 26.1) (0.2, 1.9) (1.1, 14.3) (4.0, 10.5) (2.9, 7.5)


(2.7, 8.2) (7.9, 23.7) (1.7, 14.6) (0.6, 8.1) (0.2, 9.4) (3.0, 7.6) (3.3, 6.8)


(0.5, 3.5) (8.0, 28.8) (6.0, 18.6) (1.0, 4.1) (1.1, 12.7) (2.4, 8.0) (1.9, 5.7)


(0.2, 3.6) (5.1, 29.5) (0.5, 3.8) - - (0.3, 1.7) (0.4, 1.7)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Artemether IV/IM


(2.8, 7.8) (6.0, 26.0) (12.1, 25.2) (0.8, 3.8) (5.4, 27.7) (4.9, 12.8) (4.2, 10.1)


(5.2, 14.1) (4.0, 23.6) (5.5, 19.8) (0.9, 9.0) (4.9, 18.6) (5.1, 11.6) (5.8, 11.4)


(4.2, 10.6) (27.8, 59.5) (25.1, 44.0) (5.7, 11.7) (13.2, 30.4) (13.2, 19.2) (10.5, 15.4)


(2.0, 9.6) (2.0, 26.3) (8.4, 39.2) (0.4, 2.3) (3.3, 18.6) (2.8, 8.3) (3.0, 7.4)

Quinine IV/IM


(2.2, 6.4) (0.8, 5.9) (7.1, 18.3) (0.1, 1.8) (21.9, 42.4) (4.6, 9.4) (3.8, 7.5)


(5.3, 12.8) (3.9, 24.1) (9.3, 26.6) (1.7, 14.8) (37.7, 57.6) (14.4, 26.4) (11.3, 18.8)


(3.9, 11.6) (12.1, 35.2) (15.5, 37.6) (8.4, 15.4) (54.3, 74.1) (20.5, 27.5) (15.0, 21.2)


(2.4, 9.2) (0.3, 12.0) (5.1, 17.8) (3.2, 9.8) (13.5, 31.1) (6.6, 12.2) (5.8, 10.0)



(1.6, 5.2) (8.9, 22.6) (25.0, 43.8) (20.6, 39.3) (12.3, 31.2) (20.6, 33.9) (11.9, 21.7)


(2.5, 8.1) (11.2, 35.3) (28.7, 52.7) (37.6, 60.1) (18.5, 39.5) (29.7, 43.5) (18.5, 26.5)


(2.8, 8.1) (24.0, 52.7) (53.9, 73.5) (63.1, 74.2) (10.3, 23.2) (51.4, 60.5) (33.5, 43.0)


(0.7, 4.1) (12.3, 43.3) (32.9, 62.2) (14.9, 24.5) (16.1, 37.2) (19.6, 28.8) (13.7, 20.6)

* Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 135 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).


€ At the time of the 2015 Myanmar ACTwatch outlet survey, chloroquine was the first-line treatment for uncomplicated P. vivax malaria. Includes outlets that stock chloroquine or chloroquine co-packaged in a Vivax Treatment Kit with primaquine. ^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. # At the time of the 2015 Myanmar ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. £ See Annex 2.




Table B3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type, across domain

Community Health




ALL Private

ALL Outlets

Proportion of outlets with any antimalarial in stock that:

1. N=540 2. N=240 3. N=239 4. N=230

1. N=124 2. N=61 3. N=80 4. N=40

1. N=176 2. N=82

3. N=139 4. N=104

1. N=356 2. N=91

3. N=434 4. N=319

1. N=84 2. N=88

3. N=135 4. N=90

1. N=740 2. N=322 3. N=788 4. N=553

1. N=1,280 2. N=562

3. N=1,027 4. N=783

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed antimalarials in the past week


(8.6, 14.9) (11.7, 24.6) (26.3, 45.0) (11.3, 23.0) (8.4, 24.6) (15.6, 25.5) (13.1, 19.7)


(9.0, 18.7) (6.9, 33.0) (21.0, 40.5) (15.5, 31.6) (24.9, 46.8) (21.2, 32.3) (16.6, 24.7)


(8.8, 19.2) (22.9, 50.4) (41.0, 64.1) (22.3, 35.6) (30.7, 48.5) (28.8, 39.5) (22.3, 31.3)


(14.7, 29.0) (6.6, 36.7) (24.1, 46.1) (9.9, 19.7) (20.7, 44.6) (16.9, 25.0) (17.4, 24.6)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]

Number of AETDs distributed in the past week


[0.0-0.0] [0.0-0.0] [0.0-1.4] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-0.9] [0.0-0.0] [0.0-0.1] [0.0-0.1] [0.0-0.0]


[0.0-0.0] [0.0-0.5] [0.0-1.9] [0.0-0.1] [0.0-0.2] [0.0-0.3] [0.0-0.1]


[0.0-0.0] [0.0-0.0] [0.0-1.5] [0.0-0.0] [0.0-0.2] [0.0-0.0] [0.0-0.0]




Community Health




ALL Private

ALL Outlets

Proportion of outlets with first-line ACT in stock that:

1. N=470 2. N=181 3. N=194 4. N=208

1. N=99 2. N=48 3. N=52 4. N=29

1. N=121 2. N=31 3. N=49 4. N=41

1. N=222 2. N=15 3. N=30 4. N=34

1. N=44 2. N=22 3. N=24 4. N=28

1. N=486 2. N=116 3. N=155 4. N=132

1. N=956 2. N=297 3. N=349 4. N=340

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed first-line ACT in the past week


(5.5, 10.9) (8.0, 20.8) (22.8, 41.3) (7.9, 16.3) (1.5, 20.6) (12.3, 19.0) (9.5, 13.7)


(5.1, 13.7) (3.0, 23.4) (8.8, 29.0) (6.4, 38.9) (10.0, 48.5) (8.2, 26.7) (7.3, 16.0)


(5.0, 14.8) (17.6, 39.4) (16.0, 46.5) (14.0, 43.8) (4.8, 32.2) (17.1, 31.9) (8.6, 17.1)


(12.9, 27.7) (7.0, 43.4) (17.0, 52.9) (10.7, 43.2) (9.9, 46.2) (16.3, 34.8) (15.2, 27.8)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]



[0.0-0.0] [0.0-0.0] [0.0-2.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.3] [0.0-0.8] [0.0-1.0 [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-3.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]




Community Health




ALL Private

ALL Outlets

Proportion of outlets with chloroquine € in stock that:

1. N=359 2. N=154 3. N=165 4. N=148

1. N=52 2. N=30 3. N=20 4. N=18

1. N=37 2. N=31 3. N=54 4. N=46

1. N=38 2. N=31

3. N=187 4. N=234

1. N=33 2. N=33 3. N=35 4. N=31

1. N=160 2. N=125 3. N=296 4. N=329

1. N=519 2. N=279 3. N=461 4. N=477

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed chloroqine in the past week


(3.8, 9.2) (3.6, 22.5) (7.0, 29.4) (1.3, 19.4) (0.6, 20.9) (5.0, 13.9) (4.7, 9.2)


(2.1, 9.2) (1.8, 40.2) (19.0, 55.9) (2.1, 27.7) (11.5, 40.5) (12.5, 25.4) (7.2, 14.3)


(4.6, 13.6) (1.7, 37.4) (26.4, 64.3) (18.4, 31.6) (13.8, 40.2) (20.2, 32.6) (13.3, 22.3)


(2.2, 10.0) (1.3, 21.7) (17.2, 50.7) (6.7, 17.6) (19.3, 57.6) (11.8, 21.9) (8.8, 15.7)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]



[0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-2.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-1.0] [0.0-0.0] [0.0-0.0] [0.0-0.3] [0.0-0.0]


[0.0-0.0] [0.0-0.0] [0.0-1.0] [0.0-0.0] [0.0-1.0] [0.0-0.0] [0.0-0.0]




Community Health




ALL Private

ALL Outlets

Proportion of outlets with primaquine in stock that:

1. N=316 2. N=137 3. N=163 4. N=157

1. N=47 2. N=23 3. N=10 4. N=9

1. N=2 2. N=3 3. N=5 4. N=1

1. N=3 2. N=2 3. N=3 4. N=0

1. N=6 2. N=6 3. N=2 4. N=0

1. N=58 2. N=34 3. N=20 4. N=10

1. N=374 2. N=171 3. N=183 4. N=167

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed primaquine in the past week


(1.7, 9.6) (4.0, 24.5) - - - (3.2, 20.2) (2.3, 9.2)


(0.4, 7.6) (2.1, 47.3) - - - (1.7, 37.6) (1.0, 9.2)


(5.0, 16.6) - (4.0, 75.1) (4.6, 80.7) - (3.0, 29.6) (5.1, 16.4)

4. Bangladesh border / Rakhine 16.4 5.9 0.0 - - 5.4 16.1

(10.7, 24.3) (0.8, 33.1) - - - (0.7, 30.9) (10.5, 23.9)

Proportion of outlets with oral artemisinin monotherapy in stock that:

1. N=19 2. N=10 3. N=24 4. N=3

1. N=19 2. N=8

3. N=32 4. N=7

1. N=57 2. N=29 3. N=95 4. N=38

1. N=118 2. N=42

3. N=317 4. N=49

1. N=17 2. N=19 3. N=26 4. N=16

1. N=211 2. N=98

3. N=470 4. N=110

1. N=230 2. N=108 3. N=494 4. N=113

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed oral artemisinin monotherapy in the the past week


(5.2, 38.7) (8.5, 42.3) (25.2, 57.8) (14.5, 43.8) (3.2, 43.7) (17.6, 42.9) (17.1, 41.6)


(2.0, 31.6) (8.8, 63.3) (11.2, 42.3) (22.5, 47.6) (3.8, 34.0) (18.6, 36.5) (17.3, 34.4)


(13.0, 50.1) (10.0, 37.8) (25.5, 51.0) (20.6, 36.0) (25.7, 70.0) (23.5, 36.8) (23.6, 36.4)


(56.5, 99.3) (2.4, 62.4) (11.8, 48.8) (6.7, 26.2) (9.4, 44.1) (12.2, 29.2) (13.2, 30.6)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]



[0.0-0.0] [0.0-0.0] [0.0-1.3] [0.0-0.1] [0.0-0.0] [0.0-0.2] [0.0-0.1]


[0.0-0.0] [0.0-0.1] [0.0-0.0] [0.0-0.6] [0.0-0.0] [0.0-0.2] [0.0-0.0]


[0.0-0.1] [0.0-0.0] [0.0-1.3] [0.0-0.1] [0.0-1.3] [0.0-0.1] [0.0-0.1]


[1.3-3.1] [0.0-0.0] [0.0-0.3] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]




Community Health




ALL Private

ALL Outlets

Proportion of outlets with any antimalarial that is not indicated within national treatment guidelines £ in stock that:

1. N=22 2. N=12 3. N=24 4. N=6

1. N=20 2. N=12 3. N=35 4. N=10

1. N=63 2. N=31 3. N=96 4. N=46

1. N=120 2. N=45

3. N=321 4. N=74

1. N=21 2. N=24 3. N=29 4. N=26

1. N=224 2. N=112 3. N=481 4. N=156

1. N=246 2. N=124 3. N=505 4. N=162

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Distributed antimalarial that is not indicated within national treatment guidelines in the past week


(4.3, 32.2) (7.7, 39.5) (25.9, 60.0) (15.4, 43.6) (5.5, 43.7) (18.6, 43.4) (17.7, 41.5)


(1.8, 28.0) (9.2, 60.0) (12.1, 42.8) (20.4, 44.1) (4.2, 29.4) (17.8, 34.1) (16.5, 32.1)


(13.0, 50.1) (9.7, 35.3) (25.1, 50.6) (20.2, 35.2) (25.4, 68.2) (23.0, 36.0) (23.1, 35.7)


(7.1, 72.2) (1.0, 39.0) (11.4, 42.5) (5.7, 21.8) (7.5, 35.1) (9.9, 23.0) (10.5, 23.4)

Median

[IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]

Median [IQR]



[0.0-0.0] [0.0-0.0] [0.0-1.3] [0.0-0.1] [0.0-0.0] [0.0-0.2] [0.0-0.2]


[0.0-0.0] [0.0-0.1] [0.0-0.0] [0.0-0.3] [0.0-0.0] [0.0-0.1] [0.0-0.0]


[0.0-0.1] [0.0-0.0] [0.0-1.3] [0.0-0.1] [0.0-1.3] [0.0-0.1] [0.0-0.1]


[0.0-1.3] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0] [0.0-0.0]




Community Health




ALL Private

ALL Outlets

Proportion of outlets with malaria blood testing available (microscopy or RDT) that:

1. N=494 2. N=223 3. N=198 4. N=232

1. N=99 2. N=36 3. N=42 4. N=24

1. N=50 2. N=7

3. N=13 4. N=19

1. N=38 2. N=1 3. N=5 4. N=6

1. N=29 2. N=10 3. N=23 4. N=20

1. N=216 2. N=54 3. N=83 4. N=69

1. N=710 2. N=277 3. N=281 4. N=301

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

Provided/performed a malaria test in the past week


(49.7, 61.3) (33.1, 57.1) (38.7, 67.4) (16.9, 58.3) (39.3, 73.4) (37.0, 56.1) (48.0, 58.1)


(31.0, 45.3) (35.0, 69.7) - - (6.0, 57.9) (22.1, 57.4) (31.5, 44.9)


(31.8, 49.4) (14.6, 49.5) (41.1, 87.6) (4.7, 74.7) (2.0, 18.7) (14.7, 35.3) (30.5, 45.1)


(36.2, 56.1) (19.7, 60.4) (16.5, 73.0) (13.1, 83.8) (31.9, 86.6) (32.1, 69.3) (38.1, 55.9)

Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR] Median

[IQR]

Number of malaria tests provided/performed in the past week


[0.0-4.0] [0.0-3.0] [0.0-2.0] [0.0-1.0] [0.0-3.0] [0.0-2.0] [0.0-4.0]


[0.0-2.0] [0.0-3.0] [0.0-0.0] [ - ] [0.0-0.0] [0.0-2.0] [0.0-2.0]


[0.0-2.0] [0.0-2.0] [0.0-6.0] [0.0-25.0] [0.0-0.0] [0.0-0.0] [0.0-2.0]


[0.0-3.0] [0.0-1.0] [0.0-3.0] [0.0-10.0] [0.0-1.0] [0.0-1.0] [0.0-3.0]



£ See Annex 2.




Table B4: Types of quality-assured and non-quality-assured ACTs audited in the public and private sector, across domain

ACT generic name Quality-assured ACT Non-quality-assured ACT

Community Health Worker Private sector Community Health Worker Private Sector

Proportion of all audited antimalarials*: % (95% CI) % (95% CI) % (95% CI) % (95% CI)

Eastern (AMTR intervention) N audited=932 N audited=647 N audited=29 N audited=54


- - (67.5, 93.8) (6.6, 26.2)


- - - (2.1, 18.8)


- - (6.2, 32.5) (59.9, 87.8)

Artemisinin napthoquine 0.0 0.0 0.0 3.2

- - - (0.5, 19.0)

Central (AMTR comparison) N audited=367 N audited=140 N audited=16 N audited=28


- - - (25.8, 74.1)


- - - (0.6, 24.3)


- - - (22.6, 71.2)


- - - -

Western / India border N audited=428 N audited=186 N audited=39 N audited=52


- - (88.1, 99.4) (31.2, 60.3)


- - - -


- - (0.6, 11.9) (39.7, 68.8)


- - - -

Bangladesh border / Rakhine N audited=407 N audited=151 N audited=53 N audited=18


- - (88.2, 99.8) (44.8, 91.8)


- - (0.2, 11.8) -


- - - (8.2, 55.2)


- - - -

* All ACTs found in Myanmar were tablet formulation.




Table B5: Antimalarial market composition, across domain

Outlet type, among outlets with at least 1 antimalarial in stock on the day of the survey:*


Private For-Profit



ALL Private

% % % % % %

Eastern (AMTR intervention), N= 1,330 outlets 44.3 8.4 11.2 29.5 6.7 55.7

(39.2, 49.4) (6.3, 11.2) (8.6, 14.4) (25.1, 34.3) (5.1, 8.7) (50.6, 60.8)

Central (AMTR comparison), N= 594 outlets 44.3 9.9 12.3 18.8 14.7 55.7

(37.5, 51.2) (6.1, 15.8) (8.9, 16.9) (14.2, 24.3) (11.3, 19.1) (48.8, 62.5)

Western / India border, N= 1,065 outlets 35.0 4.6 7.5 40.5 12.3 65.0

(29.1, 41.4) (3.2, 6.7) (5.5, 10.3) (35.2, 46.1) (10.0, 15.1) (58.6, 70.9)

Bangladesh border / Rakhine, N= 870 outlets 31.6 3.2 7.7 43.7 13.7 68.4

(25.9, 38.0) (1.8, 5.5) (5.3, 11.3) (37.4, 50.2) (10.5, 17.8) (62.0, 74.1)

*Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.




Table B6a: Price of tablet formulation antimalarials, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Any ACT


[0.00-0.00] (953) [0.00-0.79] (102) [0.28-0.52] (171) [0.24-0.42] (308) [0.00-0.94] (63) [0.20-0.52] (644) [0.00-0.31] (1,597)


[0.00-0.00] (382) [0.00-0.79] (49) [0.24-0.94] (39) [0.28-0.63] (17) [0.00-0.55] (29) [0.00-0.79] (134) [0.00-0.00] (516)

Western / India border $0.00 $0.51 $0.37 $0.63 $0.00 $0.39 $0.00

[0.00-0.00] (466) [0.24-1.57] (57) [0.26-0.94] (75) [0.42-1.57] (40) [0.00-0.39] (32) [0.00-0.79] (204) [0.00-0.00] (670)


[0.00-0.00] (453) [0.00-0.79] (33) [0.28-0.63] (60) [0.39-1.89] (39) [0.00-1.13] (22) [0.24-0.94] (154) [0.00-0.00] (607)

Artemether lumefantrine (AL)


[0.00-0.00] (948) [0.00-0.55] (87) [0.28-0.39] (153) [0.24-0.42] (306) [0.00-0.79] (60) [0.04-0.47] (606) [0.00-0.31] (1,554)


[0.00-0.00] (381) [0.00-0.52] (44) [0.24-0.52] (34) [0.28-0.63] (17) [0.00-0.63] (28) [0.00-0.55] (123) [0.00-0.00] (504)


[0.00-0.00] (462) [0.10-1.18] (49) [0.26-0.79] (70) [0.42-1.57] (38) [0.00-0.31] (30) [0.00-0.79] (187) [0.00-0.00] (649)


[0.00-0.00] (452) [0.00-0.79] (33) [0.28-0.63] (59) [0.39-1.89] (39) [0.00-0.94] (21) [0.24-0.94] (152) [0.00-0.00] (604)



[0.28-2.36] (5) [1.18-2.36] (15) [1.57-2.36] (15) (1) [1.34-1.89] (2) [1.34-2.36] (33) [1.34-2.36] (38)

Central (AMTR comparison) - $2.36 $1.34 - $0.00 $1.34 $1.34

- [1.42-2.83] (5) [1.34-1.57] (5) - (1) [0.71-2.04] (11) [0.71-2.04] (11)


[0.00-0.00] (4) [2.12-2.36] (8) [1.89-1.98] (5) [2.36-3.54] (2) [0.00-3.54] (2) [1.98-2.75] (17) [0.00-2.36] (21)

Bangladesh border / Rakhine - - $1.57 - $1.13 $1.13 $1.13

- - (1) - (1) [1.13-1.13] (2) [1.13-1.13] (2)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]




[0.00-0.00] (924) [0.00-0.55] (85) [0.28-0.39] (152) [0.24-0.42] (304) [0.00-0.79] (58) [0.02-0.47] (599) [0.00-0.31] (1,523)


[0.00-0.00] (366) [0.00-0.39] (40) [0.24-0.52] (33) [0.28-0.39] (14) [0.00-0.47] (25) [0.00-0.47] (112) [0.00-0.00] (478)


[0.00-0.00] (428) [0.24-0.79] (47) [0.26-0.47] (59) [0.39-1.18] (33) [0.00-0.39] (28) [0.00-0.63] (167) [0.00-0.00] (595)


[0.00-0.00] (405) [0.00-0.79] (30) [0.28-0.63] (57) [0.39-1.42] (36) [0.00-1.18] (20) [0.24-0.79] (143) [0.00-0.00] (548)

QAACT with the “Padonma” logo


[0.00-0.00] (316) [0.00-0.63] (66) [0.28-0.39] (152) [0.24-0.42] (301) [0.31-0.94] (45) [0.24-0.47] (564) [0.00-0.39] (880)


[0.00-0.00] (91) [0.00-0.39] (25) [0.24-0.42] (26) [0.28-0.39] (12) [0.39-0.63] (13) [0.16-0.47] (76) [0.00-0.31] (167)


[0.00-0.28] (19) [0.31-1.18] (30) [0.26-0.47] (57) [0.39-0.94] (30) [0.39-0.79] (16) [0.31-0.79] (133) [0.24-0.79] (152)


[0.39-3.15] (5) [0.28-0.79] (24) [0.28-0.55] (51) [0.39-0.94] (34) [0.71-1.57] (14) [0.31-0.79] (123) [0.31-0.79] (128)

QAACT without the “Padonma” logo

Eastern (AMTR intervention) $0.00 $0.00 - $0.47 $0.00 $0.00 $0.00

[0.00-0.00] (608) [0.00-0.00] (19) - [0.00-0.55] (3) [0.00-0.00] (13) [0.00-0.00] (35) [0.00-0.00] (643)


[0.00-0.00] (275) [0.00-0.79] (15) [0.00-1.18] (7) [0.00-0.00] (2) [0.00-0.00] (12) [0.00-0.31] (36) [0.00-0.00] (311)


[0.00-0.00] (409) [0.00-0.52] (17) [0.00-0.00] (2) [7.55-7.55] (3) [0.00-0.00] (12) [0.00-0.00] (34) [0.00-0.00] (443)


[0.00-0.00] (400) [0.00-0.00] (6) [0.00-4.88] (6) [2.83-2.83] (2) [0.00-0.00] (6) [0.00-0.94] (20) [0.00-0.00] (420)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]




[0.00-0.00] (29) [1.18-2.36] (17) [1.57-2.36] (19) [0.00-4.72] (4) [1.34-1.89] (5) [1.18-2.36] (45) [0.00-1.97] (74)


[0.00-0.00] (16) [0.39-2.36] (9) [1.34-2.04] (6) [0.79-1.42] (3) [0.00-1.18] (4) [0.47-1.42] (22) [0.00-1.18] (38)


[0.00-0.00] (38) [1.99-2.75] (10) [1.02-1.89] (16) [2.36-6.61] (7) [0.00-3.54] (4) [1.18-3.54] (37) [0.00-0.00] (75)


[0.00-0.00] (48) [0.00-2.52] (3) [0.42-0.94] (3) [0.47-22.65] (3) [0.94-1.13] (2) [0.94-1.13] (11) [0.00-0.00] (59)

Chloroquine


[0.00-0.00] (253) [0.00-1.18] (13) [0.08-0.39] (31) [0.16-0.39] (18) [0.20-1.97] (13) [0.08-0.39] (75) [0.00-0.08] (328)


[0.00-0.00] (120) [0.00-0.39] (10) [0.12-0.24] (33) [0.12-0.39] (16) [0.00-0.39] (19) [0.12-0.39] (78) [0.00-0.16] (198)


[0.00-0.00] (126) [0.16-0.39] (8) [0.16-0.39] (51) [0.20-0.39] (171) [0.00-0.39] (26) [0.20-0.39] (256) [0.00-0.39] (382)


[0.00-0.00] (128) [0.00-0.39] (14) [0.13-0.39] (46) [0.20-0.39] (123) [0.20-0.79] (20) [0.16-0.39] (203) [0.00-0.24] (331)

Primaquine

Eastern (AMTR intervention) $0.00 $0.00 $0.12 - $0.00 $0.00 $0.00

[0.00-0.00] (222) [0.00-0.00] (10) (1) - [0.00-0.00] (3) [0.00-0.00] (14) [0.00-0.00] (236)


[0.00-0.00] (104) [0.00-0.08] (5) (1) (1) [0.00-0.29] (3) [0.00-0.08] (10) [0.00-0.00] (114)


[0.00-0.00] (113) [0.00-0.24] (5) [0.24-0.24] (2) (1) (1) [0.00-0.24] (9) [0.00-0.00] (122)

Bangladesh border / Rakhine $0.00 $0.00 - - - $0.00 $0.00

[0.00-0.00] (132) [0.00-0.00] (7) - - - [0.00-0.00] (7) [0.00-0.00] (139)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Vivax Treatment Kit


[0.00-0.00] (41) [0.00-0.55] (17) - - - [0.00-0.55] (17) [0.00-0.00] (58)

Central (AMTR comparison) $0.00 $0.00 - - $0.88 $0.00 $0.00

[0.00-0.00] (17) [0.00-0.79] (11) - - (1) [0.00-0.79] (12) [0.00-0.00] (29)

Western / India border $0.00 $0.39 - - - $0.39 $0.00

[0.00-0.00] (28) (1) - - - (1) [0.00-0.00] (29)

Bangladesh border / Rakhine $0.00 $0.00 - - - $0.00 $0.00

[0.00-0.00] (2) (1) - - - (1) [0.00-0.00] (3)

Oral Artemisinin Monotherapy


[1.26-3.78] (19) [0.00-2.77] (9) [2.27-3.15] (61) [3.02-3.78] (115) [2.52-6.29] (15) [2.52-3.78] (200) [2.52-3.78] (219)


[0.00-3.78] (9) [1.26-3.02] (6) [1.95-2.96] (30) [2.27-3.78] (46) [3.02-3.15] (16) [2.14-3.02] (98) [2.14-3.15] (107)


[3.02-3.78] (23) [2.52-3.78] (32) [2.27-3.02] (102) [3.02-3.78] (344) [3.02-3.78] (22) [3.02-3.78] (500) [3.02-3.78] (523)


[3.15-3.15] (2) [2.01-3.78] (5) [1.89-2.27] (39) [3.02-3.78] (50) [2.39-3.78] (12) [2.27-3.02] (106) [2.27-3.02] (108)

* AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.

Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 157 any ACT, 127 artemether lumefantrine, 29 dihydroartemisinin piperaquine, 91 QA ACT with the 'padonma' logo, 23 QA ACT without the 'padonma logo', 43 non-quality assured ACT, 628 chloroquine, 201 primaquine, 14 vivax treatment kit, 79 oral artemisinin monotherapy.




Table B6b: Price of pre-packaged antimalarials, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Median price of one pre-packaged* therapy:

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Adult first-line ACT


[0.00-0.00] (494) [0.00-1.57] (83) [0.24-0.39] (128) [0.00-0.39] (218) [0.00-0.79] (40) [0.01-0.39] (469) [0.00-0.39] (963)


[0.00-0.00] (190) [0.00-0.39] (38) [0.24-1.18] (27) [0.28-0.39] (13) [0.00-0.55] (15) [0.00-0.71] (93) [0.00-0.00] (283)


[0.00-0.00] (180) [0.24-1.18] (42) [0.24-1.18] (41) [0.39-2.36] (26) [0.00-0.55] (20) [0.24-1.18] (129) [0.00-0.00] (309)


[0.00-0.00] (209) [0.00-0.39] (25) [0.24-0.55] (43) [0.39-1.57] (30) [0.00-0.94] (20) [0.22-0.94] (118) [0.00-0.00] (327)

Adult Artemether Lumefantrine


[0.00-0.00] (490) [0.00-0.55] (69) [0.24-0.39] (115) [0.00-0.39] (217) [0.00-0.79] (39) [0.00-0.39] (440) [0.00-0.31] (930)


[0.00-0.00] (190) [0.00-0.39] (34) [0.24-0.39] (22) [0.28-0.39] (13) [0.00-0.55] (15) [0.00-0.39] (84) [0.00-0.00] (274)


[0.00-0.00] (176) [0.24-0.79] (35) [0.24-0.79] (36) [0.39-1.89] (24) [0.00-0.55] (18) [0.24-0.79] (113) [0.00-0.00] (289)


[0.00-0.00] (209) [0.00-0.39] (25) [0.24-0.55] (42) [0.39-1.57] (30) [0.00-0.94] (20) [0.22-0.94] (117) [0.00-0.00] (326)

Adult Dihydroartemisinin Piperaquine


[1.97-2.36] (4) [1.97-2.36] (14) [1.97-2.36] (13) (1) (1) [1.97-2.36] (29) [1.97-2.36] (33)

Central (AMTR comparison) - $1.57 $1.34 - - $1.34 $1.34

- [1.42-2.36] (4) [1.34-1.57] (5) - - [1.34-2.04] (9) [1.34-2.04] (9)


[0.00-0.00] (4) [2.12-2.36] (7) [1.89-1.98] (5) [2.36-3.54] (2) [0.00-3.54] (2) [1.98-2.75] (16) [0.00-2.36] (20)

Bangladesh border / Rakhine - - $1.57 - - $1.57 $1.57

- - (1) - - (1) (1)



Table B6b: Price of pre-packaged antimalarials, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Pediatric Artemether Lumefantrine


[0.00-0.00] (134) [0.00-0.16] (5) [0.16-0.28] (9) [0.16-0.31] (22) [0.00-0.79] (7) [0.12-0.31] (43) [0.00-0.00] (177)


[0.00-0.00] (60) [0.00-0.00] (3) [0.16-0.94] (2) (1) [0.00-0.00] (4) [0.00-0.31] (10) [0.00-0.00] (70)


[0.00-0.00] (84) [0.00-0.39] (4) [0.08-0.24] (7) [0.24-0.39] (4) [0.00-0.00] (4) [0.00-0.24] (19) [0.00-0.00] (103)

Bangladesh border / Rakhine $0.00 $0.39 $0.31 $0.16 - $0.31 $0.00

[0.00-0.00] (75) [0.39-0.39] (4) [0.28-0.31] (3) [0.16-0.47] (3) - [0.16-0.39] (10) [0.00-0.00] (85)

* Adult pre-packaged therapy is the package size intended for a 60kg adult. Pediatric pre-packaged therapy is the package size intended for a 10kg child.

At the time of the 2015 Myanmar ACTwatch outlet survey, artemether lumefantrine, dihydroartemisinin piperaquine and artesunate meflooquine were the first-line treatments for uncomplicated P. falciparum malaria. There was no artesunate mefloquine audited during the 2015 survey.

Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 84 adult artemether lumefantrine, 25 adult dihydroartemisinin piperaquine, 9 pediatric artemether lumefantrine




Table B7: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets** stocking

1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

Any malaria blood testing


(75.5, 82.7) (59.7, 75.3) (17.7, 34.2) (4.0, 12.0) (16.7, 30.4) (17.2, 25.4) (42.4, 49.4)


(65.6, 78.4) (45.8, 68.7) (4.0, 19.1) (0.2, 7.1) (5.5, 17.9) (10.4, 20.5) (35.8, 45.2)


(78.1, 87.9) (33.6, 65.4) (5.0, 15.5) (0.3, 1.5) (11.1, 27.5) (6.0, 11.7) (28.3, 40.2)


(79.7, 90.7) (27.0, 63.2) (7.3, 25.2) (0.5, 3.6) (10.2, 35.0) (5.7, 13.0) (27.3, 38.8)

1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

Malaria microscopy


(0.0, 0.7) (2.4, 8.4) - - - (0.3, 1.2) (0.2, 0.8)


(0.0, 2.1) (1.4, 12.4) - - - (0.2, 2.0) (0.2, 1.3)


(0.2, 5.9) (3.9, 18.1) (0.2, 5.5) - - (0.3, 1.5) (0.3, 2.0)


- (0.2, 6.9) (0.2, 7.7) - - (0.0, 0.8) (0.0, 0.6)



Table B7: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

Rapid diagnostic tests (RDTs)


(75.5, 82.7) (56.3, 71.9) (17.7, 34.2) (4.0, 12.0) (16.7, 30.4) (16.7, 24.8) (42.1, 49.2)


(65.6, 78.4) (42.8, 65.2) (4.0, 19.1) (0.2, 7.1) (5.5, 17.9) (9.9, 19.8) (35.4, 45.0)


(78.1, 87.9) (31.4, 63.5) (4.2, 14.6) (0.3, 1.5) (11.1, 27.5) (5.8, 11.4) (28.2, 40.0)


(79.7, 90.7) (27.0, 63.2) (7.3, 25.2) (0.5, 3.6) (10.2, 35.0) (5.7, 13.0) (27.3, 38.8)

Quality-assured RDT Ω


(57.6, 68.6) (40.4, 58.5) (4.4, 14.3) (0.4, 3.1) (8.0, 21.6) (8.3, 13.8) (29.3, 37.3)


(57.3, 70.8) (25.5, 54.4) (1.5, 15.3) (0.2, 7.1) (4.0, 15.2) (6.6, 15.3) (29.7, 39.1)


(73.3, 84.2) (23.1, 57.0) (2.3, 11.4) (0.2, 1.5) (8.4, 23.0) (4.4, 9.5) (26.0, 37.1)


(73.5, 86.9) (24.8, 60.4) (6.3, 24.2) (0.3, 2.7) (10.2, 35.0) (5.2, 12.5) (25.5, 36.7)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. No antimalarial-stocking outlets were missing information about both availability of microscopy and availability

of RDTs. 18 antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.” Ω QA RDT status could not be determined for 55 RDTs because of missing product information.




