Outlet Survey Report Zambia 2009 - ACTwatch · Acknowledgements ACTwatch is funded by the Bill and Melinda Gates Foundation. This study was implemented by Society for Family Health

www.ACTwatch.info Copyright © 2009 Population Services International (PSI). All rights reserved.

Evidence for Malaria Medicines Policy

Outlet Survey Report

Zambia

2009

Country Program Coordinator Mr. Felton Mpasela Society for Family Health/Zambia Plot No. 549 Ituna Road Ridgeway Lusaka, Zambia Phone: + 260 211 257407 Email: [email protected]

Principal Investigator Dr. Kathryn O’Connell ACTwatch, Malaria Control & Child Survival Department Population Services International Regional Technical Office Whitefield Place, School Lane, Westlands P.O. Box 14355-00800 Nairobi, Kenya Phone: + 254 20 4440125/6/7/8 Email: [email protected]

mailto:[email protected]

Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation. This study was implemented by Society for Family Health (SFH), coordinated by Felton Mpasela, ACTwatch Country Program Coordinator, SFH/Zambia, in collaboration with Dr. Elizabeth Chizema-Kawesha, Director, National Malaria Control Centre and Dr. Mulakwa Kamuliwo, Case Management Specialist, National Malaria Control Centre, Ministry of Health, Zambia. Survey implementation was conducted by SFH/Zambia: Nicholas Shiliya, Cynthia Changufu, and Edward Ngoma. Project support was provided by Population Services International (PSI) from the following individuals: Dr. Kathryn O’Connell, Principal Investigator, ACTwatch; Dr. Desmond Chavasse, Project Director, ACTwatch, Vice President, Malaria Control and Child Survival; Illah Evance, Stephen Poyer, Tsione Solomon and Erik Munroe, ACTwatch Research Associates; Dr. Abdinasir Amin, Malaria and Child Survival Principal Investigator; Tanya Shewchuk, Project Coordinator, ACTwatch. A technical review of the outlet survey study design was provided by the following ACTwatch partners, ACTwatch Advisory Committee members and other stakeholders:

Dr. Kara Hanson Reader, Health System Economics, Health Policy Unit, London School of Hygiene and Tropical Medicine (LSHTM)

Dr. Catherine Goodman Senior Lecturer, Health Economics & Policy, Health Policy Unit, LSHTM

Mr. Suprotik Basu Advisor to the UN Secretary General's Special Envoy for Malaria

Mr. Rik Bosman Supply Chain Expert, Former Senior Vice President, Unilever

Ms. Renia Coghlan Global Access Associate Director, Medicines for Malaria Venture (MMV)

Dr. Thom Eisele Assistant Professor, Tulane University

Mr. Louis Da Gama Malaria Advocacy & Communications Director, Global Health Advocates

Dr. Paul Lalvani Executive Director, RaPID Pharmacovigilance Program

Dr. Ramanan Laxminarayan Senior Fellow, Resources for the Future

Dr. Matthew Lynch Project Director, VOICES, Johns Hopkins University Centre for Communication Programs

Dr. Bernard Nahlen Deputy Coordinator, President's Malaria Initiative (PMI)

Dr. Jayesh M. Pandit Head, Pharmacovigilance Department, Pharmacy and Poisons Board-Kenya

Dr. Melanie Renshaw Former Senior Health Advisor for Malaria, UNICEF

Mr. Oliver Sabot Director, Malaria Control Team, Clinton Foundation

Ms. Rima Shretta Senior Program Associate, Strengthening Pharmaceutical Systems Program, Management Sciences for Health

Dr. Rick Steketee Science Director, Malaria Control and Evaluation Partnership in Africa (MACEPA)

Dr. Warren Stevens Health Economist

Dr. Gladys Tetteh CDC Resident Advisor, President’s Malaria Initiative-Kenya

Prof. Nick White, OBE Professor of Tropical Medicine, Mahidol and Oxford Universities

Prof. Prashant Yadav Professor of Supply Chain Management, MIT-Zaragoza International Logistics Program

Dr. Shunmay Yeung Paediatrician & Senior Lecturer, LSHTM

Table of Contents LIST OF FIGURES ................................................................................................................................... 4

DEFINITIONS ........................................................................................................................................ 5