\

Table B8: Malaria blood testing market composition, across domain

Outlet type, among outlets with malaria blood testing available on the day of the survey:*


Private For-Profit



ALL Private

% % % % % %

Eastern (AMTR intervention), N= 722 outlets 72.4 12.3 6.1 5.4 3.8 27.6

(66.3, 77.8) (8.9, 16.6) (4.1, 9.0) (3.1, 9.1) (2.7, 5.3) (22.2, 33.7)

Central (AMTR comparison), N= 283 outlets 80.8 12.2 2.5 0.4 4.1 19.2

(71.8, 87.4) (6.6, 21.5) (1.2, 5.3) (0.1, 2.9) (2.3, 7.1) (12.6, 28.2)

Western / India border, N= 286 outlets 83.0 6.7 2.0 1.4 6.9 17.0

(77.4, 87.4) (3.9, 11.2) (1.1, 3.6) (0.5, 3.6) (4.2, 11.2) (12.6, 22.6)

Bangladesh border / Rakhine, N= 304 outlets 80.0 4.8 5.1 1.6 8.6 20.0

(72.0, 86.2) (2.6, 8.5) (2.6, 9.7) (0.6, 4.2) (4.2, 16.7) (13.8, 28.0)

* Outlets with malaria blood testing available on the day of the survey, verified by presence of at least one RDT recorded in the RDT audit sheet and/or reported availability of malaria microscopy.




Table B9: Price of malaria blood testing for adults, by outlet type, across domain

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Total median price to consumers:* Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Microscopy


(1) [0.00-2.36] (7) - - - [0.00-2.36] (7) [0.00-1.57] (8)

Central (AMTR comparison) $0.00 $0.00 - - - $0.00 $0.00

(1) [0.00-5.74] (3) - - - [0.00-5.74] (3) [0.00-1.57] (4)

Western / India border $0.00 $0.79 $0.39 - - $0.39 $0.00

(1) [0.39-0.79] (8) (1) - - [0.39-0.79] (9) [0.00-0.79] (10)

Bangladesh border / Rakhine - $2.75 $0.39 - - $0.39 $0.39

- (1) [0.39-0.79] (2) - - [0.39-0.79] (3) [0.39-0.79] (3)

Rapid diagnostic test (RDT)


[0.00-0.00] (506) [0.00-0.79] (99) [0.00-0.79] (44) [0.00-0.00] (30) [0.00-0.47] (28) [0.00-0.39] (201) [0.00-0.00] (707)


[0.00-0.00] (225) [0.00-0.79] (30) [0.39-1.57] (3) (1) [0.00-1.18] (10) [0.00-0.79] (44) [0.00-0.00] (269)


[0.00-0.00] (203) [0.00-1.18] (37) [0.00-0.00] (6) [0.00-0.16] (3) [0.00-0.39] (23) [0.00-0.79] (69) [0.00-0.00] (272)


[0.00-0.00] (235) [0.00-0.79] (24) [0.39-0.55] (15) [0.00-0.39] (3) [0.00-0.63] (19) [0.00-0.63] (61) [0.00-0.00] (296)

* Total price to the consumer including consultation and/or service fees. Malaria blood testing price information was not available (missing or “don’t know” response) for:

91 RDTs, 8 microscopy tests




Table B10.1: Antimalarial market share, Eastern (AMTR intervention) Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 20.3 11.2 18.2 9.2 2.2 40.7 61.0









Chloroquine € 9.5 2.6 2.2 0.5 0.4 5.7 15.3





* A total of 671.3 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type. £ See Annex 2.



^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 3,140 antimalarials were audited. Of these, 431 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.




Table B10.2: Antimalarial market share, Central (AMTR comparison) Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 26.3 5.3 5.4 2.3 8.8 21.8 48.1









Chloroquine € 6.3 4.2 10.0 1.0 6.1 21.2 27.6












Table B10.3: Antimalarial market share, Western / India border Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 8.0 2.1 5.3 4.6 1.8 13.7 21.8









Chloroquine € 12.4 0.3 14.2 14.5 2.6 31.6 44.0












Table B10.4: Antimalarial market share, Bangladesh border / Rakhine Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 19.7 7.2 7.9 4.5 9.1 28.8 48.5









Chloroquine € 3.1 0.2 11.5 10.4 7.9 29.8 32.9






At the time of the 2015 Myanmar ACTwatch outlet survey, artemether lumefantrine, dihydroartemisinin piperaquine and artesunate meflooquine were the first-line treatments for uncomplicated P. falciparum malaria. There was no artesunate mefloquine audited during the 2015 survey. Distribution of dihydroartemisinin piperaquine was minimal and is not included in the market share table.






Table B11.1: Antimalarial market share within outlet type, Eastern (AMTR intervention) Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 65.2 68.4 54.2 67.0 41.0 59.1 61.0









Chloroquine € 30.6 16.2 6.6 3.6 7.5 8.3 15.3




* A total of 671.3 AETDs were reportedly sold or distributed in the previous seven days: 190.7 health workers; 109.4 private for-profit health facilities; 251.8 pharmacies; 90.3 general retailers; 29.1 itinerant drug vendors. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

£ See Annex 2.



^ Other non-artemisinin therapy includes mefloquine, quinine and sulfadoxine pyrimethamine tablets, and quinine injections. Categories 1 through 4 sum to 100% within each column. A total of 3,140 antimalarials were audited. Of these, 431 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 307 health worker, 42 private for-profit health facilities; 26 pharmacy; 40 general retailers; 16 itinerant drug vendors.




Table B11.2: Antimalarial market share within outlet type, Central (AMTR comparison) Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 75.4 33.1 27.3 17.3 54.8 33.4 48.1









Chloroquine € 18.2 26.3 50.3 7.2 38.0 32.6 27.6





£ See Annex 2.







Table B11.3: Antimalarial market share within outlet type, Western / India border Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 36.6 43.2 16.8 14.2 18.9 17.6 21.8









Chloroquine € 56.6 6.0 45.3 44.6 28.2 40.5 44.0





£ See Annex 2.







Table B11.4: Antimalarial market share within outlet type, Bangladesh border / Rakhine Domain



Private For-Profit



TOTAL Private


% % % % % % %


1. Any ACT 76.6 86.6 30.5 27.0 39.5 38.8 48.5









Chloroquine € 11.9 1.8 44.0 61.9 34.1 40.2 32.9





£ See Annex 2.







Table B12.1: Malaria blood testing market share, Eastern (AMTR intervention) Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %


2. RDT 80.4 10.7 3.0 1.6 3.5 18.8 99.2


* A total of 1,941 malaria blood tests were reportedly administered in the previous seven days. ** Row sum – market share for the specified type of blood testing medicine. *** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 757 malaria blood tests were audited. Of these, 13 audited tests were not included in market share calculations due to incomplete or inconsistent information.




Table B12.2: Malaria blood testing market share, Central (AMTR comparison) Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %


2. RDT 79.2 14.4 0.0 0.0 1.0 15.4 94.6


* A total of 463 malaria blood tests were reportedly administered in the previous seven days. ** Row sum – market share for the specified type of blood testing medicine. *** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 298 malaria blood tests were audited. Of these, 9 audited tests were not included in market share calculations due to incomplete or inconsistent information.




Table B12.3: Malaria blood testing market share, Western /India Border Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %


2. RDT 85.6 3.9 4.8 2.3 0.5 11.4 97.1






Table B12.4: Malaria blood testing market share, Bangladesh border / Rakhine Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %


2. RDT 74.5 3.3 3.2 3.2 15.2 24.9 99.3






Table B13.1: Malaria blood testing market share, Eastern (AMTR intervention) Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %



2. RDT 100.0 93.0 100.0 100.0 100.0 95.9 99.2

Malaria RDT market

Manufacturer


Premier Medical Corporation LTD 2.7 5.0 34.6 72.5 19.9 18.2 5.7

Nantongegens Biotechnology Co., LTD 0.1 3.0 4.5 0.0 0.0 2.4 0.5

Other 0.5 23.7 1.3 0.0 3.6 14.4 3.1

Unknown 0.1 0.9 6.6 0.0 0.0 1.5 0.4


* 1,941 malaria blood tests reportedly administered in the previous seven days: 1,463 community health workers; 305 private for-profit health facilities; 74 pharmacies; 30 general retailers, 69 itinerant drug vendors Categories 1 through 2 sum to 100% in within each column. A total of 757 malaria blood tests were audited. Of these, 13 audited tests were not included in market share calculations due to incomplete or inconsistent information.





Table B13.2: Malaria blood testing market share, Central (AMTR comparison) Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %



2. RDT 100.0 72.6 0.0 0.0 100.0 74.0 94.6

Malaria RDT market

Manufacturer


Other 0.5 8.3 0.0 0.0 0.0 7.8 1.7

Unknown 0.6 5.7 0.0 0.0 0.0 5.3 1.4


* 463 malaria blood tests reportedly administered in the previous seven days: 369 community health workers; 90 private for-profit health facilities; 0 pharmacies; 0 general retailers, 4 itinerant drug vendors Categories 1 through 2 sum to 100% in within each column. A total of 298 malaria blood tests were audited. Of these, 9 audited tests were not included in market share calculations due to incomplete or inconsistent information.





Table B13.3: Malaria blood testing market share, Western / India border Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %



2. RDT 99.4 61.5 100.0 100.0 100.0 82.3 97.1

Malaria RDT market

Manufacturer


Other 0.5 26.0 10.8 0.0 0.0 13.5 2.0

Unknown 0.0 0.0 0.0 0.0 0.0 0.0 0.0



Manufacturer was captured for all RDTs audited. Ω QA RDT status could not be determined for 9 RDTs because of missing product information.




Table B13.4: Malaria blood testing market share, Bangladesh border / Rakhine Domain



Private For-Profit



TOTAL Private

BLOOD TEST TOTAL**

% % % % % % %



2. RDT 100.0 85.4 96.6 100.0 100.0 97.4 99.3

Malaria RDT market

Manufacturer


Other 0.3 0.0 0.0 0.0 0.0 0.0 0.2

Unknown 0.0 0.0 0.0 0.0 0.0 0.0 0.0



Manufacturer was not captured for 1 RDT audited. Ω QA RDT status could not be determined for 4 RDTs because of missing product information.




\

Table B14: Private sector case management training, supervision, support and surveillance, by outlet type

Community




ALL Private


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Have a provider who reportedly received training in the past year on:

(1) Malaria diagnosis (RDT and/or microscopy)

1. N=625 2. N=301 3. N=264 4. N=271

1. N=147 2. N=69 3. N=87 4. N=51

1. N=210 2. N=100 3. N=149 4. N=117

1. N=458 2. N=113 3. N=488 4. N=428

1. N=108 2. N=118 3. N=158 4. N=124

1. N=923 2. N=400 3. N=882 4. N=720

1. Eastern (AMTR intervention) 63.4 30.1 16.1 6.7 7.1 12.0

(58.7, 67.9) (21.2, 40.7) (9.5, 26.0) (3.9, 11.5) (4.0, 12.2) (9.1, 15.7)

2. Central (AMTR comparison) 56.5 23.5 11.9 2.2 2.8 8.1

(49.5, 63.2) (16.3, 32.6) (5.4, 24.1) (0.5, 8.2) (0.9, 8.8) (4.8, 13.2)

3. Western / India border 66.4 18.0 11.4 1.8 5.8 4.8

(58.0, 73.8) (9.4, 31.6) (6.2, 20.0) (1.0, 3.3) (1.9, 16.4) (3.2, 7.1)

4. Bangladesh border / Rakhine 64.5 8.0 5.5 0.0 2.9 1.7

(56.3, 71.8) (2.7, 21.1) (2.0, 14.0) - (1.2, 7.0) (0.9, 3.0)

(2) National malaria treatment guidelines

1. N=624 2. N=301 3. N=264 4. N=272

1. N=147 2. N=69 3. N=87 4. N=51

1. N=210 2. N=100 3. N=149 4. N=117

1. N=457 2. N=113 3. N=488 4. N=428

1. N=108 2. N=118 3. N=158 4. N=124

1. N=922 2. N=400 3. N=882 4. N=720


(57.3, 67.1) (21.1, 41.7) (6.2, 15.7) (6.5, 16.3) (3.9, 14.2) (9.7, 16.8)


(50.3, 64.1) (15.6, 31.9) (4.1, 23.0) (2.2, 14.0) (1.5, 9.9) (5.3, 14.8)


(51.4, 68.8) (6.7, 27.7) (5.8, 18.7) (1.5, 6.1) (2.9, 11.1) (3.7, 7.4)


(52.5, 67.3) (7.3, 32.0) (1.9, 14.9) (0.9, 4.5) (4.0, 30.7) (2.8, 9.7)

Supervision/regulation

(3) Report receiving a supervisory or regulatory visit within the past year

1. N=626 2. N=300 3. N=263 4. N=269

1. N=146 2. N=69 3. N=85 4. N=51

1. N=209 2. N=98

3. N=149 4. N=117

1. N=458 2. N=114 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=921 2. N=399 3. N=879 4. N=718


(53.6, 65.0) (33.9, 54.8) (29.1, 45.7) (47.1, 65.0) (22.7, 43.4) (41.2, 54.4)


(23.4, 33.8) (22.8, 45.3) (3.1, 16.6) (0.3, 6.4) (1.4, 10.2) (5.6, 13.4)


(31.2, 46.5) (2.1, 9.4) (3.5, 15.2) (0.5, 3.9) (0.7, 17.3) (1.4, 5.2)


(22.4, 36.3) (7.2, 31.2) (2.5, 12.4) (0.2, 3.3) (0.0, 1.7) (1.1, 3.8)




Community




ALL Private


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Passive surveillance

(4) Keep records on number of patients tested/treated for malaria

1. N=625 2. N=301 3. N=264 4. N=271

1. N=147 2. N=69 3. N=87 4. N=51

1. N=210 2. N=98

3. N=149 4. N=117

1. N=459 2. N=112 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=924 2. N=397 3. N=881 4. N=718


(71.9, 80.7) (49.6, 70.2) (7.7, 18.0) (3.6, 10.4) (9.9, 21.9) (13.1, 20.1)


(68.4, 80.2) (41.4, 75.4) (0.2, 9.9) (0.2, 7.2) (4.6, 16.8) (8.5, 20.3)


(76.5, 87.1) (26.2, 61.7) (2.0, 11.5) (0.1, 1.3) (6.7, 21.8) (4.2, 9.6)


(75.9, 89.3) (10.2, 37.6) (1.3, 8.3) - (3.7, 30.7) (1.8, 8.4)

(5) Report numbers of patients tested/treated for malaria to government or non-government organization

1. N=623 2. N=301 3. N=264 4. N=271

1. N=146 2. N=68 3. N=86 4. N=51

1. N=210 2. N=98

3. N=149 4. N=117

1. N=457 2. N=112 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=921 2. N=396 3. N=880 4. N=718


(70.9, 79.7) (36.1, 56.1) (6.4, 16.6) (3.3, 10.0) (7.1, 18.1) (10.5, 16.6)


(67.0, 79.1) (29.2, 64.3) (0.2, 9.9) (0.2, 7.2) (1.6, 10.8) (5.4, 16.6)


(75.3, 86.2) (10.2, 48.4) (1.3, 10.8) (0.1, 1.3) (5.0, 19.6) (2.6, 7.5)


(72.9, 87.4) (9.8, 36.8) (0.9, 7.7) - (1.8, 31.1) (1.2, 7.8)

Report numbers to government

1. N=623 2. N=301 3. N=264 4. N=271

1. N=146 2. N=68 3. N=86 4. N=51

1. N=210 2. N=98

3. N=149 4. N=117

1. N=457 2. N=112 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=921 2. N=396 3. N=880 4. N=718


(35.5, 45.2) (5.5, 19.5) (0.7, 6.0) (0.2, 1.9) (1.3, 8.3) (1.7, 4.3)


(51.3, 63.9) (5.5, 25.0) - (0.2, 7.2) (1.2, 10.3) (1.8, 6.6)


(30.9, 45.9) (1.9, 12.0) (0.6, 7.3) (0.0, 0.4) (4.0, 18.7) (1.3, 4.6)


(52.8, 71.2) (1.7, 20.6) (0.9, 7.7) - (1.5, 31.9) (0.6, 7.7)




Community




ALL Private


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Report numbers of to a non-governmental organization

1. N=623 2. N=301 3. N=264 4. N=271

1. N=146 2. N=68 3. N=86 4. N=51

1. N=210 2. N=98

3. N=149 4. N=117

1. N=457 2. N=112 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=921 2. N=396 3. N=880 4. N=718


(31.3, 41.8) (24.8, 45.4) (4.8, 14.3) (2.7, 9.5) (4.5, 14.4) (7.9, 13.6)


(13.9, 26.0) (24.7, 49.8) (0.2, 9.9) - (0.1, 4.2) (3.6, 11.8)


(35.2, 51.7) (6.4, 46.6) (0.3, 9.8) (0.1, 1.3) (0.3, 4.5) (0.8, 4.8)


(12.6, 30.2) (6.0, 28.7) - - (0.1, 4.6) (0.4, 1.8)

Composite indicators *

Reportedly have a trained provider (1 or 2) and receive supervision (2)

1. N=625 2. N=300 3. N=263 4. N=269

1. N=145 2. N=69 3. N=84 4. N=51

1. N=209 2. N=98

3. N=149 4. N=117

1. N=457 2. N=113 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=919 2. N=398 3. N=878 4. N=718


(37.1, 48.7) (15.9, 33.7) (4.8, 18.2) (6.7, 17.8) (1.7, 9.3) (8.5, 16.0)


(19.0, 29.0) (8.8, 24.6) (0.3, 8.9) (0.2, 7.2) (0.4, 6.8) (2.1, 6.3)


(27.4, 41.9) (0.5, 6.9) (2.0, 11.5) (0.2, 3.6) (0.7, 17.3) (0.9, 4.4)


(19.2, 33.4) (1.5, 16.0) (0.6, 6.2) - - (0.2, 1.5)

Reportedly have a trained provider (1 or 2), receive supervision (3), have national first-line treatment for Pf and Pv in stock, and provide malaria blood testing (RDT or microscopy)

1. N=625 2. N=300 3. N=263 4. N=269

1. N=145 2. N=69 3. N=84 4. N=51

1. N=209 2. N=98

3. N=149 4. N=117

1. N=457 2. N=113 3. N=487 4. N=426

1. N=108 2. N=118 3. N=158 4. N=124

1. N=919 2. N=398 3. N=878 4. N=718


(29.3, 39.6) (13.0, 27.1) (2.4, 12.4) (1.7, 8.1) (1.1, 7.9) (4.3, 9.0)


(14.1, 23.7) (7.4, 21.5) - (0.2, 7.2) (0.2, 7.6) (1.6, 5.1)


(21.8, 36.7) (0.5, 6.9) (0.3, 9.8) - (0.7, 17.3) (0.3, 3.7)


(15.9, 29.5) (0.4, 7.3) - - - (0.0, 0.4)




Community




ALL Private


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Reportedly have a trained provider (1 or 2), receive supervision (3), have national first-line treatment for Pf and Pv in stock, provide malaria blood testing (RDT or microscopy), keep records on numbers of patients tested/treatment for malaria (4), and report these numbers to a government or non-governmental organization (5)

1. N=622 2. N=300 3. N=263 4. N=268

1. N=143 2. N=68 3. N=84 4. N=51

1. N=209 2. N=96

3. N=149 4. N=117

1. N=455 2. N=111 3. N=486 4. N=424

1. N=108 2. N=118 3. N=158 4. N=124

1. N=915 2. N=393 3. N=877 4. N=716


(27.1, 36.8) (9.3, 23.2) (1.5, 9.0) (1.7, 8.1) (1.1, 7.9) (3.5, 8.0)


(13.2, 22.7) (7.5, 21.7) - (0.2, 7.3) (0.2, 7.6) (1.6, 5.2)


(20.3, 34.7) (0.1, 4.2) (0.3, 9.8) - (0.7, 17.3) (0.3, 3.7)

4. Bangladesh border / Rakhine 20.7 0.6 0.0 0.0 0.0 <0.1

(14.8, 28.2) (0.1, 4.0) - - - (0.0, 0.2)

Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). There were no missing responses. The number of providers who reported “don’t know” included: 7 diagnosis training, 8 case management training, 15 supervision, 12 record keeping, and 5 reporting. * Among outlets with responses for all relevant questions.




Table B15: Provider antimalarial treatment knowledge and practices, by outlet type, across domains

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

Correctly state the national first-line treatment for uncomplicated P. falciparum malaria

AL


(55.5, 65.7) (43.7, 62.5) (14.5, 26.7) (5.9, 12.3) (11.5, 25.9) (15.3, 21.3) (32.8, 39.9)


(49.8, 64.3) (40.2, 68.4) (5.2, 18.8) (1.1, 12.6) (4.9, 21.9) (10.2, 23.0) (29.6, 38.9)


(57.9, 72.7) (19.1, 47.5) (3.4, 13.3) (0.0, 0.7) (1.8, 9.3) (2.7, 5.6) (20.3, 30.2)


(43.1, 60.3) (37.2, 72.1) (5.6, 21.5) - (2.7, 10.4) (2.8, 8.4) (16.1, 23.3)

AL, ASMQ, or DHA PPQ


(56.1, 66.2) (48.1, 66.5) (15.2, 29.1) (6.0, 12.4) (15.9, 33.6) (16.7, 23.3) (34.0, 41.2)


(51.5, 66.0) (49.6, 74.5) (6.2, 24.5) (1.1, 12.6) (7.1, 24.4) (12.6, 26.0) (31.6, 41.5)


(59.5, 73.9) (21.7, 50.5) (4.3, 14.5) (0.0, 0.7) (3.3, 17.9) (3.3, 7.4) (21.3, 31.6)


(44.3, 62.3) (40.4, 74.2) (5.6, 21.5) - (4.1, 13.0) (3.3, 8.9) (16.9, 24.4)

AL, ASMQ, or DHA PPQ and primaquine


(4.9, 10.1) (1.6, 9.2) - - (0.3, 4.1) (0.3, 1.4) (2.4, 4.8)


(2.8, 8.4) (2.1, 16.8) (0.3, 8.7) (0.2, 7.1) (0.2, 7.6) (0.7, 5.7) (2.0, 5.4)


(13.3, 27.2) (1.1, 10.0) (0.2, 7.5) - (0.3, 8.4) (0.3, 1.8) (4.9, 10.0)


(3.3, 9.7) (0.1, 4.4) - - (0.1, 4.4) (0.0, 0.9) (1.1, 3.3)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Correctly state the national first-line treatment for uncomplicated P. vivax malaria

Chloroquine


(55.9, 65.0) (42.2, 60.6) (5.8, 14.0) (1.7, 6.4) (23.5, 42.2) (11.6, 18.4) (30.9, 37.8)


(49.3, 64.1) (35.0, 63.0) (2.6, 12.8) (0.9, 7.4) (8.3, 26.8) (10.1, 20.8) (29.0, 38.2)


(57.0, 72.2) (12.6, 32.7) (3.0, 13.2) (0.1, 0.9) (4.4, 20.0) (2.7, 6.6) (20.3, 30.2)


(42.3, 58.5) (41.5, 82.7) (3.1, 11.9) (0.1, 3.0) (6.3, 18.1) (4.2, 9.4) (16.6, 23.8)



(35.2, 44.7) (29.8, 48.4) (1.4, 6.5) (0.6, 2.8) (10.7, 26.1) (6.4, 11.9) (19.4, 24.9)


(28.8, 41.9) (21.1, 48.0) (0.2, 7.5) (0.2, 7.1) (1.1, 9.7) (3.9, 12.3) (16.2, 23.2)


(34.6, 52.0) (6.8, 24.8) (0.3, 9.9) (0.0, 0.5) (0.8, 8.1) (1.0, 3.0) (12.2, 20.1)


(22.8, 36.8) (6.4, 33.7) (0.3, 3.6) - (0.4, 5.2) (0.5, 2.3) (7.6, 12.8)


1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

Correctly state the first-line dosing regimen for uncompliated P. falciparum malaria

AL


(47.9, 58.3) (42.7, 61.5) (11.0, 22.1) (3.0, 7.6) (9.1, 24.4) (11.9, 18.3) (27.9, 34.6)


(41.4, 56.4) (36.5, 67.8) (3.0, 16.6) (0.9, 8.4) (4.2, 21.0) (8.9, 21.2) (25.1, 34.3)


(48.6, 64.8) (18.4, 46.5) (1.9, 10.3) (0.0, 0.7) (1.6, 9.1) (2.3, 5.2) (17.6, 26.5)


(34.1, 50.7) (28.3, 69.3) (5.2, 21.2) - (2.2, 9.6) (2.4, 7.8) (13.0, 19.9)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


1. N=597 2. N=277 3. N=257 4. N=251

1. N=139 2. N=67 3. N=85 4. N=47

1. N=207 2. N=100 3. N=148 4. N=114

1. N=454 2. N=114 3. N=487 4. N=428

1. N=104 2. N=117 3. N=157 4. N=122

1. N=904 2. N=398 3. N=877 4. N=711

1. N=1,501 2. N=675

3. N=1,134 4. N=962

For uncomplicated P. falciparum malaria in adults, report an ACT as the:

Most effective treatment


(77.5, 84.9) (61.6, 80.1) (23.3, 37.8) (16.3, 27.3) (24.4, 41.9) (27.6, 35.5) (48.7, 56.9)


(59.1, 72.8) (51.4, 72.9) (9.3, 23.1) (1.2, 8.9) (7.2, 24.5) (13.6, 25.1) (35.4, 44.5)


(68.7, 81.9) (27.6, 56.1) (5.7, 17.3) (0.2, 1.0) (7.1, 22.0) (4.9, 9.4) (25.4, 35.9)


(56.7, 75.5) (44.7, 76.9) (8.7, 27.6) (0.2, 2.8) (7.8, 20.9) (5.2, 11.6) (21.6, 31.3)

Treatment he/she most commonly recommends


(72.5, 81.7) (61.3, 78.1) (22.8, 38.3) (18.4, 30.2) (26.4, 44.9) (28.9, 37.1) (47.8, 56.0)


(55.0, 69.1) (45.7, 64.4) (8.5, 21.4) (1.2, 8.9) (8.3, 26.3) (12.8, 23.8) (33.0, 42.2)


(49.6, 66.9) (20.9, 44.7) (3.5, 13.0) (0.1, 1.1) (7.1, 22.0) (4.1, 8.0) (19.4, 28.8)


(47.0, 67.2) (40.1, 73.5) (7.0, 26.7) (0.1, 2.4) (8.1, 22.1) (4.8, 11.1) (18.2, 28.4)

Numbers of providers (N) in this table are the total number of providers eligible for table indicators. There were no providers with missing information.




Results Section C: Oral Artemisinin Monotherapy Indicator National Estimates

Table C1: Availability of oral artemisinin monotherapy, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of screened outlets stocking*: N=2,737 N=610 N=970 N=22,733 N=1,217 N=25,530 N=28,267

Any oral AMT on the day of the survey or in the past 3 months 2.3 8.0 20.8 1.8 9.7 2.9 2.8

(1.5, 3.1) (5.7, 10.3) (16.7, 24.8) (1.4, 2.1) (7.0, 12.4) (2.4, 3.3) (2.4, 3.2)

Any oral AMT in the past 3 months, not on the day of the survey 1.1 0.7 3.5 0.3 3.5 0.6 0.6

(0.5, 1.7) (0.1, 1.4) (1.7, 5.2) (0.2, 0.4) (2.2, 4.9) (0.5, 0.7) (0.5, 0.8)

Any oral AMT on the day of the survey 1.2 7.2 17.3 1.5 6.2 2.3 2.1

(0.7, 1.8) (5.0, 9.4) (13.5, 21.0) (1.2, 1.8) (3.9, 8.5) (1.9, 2.7) (1.8, 2.5)

Artesunate tablets on the day of the survey 1.2 7.1 16.9 1.3 6.0 2.1 2.0

(0.7, 1.8) (4.9, 9.3) (13.2, 20.7) (1.0, 1.6) (3.8, 8.3) (1.7, 2.5) (1.6, 2.4)

Artemether tablets on the day of the survey 0.0 0.5 0.7 0.2 0.4 0.2 0.2

(0.0, 0.0) (0.1, 0.8) (0.2, 1.3) (0.1, 0.3) (0.0, 0.9) (0.1, 0.3) (0.1, 0.3)

Proportion of antimalarial-stocking outlets stocking**: N=1,263 N=314 N=522 N=1,341 N=419 N=2,596 N=3,859

Any oral AMT on the day of the survey or in the past 3 months 4.6 15.2 41.0 38.2 23.1 31.4 20.3

(2.6, 6.5) (10.5, 19.9) (33.7, 48.2) (32.2, 44.3) (17.0, 29.3) (27.3, 35.5) (17.6, 23.0)

Any oral AMT in the past 3 months, not on the day of the survey 1.7 1.4 4.4 3.7 4.2 3.7 2.9

(0.2, 3.1) (0.0, 3.0) (1.0, 7.9) (1.7, 5.6) (1.9, 6.6) (2.4, 4.9) (1.9, 3.9)

Any oral AMT on the day of the survey 2.9 13.8 36.5 34.6 18.9 27.7 17.3

(1.6, 4.2) (9.3, 18.2) (29.9, 43.2) (28.5, 40.7) (13.1, 24.7) (23.8, 31.7) (14.8, 19.8)

Artesunate tablets on the day of the survey 2.9 13.4 35.8 31.5 18.4 26.0 16.3

(1.6, 4.2) (9.0, 17.8) (29.2, 42.5) (25.4, 37.6) (12.5, 24.2) (22.0, 29.9) (13.8, 18.8)

Artemether tablets on the day of the survey 0.0 0.8 1.5 3.9 1.0 2.3 1.3

(0.0, 0.0) (0.1, 1.5) (0.5, 2.6) (1.9, 6.0) (0.0, 2.4) (1.4, 3.3) (0.8, 1.9)


** Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 135 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).




Table C2: Characteristics of oral AMT supply & demand, among oral AMT stockists*, by outlet type

Community

Health Worker

Private For-Profit

Facility Pharmacy

General Retailer


ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of oral AMT-stocking outlets* that: N=83 N=75 N=259 N=653 N=135 N=1,122 N=1,205

Reportedly obtained oral AMT from**:

Pharmacy 64.9 59.3 37.6 54.0 65.1 52.1 53.5

(50.2, 79.7) (40.6, 78.0) (28.0, 47.2) (45.1, 62.9) (51.6, 78.6) (45.7, 58.5) (47.4, 59.6)

Fixed-location medicine wholesale outlet 27.4 27.1 54.6 40.1 27.1 41.2 39.5

(12.8, 41.9) (10.8, 43.4) (44.2, 65.1) (30.8, 49.4) (14.9, 39.2) (34.6, 47.8) (33.1, 45.9)

Other # 10.0 16.2 7.8 6.3 11.4 8.1 8.4

(1.0, 19.1) (4.0, 28.4) (3.1, 12.4) (2.6, 10.1) (3.0, 19.7) (5.0, 11.2) (5.4, 11.3)

Reportedly obtained oral AMT from a supplier within the past 3 months 66.1 48.4 49.2 52.9 51.8 51.5 53.1

(51.7, 80.5) (31.9, 64.9) (40.5, 57.8) (43.7, 62.1) (39.4, 64.1) (45.4, 57.6) (47.2, 58.9)

Among oral AMT-stocking outlets*, median: Median (IQR) N of Outlets*

Median (IQR) N of Outlets*






Number of times oral AMT was obtained from a supplier within the past 3 months

1.2 0.2 0.4 1.0 0.5 0.6 0.6

[0.1-1.8] (80) [0.0-1.7] (74) [0.0-1.2] (252) [0.0-1.2] (642) [0.0-2.1] (132) [0.0-1.2] (1,100) [0.0-1.2] (1,180)

Number of oral AMT packages in stock on the day of the survey 0.4 1.1 1.8 1.0 0.8 1.0 1.0

[0.1-1.6] (83) [0.8-3.2] (75) [0.6-5.1] (259) [0.8-1.8] (653) [0.3-2.2] (135) [1.0-2.4] (1,122) [0.4-2.4] (1,205)

Proportion of oral AMT-stocking outlets* that: %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Report availability of artesunate and/or artemether tablets among other outlets in the village/town

34.2 44.5 51.0 40.5 31.3 41.2 40.9

(20.5, 47.8) (29.0, 60.1) (40.7, 61.3) (32.8, 48.2) (17.8, 44.8) (35.2, 47.2) (34.9, 46.8)

Report artesunate and/or artemether tablets are requested by name by consumers

28.3 28.5 83.4 93.3 27.9 74.5 69.5

(15.5, 41.0) (12.2, 44.8) (76.8, 90.0) (89.7, 97.0) (15.4, 40.3) (69.2, 79.7) (64.5, 74.5)

* Outlets with oral AMT in stock on the day of the survey or reportedly in stock in the past 3 months.

** Categories are not mutually exclusive; oral AMT stockists could name more than 1 supplier for a given product.

# Includes: mobile distributor, village buyer, rural health centers, and ‘floating shops’ (i.e. shops on boats that travel local rivers).




Table C3: Distribution of oral AMT, among outlets stocking oral AMT, by outlet type

Community

Health Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets with oral AMT in stock on the day of the survey that:

N=56 N=66 N=219 N=526 N=78 N=889 N=945*

Did not distribute oral AMT in the past week 72.8 76.4 69.8 72.4 83.5 73.9 74.7

(64.5, 81.1) (61.0, 91.8) (60.1, 79.5) (64.6, 80.1) (74.0, 92.9) (67.8, 79.9) (69.0, 80.4)

Distributed less than 1 full course** of oral AMT in the past week 2.5 6.7 10.3 20.0 4.9 14.4 13.5

(0.0, 5.1) (0.0, 16.1) (4.7, 15.9) (13.4, 26.7) (0.0, 10.3) (10.3, 18.6) (9.6, 17.3)

Distributed 1 full course** or more of oral AMT in the past week 24.7 16.9 19.9 7.6 11.6 11.7 11.8

(16.6, 32.8) (3.5, 30.2) (11.9, 27.9) (2.8, 12.5) (3.9, 19.4) (7.4, 16.1) (7.7, 15.9)

Among outlets that distributed oral AMT in the past week, median:

N=15 N=16 N=73 N=144 N=21 N=254 N=269

Median [IQR] N of Outlets







Number of oral AMT packages in stock on the day of the survey 6.3 5 2.8 1.4 2.3 1.6 1.6

[1.3-11.5] (15) [0.3-9.7] (14) [1.6-5.5] (72) [1.0-2.8] (144) [2.2-2.4] (20) [1.0-3.6] (250) [1.0-3.3] (265)

Number of oral AMT AETDs** distributed in the past week 2.9 4.7 1.4 0.5 2.0 0.8 0.9

[1.0-6.5] (15) [2.6-6.7] (15) [0.7-2.3] (72) [0.4-1.1] (144) [1.1-2.9] (21) [0.4-2.2] (252) [0.5-2.0] (267)

Number of 50mg tablets distributed in the past week# 56.2 100.6 26.6 10.4 41.8 16.1 18.0

[19.1-123.8] (15) [49.9-128.9] (14) [12.8-43.7] (72) [7.0-21.9] (144) [25.8-54.8] (20) [1.0-43.2] (252) [9.3-38.9] (265)

Estimated number of individual customers treated with oral AMT in

the past week##

14.9 7.1 2.5 3.2 133.2 4.0 4.0

[2.5-25.4] (15) [2.3-10.1] (15) [1.0-7.7] (51) [1.4-7.3] (135) [2.5-137.9] (20) [1.0-8.7] (221) [1.2-9.1] (236)

* Excluding 43 outlets that responded to recent oral AMT distribution questions with “don’t know.”

** One adult equivalent treatment dose of artesunate or artemether tablets consists of 960mg including a recommended loading dose of 4mg/kg on the first day followed by a siz-day course of 2mg/kg once daily (WHO, 2001 Use of Antimalarials).

# There were 3 observations where the tablet strength was 40mg.

## Providers indicated a typical number of tablets dispensed to treat malaria in an adult. This indicator is shown in Table C4. The estimated number of individual customers treated is calculated within each outlet as the total number of tablets reportedly dispensed is the past week divided by the number of tablets typically dispensed to treat malaria in an adult.




Table C4: Characteristics of oral AMT products, by outlet type

Community




ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of oral AMT products: N=59 N=76 N=240 N=580 N=81 N=977 N=1,036

Audited within:

Health Worker -- -- -- -- -- -- 6.7

-- -- -- -- -- -- (3.7, 9.8)

Private For-Profit Health Facility -- -- -- -- -- 6.5 6.0

-- -- -- -- -- (4.0, 9.0) (3.7, 8.3)

Pharmacy -- -- -- -- -- 25.3 23.6

-- -- -- -- -- (19.8, 30.8) (18.5, 28.7)

Retailer -- -- -- -- -- 53.0 49.4

-- -- -- -- -- (45.4, 60.6) (42.0, 56.8)

Itinerant Drug Vendor -- -- -- -- -- 15.2 14.2

-- -- -- -- -- (10.2, 20.3) (9.6, 18.9)

Active ingredient

Artesunate 99.8 95.4 95.9 87.3 94.9 91.4 91.9

(99.5, 100.0) (90.5, 100.0) (93.1, 98.7) (81.4, 93.3) (88.3, 100.0) (87.8, 95.0) (88.5, 95.3)

Artemether 0.2 4.6 4.1 12.7 5.1 8.6 8.1

(0.0, 0.5) (0.0, 9.5) (1.3, 6.9) (6.7, 18.6) (0.0, 11.7) (5.0, 12.2) (4.7, 11.5)

Expiry Dates N=56 N=66 N=222 N=504 N=64 N=856 N=912

Expired at the time of the survey 20.7 15.9 8.2 16.9 18.7 13.7 14.7

(4.5, 37.0) (0.0, 35.1) (1.9, 14.5) (8.9, 25.0) (5.7, 31.8) (8.8, 18.7) (9.8, 19.7)

Less than 1 year to expiry 24.6 22.4 21.8 23.1 23.6 23.9 23.6

(6.6, 42.7) (6.9, 37.8) (11.8, 31.8) (15.5, 30.8) (12.3, 34.9) (18.4, 29.4) (18.3, 29.0)

1 to 2 years to expiry 9.3 10.9 7.9 11.9 7.4 9.8 9.7

(0.0, 20.3) (0.0, 27.1) (2.1, 13.8) (4.9, 18.9) (0.0, 15.1) (5.6, 14.1) (5.7, 13.8)

Greater than 2 years to expiry 46.4 66.2 66.7 60.0 55.6 61.4 60.4

(28.4, 64.3) (47.8, 84.5) (56.7, 76.7) (51.2, 68.7) (41.6, 69.7) (55.1, 67.8) (54.2, 66.6)

Manufacturer N=59 N=76 N=240 N=580 N=81 N=977 N=1,036

Mediplantex (Vietnam) 76.9 70.8 84.5 69.7 77.4 75.2 75.0

(60.8, 92.9) (53.8, 87.9) (77.2, 91.9) (60.2, 79.1) (64.6, 90.3) (69.0, 81.5) (68.9, 81.1)

AA Medical Products (Vietnam) 17.8 10.2 2.9 9.5 5.6 6.9 8.0

(2.3, 33.4) (0.0, 23.8) (0.3, 5.5) (4.6, 14.5) (0.0, 13.2) (3.9, 9.8) (4.7, 11.2)

Kunming Pharmaceutical Corporation (China) 0.0 0.3 2.7 3.2 2.4 2.8 2.6

(0.0, 0.0) (0.0, 0.7) (0.4, 5.0) (0.4, 6.0) (0.0, 7.2) (1.0, 4.5) (1.0, 4.2)

Other 5.3 18.7 9.9 17.5 14.5 15.1 14.4

(1.3, 9.2) (7.2, 30.2) (4.1, 15.7) (11.0, 24.1) (4.3, 24.7) (10.6, 19.7) (10.1, 18.7)



Table C4: Characteristics of oral AMT products, by outlet type

Community




ALL Private

ALL Outlets

Among oral AMT products, median: Median [IQR] N of products

Median [IQR] N of products






Number of packages obtained during the most recent wholesale purchase

4.8 2.5 4.9 2.1 2.6 2.7 2.7

[1.9-7.2] (59) [0.9-6.2] (76) [2.5-9.1] (240) [1.1-3.9] (580) [1.1-5.7] (81) [1.4-6.2] (977) [1.4-6.2] (1,036)

Wholesale price per 50mg tablet (most recent purchase) $0.12 $0.10 $0.10 $0.12 $0.11 $0.11 $0.11

[0.05-0.12] (52) [0.09-0.13] (59) [0.09-0.11] (203) [0.10-0.13] (460) [0.09-0.13] (74) [0.10-0.12] (796) [0.10-0.12] (848)

Retail price per 50mg tablet $0.14 $0.11 $0.12 $0.16 $0.15 $0.16 $0.16

[0.06-0.19] (55) [0.05-0.16] (53) [0.11-0.15] (235) [0.14-0.20] (578) [0.14-0.22] (68) [2.33-0.18] (934) [0.12-0.18] (989)

Retail price per AETD* $2.66 $2.15 $2.34 $3.06 $2.86 $3.06 $3.06

[1.13-3.66] (53) [1.05-3.11] (52) [2.06-2.90] (232) [2.69-3.78] (555) [2.74-4.32] (65) [2.33-3.31] (904) [2.33-3.36] (957)

Retail percentage mark-up** 22.4% 26.8% 17.8% 33.5% 32.0% 30.2% 30.1%

[9.9%-56.0%] (49) [0.6%-43.0%] (45) [10.0%-34.3%] (201) [21.6%-52.0%] (460) [19.3%-105.8%] (62) [15.5%-52.0%] (768) [14.9%-54.2%] (817)

Number of 50mg tablets typically dispensed to treat malaria in an adult 9.7 8.9 1.9 1.2 3.5 1.6 2

[2.4-11.9] (55) [1.6-12.0] (68) [1.2-7.7] (196) [1.0-2.3] (530) [2.2-12.0] (79) [1.0-3.4] (873) [1.2-7.2] (928)

There were 124 oral AMT products missing expiry date information; these were not included in the denominator.

* One adult equivalent treatment dose of artesunate or artemether tablets consists of 960mg including a recommended loading dose of 4mg/kg on the first day followed by a six-day course of 2mg/kg once daily (WHO, 2001 Use of Antimalarials).

** Retail percentage mark-up was calculated as the difference between selling price and purchase price, divided by the purchase price. Products with missing retail or wholesale price information were excluded.




Results Section D: Oral Artemisinin Monotherapy Indicators across domains

Table D1: Availability of oral artemisinin monotherapy, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of screened outlets stocking:

1. N=847 2. N=724 3. N=536 4. N=630

1. N=226 2. N=152 3. N=126 4. N=106

1. N=363 2. N=211 3. N=217 4. N=179

1. N=6,638 2. N=5,972 3. N=4,408 4. N=5,715

1. N=197 2. N=334 3. N=311 4. N=375

1. N=7,424 2. N=6,669 3. N=5,062 4. N=6,375

1. N=8,271 2. N=7,393 3. N=5,598 4. N=7,005

Any oral AMT on the day of the survey or in the past 3 months


(1.2, 3.9) (5.1, 13.7) (10.0, 23.1) (1.4, 2.9) (4.0, 14.5) (2.1, 4.1) (2.0, 4.0)


(1.9, 5.1) (3.7, 10.9) (15.7, 28.2) (0.7, 1.5) (6.2, 15.0) (1.6, 2.6) (1.8, 2.7)


(1.2, 3.5) (17.6, 37.1) (30.5, 50.0) (7.0, 11.2) (9.4, 17.0) (8.6, 12.7) (7.4, 10.9)


(0.3, 1.7) (2.5, 12.1) (14.2, 36.1) (0.8, 1.5) (8.4, 18.4) (2.0, 3.1) (1.8, 2.8)

Any oral AMT in the past 3 months, not on the day of the survey


(0.3, 1.4) (0.2, 3.2) (0.4, 2.4) (0.2, 0.5) (0.3, 5.6) (0.3, 0.6) (0.3, 0.6)


(0.9, 3.5) (0.1, 2.6) (2.8, 10.4) (0.1, 0.3) (1.6, 5.9) (0.3, 0.6) (0.4, 0.8)


(0.1, 0.5) (0.4, 4.6) (1.3, 6.6) (1.0, 2.3) (4.5, 11.6) (1.3, 2.9) (1.1, 2.5)


(0.2, 1.5) (0.2, 8.8) (1.4, 7.7) (0.1, 0.7) (4.4, 12.8) (0.6, 1.4) (0.6, 1.3)

Any oral AMT on the day of the survey


(0.8, 3.0) (4.4, 12.9) (9.2, 22.0) (1.1, 2.5) (3.1, 12.8) (1.7, 3.6) (1.6, 3.5)


(0.7, 2.6) (3.3, 10.5) (11.0, 22.2) (0.5, 1.4) (3.8, 11.3) (1.3, 2.2) (1.3, 2.1)


(1.0, 3.3) (16.6, 35.5) (28.0, 46.8) (5.9, 9.3) (3.5, 8.6) (7.1, 10.1) (6.1, 8.8)


(0.1, 0.8) (1.8, 9.6) (11.9, 31.9) (0.6, 1.1) (2.8, 8.7) (1.2, 2.0) (1.1, 1.8)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of screened outlets stocking:

1. N=847 2. N=724 3. N=536 4. N=630

1. N=226 2. N=152 3. N=126 4. N=106

1. N=363 2. N=211 3. N=217 4. N=179

1. N=6,638 2. N=5,972 3. N=4,408 4. N=5,715

1. N=197 2. N=334 3. N=311 4. N=375

1. N=7,424 2. N=6,669 3. N=5,062 4. N=6,375

1. N=8,271 2. N=7,393 3. N=5,598 4. N=7,005

Artesunate tablets on the day of the survey


(0.8, 3.0) (4.4, 12.9) (8.4, 21.0) (0.9, 2.1) (3.1, 12.8) (1.4, 3.3) (1.4, 3.2)


(0.7, 2.6) (3.3, 10.5) (11.0, 22.2) (0.5, 1.3) (3.5, 11.1) (1.2, 2.1) (1.2, 2.0)


(1.0, 3.2) (15.7, 34.4) (27.6, 46.2) (5.9, 9.3) (3.4, 8.5) (7.0, 10.1) (6.0, 8.7)


(0.1, 0.8) (1.4, 9.0) (11.9, 31.9) (0.5, 1.0) (2.8, 8.7) (1.1, 1.9) (1.0, 1.7)

Artemether tablets on the day of the survey


- (0.1, 2.0) (0.8, 4.0) (0.2, 0.7) (0.1, 4.2) (0.2, 0.7) (0.2, 0.6)


- - - (0.0, 0.2) (0.1, 2.3) (0.0, 0.2) (0.0, 0.2)


(0.0, 0.4) (2.2, 10.0) (0.9, 8.3) (0.1, 0.3) (0.0, 0.3) (0.2, 0.5) (0.2, 0.4)


- (0.1, 3.7) - (0.0, 0.3) - (0.0, 0.3) (0.0, 0.3)

Proportion of antimalarial-stocking outlets stocking:

1. N=545 2. N=244 3. N=242 4. N=232

1. N=129 2. N=65 3. N=80 4. N=40

1. N=185 2. N=88

3. N=144 4. N=105

1. N=381 2. N=104 3. N=462 4. N=394

1. N=90 2. N=93

3. N=137 4. N=99

1. N=785 2. N=350 3. N=823 4. N=638

1. N=1,330 2. N=594

3. N=1,065 4. N=870

Any oral AMT on the day of the survey or in the past 3 months


(1.6, 5.5) (9.2, 22.7) (23.7, 42.0) (22.5, 41.6) (8.3, 26.4) (20.8, 34.4) (12.0, 22.1)


(3.8, 12.3) (7.3, 23.1) (31.9, 57.9) (37.4, 59.6) (14.6, 35.8) (27.8, 42.4) (18.3, 27.2)


(2.7, 8.2) (22.4, 50.5) (57.7, 77.2) (67.5, 79.4) (18.8, 32.9) (56.2, 66.0) (36.2, 47.0)


(0.6, 4.4) (6.1, 31.1) (26.8, 55.1) (10.5, 20.6) (23.2, 50.3) (17.0, 27.7) (12.2, 19.4)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of antimalarial-stocking outlets stocking:

1. N=545 2. N=244 3. N=242 4. N=232

1. N=129 2. N=65 3. N=80 4. N=40

1. N=185 2. N=88

3. N=144 4. N=105

1. N=381 2. N=104 3. N=462 4. N=394

1. N=90 2. N=93

3. N=137 4. N=99

1. N=785 2. N=350 3. N=823 4. N=638

1. N=1,330 2. N=594

3. N=1,065 4. N=870

Any oral AMT in the past 3 months, not on the day of the survey


(0.2, 1.7) (0.3, 5.4) (0.5, 3.8) (1.7, 4.8) - (1.3, 3.0) (0.9, 2.1)


(1.0, 8.3) (0.1, 5.5) (2.6, 19.0) (1.2, 10.8) (0.2, 7.5) (1.7, 6.6) (1.7, 5.9)


(0.0, 1.2) - (1.9, 10.8) (5.1, 10.8) (5.9, 17.1) (5.3, 9.7) (3.4, 6.6)


(0.3, 4.1) (0.5, 21.3) (0.7, 10.6) (1.6, 8.8) (8.8, 31.9) (3.9, 10.6) (3.0, 7.5)

Any oral AMT on the day of the survey


(1.2, 4.7) (8.0, 21.4) (22.4, 40.5) (20.1, 38.6) (8.3, 26.4) (18.9, 32.4) (10.8, 20.5)


(2.1, 7.5) (6.8, 22.2) (26.4, 49.4) (33.7, 56.3) (13.7, 34.4) (24.8, 38.9) (15.5, 23.7)


(2.6, 7.9) (22.4, 50.5) (52.9, 73.1) (60.2, 72.1) (9.7, 22.4) (49.4, 58.7) (32.1, 41.6)


(0.2, 2.2) (4.4, 24.9) (24.3, 52.8) (7.7, 15.6) (10.1, 30.3) (11.7, 20.2) (8.2, 14.0)

Artesunate tablets on the day of the survey


(1.2, 4.7) (8.0, 21.4) (20.3, 38.7) (15.9, 33.6) (8.3, 26.4) (16.0, 29.7) (9.2, 19.0)


(2.1, 7.5) (6.8, 22.2) (26.4, 49.4) (30.8, 53.9) (12.4, 33.6) (23.6, 37.6) (14.9, 23.0)


(2.5, 7.7) (21.2, 48.9) (52.3, 72.2) (59.9, 71.8) (9.6, 22.2) (49.0, 58.2) (31.8, 41.3)


(0.2, 2.2) (3.4, 23.5) (24.3, 52.8) (6.3, 13.6) (10.1, 30.3) (10.6, 19.0) (7.5, 13.2)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Artemether tablets on the day of the survey


- (0.1, 3.2) (1.7, 8.3) (2.7, 11.3) (0.2, 9.5) (2.3, 6.9) (1.3, 3.9)


- - - (1.6, 9.0) (0.2, 7.5) (0.7, 3.6) (0.4, 2.0)


(0.0, 0.9) (3.0, 14.4) (1.6, 13.8) (0.8, 2.7) (0.0, 0.8) (1.2, 3.3) (0.8, 2.2)


- (0.2, 9.2) - (0.6, 4.5) - (0.4, 2.9) (0.3, 2.0)


** Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 135 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).




Table D2: Characteristics of oral AMT supply & demand, among oral AMT stockists*, by outlet type

Community

Health Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of oral AMT-stocking outlets* that:

1. N=26 2. N=21 3. N=29 4. N=7

1. N=22 2. N=10 3. N=35 4. N=8

1. N=63 2. N=42

3. N=108 4. N=46

1. N=149 2. N=53

3. N=383 4. N=68

1. N=19 2. N=28 3. N=49 4. N=39

1. N=253 2. N=133 3. N=575 4. N=161

1. N=279 2. N=154 3. N=604 4. N=168

Reportedly obtained oral AMT from**:

1. Eastern (AMTR intervention) N=26 N=22 N=63 N=149 N=19 N=253 N=279

Pharmacy 83.3 67.8 50.8 67.3 83.1 64.8 66.4

(65.5, 92.9) (39.1, 87.3) (34.3, 67.2) (54.3, 78.0) (55.4, 95.1) (53.6, 74.5) (55.7, 75.6)


(3.2, 24.1) (2.6, 36.2) (25.7, 58.9) (16.1, 42.2) (0.5, 24.3) (17.7, 39.8) (16.9, 37.5)

Other # 10.5 21.2 7.9 6.5 12.9 8.4 8.6

(2.5, 35.0) (7.5, 47.1) (2.4, 23.3) (3.0, 13.6) (3.0, 41.6) (4.5, 15.1) (4.7, 15.1)

2. Central (AMTR comparison) N=21 N=10 N=42 N=53 N=28 N=133 N=154

Pharmacy 60.6 60.1 31.9 49.7 62.9 48.2 50.2

(32.4, 83.2) (26.7, 86.1) (18.2, 49.8) (33.3, 66.2) (36.3, 83.5) (37.2, 59.5) (39.6, 60.7)


(8.4, 60.9) (6.2, 63.9) (42.5, 77.5) (27.9, 61.8) (10.6, 58.2) (33.4, 56.3) (31.1, 53.5)

Other # 12.0 20.4 6.6 6.1 12.3 8.5 9.0

(2.8, 39.2) (5.8, 51.8) (2.0, 19.4) (1.9, 18.0) (4.1, 31.5) (4.4, 15.8) (5.0, 15.6)

3. Western / India border N=29 N=35 N=108 N=383 N=49 N=575 N=604

Pharmacy 100.0 66.5 34.8 67.0 71.3 63.6 65.0

- (49.0, 80.4) (24.6, 46.6) (56.9, 75.7) (56.7, 82.5) (55.2, 71.1) (56.9, 72.2)


- (15.5, 46.1) (28.3, 51.4) (17.8, 35.8) (15.8, 42.9) (20.6, 36.0) (19.9, 34.6)

Other # 0.0 5.2 25.9 9.1 10.9 11.2 10.7

- (1.3, 18.2) (16.7, 37.9) (4.6, 17.2) (4.5, 24.1) (7.2, 16.9) (6.9, 16.3)

4. Bangladesh border / Rakhine N=7 N=8 N=46 N=68 N=39 N=161 N=168

Pharmacy 31.5 39.7 28.4 36.6 35.8 34.8 34.6

(7.5, 72.2) (11.5, 76.9) (15.1, 47.0) (24.5, 50.7) (17.9, 58.8) (25.2, 45.7) (25.3, 45.4)


(27.8, 92.5) (23.1, 88.5) (46.4, 82.4) (43.7, 70.5) (41.3, 82.3) (51.0, 72.0) (51.5, 72.0)

Other # 7.3 0.0 4.8 5.8 6.4 5.7 5.7

(0.9, 40.5) - (1.5, 14.4) (1.5, 19.4) (1.1, 29.1) (2.2, 13.6) (2.4, 13.3)




Community

Health Worker

Private For-Profit



ALL Private

ALL Outlets

Proportion of oral AMT-stocking outlets* that report:

1. N=26 2. N=21 3. N=29 4. N=7

1. N=22 2. N=10 3. N=35 4. N=8

1. N=63 2. N=42

3. N=108 4. N=46

1. N=149 2. N=53

3. N=383 4. N=68

1. N=19 2. N=28 3. N=49 4. N=39

1. N=253 2. N=133 3. N=575 4. N=161

1. N=279 2. N=154 3. N=604 4. N=168

Reportedly obtained oral AMT from a supplier within the past 3 months


(56.5, 86.5) (16.8, 61.8) (48.7, 72.0) (36.5, 65.4) (26.3, 69.0) (40.3, 63.2) (42.8, 64.4)


(37.1, 80.4) (21.3, 73.9) (25.0, 57.1) (37.1, 68.8) (27.1, 66.4) (37.9, 57.4) (40.1, 59.2)


(61.8, 89.4) (38.0, 75.8) (43.0, 70.2) (50.4, 62.1) (59.1, 85.3) (52.7, 63.7) (53.7, 64.3)


(16.6, 92.3) (30.4, 93.6) (36.1, 60.2) (39.1, 68.7) (47.5, 82.6) (48.7, 67.6) (48.9, 67.5)

Among oral AMT-stocking outlets*, median: Median (IQR) N of Outlets*







Number of times oral AMT was obtained from a supplier within the past 3 months


[0.0-2.0] (24) [0.0-1.0] (21) [0.0-1.0] (62) [0.0-1.0] (146) [0.0-1.0] (19) [0.0-1.0] (248) [0.0-1.0] (272)


[0.0-1.0] (21) [0.0-2.0] (10) [0.0-1.0] (40) [0.0-1.0] (52) [0.0-1.0] (26) [0.0-1.0] (128) [0.0-1.0] (149)


[1.0-3.0] (29) [0.0-2.0] (35) [0.0-2.0] (106) [0.0-1.0] (378) [0.0-4.0] (49) [0.0-2.0] (568) [0.0-2.0] (597)


[0.0-3.0] (6) [0.0-2.0] (8) [0.0-2.0] (44) [0.0-2.0] (66) [0.0-6.0] (38) [0.0-2.0] (156) [0.0-2.0] (162)

Number of oral AMT packages in stock on the day of the survey


[0.0-2.0] (26) [1.0-3.0] (22) [1.0-7.0] (63) [1.0-3.0] (149) [1.0-2.0] (19) [1.0-3.0] (253) [1.0-3.0] (279)


[0.0-2.0] (21) [1.0-4.0] (10) [0.0-4.0] (42) [1.0-1.0] (53) [0.0-3.0] (28) [1.0-2.0] (133) [0.0-2.0] (154)


[1.0-1.0] (29) [1.0-5.0] (35) [2.0-9.0] (108) [1.0-3.0] (383) [0.0-1.0] (49) [1.0-3.0] (575) [1.0-3.0] (604)


[0.0-0.0] (7) [0.0-1.0] (8) [1.0-3.0] (46) [0.0-1.0] (68) [0.0-1.0] (39) [0.0-2.0] (161) [0.0-2.0] (168)




Community

Health Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of oral AMT-stocking outlets* that:

1. N=26 2. N=21 3. N=29 4. N=7

1. N=22 2. N=10 3. N=35 4. N=8

1. N=63 2. N=42

3. N=108 4. N=46

1. N=149 2. N=53

3. N=383 4. N=68

1. N=19 2. N=28 3. N=49 4. N=39

1. N=253 2. N=133 3. N=575 4. N=161

1. N=279 2. N=154 3. N=604 4. N=168

Report availability of artesunate and/or artemether tablets among other outlets in the village/town


(12.5, 53.4) (16.1, 57.8) (38.7, 70.2) (27.1, 48.4) (7.0, 54.5) (29.9, 50.7) (28.8, 49.9)


(21.9, 69.3) (30.3, 82.8) (25.0, 61.2) (29.2, 57.0) (17.7, 61.9) (32.3, 52.7) (32.8, 52.8)


(52.6, 82.4) (53.7, 90.9) (62.2, 82.8) (52.0, 65.9) (47.3, 79.2) (55.8, 68.1) (56.3, 68.3)


(1.4, 35.0) (3.7, 55.5) (44.4, 72.1) (23.9, 50.7) (10.0, 40.9) (25.9, 45.0) (25.3, 43.8)

Report artesunate and/or artemether tablets are requested by name by consumers


(14.3, 56.9) (7.2, 37.3) (83.8, 97.4) (90.9, 97.7) (9.6, 55.8) (78.2, 88.3) (73.2, 84.6)


(11.1, 48.0) (15.7, 76.2) (63.7, 88.1) (82.8, 97.5) (13.1, 52.3) (60.5, 80.9) (54.6, 73.3)


(35.6, 80.0) (43.1, 81.3) (73.1, 92.3) (93.0, 98.8) (29.0, 54.5) (84.9, 91.8) (83.6, 91.0)


(2.6, 67.9) - (56.4, 90.3) (73.8, 95.6) (10.3, 44.3) (47.9, 70.1) (46.9, 68.5)

* Outlets with oral AMT in stock on the day of the survey or reportedly in stock in the past 3 months.

** Categories are not mutually exclusive; oral AMT stockists could name more than 1 supplier for a given product.

# Includes: mobile distributor, village buyer, rural health centers, and ‘floating shops’ (i.e. shops on boats that travel local rivers).