KEY INDICATOR DESCRIPTIONS ............................................................................................................ 7

EXECUTIVE SUMMARY ......................................................................................................................... 9

COUNTRY BACKGROUND ................................................................................................................... 15

RESULTS ............................................................................................................................................. 17

Study-wide Trends: 2008 vs. 2009 ........................................................................................................... 17

Availability of Antimalarials ........................................................................................................ 17

Disruption in Stock, Storage Conditions & Blood Testing ............................................................. 18

Price of Antimalarials .................................................................................................................. 19

Volumes of full course sold or distributed in the past week ......................................................... 20

Provider Knowledge and Perceptions .......................................................................................... 21

Outlet Survey 2: Comparisons by Outlet Type ......................................................................................... 22



Volumes of Antimalarials Sold/Distributed .................................................................................. 25




Volumes of Antimalarials Sold/Distributed .................................................................................. 29


Outlet Survey 2: Staff and Outlet Characteristics .................................................................................... 31

APPENDIX A: ZAMBIA OUTLET TYPE DESCRIPTIONS ........................................................................... 32

APPENDIX B: FIRST-LINE ACT AND NATIONALLY REGISTERED ACTS .................................................... 34

APPENDIX C: STUDY-WIDE TABLET/NON TABLET AETD PRICES ........................................................... 35

List of Figures

Figure 1 Diversity of outlets sampled in OS1 and OS2 ...................................................................................... 10

Figure 2 Diversity of outlets stocking antimalarials in OS1 and OS2 ................................................................ 10

Figure 3. Trends in the Availability of Antimalarials in the Public Health Sector .............................................. 11

Figure 4. Trends over time in Availability of Antimalarials in the Private Health Sector .................................. 11

Figure 5. Trends in Microscopic Blood Testing Facilities & Rapid Diagnostic Tests in the Public Health Sector

........................................................................................................................................................................... 12

Figure 6. Trends in Microscopic Blood Testing Facilities & Rapid Diagnostic Tests in Private Health Sector ... 12

Figure 7. Median Price of a Full Adult Course Antimalarial Treatment in Private Health Sector ..................... 13

Figure 8. Relative Volumes of Full Course Adult Treatments Sold/Distributed in the Past Week .................... 13

Figure 9. Provider Knowledge of Recommended First-Line Treatment and Dosing Regimen within the Public

Health Sector ..................................................................................................................................................... 14

Figure 10. Provider Knowledge of Recommended First-Line Treatment and Dosing Regimen within the

Private Health Sector ........................................................................................................................................ 14

Suggested citation:

ACTwatch Group and Society for Family Health (SFH)/Zambia. (2009). Zambia Outlet Survey Report, 2009.

Population Services International: DC. Available from: www.ACTwatch.info

http://www.actwatch.info/

DEFINITIONS

Adult Equivalent Treatment Dose [AETD] - Non split tablets of antimalarial treatment. Antimalarial combination therapy – The simultaneous use of two or more drugs with different modes of action to treat malaria. Artemisinin and its derivatives – Artemisinin is a 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) – A combination of artemisinin or one of its derivatives with a partner drug. The partner drug is an antimalarial(s) of a different class. First-line treatment – The government recommended treatment for uncomplicated malaria. Zambia’s first-line treatment for malaria is artemether-lumefantrine (AL), 20mg/120mg. (See Appendix B for adult and child dosing regimens.) Monotherapy – Antimalarial treatment with a single medicine: either a single active compound or a synergistic combination of two compounds with related mechanisms of action, such as sulfadoxine-pyrimethamine. 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. (See Appendix B for a complete list of Zambia’s nationally registered ACTs.) Non-artemisinin therapy – An antimalarial treatment that does not contain artemisinin or any of its derivatives. Non-WHO/Nationally registered ACTs – ACTs that neither appear on the WHO list of ACTs approved for procurement nor are registered with a given country’s national drug regulatory authority. 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. Second-line treatment – The government recommended second-line treatment for uncomplicated malaria. Zambia’s second-line treatment for malaria is quinine. Second-line treatment indicators include all dosage forms. WHO approved ACTs – ACTs that appear on the WHO list of antimalarials approved for procurement. Legend for tables –

Symbol

-- No data was available

n/a Not applicable: Indicates ratios cannot be calculated as the numerator is zero