Table D3: Distribution of oral AMT, among outlets stocking oral AMT, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets*

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets with oral AMT in stock on the day of the survey that:

1. N=19 2. N=10 3. N=24 4. N=3

1. N=19 2. N=8

3. N=32 4. N=7

1. N=57 2. N=29 3. N=95 4. N=38

1. N=118 2. N=42

3. N=317 4. N=49

1. N=17 2. N=19 3. N=26 4. N=16

1. N=211 2. N=98

3. N=470 4. N=110

1. N=230 2. N=108 3. N=494 4. N=113

Did not distribute oral AMT in the past week


(61.3, 94.8) (57.7, 91.5) (42.2, 74.8) (56.2, 85.5) (56.3, 96.8) (57.1, 82.3) (58.7, 82.7)


(68.4, 98.0) (36.7, 91.2) (57.7, 88.8) (52.4, 77.5) (66.0, 96.2) (63.5, 81.4) (65.8, 82.6)


(49.9, 87.0) (62.2, 90.0) (49.0, 74.5) (64.0, 79.4) (30.0, 74.3) (63.2, 76.5) (63.6, 76.3)


(0.7, 43.5) (37.6, 97.6) (51.2, 88.2) (73.8, 93.3) (55.9, 90.6) (70.8, 87.8) (69.6, 86.6)

Distributed less than 1 full course** of oral AMT in the past week


(0.8, 21.4) (0.9, 18.9) (5.1, 19.6) (10.6, 30.4) - (9.1, 20.8) (8.7, 19.7)


- (1.5, 49.2) (3.1, 23.1) (13.5, 38.0) (2.1, 29.9) (9.7, 25.4) (8.7, 23.1)


(8.2, 39.2) (3.1, 23.8) (4.0, 20.1) (14.4, 28.3) (7.4, 43.3) (13.3, 24.8) (13.5, 24.5)


- - (3.9, 39.4) (6.7, 26.2) - (5.4, 18.3) (5.3, 17.9)

Distributed 1 or more full course** of oral AMT in the past week


(2.6, 37.5) (4.9, 42.4) (14.9, 51.5) (2.8, 21.4) (3.2, 43.7) (7.3, 27.3) (7.4, 26.3)


(2.0, 31.6) (4.2, 52.4) (6.8, 28.0) (4.3, 23.0) (0.5, 22.6) (5.8, 18.5) (5.9, 17.7)


(3.2, 21.3) (4.1, 28.3) (17.7, 41.4) (3.9, 12.7) (11.1, 53.7) (7.5, 16.8) (7.5, 16.4)


(56.5, 99.3) (2.4, 62.4) (5.2, 26.6) - (9.4, 44.1) (5.2, 16.0) (6.3, 17.6)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets*

Among outlets that distributed oral AMT in the past week, median:

1. N=3 2. N=2 3. N=8 4. N=2

1. N=5 2. N=3 3. N=7 4. N=1

1. N=22 2. N=9

3. N=32 4. N=10

1. N=30 2. N=14 3. N=91 4. N=9

1. N=2 2. N=3

3. N=12 4. N=4

1. N=59 2. N=29

3. N=142 4. N=24

1. N=62 2. N=31

3. N=150 4. N=26








Number of oral AMT packages in stock on the day of the survey


[1.0-2.0] (3) [0.0-1.0] (4) [1.0-9.0] (21) [1.0-4.0] (30) (1) [1.0-6.0] (56) [1.0-5.0] (59)


[2.0-24.0] (2) [0.0-20.0] (2) [2.0-3.0] (9) [1.0-2.0] (14) [1.0-1.0] (3) [1.0-2.0] (28) [1.0-2.0] (30)


[1.0-1.0] (8) [2.0-6.0] (7) [3.0-9.0] (32) [1.0-4.0] (91) [1.0-3.0] (12) [1.0-5.0] (142) [1.0-5.0] (150)


[0.0-1.0] (2) (1) [1.0-4.0] (10) [1.0-2.0] (9) [2.0-3.0] (4) [1.0-3.0] (24) [1.0-3.0] (26)

Number of oral AMT AETDs** distributed in the past week


[0.6-7.5] (3) [3.8-7.5] (4) [0.6-3.8] (21) [0.2-1.3] (30) [2.5-3.1] (2) [0.3-2.5] (57) [0.3-2.5] (60)


[1.3-7.5] (2) [0.1-6.3] (3) [0.6-1.3] (9) [0.6-1.3] (14) [0.2-1.3] (3) [0.6-1.3] (29) [0.6-1.3] (31)


[0.3-2.5] (8) [0.4-3.1] (7) [1.3-3.1] (32) [0.2-1.3] (91) [0.6-3.1] (12) [0.2-1.9] (142) [0.2-1.9] (150)


[1.3-3.1] (2) (1) [0.7-1.9] (10) [0.2-0.6] (9) [1.3-6.3] (4) [0.4-4.4] (24) [0.6-3.1] (26)

Number of 50mg tablets distributed in the past week#


[12.0-144.0] (3) [72.0-144.0] (4) [12.0-72.0] (21) [3.0-24.0] (30) (1) [5.0-48.0] (56) [5.0-48.0] (59)


[24.0-144.0] (2) [1.0-120.0] (2) [12.0-24.0] (9) [12.0-24.0] (14) [3.0-24.0] (3) [12.0-24.0] (28) [12.0-24.0] (30)


[6.0-48.0] (8) [7.0-60.0] (7) [24.0-60.0] (32) [3.0-24.0] (91) [12.0-60.0] (12) [4.0-36.0] (142) [4.0-36.0] (150)


[24.0-60.0] (2) (1) [13.0-36.0] (10) [3.0-12.0] (9) [24.0-120.0] (4) [8.0-84.0] (24) [12.0-60.0] (26)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets*

Estimated number of individual customers treated with oral AMT in the

past week##


[1.0-12.0] (3) [0.0-6.0] (4) [1.0-12.0] (18) [0.0-3.0] (30) [5.0-400.0] (2) [0.0-5.0] (54) [0.3-6.0] (57)


[4.0-36.0] (2) [0.1-10.0] (3) [0.0-1.5] (5) [3.0-12.0] (13) [1.0-12.0] (3) [2.0-12.0] (24) [2.0-12.0] (26)


[0.5-5.0] (8) [1.5-30.0] (7) [12.0-36.0] (19) [1.5-6.0] (84) [2.0-12.0] (11) [2.0-12.0] (121) [1.7-12.0] (129)


[2.0-30.0] (2) (1) [0.0-6.5] (9) [0.0-4.0] (8) [2.0-10.0] (4) [0.2-6.5] (22) [0.6-6.5] (24)

* Excluding 43 outlets that responded to recent oral AMT distribution questions with “don’t know.”

** One adult equivalent treatment dose of artesunate or artemether tablets consists of 960mg including a recommended loading dose of 4mg/kg on the first day followed by a siz-day course of 2mg/kg once daily (WHO, 2001 Use of Antimalarials).


## Providers indicated a typical number of tablets dispensed to treat malaria in an adult. This indicator is shown in Table D4. The estimated number of individual customers treated is calculated within each outlet as the total number of tablets reportedly dispensed is the past week divided by the number of tablets typically dispensed to treat malaria in an adult.




Table D4: Characteristics of oral AMT products, by outlet type

Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of oral AMT products:

1. N=20 2. N=10 3. N=26 4. N=3

1. N=21 2. N=9

3. N=39 4. N=7

1. N=664 2. N=32

3. N=105 4. N=39

1. N=130 2. N=48

3. N=352 4. N=50

1. N=19 2. N=19 3. N=27 4. N=16

1. N=234 2. N=108 3. N=523 4. N=112

1. N=254 2. N=118 3. N=549 4. N=115

Audited within: 1. Eastern (AMTR intervention)

Health Worker -- -- -- -- -- -- 6.9

- - - - - - (4.0, 11.5)


- - - - - (4.7, 13.0) (4.4, 11.9)

Pharmacy -- -- -- -- -- 25.5 23.7

- - - - - (18.7, 33.6) (17.5, 31.2)

Retailer -- -- -- -- -- 58.5 54.5

- - - - - (48.8, 67.6) (44.5, 64.2)


- - - - - (4.6, 14.1) (4.3, 13.0)

Audited within: 2. Central [AMTR comparison)

Health Worker -- -- -- -- -- -- 9.0

- - - - - - (4.4, 17.4)


- - - - - (3.5, 13.3) (3.2, 12.2)

Pharmacy -- -- -- -- -- 25.6 23.3

- - - - - (17.1, 36.4) (15.6, 33.2)

Retailer -- -- -- -- -- 49.1 44.7

- - - - - (35.0, 63.3) (31.6, 58.5)


- - - - - (10.6, 29.9) (9.7, 27.4)

Audited within: 3. Western / India border

Health Worker -- -- -- -- -- -- 4.1

- - - - - - (2.4, 7.0)


- - - - - (3.5, 7.8) (3.3, 7.5)

Pharmacy -- -- -- -- -- 13.8 13.2

- - - - - (9.8, 19.1) (9.4, 18.4)

Retailer -- -- -- -- -- 75.9 72.8

- - - - - (69.6, 81.3) (66.4, 78.4)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets


- - - - - (3.2, 7.6) (3.1, 7.3)

Audited within: 4. Bangladesh border / Rakhine

Health Worker -- -- -- -- -- -- 1.7

- - - - - - (0.4, 6.3)


- - - - - (1.4, 7.3) (1.4, 7.2)

Pharmacy -- -- -- -- -- 27.8 27.3

- - - - - (16.8, 42.4) (16.5, 41.7)

Retailer -- -- -- -- -- 45.5 44.7

- - - - - (33.2, 58.3) (32.7, 57.4)


- - - - - (13.6, 37.3) (13.4, 36.7)

Active ingredient

1. Eastern (AMTR intervention)

Artesunate 100.0 96.0 88.6 81.1 91.8 85.0 86.1

- (84.3, 99.1) (77.0, 94.8) (64.9, 90.8) (63.6, 98.6) (74.2, 91.8) (75.6, 92.5)

Artemether 0.0 4.0 11.4 18.9 8.2 15.0 13.9

- (0.9, 15.7) (5.2, 23.0) (9.2, 35.1) (1.4, 36.4) (8.2, 25.8) (7.5, 24.4)

2. Central (AMTR comparison)

Artesunate 100.0 100.0 100.0 91.7 94.5 94.9 95.4

- - - (80.9, 96.7) (69.5, 99.2) (89.0, 97.7) (90.0, 97.9)

Artemether 0.0 0.0 0.0 8.3 5.5 5.1 4.6

- - - (3.3, 19.1) (0.8, 30.5) (2.3, 11.0) (2.1, 10.0)

3. Western / India border

Artesunate 96.5 83.9 92.8 97.7 99.1 96.4 96.4

(81.1, 99.4) (70.4, 91.9) (81.6, 97.4) (95.8, 98.8) (95.0, 99.9) (94.2, 97.8) (94.3, 97.7)

Artemether 3.5 16.1 7.2 2.3 0.9 3.6 3.6

(0.6, 18.9) (8.1, 29.6) (2.6, 18.4) (1.2, 4.2) (0.1, 5.0) (2.2, 5.8) (2.3, 5.7)

4. Bangladesh border / Rakhine

Artesunate 100.0 86.3 100.0 84.9 100.0 92.7 92.8

- (43.3, 98.1) - (65.3, 94.4) - (82.2, 97.2) (82.5, 97.2)

Artemether 0.0 13.7 0.0 15.1 0.0 7.3 7.2

- (1.9, 56.7) - (5.6, 34.7) - (2.8, 17.8) (2.8, 17.5)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets

Expiry Dates

1. N=19 2. N=10 3. N=24 4. N=3

1. N=18 2. N=6

3. N=36 4. N=6

1. N=63 2. N=28 3. N=97 4. N=34

1. N=99 2. N=38

3. N=323 4. N=44

1. N=16 2. N=16 3. N=19 4. N=13

1. N=196 2. N=88

3. N=475 4. N=97

1. N=215 2. N=98

3. N=499 4. N=100



(0.9, 37.5) (2.3, 36.2) (4.7, 36.5) (6.8, 24.2) (17.9, 70.4) (9.3, 25.8) (8.9, 24.9)


(7.1, 32.9) (10.8, 52.9) (7.2, 26.1) (9.4, 36.8) - (9.2, 28.9) (9.5, 27.9)


(2.8, 42.4) (0.7, 30.3) (0.7, 9.7) (4.4, 21.4) (0.9, 37.0) (3.5, 13.6) (3.8, 14.1)


(44.0, 83.8) (41.4, 83.9) (46.4, 85.7) (59.5, 78.6) (32.4, 80.4) (57.4, 77.8) (57.4, 77.6)



(13.8, 74.1) (4.2, 75.2) (0.6, 24.6) (9.8, 41.3) (1.6, 48.4) (8.3, 26.0) (10.6, 28.6)


(2.9, 64.3) (4.3, 56.1) (9.6, 48.7) (12.7, 36.6) (17.3, 58.4) (17.6, 35.3) (17.1, 34.3)


(1.6, 50.2) (3.0, 69.0) (6.8, 33.1) (8.8, 37.8) (3.3, 34.1) (9.9, 27.7) (9.7, 26.4)


(9.7, 62.1) (24.6, 85.9) (47.8, 77.1) (35.0, 67.3) (26.8, 68.0) (43.0, 64.9) (41.4, 62.3)



(3.7, 30.7) (5.3, 28.7) (5.2, 36.6) (4.9, 12.7) (0.8, 25.6) (5.8, 13.8) (6.0, 13.8)


(0.2, 9.0) (7.3, 29.6) (0.7, 8.6) (12.2, 23.0) (1.9, 17.5) (10.7, 19.0) (10.4, 18.4)


(0.3, 10.1) - (0.1, 2.9) (0.1, 2.4) - (0.1, 1.9) (0.2, 2.0)


(71.9, 95.1) (59.1, 86.6) (64.8, 93.2) (69.6, 82.2) (78.9, 97.2) (72.5, 82.9) (73.1, 83.2)



- - (1.1, 14.9) (5.1, 34.9) - (3.1, 18.4) (3.0, 18.0)


(11.9, 95.1) (3.5, 72.6) (20.9, 54.1) (18.4, 51.3) (17.4, 73.7) (25.3, 48.1) (25.9, 48.4)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets


- - - - - - -


(4.9, 88.1) (37.6, 97.6) (47.3, 78.0) (40.6, 74.5) (31.9, 84.4) (50.0, 72.0) (49.8, 71.5)

Manufacturer

1. N=20 2. N=10 3. N=26 4. N=3

1. N=21 2. N=9

3. N=39 4. N=7

1. N=664 2. N=32

3. N=105 4. N=39

1. N=130 2. N=48

3. N=352 4. N=50

1. N=19 2. N=19 3. N=27 4. N=16

1. N=234 2. N=108 3. N=523 4. N=112

1. N=254 2. N=118 3. N=549 4. N=115



(69.0, 93.6) (33.7, 79.2) (50.9, 84.7) (50.1, 79.5) (31.7, 85.4) (52.6, 78.0) (54.4, 78.8)


- - (1.7, 13.8) (1.4, 11.9) (1.1, 39.5) (2.0, 9.2) (1.9, 8.7)


- - (3.0, 18.0) (0.9, 7.9) - (1.7, 7.2) (1.6, 6.8)

Other 15.0 41.8 16.8 26.7 29.9 25.6 24.9

(6.4, 31.0) (20.8, 66.3) (7.8, 32.6) (16.8, 39.6) (9.8, 62.6) (16.7, 37.1) (16.4, 35.8)



(25.9, 86.2) (35.0, 93.6) (77.2, 97.7) (50.0, 82.2) (58.1, 94.5) (66.6, 85.6) (65.4, 84.0)


(13.8, 74.1) (2.4, 61.4) - (5.9, 25.0) (1.0, 35.9) (4.5, 16.0) (6.5, 19.6)


- - - (0.6, 11.2) (0.8, 30.5) (0.7, 7.3) (0.7, 6.6)

Other 0.0 9.7 7.7 16.4 4.5 11.5 10.5

- (1.3, 46.3) (2.3, 22.8) (7.9, 30.8) (1.1, 17.4) (6.5, 19.6) (5.9, 17.9)



(76.4, 97.9) (52.9, 86.0) (75.7, 94.6) (78.0, 88.2) (63.4, 90.2) (78.6, 87.5) (79.2, 87.7)


- (2.3, 20.8) (0.4, 7.0) (0.2, 2.0) - (0.5, 2.3) (0.5, 2.2)


- (1.5, 19.0) (0.7, 18.7) (0.7, 3.4) - (1.0, 4.2) (0.9, 4.0)

Other 7.6 14.7 6.1 14.1 20.0 13.3 13.1

(2.1, 23.6) (5.1, 35.5) (2.7, 13.3) (9.9, 19.7) (9.8, 36.6) (9.8, 18.0) (9.6, 17.5)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets



- (43.3, 98.1) (71.7, 96.8) (55.1, 88.0) (68.1, 97.7) (72.5, 90.2) (72.9, 90.3)


- (1.9, 56.7) (1.2, 28.2) (5.8, 31.5) - (4.2, 17.5) (4.1, 17.2)


- - - (0.9, 30.0) - (0.4, 15.6) (0.4, 15.4)

Other 0.0 0.0 3.8 4.8 9.5 5.5 5.4

- - (1.0, 13.4) (0.7, 25.9) (2.3, 31.9) (2.1, 13.4) (2.1, 13.1)

Median Median [IQR] N of products







Number of packages obtained during the most recent wholesale purchase


[1.0-5.0] (20) [2.0-5.0] (21) [3.0-10.0] (64) [1.0-5.0] (130) [1.0-10.0] (19) [2.0-8.0] (234) [2.0-8.0] (254)


[1.0-4.0] (10) [0.0-5.0] (9) [2.0-10.0] (32) [1.0-3.0] (48) [1.0-3.0] (19) [1.0-5.0] (108) [1.0-5.0] (118)


[1.0-5.0] (26) [2.0-10.0] (39) [5.0-10.0] (105) [2.0-7.0] (352) [2.0-5.0] (27) [2.0-10.0] (523) [2.0-10.0] (549)


[6.0-20.0] (3) [1.0-10.0] (7) [2.0-5.0] (39) [1.0-3.0] (50) [1.0-5.0] (16) [1.0-5.0] (112) [1.0-5.0] (115)

Wholesale price per 50mg tablet (most recent purchase)#

1. Eastern (AMTR intervention) $0.10 $0.10 $0.10 $0.12 $0.10 $0.12 $0.12

[0.04-0.10] (18) [0.07-0.10] (14) [0.10-0.13] (55) [0.10-0.13] (102) [0.08-0.12] (19) [0.10-0.13] (190) [0.10-0.12] (208)

2. Central (AMTR comparison) $0.10 $0.10 $0.10 $0.11 $0.11 $0.10 $0.10

[0.00-0.11] (9) [0.10-0.11] (6) [0.09-0.10] (29) [0.10-0.12] (34) [0.10-0.13] (16) [0.10-0.12] (85) [0.10-0.12] (94)

3. Western / India border $0.13 $0.12 $0.11 $0.12 $0.13 $0.12 $0.12

[0.12-0.13] (22) [0.12-0.13] (33) [0.10-0.12] (85) [0.12-0.13] (278) [0.12-0.15] (23) [0.11-0.13] (419) [0.11-0.13] (441)

4. Bangladesh border / Rakhine $0.18 $0.10 $0.10 $0.12 $0.12 $0.11 $0.12

[0.14-0.18] (3) [0.10-0.20] (6) [0.09-0.10] (34) [0.11-0.13] (46) [0.08-0.12] (16) [0.10-0.12] (102) [0.10-0.12] (105)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets








Retail price per 50mg tablet#


[0.07-0.20] (19) [0.00-0.14] (9) [0.12-0.16] (61) [0.16-0.20] (129) [0.13-0.33] (15) [0.13-0.20] (214) [0.13-0.20] (233)


[0.00-0.20] (9) [0.07-0.16] (6) [0.10-0.15] (30) [0.12-0.20] (47) [0.16-0.16] (16) [0.11-0.16] (99) [0.11-0.16] (108)


[0.16-0.20] (25) [0.12-0.16] (33) [0.12-0.16] (105) [0.16-0.20] (352) [0.16-0.20] (25) [0.16-0.20] (515) [0.16-0.20] (540)


[0.16-0.16] (2) [0.10-0.20] (5) [0.10-0.12] (39) [0.16-0.20] (50) [0.12-0.20] (12) [0.12-0.16] (106) [0.12-0.16] (108)

Retail price per AETD*


[1.26-3.78] (19) [0.00-2.77] (9) [2.27-3.15] (61) [3.02-3.78] (115) [2.52-6.29] (15) [2.52-3.78] (200) [2.52-3.78] (219)


[0.00-3.78] (9) [1.26-3.02] (6) [1.95-2.96] (30) [2.27-3.78] (46) [3.02-3.15] (16) [2.14-3.02] (98) [2.14-3.15] (107)


[3.02-3.78] (23) [2.52-3.78] (32) [2.27-3.02] (102) [3.02-3.78] (344) [3.02-3.78] (22) [3.02-3.78] (500) [3.02-3.78] (523)


[3.15-3.15] (2) [2.01-3.78] (5) [1.89-2.27] (39) [3.02-3.78] (50) [2.39-3.78] (12) [2.27-3.02] (106) [2.27-3.02] (108)

Retail percentage mark-up**

1. Eastern (AMTR intervention) 33.3% 22.2% 25% 33.3% 25% 33.3% 33.3%

[20.0%-125.0%] (17) [0.0-33.3] (7) [14.3-44.0] (53) [20.0-60.0] (102) [11.1-222.6] (15) [20.0-60.0] (177) [20.0%-66.7%] (194)

2. Central (AMTR comparison) 17.6% 41.2% 14.3% 25.0% 36.4% 25.0% 25.0%

[0.0%-25.0%] (8) [0.0%-41.2%] (4) [7.1%-33.3%] (29) [16.7%-41.2%] (34) [25.0%-41.2%] (14) [12.5%-41.2%] (81) [11.1%-41.2%] (89)

3. Western / India border 25.0% 25.0% 18.0% 50.0% 33.3% 43.7% 41.2%

[17.6%-33.3%] (22) [10.3%-38.9%] (29) [11.1%-38.9%] (85) [33.3-%66.7%] (278) [20.0%-44.0%] (21) [20.0%-66.7%] (413) [20.0%-66.7%] (435)

4. Bangladesh border / Rakhine 13.6% 0.0% 13.3% 50.0% 33.3% 33.3% 33.3%

[13.6%-13.6%] (2) [0.0%-66.7%] (5) [9.1%-17.6%] (34) [33.3%-60.0%] (46) [20.0%-71.4%] (12) [13.3%-60.0%] (97) [13.3%-60.0%] (99)




Community Health

Worker

Private For-Profit



ALL Private

ALL Outlets








Number of 50mg tablets typically dispensed to treat malaria in an adult


[2.0-12.0] (20) [2.0-12.0] (21) [1.0-12.0] (61) [1.0-3.0] (129) [2.0-12.0] (19) [1.0-4.0] (230) [1.0-12.0] (250)


[3.0-12.0] (10) [1.0-12.0] (8) [1.0-3.0] (25) [1.0-2.0] (44) [2.0-12.0] (18) [1.0-2.0] (95) [1.0-3.0] (105)


[2.0-10.0] (22) [2.0-12.0] (33) [1.0-12.0] (79) [1.0-2.0] (314) [2.0-12.0] (26) [1.0-3.0] (452) [1.0-3.0] (474)


[2.0-12.0] (3) [2.0-12.0] (6) [2.0-10.0] (31) [1.0-2.0] (43) [3.0-12.0] (16) [1.0-6.0] (96) [2.0-10.0] (99)

There were 124 oral AMT products missing expiry date information; these were not included in the denominator.

* One adult equivalent treatment dose of artesunate or artemether tablets consists of 960mg including a recommended loading dose of 4mg/kg on the first day followed by a six-day course of 2mg/kg once daily (WHO, 2001 Use of Antimalarials).


** Retail percentage mark-up was calculated as the difference between selling price and purchase price, divided by the purchase price. Products with missing retail or wholesale price information were excluded.




Annex 1: ACTwatch Background ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. Project countries include: Benin, Cambodia, the Democratic Republic of Congo, Kenya, Laos, Madagascar, Myanmar, Nigeria, Tanzania (currently mainland only, previous work in Zanzibar), Thailand, Uganda, Vietnam, and Zambia. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF. The project is also supported with funding from UNITAID and the Department for International Development (DFID). ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence.2 The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. ACTwatch is monitoring antimalarial markets in the context of policy shifts and investments in the scale-up of first-line ACT and blood testing using RDTs. This has included adaptation of project methods for the evaluation of the Affordable Medicines Facility-malaria (AMFm) pilot.3 Project scale-up in the Greater Mekong sub-Region (GMS) in 2015 was designed to deliver key indicators for informing and monitoring strategies and policies for malaria elimination. The project implements a set of research tools designed to: 1) Provide a picture of the total market for malaria case management including: all providers carrying

antimalarials and RDTs and providing case management services; the relative antimalarial market share for each provider type; the antimalarial supply chain; and price markups within the supply chain for antimalarials and RDTs.

2) Monitor the readiness of market components for appropriate malaria case management, including: availability

of antimalarials and malaria blood testing; consumer price of antimalarial treatment and malaria blood testing; and provider qualifications, training and knowledge.

3) Monitor the performance of market components for appropriate malaria case management, including: the

relative market share for quality-assured ACT relative to other antimalarial medicines; the demand for appropriate malaria case management captured through consumer knowledge, attitudes, and fever treatment seeking behavior; and the quality of provider service delivery measured against national policies, guidelines and minimum standards.

ACTwatch research tools for malaria market monitoring include: 1. Outlet surveys Outlet surveys entail collecting quantitative data from all outlets and providers with the potential to sell or distribute antimalarials and/or provide malaria blood testing. These include health facilities, community health workers, pharmacies, drug stores, retail outlets, market stalls, and mobile providers. A screening process identifies outlets that provide antimalarials and/or malaria blood testing. Among these eligible outlets, service providers are interviewed and all antimalarials and RDTs are audited. The audit collects information about each antimalarial and RDT in stock (e.g. brand name, drug active ingredients and strengths, manufacturer, etc.) and retailer reports on consumer price and sale/distribution volumes for each product. A representative sample of outlets is identified within target study domains such that findings from the outlet survey provide estimates of antimalarial and RDT availability, price, and relative market share across the entire market as well as within key market channels.4

3 AMFm Independent Evaluation Team. 2012. Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi-country independent evaluation report: final report. Calverton, MD and London: ICF International and London School of Hygiene and Tropical Medicine. 4 O’Connell KA, Poyer S, Solomon T, et al. 2013. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malaria Journal, 12: 52.


http://www.psi.org/


From 2008 through 2014, ACTwatch conducted 35 national outlet surveys across the 10 project countries.5 Reports are available at www.actwatch.info, and peer-reviewed publications have appeared in Malaria Journal and The Lancet.6 2. Supply chain studies Supply chain studies employ quantitative and qualitative research methods to effectively map the antimalarial supply chain in a given country. The supply chain is mapped from the antimalarial outlets (service delivery points) identified during an outlet survey to national importers and distributors with identification of all mid-level distributers in between. Retail prices are documented along the supply chain to facilitate calculation of commodity mark-ups. From 2008 through 2012, ACTwatch conducted 8 national supply chain studies. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in PLoS One.7 2015 outlet surveys in the Greater Mekong sub-Region include a component to collect additional information about the supply chain for oral artemisinin monotherapy (oral AMT, e.g. artesunate tablets). Oral AMT identified during the outlet surveys was further investigated and research teams identified and visited named suppliers to collect further information about the supply chain. 3. Population-based surveys Population-based surveys are conducted among consumers to document fever treatment-seeking behavior. A representative sample of the target population (caregivers of children and/or adults according to burden and risk) is identified, and a screening tool is used to identify individuals who have recently experienced fever. The surveys investigate the extent to which health care was sought, as well as common sources of care received. Respondent reports of malaria blood testing and antimalarials acquired are documented and summarized. The survey includes measures of demographic and other individual, household/family, and community characteristics that can be used to develop consumer profiles as well as monitor equity in access to malaria case management. From 2008 through 2012, ACTwatch conducted 14 household surveys focused on fever treatment-seeking behavior. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in Malaria Journal.8

4. Fever case management quality of care Fever case management quality of care is monitored using a set of research tools designed to measure aspects of the interaction between providers and clients. ACTwatch launched fever case management quality of care studies in 2015 in a subset of project countries. The following research tools were integrated into the outlet surveys in Cambodia and Uganda and were implemented among private sector outlets providing malaria testing and treatment:

Exit interviews conducted with target consumers immediately after receiving fever case management services in the private sector. A structured interview documented client reports about key aspects of service delivery including malaria blood testing, test results, medicines recommended/prescribed and obtained, counseling, and costs of services and commodities received. Exit interviews were also used to measure client recall and comprehension of provider counseling including instructions for completing prescribed drug regimens, as well as client satisfaction with services provided.

5 Surveys in the DRC (2) and Myanmar (3) were sub-national. 6 O’Connell K, Gatakaa H, Poyer S, et al. 2011. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malaria Journal, 10: 326. Tougher S, the ACTwatch Group, Ye Y, et al. 2013. Effect of the Affordable Medicines Facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet, 380: 1916-26. 7 Palafox B, Patouillard E, Tougher S, et al. 2014. Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries. PLoS One, 9(4). 8 Littrell M, Gatakaa H, Evance I, et al. (2011). Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 10: 327.






A consultation observation checklist was used to document aspects of the provider-client interaction in the private sector. A trained observer completed the checklist designed to document provider compliance with standard practice and procedures as well as aspects of client demand for specific products or services. The observer remained silent during the consultation.

ACTwatch in Myanmar Population Services International (PSI) Myanmar conducted a baseline private sector malaria commodity outlet survey and household survey in 2012 in the Artemisinin Monotherapy Replacement Project (AMTR) intervention and comparison areas. Follow-up outlet surveys were conducted in 2013 and 2014 and follow-up household surveys were conducted in 2013, 2014, and 2015. All surveys were based on ACTwatch outlet survey methodology. In 2015 a full ACTwatch outlet survey was conducted nationally and comprised the fourth round of evaluation for private sector outlets in the AMTR intervention and comparison areas and served as a baseline private sector survey in the Western / India border region and Bangladesh border / Rakhine region. All reports are available at

www.actwatch.info.




Annex 2: Country Background Myanmar is located in the Greater Mekong Subregion (GMS) of Southeast Asia and is bordered by five countries: Bangladesh to the west, India to the northwest, China to the north east, the People’s Democratic Republic of Laos to the east, and Thailand to the southeast. The country is divided into 21 administrative subdivisions including states, regions, and union territories, which are further divided into districts, then townships, then village-tracts, wards, and towns. The climate is primarily classified as a tropical monsoon climate, with three distinct seasons: the hot dry season (February through May), the rainy season (May through October), and the cool dry season (October through February). In 2011, the population was estimated at 61.3 million, with 135 ethnic groups—primarily Bamar, Chin, Kachin, Kayah, Kayin, Mon Rakhine, and Shan.9 The economy has been highly focused on foreign investment since 2011, especially in the energy sector, the garment industry, information technology, and food and beverage, but despite the government’s efforts to improve the country’s economy over one-fourth of the population still lives in poverty.10 The World Bank classifies Myanmar as having a lower-middle income economy.11

Healthcare system

In 2007, life expectancy at birth in rural areas was 67 for females and 63 for males and 69 and 64, respectively, in urban areas, demonstrating an increase since the previous data from 1988.12 During the same time period, under-5 mortality rate, infant mortality rate, and maternal mortality rate all declined.13 The diseases of primary concern are tuberculosis, malaria, and HIV/AIDS, but lack of skilled assistance during childbirth, malnutrition, and natural disasters are other major areas of health-related concern.14 There remains a significant inequity in quality of healthcare in different regions of the country, with people living in poverty and certain ethnic groups experiencing lower qualities of health care and higher exposure to certain public health risks.15

In an effort to meet health and development goals, the Ministry of Health (MOH) developed the “Myanmar Health Vision 2030” in 2000. One of its main components was the National Health Plan (NHP) 2011-2016, which was originally a top-down exercise. However, in 2012, the MOH and the States and Regions worked together to develop a “bottom-up planning approach” using local data.16 There was also a focus on a Universal Health Coverage (UHC) strategy, developed to provide affordable access to promotive, preventive, curative, and rehabilitative services, especially for vulnerable populations like women and children. To achieve UHC, improved health financing must be prioritized through measures such as increasing tax-based financing, expanding coverage of social health insurance, and incorporating community-based health insurance and social assistance from community-based organizations.17 A primary challenge to adequate health service delivery in general is limited human resources at multiple levels in the system.18

In the public sector at the township level, the township governments provide hospital, clinics, and rural health centers (RHCs), in addition to sub-centers at each RHC that also include voluntary health workers. Local NGOs and faith-based organizations are also a major contributing entity in terms of village-level healthcare delivery. Additionally, there is a governmental focus on the promotion of traditional medicine, which is provided free of charge alongside allopathic medicine.19

9 World Health Organization. (2014). WHO country cooperation strategy 2014-2018, Myanmar. Myanmar: WHO Country Office

for Myanmar. 10 Central Intelligence Agency. (2013). The World Factbook, 2013 - 2014. Washington, DC: Central Intelligence Agency. 11 The World Bank. (2016). Myanmar. Retrieved August 26, 2016, from http://data.worldbank.org/country/myanmar 12 World Health Organization. (2014). WHO country cooperation strategy 2014-2018, Myanmar. Myanmar: WHO Country Office

for Myanmar. 13 Ibid 14 Ibid 15 Ibid 16 Ibid 17 Ibid 18 Ibid 19 Ibid



The role of the private sector in Myanmar An estimated 70% of people seek malaria treatment in the private sector in Myanmar. An estimated 80% of ambulatory care is also provided in the private sector.20 Treatment seeking in the private sector is largely due to the historical underfunding of the public sector, and difficulties of service delivery in remote, border, and conflict affected areas. These remote border areas are the very places that experience high malaria burden and are at the heart of emerging drug resistance.

Private sector outlets consist of private doctors, private health workers, pharmacies, general retail shops, and informal providers (also known as itinerant drug vendors). The last three categories are largely unregulated and historically had very low availability of ACTs due to cost. They therefore experienced subsequent lack of consumer demand for ACTs, and thus carried the majority of oral AMT across Myanmar.21 In 2010, there were an estimated 103 private hospitals, 192 specialty clinics, and 2,891 general clinics.22 To date, private sector involvement in public sector health programs has been limited. Certain entities have been providing training to private sector providers on key public health issues and contributing in other ways to the growing private sector, including members of the Myanmar Medical Association, the MMCWA, and the Myanmar Red Cross Society.23

Malaria risk and burden

Within the GMS, the malaria burden is highest in Myanmar, where it remains a leading cause of morbidity and mortality.24 Although malaria cases in Myanmar have experienced a sharp decline in recent years, approximately 60% of the population lives in malaria endemic areas with 16% (8.4 million) living in high-transmission areas and 44% residing in areas with low transmission (23.3 million people).25

The peak malaria transmission period is associated with the rainy season and generally occurs July through October for the majority of the country but may begin as early as May in some parts of the country, such as Rakhine state.26 The primary malaria vectors include Anopheles dirus and An. minimus mosquito species, however, vector species varies based on location; An. annularis, An. sundaicus, An. culicifacies, and An. philippinensis are important vectors in some regions.27,28

Figure X1. Malaria confirmed cases per 1000 population, 201529

20 World Health Organization. (2014). WHO country cooperation strategy 2014-2018, Myanmar. Myanmar: WHO Country Office

for Myanmar. 21 ACTwatch Group, PSI Myanmar. (216). Study Reference Document: Myanmar Outlet Survey 2015. Yangon, Myanmar: PSI

Myanmar. 22 Ibid 23 Ibid 24 Initiative USPsM. (2015). Greater Mekong Subregion - Malaria Operational Plan FY 2015. 25 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. 26 Smithuis F, Kyaw MK, Phe UO, Broek Ivd, Katterman N, et al. (2010). Effectiveness of five artemisinin combination regimens

with or without primaquine in uncomplicated falciparum malaria: an open-label randomised trial. The Lancet Infectious Diseases

10: 187-180. 27 Initiative USPsM (2015) Greater Mekong Subregion- Malaria Operational Plan FY 2015. 28 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. 29 Ibid



In 2015, there were 152,195 reported confirmed cases and 92 reported deaths from malaria30. Approximately 75% of confirmed cases were Plasmodium falciparum (Pf) malaria and 25% from Plasmodium vivax (Pv) malaria.31 Transmission is concentrated along border regions with Thailand, Bangladesh, India, and Yunan Province, China. Most malaria cases occur among people residing in villages near or in the forests (Figures X1 and X2). People at risk of malaria are typically migrants and members of ethnic minority groups who engage in subsistence farming and income-generating activities such as logging, mining or dam construction in the forest, and plantation workers (rubber trees, oil palms).32

Figure X2. Malaria Risk Stratification in Myanmar, 200833

30 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. 31 Ibid 32 Vector-borne Disease Control Division MoH, Union of Myanmar. World Health Organization. (2011) Strategic framework for

artemisinin resistance containment in Myanmar (MARC) 2011-2015. Geneva, Swizerland.: World Health Organization. 33 Ibid



Artemisinin resistance

Artemisinin resistance to Pf is present in the eastern-border region with Thailand, within Kachin, Kayah, and Kayin states,34,35,36 and slow parasite clearance after treatment with ACTs is emerging in Mon, Tanintharyi, and Bago-East.37,38 Recent studies have documented resistance along the north-eastern border with China and north-western border with India in Chin state.39 Pf parasites resistant to artemisinins, chloroquine, and SP are present in these regions, and there is evidence of reduced parasite sensitively to quinine and mefloquine. Artemisinin resistance, characterized by slow parasite clearance and treatment failure, likely emerged at the border between Thailand and Myanmar in 2001 and was clearly observed along the Myanmar-Thai border in 2008.40 Available 2009 data show consistently delayed parasite clearance rates in patients with Pf malaria treated with AL, ASAQ, and DHA PPQ in five regions and states in south-eastern Myanmar including Kachin, Kayah, Kayin, Mon, and Tanintharyi States.41,42,43,44,45,46

As of September 2014, the three first-line ACTs used in the country were still effective as treatment for uncomplicated falciparum malaria, with high cure rates.47 However, a recent study revealed that artemisinin resistance now extends across much of Myanmar and more of SE Asia than had previously been known. The authors recorded Pf parasites carrying K13-propeller mutations (de novo expansion) next to the northwestern border with India and along the China-Myanmar border. This finding expands the area in which containment and elimination are needed to prevent the possibility of global spread of artemisinin resistance.48 Figure X3 displays the distribution of the tiers across the GMS.49

34 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. 35 Phyo AP, Nkhoma S, Stepniewska K, Ashley EA, Nair S, et al. (2012) Emergence of artemisinin-resistant malaria on the

western border of Thailand: a longitudinal study. The Lancet 379: 1960-1966. 36 Carrara VI, Zwang J, Ashley EA, Price RN, Stepniewska K, et al. (2009) Changes in the Treatment Responses to Artesunate-

Mefloquine on the Northwestern Border of Thailand during 13 Years of Continuous Deployment. PLoS ONE 4: e4551. 37 Brown T, Smith LS, Oo EKS, Shawng K, Lee TJ, et al. (2012) Molecular surveillance for drug-resistant Plasmodium

falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a

systematic review of resistance studies. Malaria Journal 11: 333-333. 38 Kyaw M Tun MI, Khin M Lwin, Aye A Win, Tin M Hlaing, Thaung Hlaing, et al. (2015) Spread of artemisinin-resistant

Plasmodium falciparum in Myanmar: a cross-sectional survey of the K13 molecular marker. Lancet Infectious Disease 15: 415-

421. 39 Kyaw MP, Nyunt MH, Chit K, Aye MM, Aye KH, et al. (2013) Reduced Susceptibility of Plasmodium falciparum to

Artesunate in Southern Myanmar. PLoS ONE 8: e57689. 40 WHO (2014) Status report on artemisinin resistance: September 2014. Geneva, Switzerland. World Health Organization. 41 Kyaw M Tun MI, Khin M Lwin, Aye A Win, Tin M Hlaing, Thaung Hlaing, et al. (2015) Spread of artemisinin-resistant


421. 42 Smithuis F, Kyaw MK, Phe UO, Broek Ivd, Katterman N, et al. (2010) Effectiveness of five artemisinin combination regimens

with or without primaquine in uncomplicated falciparum malaria: an open-label randomised trial. The Lancet Infectious Diseases

10: 187-180. 43 Phyo AP, Nkhoma S, Stepniewska K, Ashley EA, Nair S, et al. (2012) Emergence of artemisinin-resistant malaria on the

western border of Thailand: a longitudinal study. The Lancet 379: 1960-1966. 44 Carrara VI, Zwang J, Ashley EA, Price RN, Stepniewska K, et al. (2009) Changes in the Treatment Responses to Artesunate-

Mefloquine on the Northwestern Border of Thailand during 13 Years of Continuous Deployment. PLoS ONE 4: e4551. 45 Brown T, Smith LS, Oo EKS, Shawng K, Lee TJ, et al. (2012) Molecular surveillance for drug-resistant Plasmodium

falciparum in clinical and subclinical populations from three border regions of Burma/Myanmar: cross-sectional data and a

systematic review of resistance studies. Malaria Journal 11: 333-333. 46 Kyaw MP, Nyunt MH, Chit K, Aye MM, Aye KH, et al. (2013) Reduced Susceptibility of Plasmodium falciparum to

Artesunate in Southern Myanmar. PLoS ONE 8: e57689. 47 WHO (2014) Status report on artemisinin resistance: September 2014. Geneva, Switzerland. World Health Organization. 48 Kyaw M Tun MI, Khin M Lwin, Aye A Win, Tin M Hlaing, Thaung Hlaing, et al. (2015) Spread of artemisinin-resistant


421. 49 WHO. (2013). Emergency Response to Artemisinin Resistance in the Greater Mekong subregion: regional framework for

action 2013-2015. Geneva, Switzerland: World Health Organization.



Figure X3. WHO Emergency Response to Artemisinin Resistance Tier Map, Sep 201450

Malaria case management guidelines

The 2012 Myanmar National Treatment Guidelines (the guidelines in practice at the time of the survey) recommend confirmatory blood testing for malaria infection through microscopy or rapid diagnostic tests, however, presumptive treatment for Pf was acceptable where testing was not available. The new National Treatment guidelines require confirmatory testing prior to treatment with the exception of provisional stand-by treatment for migrant and plantation workers.51 According to 2012 treatment guidelines, recommended first-line treatment for uncomplicated Pf malaria in adults and children includes a 3-day regimen of artemether lumefantrine (AL), artesunate mefloquine (ASMQ), or dihydroartemisinin piperaquine (DHA PPQ) followed by a single radical cure dose of primaquine (PQ, 0.25mg/kg). ASMQ and DHA-PPQ are now second line treatment medications following the new national guidelines.52 Chloroquine is the first-line treatment for other infections together with PQ in the case of Pv or Po (0.25mg/kg/day for 14 days). In cases of first- and second-line treatment failure, other ACTs or artemether plus either doxycycline, tetracycline, or clindamycin is recommended.53

The recommended treatment for severe malaria is intravenous (IV) or intramuscular (IM) parenteral artesunate. IM artemether or quinine-dihydrochloride is recommended if IM artesunate is not available. Parenteral treatment should be given for at least 48 hours and followed by a full 3-day course of a recommended oral ACT. Any of these parenteral medications or rectal artesunate suppositories may be given as pre-referral treatment for severe cases not immediately admitted to a referral hospital. The recommended first-line treatment for malaria in pregnancy is a 7-day course of quinine (10mg/kg) plus clindamycin (10mg/kg) in the first trimester of pregnancy, followed by any of the three recommended ACTs in the second and third trimesters of pregnancy.54

PQ is contraindicated during pregnancy, infancy, and in cases of severe glucose-6-phosphate dehydrogenase deficiency (G6PDd). G6PDd is thought to be present in approximately 10-15% of the Burmese population.55,56 People with G6PDd may experience life-threatening hemolysis if they ingest a sufficient dose of PQ. Radical curative

50WHO. (2013). Emergency Response to Artemisinin Resistance in the Greater Mekong subregion: regional framework for action

2013-2015. Geneva, Switzerland: World Health Organization. 51 Ministry of Health UoM (2015) Guidelines for Malaria Diagnosis and Treatment in Myanmar. 52 Ibid 53 Ministry of Health UoM (2012) National Policy for the Treatment of Malaria in the Republic of the Union of Myanmar. 54 Ibid 55 Nuchprayoon I LC, Charoenvej W (2008) Glucose-6-phosphate dehydrogenase mutations in Mon and Burmese of southern

Myanmar. Journal of Human Genetics 53: 48-54. 56 Bancone G CC, Somsakchaicharoen R, Chowwiwat N, Parker DM, Charunwatthana P, White NJ, Nosten FH (2014)

Characterization of G6PD Genotypes and Phenotypes on the Northwestern Thailand-Myanmar Border. PLoS ONE 9: e116063.



treatment with PQ (0.25mg/kg for 14 days) should be given for Pv and Po malaria with precautions. Patients with confirmed G6PDd should also be treated with PQ (0.75mg/kg, once per week for 8 weeks).57

It was recommended at the time of the survey that the first dose of oral antimalarial treatment should be observed, and, when possible, the patient should remain for one hour for further observation. Directly observed treatment (DOT) and patient follow-up are now a requirement under the 2016 National treatment guidelines.58

The National Malaria Control Programme (NMCP) promotes the use of RDTs and provision of antimalarials in accordance with the National Treatment Guidelines by educated and trained public health providers, private medical practitioners, and Village Health Volunteers (VHV).59

Malaria control and elimination strategies

The recent discovery of expanding de novo artemisinin resistance has promoted a change in strategy from the ‘fire-wall’ style control and elimination along the Eastern border of Myanmar to actively pursuing control and elimination in all at-risk areas of the country. Given progress in malaria control in recent years, goals to eliminate Pf malaria by 2030 and all malaria by 2035 have been agreed upon for Myanmar. Accelerating progress towards malaria elimination in Myanmar will require high coverage of appropriate management of suspected malaria cases. When malaria blood testing is available, suspected cases should receive confirmatory testing, and treatment must be dispensed according to national policy. Any use of non-recommended or banned drugs, including oral AMT, must urgently be addressed to protect the efficacy of artemisinins and ensure full clearance of malaria parasites from infected people.

In 2014, the WHO used available evidence about artemisinin resistance to define a 3-tier stratification system for targeting action to address drug resistance. Areas designated as Tier 1 are prioritized for immediate multifaceted response to contain or eliminate resistance. Areas designated as Tier 2 are prioritized for intensified malaria control to reduce transmission and/or limit the risk of emergence or spread of resistant parasites. Tier 3 areas have no evidence of artemisinin resistance and limited contact with Tier 1 areas. Malaria control in these areas focuses on vector control, increasing coverage with confirmatory testing, and treatment with quality-assured ACTs.

Current case management activities include the intensive scale up of RDT availability and subsidized ACTs, case management training of public and private providers including community-based diagnosis and treatment, and targeted BCC interventions.60,61,62 National malaria control and prevention activities in Myanmar are led by the National Malaria Control Program (NMCP) under direction of the Vector-Borne Disease Control (VBDC) program within the MOH in collaboration with private sector partners.

With guidance from the WHO, the NMCP and Department of Medical Research set up a quality assurance system for procurement of WHO pre-qualified RDTs and quality-assured ACTs (QAACTs) in 2010-2011 to improve malarial commodity access and affordability.63 Within the public sector, commodities are imported with the support of Three Millennium Development Goal (3MDG) fund and a number of international partners, and the NMCP is responsible for distribution through the VBDC program and the Central Medical Store Depot (CMSD) within the Medical Care Services of the Department of Health.64 The VBDC distributes antimalarial commodities to township hospitals and health departments and supplies sub-national VBDC teams located in states and divisions. Township health departments then are responsible for the distribution to the station hospitals, rural health centers, and sub-rural health centers. The CMSD purchases antimalarial drugs using government funds and distributes to all township hospitals and health departments. PMI is currently supporting a strategic review and assessment of the national supply chain system with the Supply System Management Officers in the MOH and working to develop strategies for

57 Ministry of Health UoM (2012) National Policy for the Treatment of Malaria in the Republic of the Union of Myanmar. 58 Ministry of Health UoM (2015) Guidelines for Malaria Diagnosis and Treatment in Myanmar. 59 Ibid 60 Ministry of Health UoM (2014) National Strategic Plan for Malaria Prevention and Control 2010-2016. 61 Vector-borne Disease Control Division MoH, Union of Myanmar. World Health Organization. (2011) Strategic framework for

artemisinin resistance containment in Myanmar (MARC) 2011-2015. Geneva, Switzerland: World Health Organization. 62 Myanmar AGaP (2014) ACTwatch Study Reference Document: Myanmar Outlet Survey 2014. Washington D.C.: Population

Services International. 63 Ministry of Health UoM (2014) National Strategic Plan for Malaria Prevention and Control 2010-2016. 64 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015.



improved coordination among the NMCP and donor agencies. Commodities management coordination is a critical area in need of support.65

Subsidized quality-assured ACTs were delivered to first-line private sector buyers in Myanmar from 2010-2013. Combination RDTs (for multiple species detection) and cooler boxes for storage and transport of RDTs and antimalarials were distributed for pilot testing in remote health facilities. However, diagnostic coverage remains low in both the public and private sector and quality assurance/control of both microscopy and RDTs is of concern.66,67 GF grants currently cover procurement and distribution of QA ACTs, RDTs and other malaria medicines for the 284 malaria endemic townships.68 As part of the Artemisinin Monotherapy Replacement Project (AMTR, see below), PSI has rapidly replaced oral AMT and sells subsidized, commercial QA ACTs to private outlets through a social franchising scheme.

The NMCP provides malaria case management training to public sector providers and VHVs. Within the private sector, PSI supports a network of licensed private general practitioners and VHVs serving low-income populations through the Sun Quality Health (SQH) network. In 2013, over 3,300 private providers were registered in the SQH network.69 These practitioners are trained on and contribute significantly to malaria diagnosis and treatment, and in 2013, SQH practitioners tested approximately 350,000 suspected malaria cases and treated 50,000 confirmed cases.70

The Myanmar Medical Association (MMA), with support from VBDC and WHO, has adapted PSI’s social franchising approach and created a network of private general practitioners under the Quality Diagnosis and Standard Treatment of Malaria project. The project aims to improve malaria case management among private general practitioners, educate vendors on rational use of antimalarial drugs, promote the use of insecticide treated nets for malaria prevention, improve early treatment seeking behaviour and improve adherence to treatment. The MMA has also initiated a review of the malaria case management training curriculum in medical schools.71 MMA currently has over 17,000 registered medical providers and is also working with Malaria Consortium and other partners to roll out integrated vector management and Behaviour Change Communication (BCC) interventions in pilot communities.72 This project is currently being expanded with support from the GF and 3MDG.73

In 2004 the International Organization for Migration signed an MOU with the MOH to provide diagnostics and treatment for malaria and other healthcare provisions.74 Much of Myanmar’s private industry sector, palm oil and rubber plantations, prawn farms, gold panning and gem mining, attracts and employs large numbers of migrant workers in malaria-endemic areas, and thereby puts this group at even higher risk of contracting malaria. The NMCP provides technical guidance on development of diagnostic and treatment services, BCC interventions and prevention strategies for malaria to private companies that employ a significant number of mobile laborers. In return, the NMCP seeks malaria surveillance data from these private companies, although it remains unclear if surveillance data is being reported on a regular basis.75 The Back Pack Health Worker Team (BPHWT) provides primary health care services including malaria diagnosis with RDTs and treatment with ACTs, and community health education and prevention for internally displaced persons and other vulnerable populations in conflict-affected and rural areas of Myanmar.76 PSI has a research project related to malaria surveillance and elimination among plantation workers in Myanmar and Cambodia. More programs that target mobile migrant populations are urgently needed, especially in

65 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015. 66 Ministry of Health UoM (2014) National Strategic Plan for Malaria Prevention and Control 2010-2016. 67 Myanmar AGaP (2014) ACTwatch Study Reference Document: Myanmar Outlet Survey 2014. Washington D.C.: Population

Services International. 68 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015. 69 D M, K L, C B, T. A (2013) Private sector healthcare in Myanmar: evidence from the ‘Sun’ social franchise. 70 Myanmar PSI- (2014) Solutions- Malaria. PSI-Myanmar website. 71 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015. 72 Bennett A, Avanceña ALV, Wegbreit J, Cotter C, Roberts K, et al. (2014) The Private Sector’s Role in Malaria Surveillance.

UCSF: Global Health Group at the University of California, San Francisco 73 Initiative USPsM (2015) Greater Mekong Subregion- Malaria Operational Plan FY 2015. 74 Ibid 75 Bennett A, Avanceña ALV, Wegbreit J, Cotter C, Roberts K, et al. (2014) The Private Sector’s Role in Malaria Surveillance.

UCSF: Global Health Group at the University of California, San Francisco 76 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015.



light of pending large scale projects such as the Dawei Deep-sea Port Project that will attract huge swaths of migrant populations to malaria endemic areas in Myanmar.77

Several other programs use Information, Education and Communication (IEC) and BCC campaigns to increase informed demand of malaria services in the community. JICA developed an IEC plan for the Ko Kant ethnic groups in Northern Shan State and selected population in Bago Region to educate and raise awareness of the public for malaria prevention and control78. A community-level BCC program focusing on malaria prevention using mobile video units was also developed by the NMCP, PSI, and UNICEF79. In support of ongoing case management strategies, the Malaria Consortium’s IMMERSE project aims to further improve malaria programming implementation by building an evidence platform capable of developing and evaluating operational research, surveillance and monitoring and evaluation activities.80

The newly drafted 2016-2020 National Strategic Plan for Malaria Control and Elimination aims to improve upon the strategies currently in place for malaria control and move towards malaria elimination. Current demand from the community for universal coverage of access and availability of diagnosis and treatment has resulted in the specific targeting of mobile and migrant populations. In order to ensure availability in hard to reach areas the new strategy now promotes a pre-emptive supply of commodities. There has also been a change in strategy to active case detection in order to improve access to testing and quality treatment. This also includes going to more inaccessible areas and targeting migrant populations. The FDA is in charge of promoting good pharmaceutical practice (GPP) in drug sellers with support from the WHO. The plan also calls on current partners to further strengthen the public sector and support PPM, community-based volunteers, and the private sector through scale up of current, effective activities and move towards activities that incorporate active screening and case detection, especially in mobile populations and hard-to-reach areas. Efforts to further strengthen the antimalarial commodity supply-chain are being supported by ERAR.

The Artemisinin Monotherapy Replacement Project (AMTR)

A supply chain study conducted by PSI in 2010 in Kayin State indicated that the majority of antimalarials distributed through the informal private sector were artesunate tablets from the manufacturer AA Pharma (imported from Vietnam). The study documented typical consumption patterns among patients finding that patients were typically consuming artesunate tablets in sub-clinical doses. The need to address the availability and widespread sub-clinical use of oral AMT was urgent and required engaging AA Pharma and the informal private sector providers who were commonly distributing the tablets. The Artemisinin Monotherapy Replacement Project (AMTR) implemented by PSI/Myanmar was designed to rapidly replace the widespread availability and use of oral AMT with quality-assured ACT (further information is provided in annex 3).

77 Initiative USPsM (2015) Greater Mekong Subregion - Malaria Operational Plan FY 2015. 78 Ministry of Health UoM (2014) National Strategic Plan for Malaria Prevention and Control 2010-2016. 79 Ibid 80 Malaria Consortium. (2014) Innovative Malaria M&E, Research and Surveillance towards Elimination (IMMERSE) Project .



Annex 3: Artemisinin Monotherapy Replacement Project The Artemisinisn Monotherapy Replacement Project (AMTR) implemented by PSI/Myanmar was designed to rapidly replace the widespread availability and use of oral artemisinin monotherapy (oral AMT) with quality-assured ACT. The project was launched in 2012 and is funded by the UK Department for International Development (DFID), the Bill and Melinda Gates Foundation (BMGF), and Good Ventures. Negotiations with the primary importer of oral AMT led to an agreement to halt the distribution of artesunate tablets and artemether tablets and instead distribute quality-assured artemisinin combination therapy (ACT). Highly subsidized artemether lumefantrine (AL) was provided to two manufacturers. The AL was given one of two brand names Supa Arte or Artel Plus (depending on manufacturer) and packaging includes a quality-assurance padonma logo. The AMTR project promotes use of AL among consumers and target private sector providers. The switch of AMTs to ACTs and the correct use of diagnostic testing, are supported by product and behavior change promotion, which is vital for changing market preferences. This includes the use of product promoters to work with private outlets and national communication campaigns to encourage the public to demand quality ACTs from drug sellers. Interpersonal communicators who speak local languages enable the project to reach ethnic minority communities with targeted messaging. While the project’s coverage is national there is particular emphasis in townships in eastern Myanmar with indicated or potential high artemisinin resistance. Provider promotion and support is delivered by a team of medical detailers who promote Supa Arte and Artel Plus and implement strategies to facilitate provider behavior change. The project targets ‘pure private sector’ providers that do not generally have ties with government or non-government not-for-profit organizations: general retail outlets, itinerant drug vendors, and pharmacies. Outlets that are not project targets include government health facilities and non-government outlets that frequently have ties to government or non-government organizations including private facilities and community-based health workers. A baseline OS was conducted in 2012 and was followed by outlet surveys in 2013, 2014 and 2015. An endline round is planned in 2016. Each study round included study areas in project intervention and non-intervention comparison areas. At each survey round, a representative sample was drawn for intervention areas and comparison areas. Intervention areas are target project townships located along the eastern part of the country bordering with China and Thailand, including the resistance containment Tier 1 zone—the Myanmar Artemisinin Containment Project (MARC) area. The MARC area is targeted by national partners for implementation of interventions to identify, track, and address the spread of artemisinin drug resistance. A comparison area sample was drawn from locations in proximity to the project townships. Figure X4 shows townships included in the AMTR project area. Figure X4. Townships in the AMTR project area

In 2015, Myanmar became an official ACTwatch country and all survey methodology strictly followed the ACTwatch standard operating procedures. In 2015 the outlet survey was expanded to the national level with two additional domains added in the western region. The methodology used for the 2012-14 outlet surveys was adapted from the ACTwatch project. Since the start of the project the Ministry of Health’s Food and Drug Administration has banned the new importation of two artemisinin monotherapies (artesunate and artemether).81 This supports the uptake of ACTs. However, AMTs can still be purchased in Myanmar while existing stocks are used up and there is ongoing risk of illegal importation. The national scale of the AMTR project and its demonstrated ability to shape the antimalarial market in Myanmar can be a key asset in Myanmar’s national effort to delay artemisinin resistance and move toward the pre-elimination phase of

malaria elimination in accordance with the Greater Mekong Subregion Malaria Elimination Plan.82

81 The main oral AMTs, artesunate and artemether, were banned in Myanmar in December 2011 and August 2012 respectively. 82 Draft Strategy to move from malaria control to elimination in the Greater Mekong Subregion, 2015-2030, WHO, 2015.



Annex 4: Outlet Survey Methods

Design and Study Population The 2012, 2013, 2014, and 2015 outlet surveys in Myanmar were repeat cross-sectional surveys. The study population was defined as all outlets with the potential to sell or distribute antimalarial medicines and/or provide malaria blood testing. However government health facilities were excluded from the study given that the outlet survey was designed to monitor the private sector antimalarial market. In Myanmar, these outlet types include:

Community health workers Community-based health workers provide patient services and typically are linked with government or non-government not-for-profit organizations, facilities, and/or medicine supplies.

Private health facilities Private general practitioners are providing patient services within privately owned facilities that are licensed by the Ministry of Health. These practitioners may have formal or informal ties with government health facilities including serving on staff at government facilities and/or accessing government or non-government not-for-profit medicine supplies.

Pharmacies Pharmacies are licensed by the Ministry of Health and are authorized to sell all classes of medicines including prescription-only medicines.

General retailers General retailers are grocery stores and village shops that sell fast-moving consumer goods, food and provisions. Although retailers may have over-the-counter medicines including antimalarials available, national authorities do not regulate the sale of medicines by retailers.

Itinerant drug vendors Mobile providers selling medicines and other goods. They are not registered with any national regulatory authority.

Stratification The Myanmar outlet survey uses explicit stratification to provide estimates within four study domains: 1) AMTR intervention domain: Areas primarily along the eastern border with Thailand and Yunan are

included within the AMTR intervention, (originally based on the MARC project area and are now classified as Tier I or Tier II). Artemisinin resistance is thought to have emerged in 2001 and was documented in this area in 2008 and has continued to expand. This area has also benefited from AMTR intervention program activities and is expected to have different market share outcomes than other domains.

2) AMTR comparison domain: Areas of eastern and central Myanmar that are located in proximity to the AMTR intervention project area but are not a part of the project area and are categorized as Tier I or Tier II areas. This includes townships that have not been included in any of the other domains.

3) Western / India border domain: Regions within Chin State, Sagaing, and Magway (all Tier II) that are immediate or proximate border townships (approximately 2 layers of townships along the border) are included in this domain. Pf parasites carrying mutations indicative of artemisinin resistance have been recently observed in these areas. This region is home to a large number of transient populations and socioeconomic status is among the lowest in Myanmar.

4) Bangladesh border / Rakhine domain: Regions within Rakhine State, Magway, Bago, and Ayeyarwaddy (all Tier II) that are immediate or proximate border townships (approximately 2 layers of townships along the border) are included in this domain. Malaria endemicity is particularly high in this region and artemisinin resistance is thought to exist though little research data exists. This domain is particularly relevant in light of the updated elimination strategy to reduce transmission in high-risk areas. Accessibility in this region is generally more difficult than in other areas due to topography. Ethnic tensions are higher in northern part of this area.



Eligibility Criteria All outlets with the potential to sell or distribute antimalarials are included in the census screening. Outlets are eligible for a provider interview and malaria product audit if they meet at least one of three study criteria: 1) one or more antimalarials reportedly in stock the day of the survey; 2) one or more antimalarials reportedly in stock within the three months preceding the survey; and/or 3) provides malaria blood testing (microscopy or RDT). Government health facilities were not included in the study.

Sample Size The study was powered to provide estimates for key market indicators within each of the research domains, as well as to compare QA ACT availability among target outlet type outlets in intervention versus comparison areas for the ATMR project. Minimum sample size requirements for the western domains were calculated to estimate with precision (+/- 10 percentage points) 2 key indicators for each research domain: 1) proportion of private sector outlets with quality-assured ACT available, among outlets with antimalarial(s) in stock on the day of the survey; and 2) proportion of private sector outlets with oral AMT in stock, among outlets with antimalarial(s) in stock on the day of the survey. Sample sizes for the AMTR Intervention and Comparison domains were powered to detect a 15 percentage point increase between survey rounds within intervention and comparison areas, and between intervention and comparison areas at each survey round for the indicator, 1) proportion of private sector outlets with quality-assured ACT available, among outlets with antimalarial(s) in stock on the day of the survey. Given the large difference in QA ACT availability among antimalarial-stocking target outlet types in 2014 in intervention (79%) versus comparison areas (32%), powering the 2015 survey to detect a 25 percentage point difference between groups was conservative and sufficient.

The required sample size for each research domain was calculated in three steps: 1) determine the required number of antimalarial-stocking outlets; 2) determine the number of outlets to be enumerated to arrive at this number of antimalarial-stocking outlets; and 3) determine the number of clusters for the census to arrive at this number of outlets. Estimates for the proportion of outlets with antimalarials in stock at the time of the survey among all outlets enumerated were based on 2014 outlet survey results as follows: 0.14 in AMTR project areas; 0.10 in AMTR comparison areas; and 0.10 in new domains. According to results from the 2014 outlet survey, the average numbers of private sector outlets per urban ward or village tract in study areas is assumed to be at least 18 in AMTR project areas. This number was used to identify the ideal number of wards and tracts for the census:

1) AMTR Intervention domain: 13 townships x 16 clusters per township = 208 clusters

2) AMTR Comparison domain: 15 townships x 16 clusters per township = 240 clusters

3) Western / India border domain: 180 clusters

4) Bangladesh border / Rakhine domain: 180 clusters

Sampling A representative sample of clusters (defined as urban wards in urban areas and village tracts in rural areas) was selected in each domain. Sampling was conducted in two phases, to match two phases of data collection. During phase one, a national sampling frame with population data at the ward / village tract level was not yet publicly available. Therefore, AMTR intervention and comparison domains used two-stage sampling. At first stage, 13 townships were selected with probability proportional to population size (PPS) in the AMTR Intervention domain and 15 townships were selected with PPS in the AMTR Comparison domain in the first stage. Cluster population estimates were calculated within each township based on the population distribution of urban wards and rural village tracts per township. Sixteen clusters were then selected using PPS in each township reflecting the respective urban/rural population distributions. By the second phase of sampling and fieldwork, newly released 2014 UNFPA



census data were used for sampling with PPS. In the Western / India border domain and Bangladesh border / Rakhine domain, 180 clusters (wards and village tracts) were selected within in each domain using probability PPS. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. A list of selected townships is provided in Annex 5. The major assumption in using population figures for sampling is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size. Within each selected ward/village tract, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted. This census excluded government health facilities due to lack of approvals to conduct the survey in these facilities.

Data Collection Interviewers, supervisors, and quality controllers received training that included an orientation to the study, questionnaire, classroom training on completing antimalarial and RDT audits, and a field exercise. Following training, data collection was implemented from August 18th 2-15 thru January 4th 2016. For all interviews, a structured paper-based questionnaire was administered (see Annex 7). A series of screening questions were administered at all outlets to determine eligibility for the survey. Outlets where antimalarial medicines were reportedly sold and/or malaria blood testing was reportedly provided were invited to participate in the survey. Following informed consent procedures, an audit of all available antimalarial medicines and RDTs was conducted. Antimalarial audit information included formulation, package size, brand name, active ingredients and strengths, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. RDT audit information included brand name, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. Detailed descriptions of antimalarials and RDTs audited are provided in Annex 8 and Annex 9. In addition to the product audit, a series of questions was administered to the senior-most provider regarding malaria case management knowledge and practices as well as provider training and qualifications. In instances where oral AMT was identified an oral AMT module was also administered (see Annex 7, section B). Up to three visits were made to all outlets to complete the screening process, audit, and provider interview as needed (e.g. where outlets were closed or providers were not available).

Data Entry, Processing, and Analysis Data were entered using CSPro. All data cleaning and analysis was completed using Stata 13.1 (©StataCorp, College Station, TX). Sampling weights were applied to account for variations in probability of selection (see Annex 10) and standard error estimation accounted for clustering at the township level. Indicator definitions are provided in Annex 11.

Protection of Human Subjects The 2015 outlet survey protocol received ethical approval from PSI’s Research Ethics Board, headquarters in Washington DC, USA. Provider interviews and product audits were completed only after administration of a standard informed consent form and provider consent to participate in the study. Providers had the option to end the interview at any point during the study. Standard measures were employed to maintain provider confidentiality and anonymity.