*** Undefined ratio as a non-zero value is being divided by a value of zero

AM Antimalarial

AETD Adult Equivalent Treatment Dose

AL Artemether-Lumefantrine

ACT Artemisinin-based Combination Therapy

SP Sulfadoxine-Pyrimethamine

Key Indicator Descriptions Acceptable storage conditions for medicines – An outlet is considered to have acceptable storage conditions for medicines if it is in compliance with all the following three standards: (1) medicines are stored in a dry area; (2) medicines are protected from direct sunlight; and (3) medicines are not kept on the floor. Adult Equivalent Treatment Dose [AETD] – Non split tablets of antimalarial treatment. Availability of antimalarials – The proportion of outlets in which an antimalarial medicine was found on the day of the survey, based upon an audit conducted by the interviewer. For indicators of availability, all outlets surveyed are included in the denominator. Availability of antimalarials – The proportion of outlets in which an antimalarial medicine was found on the day of the survey, based upon an audit conducted by the interviewer. For indicators of availability by class of antimalarials, only outlets with antimalarials in stock at the time of survey are included in the denominator. Credit to consumers – An outlet is considered to provide credit to consumers based on response of the provider. Providers in public health facilities were not asked this question. Disruption in stock – An outlet is considered to have a disruption in stock where any drug is reported to have been out of stock in the three months prior to interview, or where a drug is not in stock at the time of the visit but was stocked at some point in the previous three months. Expired stock – Indicators of expired stock are based upon the expiry information from one sample of each drug audited in an outlet; a full examination of all packages in stock was not conducted. Health danger signs – Indications considered health danger signs are taken from the World Health Organization, (2005). Handbook: IMCI integrated management of childhood illness. Available at http://whqlibdoc.who.int/publications/2005/9241546441.pdf. Questions assessing knowledge of health danger signs were not asked of providers at public health facilities. International reference price – International reference price information taken from: Management Sciences for Health, (2007). International Drug Price Indicator Guide. Available at http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=DMP&language=English. The international reference price for AL 20mg/120mg is US$2.12 for a full adult treatment. Minimum legal daily wage – Minimum daily wage information taken from: United States Department of State, (2007). Country Reports on Human Rights Practices. Available at http://www.state.gov/g/drl/rls/hrrpt/2007/index.htm. In Zambia, the minimum legal daily wage is US$2.25. Microscopic blood or rapid diagnostic testing – An outlet is considered to have microscopic or rapid diagnostic blood testing based on provider response. Functionality of the diagnostic test was not observed by the interviewer. Most popular antimalarial – The antimalarial with the largest volume of full adult courses sold or distributed in the past week. Price – Prices are calculated in terms of purchases required for a full-course treatment. Only adult tablet formulations are included these calculations. Prices are shown in US dollars. The average exchange rate during the data collection period (14th April 2009 to 3rd July 2009) was 5342.47 Zambian Kwacha to US$1 (www.oanda.com). Statistical significance – Mood’s median test is used to compare medians and chi-square tests are used to compare proportions between categories. P values are based on the standard type 1 error rate of 0.05, divided by the number of comparisons, to determine a type 1 error rate that is no more likely to produce a false positive across multiple tests than a single test with a p<0.05.

http://whqlibdoc.who.int/publications/2005/9241546441.pdf

http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=DMP&language=English

http://www.state.gov/g/drl/rls/hrrpt/2007/index.htm

Volumes – Volumes are calculated in terms of purchases required for an adult equivallent full-course treatment.

Executive Summary

Background: The outlet survey is one of the ACTwatch research components. The objective is to monitor levels and trends in the availability, price and volumes of antimalarials, and providers’ perceptions and knowledge of antimalarial medicines at different outlets. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials. National trends over time are presented first, followed by outlet survey round 2 indicators presented across outlet categories and urbanisation. Methods:

A nationally representative sample of all outlets that could sell or provide antimalarials to a consumer was taken

through a census approach in 38 sub-districts/wards across two strata, urban and rural areas, in Zambia. Sampling was

conducted using a one-stage probability proportional to size (PPS) cluster design, with the measure of size being the

relative sub-district/ward population.