Annex 5: Sampled Townships

Table X1. Sampled Townships

Domain State / Division Township Population

AMTR Intervention Kayin Hlaingbwe 265,883

AMTR Intervention Kachin Hpakant 331,708

AMTR Intervention Kayin Kawkareik 220,342

AMTR Intervention Tanintharyi Kyunsu 171,753

AMTR Intervention Shan (North) Lashio 323,405

AMTR Intervention Shan (South) Lawksawk 164,730

AMTR Intervention Mon Mudon 190,737

AMTR Intervention Kachin Myitkyina 317,604

AMTR Intervention Bago (East) Nyaunglebin 199,483

AMTR Intervention Mandalay Singu 157,585

AMTR Intervention Shan (East) Tachileik 177,313

AMTR Intervention Tanintharyi Thayetchaung 105,662

AMTR Intervention Mon Ye 263,624

AMTR Comparison Bago (East) Bago 491,434

AMTR Comparison Sagaing Kanbalu 295,561

AMTR Comparison Napyitaw Lewe 284,393

AMTR Comparison Sagaing Mingin 104,363

AMTR Comparison Mandalay Mogoke 167,149

AMTR Comparison Shan (North) Nawnghkio 149,842

AMTR Comparison Shan (South) Nyaungshwe 189,407

AMTR Comparison Bago (East) Oktwin 159,828

AMTR Comparison Magway Pauk 171,514

AMTR Comparison Mandalay Pyinoolwin 255,508

AMTR Comparison Yangon Taikkyi 277,268

AMTR Comparison Magway Taungdwingyi 259,860

AMTR Comparison Shan (South) Taunggyi 438,056

AMTR Comparison Bago (West) Thayarwady 151,104

AMTR Comparison Bago (East) Yedashe 213,593

Western / India border Chin Falam 48,077

Western / India border Chin Haka 48,352

Western / India border Chin Kanpalet 21,943

Western / India border Chin Matupi 51,351

Western / India border Chin Mindat 42,600

Western / India border Chin Tedim 87,623

Western / India border Chin Thantlang 50,374

Western / India border Chin Tonzaung 31,878

Western / India border Magway Gangaw 133,295

Western / India border Magway Htilin 48,866

Western / India border Sagaing Hkamti 47,658

Western / India border Sagaing Homalin 258,206

Western / India border Sagaing Kalay 348,573



Western / India border Sagaing Lahe 54,357

Western / India border Sagaing Leshi 10,491

Western / India border Sagaing Mawlaik 51,314

Western / India border Sagaing Phaungpyin 112,694

Western / India border Sagaing Tamu 114,869

Bangladesh border / Rakhine Ayeyarwaddy Ingapu 214,384

Bangladesh border / Rakhine Ayeyarwaddy Kangyidaunt 177,990

Bangladesh border / Rakhine Ayeyarwaddy Kyangin 96,083

Bangladesh border / Rakhine Ayeyarwaddy Kyaungon 163,035

Bangladesh border / Rakhine Ayeyarwaddy Labutta 315,218

Bangladesh border / Rakhine Ayeyarwaddy Laymyethnar 103,024

Bangladesh border / Rakhine Ayeyarwaddy Myanaung 218,581

Bangladesh border / Rakhine Ayeyarwaddy Myaungmya 298,637

Bangladesh border / Rakhine Ayeyarwaddy Ngaputaw 324,479

Bangladesh border / Rakhine Ayeyarwaddy Pathein 380,985

Bangladesh border / Rakhine Ayeyarwaddy Thapaung 154,400

Bangladesh border / Rakhine Ayeyarwaddy Yekyi 194,100

Bangladesh border / Rakhine Bago West Padaung 144,214

Bangladesh border / Rakhine Magway Kamma 75,195

Bangladesh border / Rakhine Magway Mindon 59,357

Bangladesh border / Rakhine Magway Minhla 146,082

Bangladesh border / Rakhine Magway Ngape 52,142

Bangladesh border / Rakhine Magway Saytottara 47,526

Bangladesh border / Rakhine Rakhine An 119,714

Bangladesh border / Rakhine Rakhine Gwa 66,015

Bangladesh border / Rakhine Rakhine Kyaukpyu 165,352

Bangladesh border / Rakhine Rakhine Kyauktaw 173,100

Bangladesh border / Rakhine Rakhine Mannaung 56,966

Bangladesh border / Rakhine Rakhine Mauk U 189,630

Bangladesh border / Rakhine Rakhine Minbya 169,208

Bangladesh border / Rakhine Rakhine Myebon 137,193

Bangladesh border / Rakhine Rakhine Pauktaw 145,957

Bangladesh border / Rakhine Rakhine Ponnagyan 129,753

Bangladesh border / Rakhine Rakhine Sittwe 147,899

Bangladesh border / Rakhine Rakhine Taungup 158,341

Bangladesh border / Rakhine Rakhine Thandwe 133,484

Bangladesh border / Rakhine Rakhine Yanbye 97,891

Bangladesh border / Rakhine Rakhine Yathedaung 111,974



Annex 6: Detailed Sample Description

Table X2: Detailed sample description

Community

Health Worker

Private for-Profit

Facility Pharmacy

General Retailer


Private Outlets ALL

Outlets

Number of outlets screened (Figure 1 Box B) 2,737 610 970 22,733 1,217 25,530 28,267

AMTR Intervention 847 226 363 6,638 197 7,424 8,271

AMTR Comparison 724 152 211 5,972 334 6,669 7,393

Western / India border 536 126 217 4,408 311 5,062 5,598

Bangladesh border / Rakhine 630 106 179 5,715 375 6,375 7,005

Number of outlets eligible and interviewed (Figure 1 Box D) 1,463 357 576 1,491 508 2,932 4,395

AMTR Intervention 626 149 210 461 108 928 1,554

AMTR Comparison 301 69 100 114 118 401 702

Western / India border 264 88 149 488 158 883 1,147

Bangladesh border / Rakhine 272 51 117 428 124 720 992

Number of outlets eligible but not interviewed (interview non-participation) 6 12 1 2 1 16 22

AMTR Intervention 2 5 0 1 1 7 9

AMTR Comparison 1 5 1 1 0 7 8

Western / India border 2 0 0 0 0 0 2

Bangladesh border / Rakhine 1 2 0 0 0 2 3 Number of interviewed outlets with at least one antimalarial in stock on the day of the survey (Figure 1, Box D1) 1,263 314 522 1,341 419 2,596 3,859


AMTR Comparison 244 65 88 104 93 350 594

Western / India border 242 80 144 462 137 823 1,065


Number of interviewed outlets with at least one antimalarial in stock on the day of the survey or at least one antimalarial reportedly in stock in the previous 3 months (Figure 1 sum of Box 1 and Box 2) 1,382 338 569 1,483 500 2,890 4,272


AMTR Comparison 277 67 100 114 117 398 675





Table X2: Detailed sample description

Community

Health Worker

Private for-Profit

Facility Pharmacy

General Retailer


Private Outlets ALL

Outlets

Number of interviewed outlets that provide malaria blood testing, but do not stock antimalarial medicines (Figure 1 Box D3) 81 19 7 8 8 42 123

AMTR Intervention 29 10 3 7 4 24 53

AMTR Comparison 24 2 0 0 1 3 27



Percentage of eligible and interviewed antimalarial-stocking outlets with at least one provider with a health-related qualification*

28.4 85.7 17.4 1.3 14.1 16.8 20.6

AMTR Intervention 30.3 96.9 19.5 1.1 38.9 25.5 27.4

AMTR Comparison 34.8 93.9 15.9 3.9 9.7 25.1 29.1

Western / India border 18.2 60.0 17.4 1.5 5.1 10.6 12.3


* Health-related qualifications include: medical doctor, pharmacists, pharmacy technician, pharmacy assistant, nurse, nursing officer, medical assistant, nursing assistant, nursing aid, midwife, and community health worker.




Annex 7: Questionnaire

A. ACTwatch Myanmar 2015 Outlet Survey B. ACTwatch Myanmar 2015 Oral AMT Module


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


A. ACTwatch Outlet Survey MYANMAR 2015

Section 1: Census Information

Interviewer completes this section for all outlets.

Outlet ID: Interviewer- Township-Ward/Village tract-Outlet ID [___|___]-[___|___]-[___|___|___|___]--[___|___|___]

C1. Today’s date (dd/mm/yyyy) [___|___]-[___|___]-[_2_|_0_|_1_|_5_]

C2. Interviewer’s name [_________________________________________] C2a. Interviewer’s code [___|___]

D3. Division/State [______________________________________] D3a. Division/State code [___|___]

C3. Township [_______________________________________________] C3a. Township code [___|___]

C4. Ward/Village tract [_________________________________________] C4a. Ward/Village tract code [___|___|___|___]

C5. Village [___________________________________________________] C5a. Village code [___|___|___]

C6. Name of outlet If no name, record “no name” or owner’s name

[___________________________________________________________] C6a. Outlet code [___|___|___]

C7. Type of Outlet 01 Private Hospital 02 Poly Clinic

03 Non-SQH Clinic (GP) 04 SQH Clinic

05 SPH provider 06 Government Health Staff (specify) [_______________________________]

07 Informal Provider (Quack) 08 Village Malaria Volunteer/ Mobile Malaria Worker

09 Pharmacy/drug shop-mainly whole sale 10 Pharmacy/drug shop-mainly retail 11 General Store/convenience store 12 Village Shop

96 Other (specify)

[_______________________________]

[___|___]

Hello, my name is __________, I work on behalf of PSI-Myanmar. We are conducting a study on the availability of antimalarial medicines and diagnostic testing services. The results will be used to improve the availability of appropriate antimalarial treatment in Myanmar. I would like to ask you a few questions to see if you could be part of the survey.

Ask to speak to the senior-most staff member who is responsible for providing treatment, prescriptions or medicines to clients/patients. If this person is not available, go to C9 and answer ‘04’ and return at a better time.

Section 2: Screening & Eligibility

S1. Do you have any medicines in stock today?

1 = Yes Go to S3 0 = No

[___]

S2. Are there any medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes Go to S4 0 = No Go to S5 8 = Don’t know Go to S5

[___]

S3. Do you have any antimalarial medicines in stock today?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to Section 3: Antimalarial Audit.

0 = No Verify with prompt card. Go to S4

[___]

S4. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to A17.

0 = No Verify with prompt card. Go to S5

8 = Don’t know Verify with prompt card. Go to S5

[___]

S5. Are you offering any diagnostic services or selling any diagnostic tests here today?

1 = Yes Go to S6 0 = No Verify with prompt card. Record details in C9 then complete Section X: Ending Interview

[___]

S6. Are any of these services or tests for suspected malaria?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to Section 4: Diagnostic Audit

0 = No Verify with prompt card. Record details in C9 then complete Sec X: Ending Interview

[___]

Before proceeding to the full interview ensure you have given the respondent a study information sheet, explained the study and obtained informed consent


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


C9. Result of Visit(s)

Date (dd/mm/yy)

Visit 1 Visit 2 Visit 3

[___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_]

Time started (in 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___]

Time completed (in 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___]

Result [___|___] [___|___] [___|___]

01 = Outlet eligible & survey completed go to E1

02 = Outlet ineligible: does not meet any screening criteria go to E1

03 = Interview interrupted go to C11

04 = Respondent not available/time not convenient go to C11

05 = Outlet not open at the time go to C11

06 = Outlet closed permanently go to E1

96 = Other (specify):[_________________________________________________________]

97 = Refused go to C10

C10. If the provider refused, why?

1 = Client load Ask respondent for a time they would prefer to be interviewed and note in C11 2 = Thinks it’s an inspection / nervous about license go to E1 3 = Not interested go to E1 6 = Other (specify):[___________________________________________________________________] 7 = Refuses to give reason go to E1

[___]

C11. Use this space to record call back details. If it is not possible to complete the interview at another time, go to E1.

THANK THE PROVIDER AND END THE INTERVIEW

Section X: Ending the interview

E1. Name of interviewee:

[________________________________________________________]

5 = Not applicable, no respondent; 7 = Refused

E2. Physical address or location identifiers of outlet (not PO box)(Give detailed description that will help supervisor to find the outlet)

E3. Telephone number

[___|___|___|___|___|___|___|___|___|___|___]

9999999995 = N/A: no respondent or has no telephone 9999999997 = Refused

E4. Additional observations by interviewer (if any)


Outlet ID: [__|__]-[__|__|__]-[__|__|__]-[__|__|__|__]-[__|__|__]


Section 3: Antimalarial Audit

A0. Read to the provider: Can you please show us the full range of antimalarials that you currently have in stock? Do you currently have any of the following? Prompt entire list using antimalarial prompt card; No response to be recorded.

Artemisinin combination therapies (ACTs), such as:

Artemether lumefantrine (AL): Supa Arte 1-4, Artemether and lumefantrine, Coartem20/120, Coartem Dispersible, Artefan

20/120, Lumartem

Artesunate amodiaquine (ASAQ): Artemodi, Quinsunat, Arsuamoon, Co-Artesun, Macsunate FD(kid)

Dihydro-artemisinin piperaqiune (DHA-PPQ): Duo-cotecxin, D-Artepp, Darplex, Artecom

Artesunate mefloquine (ASMQ): Arfloquin

Artemisinin Napthoquine: ARCO

Artesunate-SP: Artecospe (adults)

Artemisinin monotherapies (AMT), such as:

Artemether: Artem, AA-Artemether, Armether

Artesunate: AA-Artesunat (tab), Artesunat, Artesunate(tab), Traphasunat, Arthesis, Falcinate

Arteether/Artemotil: Betamotil

Injections:

o Artemether injection: Artem, Artemether injection, Larither, Arcomether, Artim 80, Glinther, Artemedine, Artesiane 80,

Euroart-M

o Aresunate injection: Artesunate for Injection, Artesun | Arthesis

o Arteether injection: EMAL

Chloroquine (CQ): Chloroquine tablets, Chlorofos, Paraquin, Chloroquine phosphate, Nivaquin, Malacin, Pekquine Injection,

Chloroquine diphosphate, Tabellaechloro-quiniphosphates, Jasochlor, MKIN 250, Nitaquin

Primaquine: Primaquine, Primaquine Phosphate, Kanaprim, Jasoprim, Antipaludique,

Chloroquine-Primaquine: Vivax treatment kit

Sulfadoxine pyrimethamine (SP): Pyrixine, Malidar

Quinine: Quinine tablets, Quinine sulphate, Quinine injection, Quinine dihydrochloride, Jasoquin, Quinine-S | Anoginquinin

Mefloquine: Mefloquine tablets, Mephaquine, Larium, Eloquine Mequin

Injectables & powders/granules: Artem, Quinine Dihydrochloride, Quinine (Injection), Artesunate for Injection, Artemedine, Larither,

Artesun, Arcomether,Pekquine Injection, Glinther, Betamotil, Artim 80, Malacin, EMAL, Artesiane 80, Artemether injection, Euroart-M

If the outlet has no antimalarials in stock cross-check screening results then proceed to question A17.

Proceed to the antimalarial audit. Different antimalarial audit sheets will be used to record the antimalarial information based on the dosage form of the medicine. Separate the antimalarials into two piles:

The first pile should contain all the antimalarials in the form of tablets, suppositories, or granules. Use the Tablets, Suppositories & Granules Drug Audit Sheet to record these.

The second pile should contain all the antimalarials in any form other than tablets, suppositories or granules. Use the Non-Tablet Drug Audit Sheet to record these.

If additional audit sheets are used, add these sheets after the ones provided and staple the questionnaire again. All pages should be in order before you move onto the next outlet. Number each drug by assigning a Product Number (starting from 1 for TSG drugs and again from 1 for NT drugs). Number each audit sheet used in the spaces provided at the bottom of the page.


TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG) OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


Product number [__|__]

[__|__]

[__|__]

[__|__]

1. Generic name

2. Strength [__|__|__].[__]mg [__|__|__].[__]mg [__|__|__].[__]mg

2a. Is this base strength? If no, specify salt: [__] [___________________] [__] [___________________] [__] [___________________] 1 = Yes 0 = No 8 = Don’t know

3. Dosage form/formulation 1 = Tablet

2 = Suppository

3 = Granule

[___]

4. Brand name (Include weight and age information)

[__|__] [__|__|__]

5. Manufacturer

6. Country of manufacture

7. Package size There are a total of [___|___|___|___] tablets/suppositories/granule sachets in each:

1 = Package

2 = Pot/tin

[___]

8. Is product a fixed-dose combination (FDC) 1 = Yes

0 = No

8 = Don’t know

[___]

9. Does product have the Padonma logo? 1 = Yes

0 = No

8 = Don’t

know

[___]

10. Amount sold/distributed in the last 7 days to individual consumers (Record # of packages / tins described in Q7 OR record the total # of tablets / suppositories / granule packs sold) This outlet sold [___|___|___] packages/ tins in the last 7 days OR This outlet sold [___|___|___] tablets/ suppositories or granule sachets in the last 7 days Not applicable = 995; Refused = 997; Don’t know = 998

11a. Stocked out at any point in the past 3 months?

1 = Yes

0 = No

8 = Don’t know

[___]

If No or Don’t

know then go to 12

11b. The

stock out

period in

past 3

months?

1. < 1 week

2. ≥ 1 week 8. Don't know

[___]

[__|__] [__|__|__]

12. Retail selling price [___|___|___] tablets, suppositories or granule sachets cost an individual customer [___|___|___|___|___] KYAT

Free = 00000 Refused = 99997

Don’t know = 99998

13. Wholesale purchase price For the outlet’s most recent wholesale purchase [___|___|___|___] tablets, suppositories or granule sachets cost [___|___|___|___|___|___] KYAT

Free = 000000 Refused = 999997


14. Comments DO NOT ASK PROVIDER. REFER TO Q1 & Q3 FOR THE FOLLOWING: 15a. Is this medicine a tablet?

1 = Yes 0 = No [___]

If No then continue to the next audit sheet. 15b. Does this medicine have only 1 active ingredient?

1 = Yes 0 = No [___]

If No then continue to the next audit sheet. 15c. Is the active ingredient one of the following?

ARTEMETHER ARTESUNATE DIHYDROARTEMISININ

1 = Yes 0 = No [___]

IF NO, GO TO NEXT MEDICINE.

16. Expiration dates. DO NOT directly ask the provider. Ask to see the stock of this medicine and check the expiration dates. Record up to 4 unique expiration dates.

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

Month – Year Refusal = 97

Don't know = 98

Complete oral AMT module for this medicine after




"Antimalarial stock out section" completed

Tablet Audit Sheet [__|__] of [__|__]


[__|__]

[__|__]

[__|__]

1. Generic name

2. Strength [__|__|__].[__]mg [__|__|__].[__]mg [__|__|__].[__]mg

2a. Is this base strength? If no, specify salt: [__] [___________________] [__] [___________________] [__] [___________________] 1 = Yes 0 = No 8 = Don’t know

3. Dosage form/formulation 1 = Tablet

2 = Suppository

3 = Granule

[___]


[__|__] [__|__|__]

5. Manufacturer

6. Country of manufacture

7. Package size There are a total of [___|___|___|___] tablets/suppositories/granule sachets in each:

1 = Package

2 = Pot/tin

[___]

8. Is product a fixed-dose combination (FDC) 1 = Yes

0 = No

8 = Don’t know

[___]

9. Does product have the Padonma logo? 1 = Yes

0 = No

8 = Don’t

know

[___]

10. Amount sold/distributed in the last 7 days to individual consumers (Record # of packages / tins described in Q7 OR record the total # of tablets / suppositories / granule packs sold) This outlet sold [___|___|___] packages/ tins in the last 7 days OR This outlet sold [___|___|___] tablets/ suppositories or granule sachets in the last 7 days Not applicable = 995; Refused = 997; Don’t know = 998

11a. Stocked out at any point in the past 3 months?

1 = Yes

0 = No

8 = Don’t know

[___]

I f No or Don’t

know then go to 12

11b. The

stock out

period in

past 3

months?

1. < 1 week

2. ≥ 1 week 8. Don't know

[___]

[__|__] [__|__|__]




12. Retail selling price [___|___|___] tablets, suppositories or granule sachets cost an individual customer [___|___|___|___|___] KYAT

Free = 00000 Refused = 99997


13. Wholesale purchase price For the outlet’s most recent wholesale purchase [___|___|___|___] tablets, suppositories or granule sachets cost [___|___|___|___|___|___] KYAT

Free = 000000 Refused = 999997


14. Comments DO NOT ASK PROVIDER. REFER TO Q1 & Q3 FOR THE FOLLOWING: 15a. Is this medicine a tablet?

1 = Yes 0 = No [___]

If No then continue to the next audit sheet. 15b. Does this medicine have only 1 active ingredient?

1 = Yes 0 = No [___]

If No then continue to the next audit sheet. 15c. Is the active ingredient one of the following?


1 = Yes 0 = No [___]

IF NO, GO TO NEXT MEDICINE.

16. Expiration dates. DO NOT directly ask the provider. Ask to see the stock of this medicine and check the expiration dates. Record up to 4 unique expiration dates.

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

[___|___| - 20 [___|___]

Month – Year Refusal = 97

Don't know = 98

Complete oral AMT module for this medicine after "Antimalarial stock out section" completed

Tablet Audit Sheet [__|__] of [__|__]


NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & OTHERS OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___]



[__|__]

[__|__]

[__|__]

1. Generic name

2. Strength [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__|__|__|__].[__]mg/[__|__|__] .[__]mL (Note: no mL recorded for powder injection)

2a. Is this base strength? If no, specify salt: [__] [________________] [__] [________________] [__] [________________] 1 = Yes 0 = No 8 = Don’t know

3. Dosage form/formulation 1 = Syrup

2 = Suspension

3 = Liquid injection

4 = Powder injection

5 = Drops

6 = Other (specify) [___________]

[___] [__|__]


5. Manufacturer 6. Country of manufacture 7. Package size There are a total of [___|___|___|___].[___] mL (or mg for powder injections) in each:

1 = Bottle

2 = Ampoule/vial

[___]

9. Does this product have the Padonma logo? 1 = Yes

0 = No

8 = Don’t know

[___]

10. Amount sold/ distributed in the last 7 days to individual consumers This outlet sold [___|___|___|___] bottles, ampoules or vials in the last 7 days Refused = 9997; Don’t know = 9998

11a. Stocked out at any point in the past 3 months? 1 = Yes

0 = No

8 = Don’t know

[___]

If No or Don’t know then go to 12

11b. The stock out period in past 3 month (Ask only those who answered “1” in 10b)

1. <1week 2. ≥1week 8. Don’t know

[___]

[__|__|__] [__|__] [__|__|__]

12. Retail selling price [___|___|___] bottles ampoules or vials cost an individual customer [___|___|___|___|___] KYAT

13. Wholesale purchase price For the outlet’s most recent wholesale purchase: [___|___|___|___] bottles, ampoules or vials cost [___|___|___|___|___|___] KYAT

14. Comments

Free = 00000 Refused = 99997


Free = 000000 Refused = 999997


Non-Tablet Audit Sheet [___|___] of [___|___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


A15. What are the 3 antimalarials you most often sell/distribute? (Record ‘None’ in the boxes if there are less than three antimalarials.) Generic or brand name. a. [_____________________________] b. [_____________________________] c. [_____________________________]

Record response from A15a below. A16a. Why do you stock the medicine specified in A15a? Do not read list. Circle ALL responses given.

Generic or brand name [_____________________________]

Free supply A

Profitable B

Recommended by the government C

Low Price D

Customer demand or preference E

Positive brand reputation F

Often prescribed by doctors G

Most effective for treating malaria H

Don’t know X

Other Z

specify [ ]

Record response from A15b below. A16b. Why do you stock the medicine specified in A15b? Do not read list. Circle ALL

responses given.


Free supply A

Profitable B


Low Price D





Don’t know X

Other Z

specify [ ]

Record response from A15c below. A16c. Why do you stock the medicine specified in A15c? Do not read list. Circle ALL

responses given.


Free supply A

Profitable B


Low Price D





Don’t know X

Other Z

specify [ ]

Antimalarial stock outs

A17. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes go to A18 0 = No go to A20 8 = Don’t know go to A20

[___]

A18. Do you know the names of the antimalarial medicines that are out of stock?

1 = Yes 0 = No, provider can’t remember Go to A20

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


A19. What are the names and formulations of the antimalarial medicines that are out of stock? Refer to the following list of brand names when completing question #4 below.

Brand Name

Artesunate: AA-Artesunate (tab), Artesunate(tab), Artesunat, Arthesis, Arinate, Actitesunate, Adamsnate, Artemed, Askasunate, Cusnat-

Artesunate, Eurosunate, Falcinate, Gricin, Gsunate, Lever-Artesunate, MD-Artesunate, Pedisunate, Plasmotrim, Traphasunat, Vatunate

Artemether: Artem, Artim, AA-Artemether, Artemether, Artemedine, Betamotil, Cether

Dihydroartemisinin: Alaxin, Codisin, Cotecxin, Santecxin, Temecxin

Arsumax, Arquine, Prevention-A

1. Generic or brand name [_________________________]

98 = Don't know

2. Dosage form/formulation 01 = Tablet 05 = Suspension 02 = Suppository 06 = IM/IV Injection (liquid or powder) 03 = Granule 07 = Drops 04 = Syrup 98 = Don't know

[___|___]

3. Do you plan to purchase more of this medicine?

1 = Yes 0 = No 8 = Don't know

[___]

Do not ask provider. 4. Does this medicine have a brand name included in the list of oral AMT brands?

1 = Yes If Yes GO TO NEXT MEDICINE.. 0 = No

[___]

Do not ask provider. 5. Is this medicine a tablet?

1 = Yes 0 = No If No, continue to the next medicine. 8 = Don't know If Don't know, continue to the next medicine.

[___]

6. Does this medicine have only 1 active ingredient? Prompt for the number of active ingredients if the brand name provided in 1.


[___]

7. Is the active ingredient one of the following? Prompt for the active ingredient name if the brand name provided in 1.


1 = Yes . 0 = No 8 = Don't know

[___]


98 = Don't know


[___|___]



[___]


1 = Yes If Yes then complete oral AMT module after ‘Antimalarial Stock out section’ is completed. 0 = No If No then go to 5.

[___]



[___]



[___]



1 = Yes If Yes then complete oral AMT module after ‘Antimalarial Stock out section’ is completed. 0 = No 8 = Don't know

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]



98 = Don't know


[___|___]



[___]



[___]



[___]



[___]




[___]


98 = Don't know


[___|___]



[___]



[___]



[___]



[___]




[___]


98 = Don't know


[___|___]



[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]




[___]



[___]



[___]




[___]

A20. Don't read: Was oral AMT identified during the antimalarial audit or in question A19?

1 = Yes Complete the oral AMT module for each oral AMT identified. An oral AMT module should be completed for: 1) All audited TSG products with responses of 1 for questions 15a, 15b and 15c 2) All currently out of stock products with responses of 1 for question A19, #4 and #7. 0 = No Proceed to Section 4: Diagnostic Audit.

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


Section 4: Diagnostic Audit This section is about availability of malaria blood testing. Completing the questions may require speaking with more than 1 staff member at the outlet. If the respondent does not know the answer to a question in this section, ask to speak with another staff member who can provide the information.

D1. Does this outlet/facility have disposable gloves available today for staff to use when seeing customers/patients?

1 = Yes 0 = No 8 = Don’t know

[___]

D2. Does this outlet/facility have a sharps container, also called a sharps disposal box or safety box, available today for staff to use?


[___]

D3. Is malaria microscopic testing available here today?

1 = Yes 0 = No go to D6

[___]

D4. How many people were tested for malaria at this facility/outlet using microscopy within the past 7 days?

997 = Refused; 998 = Don’t know [___|___|___]

D5. What is the total cost for a microscopic test for malaria for an adult: [___|___|___|___|___|___] KYAT

Free = 000000; NA =999995; Refused = 999997; Don’t know=999998

D6. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

Are malaria RDTs available here today?

1 = Yes 0 = No go to D8 Don’t know ask to speak with a respondent who has this information

[___]

D7. Please show us the full range of RDTs that you currently have in stock. Do you currently have any of the following? Read entire list; No response to be recorded.

Accurate, Carestart, Clungene, First Response, Malacheck, One Step, ParaHit, Paracheck, SD Bioloine (Pf/Pv) & (Pf/Pan), SD Malaria Ag (Pf/Pv), Humasis, Dialab

Proceed to the RDT audit. If additional audit sheets are used, add these sheets after the ones provided and staple the questionnaire again. All pages should be in order before you move onto the next outlet.

Number each RDT by assigning a Product Number. Number each audit sheet used in the spaces provided at the bottom of the page.


RAPID DIAGNOSTIC TEST AUDIT SHEET (RDT) OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


RDT Audit Sheet [___|___] of [___|___]


1. Brand name

2. Antigen test

(circle ALL that apply)

HRP2 A

pLDH B

Aldolase C

Not indicated Z

3. Parasite species (circle ALL that apply)

Pf A

Pv B

Po C

pm D

pan E

vom/Pvom F

Other G

Specify [_____________________]

Not indicated Z

4. Manufacturer 5. Country of Manufacture

5b. Product Catalogue Number

6. Lot Number 6b. Is this a self test kit, with each test kit co-packaged with its own buffer, pipette and lancet ? 1 = Yes 0 = No 8 = Don’t know [___]

[__|__|__] [__|__] [__|__|__] 12. Number of tests sold/ distributed /used in the last 7 days to individual consumers (Record total # of tests) This outlet sold or distributed [___|___|___|___] tests in the last 7 days

Refused = 9997; Don’t know=9998

13. Has this test been stocked out at any point in the past 3 months? 1 = Yes 0 = No 8 = Don’t know

[___]

14a. Do you or other staff use this brand of RDT to test clients here at this facility/outlet?

1 = Yes 0 = No go to 15a 8 = Don’t know go to 15a

[___]

14b. If yes, what is the total cost to have a test conducted with this RDT, including RDT cost and service fee?

[___|___|___|___|___] KYAT

14c. What is the cost for the RDT test cartridge (not including service/consultation, or other fees)?

[___|___|___|___|___] KYAT

15a. Does this facility/outlet provide this brand of RDT for clients to take away for testing somewhere else? 1 = Yes 0 = No go to 16 8 = Don’t know go to 16

[___]

15b. If yes, what is cost of this RDT?

[___|___|___|___|___] KYAT

16. Wholesale purchase price For the outlet’s most recent wholesale purchase: [___|___|___|___] tests

cost

[___|___|___|___|___|___] KYAT

Free = 000000Refused = 999997

Don’t know=999998

17. Why do you stock this RDT [SHOW RDT]? Do not read list Circle ALL responses given

Free supply A

Profitable B

Recommended by government C

Low price D



Don’t know X

Other , specify Z

[_____________________________]

18. Comment

Free = 00000; Refused = 99997; Don’t know=99998


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


RDT stock outs

D8. Are there any malaria RDTs that are out of stock today, but that you stocked in the past 3 months?

1 = Yes 0 = No go to Provider Module 8 = Don’t know go to Provider Module

[___]

D9. What are the brand names of the malaria RDTs that are out of stock? Record one brand per line.

1 = Yes, specify

[____________________________________________________________________________]

[____________________________________________________________________________]

[____________________________________________________________________________]

0 = No, provider can’t remember

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


Section 5: Provider Module This section is for the senior-most staff member who is responsible for providing treatment, prescriptions or medicines to clients/patients.

DEMOGRAPHICS

P1. Do your responsibilities at this outlet/facility include: providing prescriptions, treatment, or medicines to clients?

1 = Yes No ask to speak with the senior-most person at the outlet with 1 or more of these

responsibilities.

|___]

P2. What is your job at this outlet? Do not read list and circle all that apply.

Medical doctor A

Owner B

Nurse C

Clinic assistant D

Shop assistant E

Relative of the owner F

Other, specify [__________________________________________________] X

P3. For how many years have you worked in this outlet/facility? If less than 1 year, enter 01 [___|___]

P4. What age are you today? Write age in years 97 = Refused 98 = Don’t know

[___|___]

P5. Don’t read: Is respondent male or female?

1 = Male 2 = Female

[___|___]

P6. What is the highest level of education you completed?

1 = No formal education 2 = Completed monastic/primary school 3 = Middle grade 4 = High grade 5 = Passed matriculation 6 = Diploma or degree 7 = Post graduate

[___]

P7. Including the owner and yourself, how many people work here? If the outlet has multiple dispensaries, record the number of workers at this dispensary only.

98 = Don’t know

[___|___] 1 -> P10

P8. Of all the people who work here, how many prescribe or dispense medicines?

98 = Don’t know [___|___]

P9.Not including yourself, what is the highest level of education among the people working in this outlet? 1 = No formal education

2 = Completed monastic/primary school

3 = Middle grade

4 = High grade

5 = Passed matriculation

6 = Diploma or degree

7 = Post graduate

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


TRAINING & HEALTH QUALIFICATIONS

P10. Has anyone in this outlet (including you) received any training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy?

Include pre-service training and stand-alone workshops.

1 = Yes 0 = No go to P13 8 = Don’t know go to P13

[___]

P11. Who at the outlet received training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy?

Read list and circle all that apply.

Myself (respondent) A

Medical doctor B

Owner C

Nurse D

Clinic assistant E

Shop assistant F

Relative of the owner G

Other, specify [__________________________________________________] X

P12. What organization provided the training that included a component on malaria diagnosis?

Do not read list and circle all that apply. Prompt “any other organizations” until the respondent is finished.

MOH / NMCP A

PSI B

Other, specify [__________________________________________________] X

Don't Know Z

P13. Has anyone in this outlet (including you) received any training in the last 12 months on the national treatment guidelines for malaria? Include pre-service training and stand-alone workshops.


[___]

P14. What organization provided the training on the national treatment guidelines for malaria?

Do not read list and circle all that apply. Prompt “any other organizations” until the respondent is finished.

MOH / NMCP A

PSI B

Other, specify [__________________________________________________] X

Don't Know Z

P15. Do you have any of the following health qualifications? Read list. Record 1 for yes, 0 for no If there are no other employees at this outlet then to go P17.

I. Pharmacist [___]

II. Medical Doctor [___]

III. Health Assistant [___]

IV. Nurse / Midwife [___]

V. PHS [___]

VI. Laboratory technician [___]

VII. Pharmacist trained by a private agency [___]

VIII. Compounder [___]

IX. Village Malaria Volunteer/ Mobile Malaria Worker [___]

If P7 = 1, GO TO P17.


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P16. Not including yourself, how many of the other people working in this outlet or facility have the following health qualifications? Read list. Record 00 for no, 98 for don’t know

I. Pharmacist [__|__]

II. Medical Doctor [__|__]

III. Health Assistant [__|__]

IV. Nurse / Midwife [__|__]

V. PHS [__|__]

VI. Laboratory technician [__|__]

VII. Pharmacist trained by a private agency [__|__]

VIII. Compounder [__|__]

IX. Village Malaria Worker / Mobile Malaria Worker [__|__]

SUPPORT AND SURVEILLANCE

P17. Has this outlet received a visit within the last year from a government or non-government organization that is providing a kind of support, regulation or supervision for the outlet specifically for malaria case management?

1 = Yes 0 = No Go to P20 8 = Don’t know Go to P20

[___]

P18. From which organization(s) does this outlet receive support, regulation or supervisory visits? Do not read list and circle all that apply.

NMCP/VBDC A

FDA B

PSI C

Other, specify [___________________________________________________] X

P19. How often does this outlet receive a support, regulation or supervisor visit?

1 = One or more time per month 2 = One time per 3 months 3 = One time per 6 months 4 = One time per year

5 = Other, specify [__________________________________________________]

[___]

P20. Does this outlet record information about the number of patients that have received a malaria test or malaria treatment?


[___]

P21. May I see the record keeping system? Record 1 if the record keeping was observed and 0 if the record keeping system was not observed.

1 = Record keeping system observed 0 = Record keeping system not observed

[___]

P22. Does the system record information about each individual patient (1 line in the register = 1 patient)? Ask the provider.


[___]

P23. Does the system keep a tally or count of the number of patients that have received a malaria test or malaria treatment for a certain period such as per day, per week, or per month? Ask the provider.


[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P24. Are the numbers of patients that receive malaria testing or treatment reported to any other government or non-government organizations?


[___]

P25. To which organizations are the numbers of patients tested or treated for malaria reported? Do not read list and circle all that apply.

NMCP/VBDC A

PSI B

Other, specify [___________________________________________________] X

P26. How often are the numbers of patients tested or treated for malaria reported? Do not read list and circle all that apply.

One time per month A

One time per quarter B

Other, specify [__________________________________________________] X

P27. How do you share the patient data with these organizations? Read list. Record 1 for yes, 0 for no, 8 for don’t know

I. By paper form/record [___]

II. By phone – SMS/text [___]

III. By phone – electronic form [___]

IV. By phone - verbal report [___]

V. By computer - electronic form [___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


PATIENT AND PROVIDER PRACTICES

P28. Do your customers ask for antimalarial medicines by name? Read list.

1 = Yes 0 = No go to P31 2 = No, they have a written prescription go to P30 8 = Don’t know go to P31

[___]

P29. What are the three most common antimalarial medicines that people ask for by name? Looking for either Generic name or Brand name or Cocktail. Ask provider to show you the medicine if in stock.

Go to P31.

[_________________________________]

[_________________________________]

[_________________________________]

8 = Don't know

P30. What are the three most common antimalarial medicines that were prescribed by providers (came to you through prescription notes)? Looking for either Generic name or Brand name or Cocktail. Ask provider to show you the medicine if in stock.

[_________________________________]

[_________________________________]

[_________________________________]

8 = Don't know

P31. Do you normally decide which antimalarial medicines customers receive? Read list.

1 = Yes 0 = No 2 = No, they have a written prescription 8 = Don’t know

[___]

P32. In the past month, did you ever cut blister packs or sell partial courses of antimalarials?

1 = Yes 0 = No 8 = Don’t know Go to P34

[___]

P33. What is/are the reason(s) that you cut blisters or sell partial courses? Do not read list and circle all that apply. Probe for anything else.

Customers / patient's request A

Cut / partial is sufficient B

I have small / insufficient stock C

Customers / patients cannot afford full blister / pack D

Makes it easier for the patient to take medicine E

Other, specify [__________________________________________________] X

Don't Know Z

INFORMATION, EDUCATION AND COMMUNICATION

P34. Have you heard/seen any messages or information about malaria in the past month?

1 = Yes 0 = No go to P37

[___]

P35. Where did you see or hear these messages/information? Do not read list and circle all that apply.

TV A

Radio B

Billboard C

Pamphlet D

Newspaper / Journal E

Health Talk F

Sales representative from AA pharma G

PSI detailer H

Other, specify [__________________________________________________] X


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P36. What type of malaria messages or information did you see or hear? Do not read list and circle all that apply.

Importance of giving full course of treatment A

Using the quality assured ACT B

Using diagnostic test C

Always test D

Selling price E

Not to cut the strips F

AM monotherapy is dangerous G

Monotherapies are not recommended by WHO/NMCP H

Monotherapies are replaced by ACTs I

ACTs are recommended drug for malaria by WHO/NMCP J

ACTs are more effective K

ACTs have more attractive profit margin L

Quality seal logo on drug M

Sleeping under ITN N

Messages not related to ACT O

Do not remember Z

P37. What does this logo on this drug mean? (Podonma show card)

1 = Quality malaria drug (correct answer) 0 = Other responses (incorrect answer)

8 = Don’t know

[___]

P38. Has someone from PSI ever visited you?


[___]

P39. When was the last visit from PSI?

1 = within one month 2 = within 3 months 3 = within 6 months 4 = within last year 8 = don’t remember

[___]

P40. What kind of messages/information did he/she share with you? Do not read list and circle all that apply.

Importance of giving full course of treatment A

Using the quality assured ACT B

Using diagnostic test C

Always test D

Selling price E

Not to cut the strips F

AM monotherapy is dangerous G

Monotherapies are not recommended by WHO/NMCP H

Monotherapies are replaced by ACTs I

ACTs are recommended drug for malaria by WHO/NMCP J

ACTs are more effective K

ACTs have more attractive profit margin L

Quality seal logo on drug M

Sleeping under ITN N

Messages not related to ACT O

Do not remember Z


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


PROVIDER KNOWLEDGE AND BELIEFS

For the following four questions record the antimalarial brand name or generic name, and dosage form, in the spaces provided. Ask the provider to show you the medicine if it is in stock to verify the name and dosage form.

P41. In your opinion, for treating uncomplicated Plasmodium falciparum malaria in adults, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock.

Generic or brand name [______________________________________]

Don’t know = 98

Dosage form/formulation

01 = Tablet 02 = Suppository 03 = Granule

04 = Syrup 05 = Suspension 06 = IM/IV Injection (liquid or powder)

07 = Drops 95 = None specified 98 = Don’t know

[___|___]

SKIP INSTRUCTIONS

If Artemether Lumefantrine (including Supe Arte,Coartem, Lumartem, Artefan) was named in question P41 >>> continue to P41a

If Artemether Lumefantrine was not named in question P41 then continue to P42 P41a. Please explain the treatment regimen for Artemether Lumefantrine to treat uncomplicated

Plasmodium falciparum malaria for an adult (60kg).

If the provider has the medicine(s) available, use the package to complete the medicine(s) details.

If the medicine(s) is not available, ask the provider to identify the medicine(s) from the prompt card.

If identification of the medicine(s) is not possible, ask the provider to recall the medicine(s) details.

i. What is the strength of Artemether?

ii. What is the strength of Lumefantrine?

Read the following 3 questions to the provider (do not record this information from the package).

iii. How many tablets of Artemether Lumefantrine should they take at a time?

iv. How many times per day should Artemether Lumefantrine be taken?

v. Over how many days should Artemether Lumefantrine be taken?

[__|__|__].[__]mg

[__|__|__].[__]mg

Don’t know = 999.8

[___|___].[___|___]

[___|___]

[___|___]

Don’t know = 98

P42. In your opinion, for treating uncomplicated Plasmodium vivax malaria in adults, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock.


Don’t know = 98





[___|___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P43. What antimalarial medicine for treating uncomplicated Plasmodium falciparum malaria in adults do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock.


Don’t know = 98





[___|___]

P44. What antimalarial medicine for treating uncomplicated Plasmodium vivax malaria in adults do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock.


Don’t know = 98





[___|___]

P45. Please name the first line treatment recommended by the government to treat uncomplicated Plasomodium falciparum malaria in adults. Do not read list. Circle ALL responses given.

Artesunate Mefloquine (A+M, Malarine, Artequin) A

Dihydroartemisinin Piperaquine (Duo-cotecxin, Eurartesim) B

Artemether Lumefantrine (A+L, Supa Arte) C

Primaquine D

Other, specify: [_____________________________________________________] X

Don’t know Z

SKIP INSTRUCTIONS

If Artemether Lumefantrine (including Supe Arte,Coartem, Lumartem, Artefan) was named in question P45 >>> continue to P45a

If Artemether Lumefantrine was not named in question P45 then continue to P46 P45a. Please explain the government recommended treatment regimen for Artemether Lumefantrine

to treat uncomplicated Plasmodium falciparum malaria for an adult (60kg).

If the provider has the medicine(s) available, use the package to complete the medicine(s) details.

If the medicine(s) is not available, ask the provider to identify the medicine(s) from the prompt card.

If identification of the medicine(s) is not possible, ask the provider to recall the medicine(s) details.

i. What is the strength of Artemether?

ii. What is the strength of Lumefantrine?

Read the following 3 questions to the provider (do not record this information from the package).

iii. How many tablets of Artemether Lumefantrine should they take at a time?

iv. How many times per day should Artemether Lumefantrine be taken?

v. Over how many days should Artemether Lumefantrine be taken?

[__|__|__].[__]mg

[__|__|__].[__]mg

Don’t know = 999.8

[___|___].[___|___]

[___|___]

[___|___]

Don’t know = 98


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P46. Please name the first line treatment recommended by the government to treat uncomplicated Plasomodium vivax malaria in adults. Do not read list. Circle ALL responses given.

Chloroquine A

Primaquine B

Other specify: [_____________________________________________________] X

Don’t know Z

If the provider answered ‘Primaquine’ in P45 or P46 then skip P47 and proceed directly to P48. P47. Have you seen or heard of a medicine called primaquine before? Show primaquine images in prompt

card. 1 = Yes 0 = No go to P51 8 = Don’t know go to P51

[___]

P48. What is primaquine used for?

Do not read list. Circle ALL responses given.

As an antimalarial medicine / to treat malaria A

As a gametocyde / to prevent transmission of malaria B

As a radical cure/treatment for P. vivax malaria / to prevent relapse of P. vivax malaria C

Don't know Z

P49. Have you ever prescribed primaquine for a patient/customer?

1 = Yes 0 = No

[___]

P50. Have you ever provided or sold primaquine to a patient/customer? 1 = Yes 0 = No

[___]

P51. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

Have you ever seen or heard of malaria RDTs?


[___]

P52. Have you ever tested a client for malaria using an RDT?


[___]

P53. Would you ever recommend a patient/customer take an antimalarial if a blood test using a rapid diagnostic test produced a negative test result for malaria? Read list. Record only one response.

1 = Yes, Sometimes 2 = Yes, Always 3 = No, Never go to P55 8 = Don’t know go to P55

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P54. Under what circumstances would you recommend a patient/customer take an antimalarial following a negative RDT test for malaria? Do not read list. Prompt “anything else” until the respondent is finished. Circle ALL responses given

When they have signs/symptoms of malaria A

When they ask for antimalarial treatment B

When they are a child C

When they are an adult D

When they are a pregnant woman E

When I do not trust/believe the test F

When I know the patient/customer G

Other (specify) [_______________________________________________________] X

P55. How often do you test people who have fever for malaria using a blood test? Read list. Record only one response.

1 = Always 2 = Most of the time 3 = Sometimes 4 = Rarely 5 = Never go to P57

[___]

P56. Did the last patient you provided an antimalarial to also receive a malaria diagnostic test from this outlet?


If the respondent answered "1" in P55 then skip to P58.

[___]

P57. What is the main reason that you would not test a client with fever for malaria using a blood test? Read list. Record only one response.

1 = Do not have tests in stock 2 = Do not think is necessary 3 = Customers do not want a test 4 = Customers cannot afford a test 5 = I don't know how to do that 6 = Other, specify [____________________________________________]

[___]

P58. When an RDT is positive for malaria, how likely do you think it is that the person tested actually has malaria? Read list. Record only one response.

1 = Certain they have malaria 2 = Very likely they have malaria 3 = Somewhat likely they have malaria 4 = Not very likely they have malaria 5 = Not at all likely they have malaria 8 = Don't know

[___]

P59. In your opinion, how important is if for a person with fever to get tested to confirm malaria before treatment? Read list. Record only one response.

1 = Very important go to P61 2 = Somewhat important go to P61 3 = Not very important 4 = Not at all important 8 = Don't know go to P61

[___]

P60. Why do you think it is not important to provide a test for a person with fever before giving malaria treatment?

[_________________________________________________]

[_________________________________________________]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


P61. Who is at risk of getting malaria in Myanmar? Do not read list and circle all that apply.

Forest related worker A

Migrant people / worker B

Plantation worker C

Gold / jade / gem miner D

Pregnant women E

Children under 5 years F

Other, specify [__________________________________________________] X

Don't Know Z

P62. Are some antimalarial drugs are banned in Myanmar?


[___]

P63. Which antimalarial drugs are banned in Myanmar? Looking for either Generic name or Brand name.

[_________________________________]

[_________________________________]

[_________________________________] 8 = Don't know

LICENSE, COCKTAILS & MEDICINE STORAGE

P64. Do you have a license / temporary license to sell drugs?


[___]

P65. Interviewer observes the license and record response based on observation.

1 = Yes, license physically observed 0 = No, license not physically observed

[___]

P66. Do not ask if the outlet is clinic/health facility. Does this outlet provide "cocktail" for the treatment of patients with uncomplicated malaria?

1 = Yes 0 = No

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


Do not ask the following three questions. Observe and circle the appropriate response in each case.

P67. Do not ask: Are medicines stored in a dry area?

1 = Yes, stored in a dry area 0 = No, not stored in a dry area 8 = Did not observe medicines

[___]

P68. Do not ask: Are medicines protected from direct sunlight?

1 = Yes, protected from direct sunlight 0 = No protection from direct sunlight 8 = Did not observe medicines

[___]

P69. Do not ask: Are medicines kept on the floor?

1 = Yes, they are kept on the floor. 0 = No, not kept on the floor. 8 = Did not observe medicines

[___]

Complete the audit sheet tracker on the next page then follow the instructions for ending the interview.


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


Section 6: Audit Tracking Sheet

T1. Were there any antimalarial TABLETS/SUPPOSITORIES/GRANULES in stock at this outlet?

1 = Yes 0 = No go to T4 8 = Don’t know go to T4

[___]

T2. Total number of TABLET/SUPPOSITORY/GRANULE audit sheets completed

[___|___]

T3. Did you complete audit sheet information for all available TABLETS/SUPPOSITORIES/GRANULES? 1 = Yes, audit complete 0 = No, audit not complete

[___]

T4. Were there any antimalarial NON TABLETS (Syrups, suspensions, Injectables) in stock at this outlet?


[___]

T5. Total number of NON-TABLET audit sheets completed

[___|___]

T6. Did you complete audit sheet information for all available NON-TABLETS? 1 = Yes, audit complete 0 = No, audit not complete

[___]

T7. Were there any RDTs in stock at this outlet?


[___]

T8. Total number of RDT audit sheets completed

[___|___]

T9. Did you complete audit sheet information for all available RDT? 1 = Yes, audit complete 0 = No, audit not complete

[___]

T10. COMMENTS: Reason for incomplete audit sheets (if response is no to T3, T6, or T9):

Proceed to C9 and record the final status of the interview and time completed then, complete

Section X: Ending the Interview.


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


B. Oral AMT Module MYANMAR 2015

This module includes questions about oral artemisinin monotherapy (oral AMT). The entire module should be administered one time for each oral AMT that was audited at the outlet or reportedly stocked within the past 3 months. If the provider doesn't know the answer to a question, ask to speak with another staff member who can provide the information.

1. Do not ask: How was this product identified?

1 = TSG audit go to question 2 2 = Question A19 go to question 3

[___]

2. Do not ask: What is the TSG audit sheet product number for this medicine? go to question 5

[___|___]

3. Do not ask: What is the generic or brand name recorded in question A19? [___________________________________________]

Questions 5-11 are about the supplier/distributor of the medicine. If the medicine was purchased from more than 1 supplier then ask questions 5-11 for the first supplier and record responses in the first column. Afterwards, the questions will be repeated for the second supplier and the responses recorded in the second column.

Supplier #1 Supplier #2

5. Where do you purchase this medicine?

1 = Pharmacy 2 = Fixed-location medicine wholesale outlet 3 = Mobile distributor 4 = Village Buyer

5= Other, specify

[___]

Other, specify

[___________________]

[___]

Other, specify

[___________________]

6. How many times have you purchased this medicine from this supplier in the past 3 months?

Times purchased

[___|___] Don't know = 98

Times purchased

[___|___] Don't know = 98

7. When did you last purchase this medicine from this supplier?

[___|___| - 2 0 [___|___]

Month - Year Don't know = 98

[___|___| - 2 0 [___|___]

Month - Year Don't know = 98

8. How many packages of this medicine did you purchase on the last order from this supplier?

# packages

[___|___|___] Don't know = 98

# packages

[___|___|___] Don't know = 98

9. How much did your last order cost from this supplier?

[___|___|___] packages cost:

[___|___|___|___|___|___] KYAT

Free = 000000

Refused = 999997 Don’t know=999998


[___|___|___|___|___|___] KYAT

Free = 000000


10. Was the last order delivered to you or did you travel to the supplier to pick up the order?

1 = Order was delivered 2 = Travelled to supplier to pick up order 8 = Don't know

[___] [___]

11. Why do you purchase medicines from this particular supplier?

Do not read list. Circle all responses provided

Price: low cost A Price: low cost A

Convenience: location B Convenience: location B

Trust the supplier C Trust the supplier C

Quality products D Quality products D Speed: fills orders quickly E Speed: fills orders quickly E

Other, specify F [_____________________]

Other, specify F [_____________________]

Have you purchased this medicine from any other suppliers within the past 3 months? If yes then repeat questions 5-11 for the second supplier and record responses in the second column.


OUTLET ID: [___|___]-[___|___]-[___|___|___|___]-[___|___|___]


12. How many individual customers seeking treatment for illness have you distributed this medicine to in the past month?

# Customers

[___|___] Don't know = 98

Refused = 97

13. How many tablets of this medicine do you most often dispense or prescribe to treat malaria in an adult?

[___|___] # Tablets

14. Do individual customers seeking treatment for illness ever request this medicine by name?

1 = Yes 2 = No

[___]

Review the TSG audit sheets, and question A19. If there were any other oral AMT identified in question 15 of the TSG audit sheets (questions 15a, 15b and 15c all coded 1) or question A19 (questions 4 or 7 both coded 1) then complete the oral AMT module again for each identified oral AMT.

If there are no other oral AMT then proceed to Section 4: Diagnostic Audit.

15. Do you ever distribute this medicine wholesale to other business owners or health providers?

1 = Yes 2 = No go to question 19

[___]

16. Do you distribute this medicine wholesale to any of the following outlet types? Read list. Record 1 for yes, 0 for no.

Hospital / clinic [___]

Pharmacy/drug shop [___]

Village malaria worker/Mobile malaria worker [___]

General store/ convenience store/village shop [___]

Informal provider (quack) [___]

Other, specify [________________________________________________] [___] 17. What is the price that you most often charge for this medicine when you sell it to other outlets/individuals wholesale?


[___|___|___|___|___|___] KYAT

Free = 000000


18. How many packages of this medicine have you sold wholesale to other business owners or health providers in the past month?

[___|___|___] # packages

Don't know = 998 19. Is this medicine available at other outlets like this one in this ward or village tract? 1 = Yes 2 = No 8 = Don't know

[___]

20. How many packages of this medicine do you currently have in stock? Note: A blister package missing tablets should be counted as a full package.

# Packages

[___|___|___]

20a. Why do you stock this medicine? Do not read list. Circle ALL responses given

Free supply A

Profitable B


Low Price D





Don’t know X

Other Z

specify [ ]



Annex 8: Antimalarial Product Information

Table X3: Number of antimalarials audited

Community

Health Worker

Private for-Profit

Facility Pharmacy

General Retailer


ALL Outlets

AMTR Intervention 1,709 293 396 540 202 3,140

AMTR Comparison 745 153 164 144 165 1,371

Western / India border 876 232 378 759 248 2,493

Bangladesh border / Rakhine 806 84 197 506 138 1,731

TOTAL 4,136 762 1,135 1,949 753 8,735




Table X4: Quality-Assured (QA ACT) and Non-Quality Assured ACTs

Quality-Assured ACT (QA ACT)

QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Quality Assurance Policy. A QAACT is any ACT that appeared on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy* prior to data collection, or that previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. QAACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®.

Artemether Lumefantrine Tablets

Artefan 20/120 (5-14 kg) ^#ic Coartem 20/120 (25-35 kg) ^#ic

Artefan 20/120 (15-24 kg) ^#ic Coartem 20/120 (+ 35 kg) ^#ic

Artefan 20/120 (25-34 kg) ^#ic Lumartem (5-<15 kg) ^#ic

Artefan 20/120 (+35 kg) ^#ic Lumartem (15-<25 kg) ^#ic

Artel + 1 (5-14 kg) ^#ic Lumartem (25-<35 kg) ^#ic

Artel + 2 (15-24 kg) ^#ic Lumartem (+ 35 kg) ^#ic

Artel + 3 (25-34 kg) ^#ic Supa Arte 1 ^#ic

Artel + 4 (+35 kg) ^#ic Supa Arte 2 ^#ic

Coartem 20/120 Dispersible (5-15 kg) ^#ic Supa Arte 3 ^#ic


Unbranded AL [Manufacturer]

Artemether 20mg and Lumefantrine 120mg (<4 years) [Ipca Laboratories Ltd.]^#ic

Artemether 20mg and Lumefantrine 120mg (4-10 years) [Ipca Laboratories Ltd.] ^#ic


Artemether 20mg and Lumefantrine 120mg (>14 years) [Ipca Laboratories Ltd.] ^#ic

Non-Quality-Assured ACT

ACTs that do not meet the definition of being quality-assured.


Falcee Plus 20 DT c Paicotokin^#ic

Malarte-AL-DS #i

Artemisinin Napthoquine Tablets

Arco ^

Artesunate Amodiaquine Tablets

Artemodi (Adults) #c Quinsunat ^

Dihydroartemisinin Piperaquine Tablets

Artequine ^#ic Darplex #ic

Arterakine i Duo-Cotecxin ^#i

D-Artepp 40/320 ^#ic Piperamisinin #c

* http://www.theglobalfund.org/en/procurement/quality/pharmaceutical ^ Product audited in the intervention area. # Product audited in the comparison area. i Product audited in the Western / India border area. c Product audited in the Bangladesh border / Rakhine area.


http://www.theglobalfund.org/en/procurement/quality/pharmaceutical


Table X5: Nationally Registered ACTs

ACT registered with Myanmar’s national drug regulatory authority and permitted for sale or distribution in

country.


Artel + 1 (5-14 kg) ^#ic Coartem 20/120 (+ 35 kg) ^#ic

Artel + 2 (15-24 kg) ^#ic Malarte-AL-DS #i

Artel + 3 (25-34 kg) ^#ic Paicotokin^#ic

Artel + 4 (+35 kg) ^#ic Supa Arte 1 ^#ic



Coartem 20/120 (25-35 kg) ^#ic Supa Arte 4 ^#ic

Unbranded AL [Manufacturer]

Artemether 20mg and Lumefantrine 120mg (<4 years) [Ipca Laboratories Ltd.]^#ic



Artemether 20mg and Lumefantrine 120mg (>14 years) [Ipca Laboratories Ltd.] ^#ic

Dihydroartemisinin Piperaquine Tablets

Artequine ^#ic Darplex #ic

Arterakine i Duo-Cotecxin ^#i

D-Artepp 40/320 ^#ic Piperamisinin #c

^ Product audited in the intervention area. # Product audited in the comparison area. i Product audited in the Western / India border area. c Product audited in the Bangladesh border / Rakhine area.



Table X6: Oral Artemisinin Monotherapies

Artemether monotherapy Tablets

AA – Artemether ^#ic (50mg) Artemether î (50mg)

Artem ^#ic (50mg) Artemether Soft Capsules î (40mg)

Artesunate monotherapy Tablets

AA – Artesunat ^#ic (50mg) Arthesis 50MG ^#ic (50mg)

Artesunate 50MG ^#ic (50mg) Traphasunat 50MG ^#ic (50mg)

* 1,036 oral AMTs were audited. 50 oral AMTs were missing brand name information (intervention 19, comparison 5, India 25, Bangladesh border / Rakhine 1).


Table X7: Oral AMT Manufacturers and Country of Manufacture*

China – 40 products

Chengdu Yulong Medicine Co., LTD (1) KPC – Kumming Pharmaceutical Corportation (12)

Chongging Holley Pharmaceutical Co., LTD (6) Zhangfeng Pharmaceutical Factory (17)

Guilin Pharmaceuticals (2) Zhejiang Holley Nanhu Pharmaceutical Factory (2)

Myanmar – 14 products

Myanma Pharmaceutical Company (2) Tatmadaw Pharmaceutical Factory (12)

Vietnam – 871 products

AA Medical Products (37) Medopharm (3)

Central Pharmaceutical Factory No. 1 (2) Mekophar Chemical Pharmaceutical (2)

Mediplantex (821) Traphaco (6)

* 1,036 oral AMTs were audited. 74 oral AMTs were missing manufacturer name information and CoM and an additional 37 with manufacturer name were missing CoM.



Table X8: Severe Malaria Treatment

WHO recommends intravenous or intramuscular artesunate as first-line treatment in the management of severe falciparum malaria. If artesunate is not available, artemether in preference to quinine should be used for treating severe malaria cases. Rectal artesunate is suitable for pre-referral treatment in children under 6 years of age.83

Artemether Liquid Injection (manufacturer)

Artem (Kumming Pharmaceutical Corporation) ^#ic

Artemedine (Kumming Pharmaceutical Corporation) #ic

Artesiane 80 (Dafra Pharma Ltd) ic

Artim 80 (Coral Laboratories) ^#ic

E Mal (Themis) î

Eurorart-M (Great Himalayan) ^#i

Glinther (Guilin Pharmaceutical Co. Ltd.) î

Larither (Ipca Laboratories Ltd.) #ic

Arteether Liquid Injection (manufacturer)

Arteether (Shivek Labs Ltd.) i

Artesunate Powder Injection (manufacturer)

Artesun (Guilin Pharmaceutical Co. Ltd.)^#ic

Quinine Liquid Injection

Quinine dihydrochloride (ANB Laboratories) îc

Quinine dihydrochloride (Henan Dekang Pharmaceutical Co. Ltd.) ^#ic

Quinine dihydrochloride (Shanghai Modern Pharmaceutical Co. Ltd.) ^#ic

Quinine dihydrochloride (Zhangfeng Parmaceutical Factory) ^#ic

Quinine dihydrochloride (Zhejiang Holley Pharmaceutical Co. Ltd.) ^

Quinine (Myanmar Pharmaceutical Factory) ^#ic

* Guidelines for the treatment of malaria, 3rd edition. WHO. Geneva: 2015. ^ Product audited in the intervention area. # Product audited in the comparison area. i Product audited in the Western / India border area. c Product audited in the Bangladesh border / Rakhine area.

83 World Health Organization. (2015). Guidelines for the treatment of malaria, 3rd edition. Geneva: WHO.



Annex 9: RDT Reference

Table X9: Number of RDTs audited

Community

Health Worker

Private for-Profit

Facility Pharmacy

General Retailer


ALL Outlets

AMTR Intervention 513 108 57 38 30 746

AMTR Comparison 233 37 9 1 12 292

Western / India border 204 40 14 7 23 288

Bangladesh border / Rakhine 238 26 19 6 20 309

TOTAL 1,188 211 99 52 85 1,635


Table X10: RDT Brand Names and Manufacturers*

Brand Name Manufacturer

CareStart Malaria ^#ic Access Bio Inc.

Diaquick îc Dialab GMBH

First Response î Premier Medical Corp.

Humasis ^#i Humasis Co. Ltd.

Kaung ^#i Nantongegens Biotechnology Co. Ltd.

Nang Yinn #i Zhejiang Medicine & Health Product Co. Ltd.

Paracheck ^#ic Orchid Biomedical System

Para Hit # Span Diagnostics Ltd.

Reckon ^#i Reckon Diagnostics Ltd.

SD Bioline ^#ic Standard Diagnostics Inc.

* 1,635 RDTs were audited. Two RDTs were missing brand name information (intervention 1, comparison 1) and 21 RDTs (intervention 16, comparison 4, Bangladesh border / Rakhine 1) were missing manufacturer name (missing or don’t know).




Annex 10. Sampling Weights Sampling weights were applied for analysis of outlet survey data from Myanmar to account for variations in probability of selection as a result of the sampling design. Sampling weights were applied within strata based on respective selection strategies. A different set of weights was applied across strata to create national estimates: 1) Stratification: Disproportionate allocation stratification was used to ensure adequate sample size within the four

research domains to allow for domain specific estimates. Research domains were based on differences in malaria burden and level of intervention across geographic areas.

2) Cluster sampling: a. Two-stage cluster sampling: Townships were selected from sampling frames within AMTR

intervention and AMTR comparison areas with probability proportional to size (PPS). Thirteen townships were selected from the intervention area sampling frame and 15 townships were selected from the comparison area sampling fame. Within each township, 16 total clusters (urban wards in urban areas and rural village tracts in rural areas) with estimated populations based on urbanicity distribution were selected using PPS.

b. One-stage cluster sampling: 180 clusters were selected from sampling frames within both the Western/India border domain and Bangladesh border/Rakhine domain using PPS.

The sampling weights applied during analysis are the inverse of the probability of selection:

𝑊𝑖 =1

a × Mα

∑ Mα

Where:

Mα = domain, township, or cluster population

ΣMα = sum of township populations or cluster populations in the entire stratum

a = number of townships or clusters selected within the stratum Sampling weights were calculated at the township level in the AMTR intervention and comparison domains and at the cluster level in the Western/India border and Bangladesh border /Rakhine domains. The weights were applied to all outlets within a given township or cluster, irrespective of outlet type. The population numbers used to select townships with PPS and to create sampling weights were obtained from the 2014 UNFPA Myanmar census. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size. Probability proportional to size sampling was also used to select village tracts and wards within each township. A finite population correction was applied at the cluster level within each stratum using the following formula:

√ (N – n) / (N – 1)

Where:

n = number of selected clusters in strata

N = total number of clusters in strata



3) National estimate weights: National estimate weights were created by dividing the domain population by the sum total population of the four domains. Weights were applied to their respective domain point estimate, confidence intervals for percentages, and 25th and 75th percentiles for medians as follows:

Point Estimates:

𝐸𝑁𝐴𝑇 = (𝑝1 × 𝑁1 ÷ 𝑁𝑇𝑂𝑇) + (𝑝2 × 𝑁2 ÷ 𝑁𝑇𝑂𝑇) + (𝑝3 × 𝑁3 ÷ 𝑁𝑇𝑂𝑇) + (𝑝4 × 𝑁4 ÷ 𝑁𝑇𝑂𝑇) Where:

𝑝1 = AMTR Intervention domain estimate (percentage, median, or volume)

𝑝2 = AMTR Comparison domain estimate (percentage, median, or volume)

𝑝3 = Western / India Border domain estimate (percentage, median, or volume)

𝑝4 = Bangladesh border / Rakhine domain estimate (percentage, median, or volume)

𝑁1 = AMTR Intervention domain population

𝑁2 = AMTR Comparison domain population

𝑁3 = Western / India border domain population

𝑁4 = Bangladesh border / Rakhine domain population

𝑁𝑇𝑂𝑇 = Population total (N1 + N2 + N3 + N4)

𝐸𝑁𝐴𝑇 = National proportion estimate

Confidence intervals for percentages:

𝐶𝐼𝑁𝐴𝑇 = (𝑊1 × 𝑝1) + (𝑊2 × 𝑝2) + (𝑊3 × 𝑝3) + (𝑊4 × 𝑝4) ± [2 ×

√(𝑊12 × 𝑉1) + (𝑊2

2 × 𝑉2) + (𝑊32 × 𝑉3) + (𝑊4

2 × 𝑉4)]

Where:

𝑊1 = AMTR Intervention domain weight (N1/NTOT)

𝑊2 = AMTR Comparison domain weight (N2/NTOT)

𝑊3 = Western / India border domain weight (N3/NTOT)

𝑊4 = Bangladesh border / Rakhine domain weight (N4/NTOT)

𝑉1 = AMTR Intervention domain variance (standard error squared)

𝑉2 = AMTR Comparison domain variance (standard error squared)

𝑉3 = Western / India border domain variance (standard error squared)

𝑉4 = Bangladesh border / Rakhine domain variance (standard error squared)

𝐶𝐼𝑁𝐴𝑇 = Confidence interval

Confidence intervals for medians:

𝐿𝑜𝑤𝑒𝑟𝐶𝐼𝑁𝐴𝑇 = (𝑝251 × 𝑊1) + (𝑝252 × 𝑊2) + (𝑝253 × 𝑊3) + (𝑝254 × 𝑊4) 𝑈𝑝𝑝𝑒𝑟𝐶𝐼𝑁𝐴𝑇 = (𝑝751 × 𝑊1) + (𝑝752 × 𝑊2) + (𝑝753 × 𝑊3) + (𝑝754 × 𝑊4)

Where:

𝑝251 = AMTR Intervention 25th percentile estimate (lower IQR)

𝑝751 = AMTR Intervention 75th percentile estimate (upper IQR)

𝑝252 = AMTR Comparison 25th percentile estimate (lower IQR)

𝑝752 = AMTR Comparison 75th percentile estimate (upper IQR)

𝑝253 = Western / India border 25th percentile estimate (lower IQR)

𝑝753 = Western / India border 75th percentile estimate (upper IQR)

𝑝254 = Bangladesh border / Rakhine 25th percentile estimate (lower IQR) 𝑝754 = Bangladesh border / Rakhine 75th percentile estimate (upper IQR)



Annex 11: Indicator Definitions Table A/B1: Availability of antimalarials, among all screened outlets Table 1 reports the proportion of all outlets enumerated that had any antimalarial in stock at the time of the survey visit. Antimalarial availability is reported among all outlets as well as among individual outlet types, all health workers, and all private outlets. Availability is reported for any antimalarial as well as specific types of antimalarial medicines.

Numerator Number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Denominator Number of outlets screened.

Calculation Numerator divided by denominator.

Handling missing values

All screened outlets will contribute to the denominator. This includes outlets that were eligible for interview (including antimalarial audit) but: 1) were not interviewed; or 2) the interview was partially completed.

Notes and considerations

Given partial or non-completion of interviews among eligible outlets and the inclusion of these outlets in the denominator, these availability indicators can be considered conservative estimates of antimalarial availability.

Table A/B2: Availability of antimalarials, among outlets stocking at least one antimalarial Table 2 reports the proportion of antimalarial-stocking outlets with specific antimalarial in stock at the time of the survey visit. Antimalarial availability is reported among all outlets as well as among individual outlet types, all health workers, and all private outlets. Availability is reported for any antimalarial as well as specific types of antimalarial medicines.

Numerator Number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Denominator Number of outlets with at least 1 antimalarial audited.



All outlets with at least one antimalarial recorded in the antimalarial audit sheet will contribute to the denominator. This includes outlets where the interview was not fully completed (partial interview).


Given partial completion of interviews among antimalarial-stocking outlets and the inclusion of these outlets in the denominator, these availability indicators can be considered conservative estimates of antimalarial availability.



Table A/B3: Provision of malaria blood testing and antimalarials in the past week, among outlets with testing/antimalarials available, by outlet type

Table 3 reports the provision of malaria blood testing, including RDT tests performed or distributed as well as malaria microscopy tests performed in the past week, among outlets that were stocking malaria RDTs or microscopy. Table 3 also reports the distribution of antimalarials in the past week, among outlets that were stocking antimalarials. This includes distribution of any antimalarial in the past week as well as distribution of specific types of antimalarials where they were in stock, including first-line treatments and oral artemisinin monotherapy. The table also reports median number of adult equivalent treatment dosages (AETDs) distributed in the past week. Provision of malaria blood testing:

Numerator Number of outlets that reportedly provided malaria blood testing in the past week, including performing and providing an RDT or providing a malaria microscopy test.

Denominator Number of outlets with malaria microscopy and/or RDTs available.



Outlets with values of missing/don’t know for testing provided by microscopy as well as volumes distributed for all RDTs in stock will be excluded from this indicator. Outlets with partial information about testing provision/RDT distribution will be included in the indicator (e.g. with information about RDT distribution but not microscopy provision).


Given partial information about provision of microscopy and RDTs and the inclusion of these outlets in the denominator, the indicator can be considered a conservative estimate of testing provision.

Median number of malaria tests provided/performed:

Calculation Median number of tests reportedly provided/distributed in the past week including RDTs distributed/performed and malaria microscopy tests performed, at the outlet level.


If all testing volume data are missing/refused/unknown, then the outlet is excluded from the median calculation. If partial information is available (e.g. distribution of RDTs but not microscopy test performed), then partial information will be used to calculate the median.


Given partial information about testing provision and the inclusion of these outlets in the denominator, this indicator can be considered conservative/minimum estimates of malaria testing provision.



Antimalarial distribution:

Numerator Number of outlets that reportedly distributed antimalarials in the past week, including any antimalarial and specific types of antimalarials such as first-line treatments.

Denominator Number of outlets with at least 1 antimalarial of the specified type (e.g. any antimalarial, first-line ACT, etc.) audited.



Within a given antimalarial category, outlets with missing/don’t know/refusal values for all antimalarials in that category will be excluded from the indicator. Outlets with partial information about distribution of antimalarials within a given category will be included in the indicator (e.g. with information about 2 out of 4 first-line treatments audited).


Given partial information about antimalarial distribution and the inclusion of these outlets in the denominator, these distribution indicators can be considered conservative estimates of antimalarial distribution.

Median number of AETDs distributed

Calculation Median number of AETDs (see Annex 11) reportedly distributed in the past week for the specified type of antimalarial (e.g. any antimalarial, first-line treatment, etc.) at the outlet level.


Within a given antimalarial category, if all volume data are missing/refused/unknown, then the outlet is excluded from the median calculation. If partial information is available (e.g. distribution of 1 out of 3 antimalarials in stock), then partial information will be used to calculate the median.


Given partial information about antimalarial distribution and the inclusion of these outlets in the denominator, these distribution indicators can be considered conservative/minimum estimates of antimalarial distribution.

Table A/B4: Types of quality-assured and non-quality-assured ACTs

Table 4 reports the types of quality-assured (QA) and non-quality-assured (non-QA) ACTs audited AMONG all health workers and all private sector outlets, including generic name and formulation.

Numerator By sector, the number of QA and non-QA ACTs audited within each generic and formulation category (e.g. number of QA artemether lumefantrine tablets audited in the public sector).

Denominator By sector, total number of QA and non-QA ACTs audited.

Calculation Numerator divided by the denominator within QA and non-QA ACTs for each sector.


By definition, the generic name of all ACTs is known. ACTs with missing formulation information are excluded.

Table A/B5: Antimalarial market composition Table 5 reports the distribution of outlet types among outlets with at least one antimalarial in stock on the day of the survey.

Numerator By outlet type, the number of outlets with any antimalarial in stock at the time of the survey visit,



as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Denominator Total number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Calculation Numerator for each outlet type divided by the denominator.


All outlets with at least one antimalarial recorded in the antimalarial audit sheet will contribute to the indicator. This includes outlets where the interview was not fully completed (partial interview).


Market composition is calculated among outlets located within the representative sample of clusters, and excludes the booster sample.

Table A/B6: Price of antimalarials

Table 6a provides the median price of an adult equivalent treatment dose (AETD, see Annex 11) for select tablet formulation types of antimalarials across outlet types. The inter-quartile range (IQR) is provided as a measure of dispersion.

Calculation Median antimalarial AETD (see Annex 11) price in US dollars with inter-quartile range (25th and 75th percentiles).


Antimalarials with missing price information are excluded from the median price calculation.


Price in US dollars is calculated based on exchange rates available from www.oanda.com using the historical exchange rates tool. The average exchange rate over the entire data collection period is used for converting local currency captured during data collection to US dollars.

A. Table 6b also provides the median price of two pre-packaged QAACT therapies: pediatric appropriate for a 10kg

child (2 years of age), and adult appropriate for a 60kg adult. The inter-quartile range (IQR) is provided as a measure of dispersion.

Calculation Median pre-packaged therapy price in US dollars with inter-quartile range (25th and 75th percentiles.


Antimalarials with missing price information are excluded from the median price calculation.



Table A/B7: Availability of malaria blood testing, among antimalarial-stocking outlets Table 7 reports the proportion of antimalarial-stocking outlets that had malaria blood testing available. Testing availability is reported among all outlets as well as among individual outlet types, all health workers, and all private outlets. Availability is reported for any blood test as well as specific test types: microscopy and RDTs.





Numerator Number of outlets with malaria blood testing available (any, microscopy, RDT).

Denominator Number of outlets with any antimalarials in stock at the time of the survey visit or reportedly stocked any antimalarial in the previous three months.



Antimalarial-stocking outlets with missing information about both availability of microscopy and availability of RDTs are excluded from malaria testing indicators. The number of such outlets is provided in a footnote.

Outlets with partial information about availability of blood testing (information about microcopy or RDTs) are included in the denominator of the indicator “any blood testing available.” The number of such outlets is provided in a footnote.

Indicators for RDT and microscopy availability exclude outlets with missing availability information respectively (i.e. outlets missing information about microscopy availability are excluded from the microscopy indicator).


Survey inclusion criteria extended to outlets providing blood testing but not stocking antimalarials (“diagnosis/testing-only outlets”). These outlets are excluded from this availability table.

Table A/B8: Malaria blood testing market composition

Table 8 reports the distribution of outlet types among outlets with malaria blood testing available on the day of the survey.

Numerator By outlet type, the number of outlets with malaria blood testing available at the time of the survey visit, as confirmed by presence of at least one RDT recorded in the RDT audit section and/or reported availability of malaria microscopy services.

Denominator Total number of outlets with malaria blood testing available at the time of the survey visit, as confirmed by presence of at least one RDT recorded in the RDT audit section and/or reported availability of malaria microscopy services.

Calculation Numerator for each outlet type divided by the denominator.


All outlets with non-missing values for the RDT audit or malaria microscopy availability questions are included in the indicators. This includes outlets where the interview was not fully completed (partial interview).


Market composition is calculated among outlets located within the representative sample of clusters, and excludes the booster sample.

Table A/B9: Price of malaria blood testing

A. Table 9 reports the median price of blood testing to consumers including any consultation or service fees. The

inter-quartile range (IQR) is provided as a measure of dispersion.

Calculation Median total blood test price in US dollars with inter-quartile range (25th and 75th percentiles).


Microscopy-stocking outlets that are missing information about price of microscopy are excluded from this indicator. Audited RDTs with missing information about price of testing are excluded from this indicator.





Table A/B10: Antimalarial market share

Antimalarial market share is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/distributed in the previous week. Expressed as a percentage, market share is the amount of a specific antimalarial sold/distributed by a specific outlet type relative to the entire antimalarial market (all antimalarial types sold/distributed by all outlet types). Totals are reported per antimalarial medicine type and per outlet type. Across antimalarial medicine types and outlet types, percentages in the entire table sum to 100% (the total market).

Numerator Number of AETDs sold/distributed for a specific antimalarial drug category and outlet type.

Denominator Total number of AETDs sold/distributed.



AETDs sold/distributed are calculated among audited medicines with complete and consistent information. Antimalarials with incomplete or inconsistent information among key variables that define AETD sold/distributed (active ingredients, strength, formulation, package size, amount sold/distributed) are excluded from the calculation.


See Annex 11 for a description of AETD calculation.

Table A/B11: Antimalarial market share across outlet type Antimalarial market share across outlet type is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by antimalarial type within each outlet type as a percentage of all AETDs sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific antimalarial sold/distributed relative to the entire antimalarial market segment for the specified outlet type (all antimalarial types sold/distributed by the specific outlet type). Totals are reported per antimalarial medicine type for each outlet type. Across antimalarial medicine types within each outlet type, percentages sum to 100%.

Numerator Number of AETDs sold/distributed for a specific antimalarial drug category within the specified outlet type.

Denominator Total number of AETDs sold/distributed within the specific outlet type.



AETDs sold/distributed are calculated among audited medicines with complete and consistent information. Antimalarials with incomplete or inconsistent information among key variables that define AETD sold/distributed (active ingredients, strength, formulation, package size, amount sold/distributed) are excluded from the calculation.


See Annex 11 for a description of AETD calculation.




Table A/B12: Malaria blood testing market share

Malaria blood testing market share is the number of malaria blood tests reportedly sold or distributed in the previous week by outlet type and malaria blood test type (RDT, microscopy) as a percentage of all malaria blood tests sold/distributed in the previous week. Expressed as a percentage, market share is the number of a specific malaria blood test type by a specific outlet type relative to the entire malaria blood testing market (all malaria blood tests sold/distributed by all outlet types). Totals are reported per test type and per outlet type. Across malaria blood test types and outlet types, percentages in the entire table sum to 100% (the total market).

Numerator Number of malaria blood tests sold/distributed for a specific blood test type (RDT, microscopy) and outlet type.

Denominator Total number of malaria blood tests sold/distributed.



Malaria blood tests sold/distributed are calculated among audited RDTs and microscopy services with complete and consistent information. RDTs and microscopy services with incomplete or inconsistent information about the amount sold/distributed) are excluded from the calculation.


Records and/or recall of testing with microscopy versus malaria RDT may differ within a given outlet, introducing an unquantifiable bias in estimating total tests performed.

Table A/B13: Malaria blood testing market share across outlet type Malaria blood testing market share across outlet type is the number of malaria blood tests reportedly sold or distributed in the previous week by blood test type within each outlet type as a percentage of all blood tests sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific malaria blood test sold/distributed relative to the entire blood testing market segment for the specified outlet type (all malaria tests sold/distributed by the specific outlet type). Totals are reported per test type for each outlet type. Across malaria blood test types within each outlet type, percentages sum to 100%. The market share for each RDT manufacturer is also reported across outlet type. Within each outlet type, the number of RDTs for a specific manufacturer sold/distributed relative to all RDTs distributed within that outlet type is reported as a percentage. Totals for RDT market share across all manufacturers sums to 100% within each outlet type.

Numerator Number of malaria blood tests sold/distributed for a specific blood test type (RDT, microscopy), or number of malaria RDTs sold/distributed for a specific manufacturer, within the specified outlet type.

Denominator Total number of malaria blood tests/RDTs sold/distributed within the specific outlet type.



Malaria blood tests sold/distributed are calculated among audited RDTs and microscopy services with complete and consistent information. RDTs and microscopy services with incomplete or inconsistent information about the amount sold/distributed) are excluded from the calculation.


Records and/or recall of testing with microscopy versus malaria RDT may differ within a given outlet, introducing an unquantifiable bias in estimating total tests performed.



Table A/B14: Private sector case management training, supervision, support and surveillance

Table 14 reports key indicators of outlet case management training, supervision and surveillance. These include training within the last year for any provider within the outlet on malaria diagnosis, and on the national treatment guidelines for malaria; a supervisory or regulatory visit for the outlet within the past year; access to subsidized antimalarials and/or malaria RDTs; and passive surveillance including record keeping and reporting of case data to government or non-government organizations. This table also reports composite indicators comprised of combinations of these individual indicators of private sector engagement, support and readiness. Some composite indicators include availability of first-line antimalarial treatments and malaria blood testing as part of overall measures of private sector engagement and readiness for appropriate malaria case management.

Numerator A. Training: respondents who indicated that training had been received for themselves or another provider at the outlet within the past year on 1) malaria diagnosis; and 2) national malaria treatment guidelines.

B. Supervision/regulation: respondents who indicated that the outlet had received a supervisory or regulatory visit within the past year.

C. Support/access to subsidized commodities: respondents who indicated that the outlet has access to subsidized: 1) antimalarials; and 2) malaria RDTs.

D. Passive surveillance: respondents who indicated that the outlet keeps records on the number of patients tested/treated for malaria; and report these numbers to a governmental or non-governmental organization.

E. Composite indicator for training plus supervision/regulation: trained provider (indicator A) with reported training for either malaria diagnosis or the national malaria training guidelines, as well as supervision (indicator B).

F. Composite indicator for training, supervision/regulation, and appropriate stocking: trained provider (Indicator A) with reported training for either malaria diagnosis or the national malaria training guidelines; supervision/regulatory visits (Indicator B); first-line treatment for Pf and Pv in stock on the day of the survey (Table 1); and either malaria RDTs or microscopy available (Table 7).

Denominator Training, supervision/regulation, support/access to subsidized commodities, passive surveillance (keep records on the number of patients tested/treated for malaria): Respondents who provided any response to the individual question, excluding “don’t know.” Passive surveillance (report the number of patients tested/treated for malaria to a governmental or non-governmental organization): Respondents who provided a response to the question, “Does this outlet record information about the number of patients that have received a malaria test or malaria treatment?” and who provided a response to the individual question, excluding “don’t know”. Composite indicators: The number of outlets with a response for each component of the indicator, excluding “don’t know.”



Providers with missing responses to individual questions will be excluded from the indicator.


Questions assessing provider training, outlet supervision/regulation and support, and passive surveillance systems were administered to one respondent per outlet. As such, indicators are tabulated at the outlet level. Responses of “don’t know” are excluded from each indicator. Number of “don’t know” responses are noted in table footnotes.



Table A/B15: Provider antimalarial treatment knowledge and practices, by outlet type Table 15 reports key indicators of provider antimalarial treatment knowledge and practices. These include knowledge of the first-line treatment for uncomplicated Pf and Pv malaria; knowledge of the first-line treatment dosing regimen for adults for each first-line treatment; citing ACT as most effective to treat malaria in adults; and citing ACT as most commonly recommended by the provider to manage malaria in adults.

Numerator A. State first-line: providers who responded to questions about the first line treatment with a generic or brand name consistent with a national first-line treatment. Correct responses are reported for when the first-line was reported with and without the use of primaquine.

B. First-line regimen, adult: providers who correctly stated the first-line generic ingredients and strengths, and correctly stated: number of days, times per day, and tablets per dose to be taken. Correct responses are reported for when the first-line was reported with and without the use of primaquine.

C. ACT most effective for an adult: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect.

D. ACT most often recommended for an adult: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect.

Denominator All providers who responded to the respective question, including responses of “don’t know” and responses of non-antimalarial medicines used with or without antimalarial medicines.



Providers with missing responses to individual questions will be excluded from the respective indicator. However, providers with partial information for the dosing regimen questions will be included in the denominator.



Table C/D1: Availability of oral artemisinin monotherapy Table 1 summarizes indicators for oral AMT availability. These include availability on the day of the survey and/or available recently - within the past 3 months – but not on the day of the survey. Oral AMT availability is reported among all screened outlets as well as among antimalarial-stocking outlets, or outlets with antimalarials in stock on the day of the survey.

Numerator a) Number of outlets with oral AMT in stock at the time of the survey visit, as confirmed by presence of at least oral AMT product (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

b) Number of outlets with oral AMT reportedly in stock within the past 3 months, but not in stock on the day of the survey. Defined as report of a name brand or generic name corresponding with oral AMT.

Denominator a) Number of outlets screened.

b) Number of outlets with any antimalarial in stock on the day of the survey, as confirmed by presence of at least one antimalarial product (d) recorded in the antimalarial audit section.



a) All screened outlets will contribute to the denominator. This includes outlets that were eligible for interview (including antimalarial audit) but: 1) were not interviewed; or 2) the interview was partially completed.

b) This includes outlets with a partial interview/audit.


Given partial or non-completion of interviews among eligible outlets and the inclusion of these outlets in the denominator, these availability indicators can be considered conservative estimates of oral AMT availability.

Table C/D2: Characteristics of oral artemisinin monotherapy supply, among oral AMT stockists Table 2 summarizes indicators for oral AMT supply including provider reports of: 1) supplier for oral AMT products currently or recently in stock; 2) frequency of oral AMT wholesale purchase within the past 3 months; 3) number of packages in stock on the day of the survey; 4) availability of oral AMT among other outlets in the village or town; and 5) consumer preference/demand for oral AMT. These indicators are reported at the outlet level, among outlets stocking oral AMT on the day of the survey or within the past 3 months.

C/D2 indicators reported as proportions:

Numerator a) Number of outlets that named specific source(s) for the oral AMT currently or recently in stock. More than one supplier/source may be named.

b) Number of outlets that reportedly obtained oral AMT from a supplier within the past 3 months.

c) Number of outlets with a provider who reported that other outlets in the village/town stock the oral AMT product(s) that he/she has in stock/recently stocked.

d) Number of outlets with a provider who reported that customers request by name the oral AMT product(s) that he/she has in stock/recently stocked.

Denominator Number of outlets stocking oral AMT on the day of the survey or within the past 3 months. Calculation Numerator divided by denominator.


a) Outlets that have values of missing, refused or don’t know for all oral AMT products are excluded from the denominator. If an outlet named a supplier for at least one oral AMT product, the outlet is included in the denominator.



b) Outlets that have values of missing, refused or don’t know for all oral AMT products are excluded from the denominator. If an outlet provided a response to the question on recent supply for at least one oral AMT product in stock, the outlet is included in the denominator.

c) Outlets that have values of missing, refused or don’t know for all oral AMT products are excluded from the denominator. If an outlet responded to the question for at least one oral AMT product, the outlet is included in the denominator.

d) Outlets that have values of missing, refused or don’t know for all oral AMT products are excluded from the denominator. If an outlet responded to the question for at least one oral AMT product, the outlet is included in the denominator.


Outlets may have more than one oral AMT product in stock/recently in stock (e.g. 2 different brands of artesunate tablets, or 1 artesunate and 1 artemether product). Indicators in this table are calculated at the outlet level and apply to responses across all products, including all named suppliers; and report of obtaining oral AMT within the past 3 months for any product.

C/D2 indicators reported as medians:

Calculation a) Median total number of times all oral AMT products in stock/recently in stock were obtained from a supplier within the past 3 months, with inter-quartile range (25th and 75th percentiles).

b) Median total number of oral AMT packages in stock on the day of the survey (including all brands and generics), with inter-quartile range (25th and 75th percentiles).


Oral AMT products with responses of missing, refused or don’t know for all oral AMT products are excluded from the median calculations. If an outlet responded to the question for at least one oral AMT product, the outlet is included in the median calculation.


Outlets may have more than one oral AMT product in stock/recently in stock (e.g. 2 different brands of artesunate tablets, or 1 artesunate and 1 artemether product). Indicators in this table are calculated at the outlet level and apply to responses across all products, including total numbers of times that oral AMT products were obtained from a supplier in the past 3 months and total number of packages of oral AMT in stock on the day of the survey (sum for all products).

Table C/D3: Distribution of oral artemisinin monotherapy, among outlets stocking oral AMT Table 3 summarizes indicators for oral AMT distribution among outlets with at least one oral AMT product in stock on the day of the survey. These include distribution of a product in the past week; distribution of less than 1 full course in the past week; distribution of 1 or more full course in the past week and median number of packages in stock on the day of the survey, and numbers of tablets and AETDs distributed in the past week. The table includes an estimate of the number of individual customers treated with oral AMT in the past week by using information about number of tablets distributed and typical course distributed to treat an adult with malaria.

C/D3 indicators reported as proportions:

Numerator a) Number of outlets that reportedly did not distribute at least one tablet of oral AMT to an individual customer in the past week.

b) Number of outlets that reportedly distributed at least one tablet of oral AMT to an individual customer in the past week, but did not distribute the number of tablets required for a full course (at least 20 50mg tablets given AETD of 960mg, see Annex 11).

c) Number of outlets that reportedly distributed at least one tablet of oral AMT to an individual customer in the past week, and distributed at least the number of tablets required for a full course (at least 20 50mg tablets given AETD of 960mg, see Annex 11).

Denominator Number of outlets stocking oral AMT on the day of the survey.





Outlets that have values of missing, refused or don’t know for the distribution of all oral AMT products are excluded from the denominator. If an outlet reported an amount distributed for at least one oral AMT product, the outlet is included in the denominator.


Outlets may have more than one oral AMT product in stock (e.g. 2 different brands of artesunate tablets, or 1 artesunate and 1 artemether product). Indicators in this table are calculated at the outlet level and apply to responses across all products, including distribution of any oral AMT product in stock.


Calculation a) Median total number of oral AMT packages in stock on the day of the survey (including all brands and generics), with inter-quartile range (25th and 75th percentiles).

b) Median total number of oral AMT AETDs distributed in the past week, with inter-quartile range (25th and 75th percentiles).

c) Median total number of 50mg oral AMT tablets distributed in the past week, with inter-quartile range (25th and 75th percentiles).

d) Median total estimated number of individual customers treated with oral AMT in the past week, with inter-quartile range (25th and 75th percentiles). Providers indicated a typical number of tablets dispensed to treat malaria in an adult. The estimated number of individual customers treated was calculated within each outlet as the total number of tablets reportedly dispensed is the past week divided by the number of tablets that the provider reported he/she typically dispenses to treat malaria in an adult.


Oral AMT products with responses of missing, refused or don’t know for the distribution of all oral AMT products are excluded from the median calculations. If an outlet reported an amount distributed for at least one oral AMT product, the outlet is included in the median calculation.


Outlets may have more than one oral AMT product in stock (e.g. 2 different brands of artesunate tablets, or 1 artesunate and 1 artemether product). Indicators in this table are calculated at the outlet level and apply to responses across all products, including total numbers of oral AMT tablets/AETDs distributed and estimated number of customers treated (sum for all products).

Table C/D4: Characteristics of oral artemisinin monotherapy products Table 4 summarizes characteristics of oral AMT products, including the outlet types in which they were audited; active ingredient; expiry date; and manufacturer. The table also summarizes median numbers of packages obtained during the most recent wholesale purchase; wholesale and retail price; retail percentage mark-up; and number of 50mg tablets typically dispensed to treat malaria in an adult. C/D4 indicators reported as proportions:

Numerator a) Number of oral AMT products that were audited within specific outlet types (health worker, private for-profit health facility, pharmacy, retailers, and itinerant drug vendor).

b) Number of oral AMT products audited that contained artesunate or artemether. c) Number of oral AMT products audited that were expired, had less than 1 year to expiry, had

1 to 2 years to expiry, or had greater than 2 years to expiry, at the time of the survey. d) Number of oral AMT products audited that were manufactured by specific manufacturers (3

most common plus ‘other’).

Denominator Number of oral AMT products audited.





N/A for a and b c) Outlets that have values of missing or don’t know for manufacturer will be excluded from the denominator. d) Outlets that have values of missing or don’t know for manufacturer will be excluded from the denominator.



Calculation a) Median number of packages obtained during the most recent wholesale purchase, with inter-quartile range (25th and 75th percentiles).

b) Median wholesale price per 50mg tablet for the most recent wholesale purchase, with inter-quartile range (25th and 75th percentiles).

c) Median retail price per 50mg tablet, with inter-quartile range (25th and 75th percentiles). d) Median price per AETD (see Annex 11), with inter-quartile range (25th and 75th percentiles). e) Median retail percentage market-up, with inter-quartile range (25th and 75th percentiles).

Retail percentage mark-up was calculated as the difference between selling price and purchase price, divided by the purchase price.

f) Median number of 50mg tablets typically dispensed to treat malaria in an adult, with inter-quartile range (25th and 75th percentiles).


Oral AMT products with responses of missing, refused or don’t know are excluded from the median calculation.


Price reported in US dollars. Retail or wholesale price reported for quantities greater than 1 tablet were converted to 1 tablet for price per tablet indicators.



Annex 12. Adult Equivalent Treatment Dose (AETD) Definition Antimalarial medicines are manufactured using a variety of active pharmaceutical ingredients, dosage forms, strengths, and package sizes. ACTwatch uses the adult equivalent treatment dose (AETD) as a standard unit for price and sale/distribution analyses. One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat an adult weighing 60 kilograms (kg). For each antimalarial generic, the AETD is defined as the number of mg recommended in treatment guidelines for uncomplicated malaria in areas of low drug resistance issued by the WHO. Where WHO treatment guidelines do not cover a specific generic, the AETD is defined based on peer-reviewed research or the product manufacturer’s recommended treatment course for a 60kg adult. Table X9 lists AETD definitions used in this report. While it is recognized that the use of AETDs may over-simplify and ignore many of the complexities of medicine consumption and use, this analytical approach was selected because it standardizes medication dosing across drug types and across countries (which may sometimes vary) thus permitting comparisons on both prices and volumes calculated on the basis of an AETD. Additional considerations:

Where combination therapies consist of two or more active antimalarial ingredients packaged together (co-formulated or co-blistered), the strength of only one principal ingredient is used. The artemisinin derivative is used as the principal ingredient for ACT AETD calculations.

Primaquine distribution was not included in calculations of total and relative volumes distributed. This is because primaquine is to be used only in combination with either an ACT for Pf, or with chloroquine for all other infections. Therefore, similar to the treatment of partner drugs within an ACT, we only consider volumes distributed for primaquine’s partner drugs (ACT or chloroquine).

Co-blistered combinations are generally assumed to be 1:1 ratio of tablets unless otherwise documented during fieldwork or through manufacturer websites.

Sulfamethoxpyrazine-pyrimethamine is assumed to have the same full course adult treatment dose as sulfadoxine-pyrimethamine.

Calculation Information collected on drug strength and unit size as listed on the product packaging was used to calculate the total amount of each active ingredient found in the package. The number of AETDs in a unit was calculated.84 The number of AETDs in a monotherapy is calculated by dividing the total amount of active ingredient contained in the unit by the AETD (i.e. the total number of mg required to treat a 60kg adult). The number of AETDs for a combination therapy was calculated by dividing the total amount of the active ingredient that was used as the basis for the AETD by the AETD.

84 The unit is dependent on the drug dosage form. The unit for antimalarials in tablet, suppository, or granule form is the package. The unit for injectable antimalarials is the ampoule. The unit for syrup and suspension antimalarials is the bottle.



Table X11: Adult Equivalent Treatment Dose Definitions

Antimalarial Generic [Ingredient used for AETD

mg dose value]

Dose used for calculating 1

AETD (mg required to treat a 60kg adult)

Source

Artemether 960mg WHO Use of Antimalarials, 2001

Artemether-Lumefantrine

[Artemether] 480mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Artemisinin-Napthoquine

[Artemisinin] 2400mg WHO Use of Antimalarials, 2001

Artesunate 960mg WHO Use of Antimalarials, 2001

Artesunate Amodiaquine

[Artesunate] 600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Chloroquine 1500mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Chloroquine-Primaquine

[Chloroquine] 1500mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Dihydroartemisinin-

Piperaquine

[Dihydroartemisinin]

360mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Mefloquine 1000mg WHO Model Formulary, 2008

Quinine 10408mg WHO Model Formulary, 2008

Sulfadoxine-Pyrimethamine 1500mg WHO Model Formulary, 2008


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