Outlet inclusion criteria for this study included outlets which stocked an antimalarial at the time of survey or in the

previous three months. An outlet is defined as any point of sale or provision of commodities for individuals. Outlets

included in the survey are as follows: 1) public health facilities (government health facilities, hospitals, health posts); 2)

Part One pharmacies (pharmacies licensed by the Pharmaceutical Regulatory Authority); 3) drug stores; 4) private

health facilities (private hospitals, clinics, and surgeries); 5) grocery stores; and 6) other outlets (kiosks, containers,

kantembas, and super/mini markets and petrol stations) [see Appendix A for definitions and numbers of each type of

outlet]. Oversampling of public health facilities and Part One pharmacies was conducted in districts surrounding the

selected sub-districts/wards.

Among outlets, three questionnaires were administered: 1) Screening Questionnaire 2) Audit sheet and 3) Provider Questionnaire. For all outlets, trained interviewers administered the screening questionnaire to collect information on the outlet type; location, including the outlet’s longitude and latitude; and information on availability of antimalarials. Among those outlets that stocked antimalarials at the time of survey, the audit sheet was administered. For each antimalarial, information was recorded on the brand and generic names, strength, expiry, amount sold in the last week and price to the consumer. Among outlets that stocked antimalarials at the time of interview, or in the past three months, the interviewer collected information on provider demographics, knowledge, and perceptions. Interviewers observed outlet licensing and storage conditions of medicines using the provider questionnaire. Several validation and data checking steps occurred during and after data collection. Double data entry was conducted using Microsoft Access (Microsoft Cooperation, Seattle, WA, USA). Data was analysed using SPSS 17.0 (SPSS Inc., Chigaco, IL, USA). For more information on the study design log on to www.ACTwatch.info. Results: Data were collected between 14th April 2009 and 3rd July 2009. A total of 3,840 outlets were sampled (by strata: urban, N=2,915; rural, N=925). Overall, 3,840 providers agreed to participate in the ACTwatch outlet survey. Of these, 469 outlets stocked antimalarials at any point in the three months prior to the interview, and 442 outlets stocked antimalarials at the time of the interview.

http://www.actwatch.info/

Figure 1 Diversity of outlets sampled in OS1 and OS2

OS1 OS2

Figure 2 Diversity of outlets stocking antimalarials in OS1 and OS2

OS1 OS2

Public Health Facility

6%

Part One Pharmacy

2%Drug Store

6%

Private Health Facility

2%

Grocery 65%

Other Outlets

19%


5%

Part One Pharmacy

2%

Drug Store5%


1%

Grocery58%

Other Outlets

29%


32%

Part One Pharmacy

12%Drug Store

29%


11%

Grocery15%

Other Outlets

1%


40%

Part One Pharmacy

11%

Drug Store29%


9%

Grocery10%

Other Outlets

1%

AVAILABILITY OF ANTIMALARIALS: Most public health facilities stocked antimalarials as well as non-artemisinin montherapies (AMTs). Availability of oral AMT was less than 2%. In the private sector, few differences were observed over time. Highest stockage rates were found for n-AMTs. First line treatment was found in one out of every three outlets in the private sector.

Figure 3. Trends in the Availability of Antimalarials in the Public Health Sector

Figure 4. Trends over time in Availability of Antimalarials in the Private Health Sector

89.6 89.7

98.4 96.6

1.6 1.7

0

10

20

30

40

50

60

70

80

90

100

OS1 OS2 OS1 OS2 OS1 OS2

Firstline Treatment Non-Art AMT Oral Art Mono

27.9 29.6

97.4 97.8

18.1

8.6

0

10

20

30

40

50

60

70

80

90

100


Firstline Treatment Non-Art AMT Oral Art Mono

%

%

AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: In the follow up survey, 44% of public health facilities stocked microscopic blood testing, and 89% stocked rapid diagnostic tests. Private sector availability of testing was generally low (<15%). There were few changes observed over time in public health facilities, though a slight decrease in microscopy was observed, and an increase in RDTs. Socking rates in the private sector remained similar.

Figure 5. Trends in Microscopic Blood Testing Facilities & Rapid Diagnostic Tests in the Public Health Sector

Figure 6. Trends in Microscopic Blood Testing Facilities & Rapid Diagnostic Tests in Private Health Sector

1

57.1

44.1

84.289.3

0

10

20

30

40

50

60

70

80

90

100

OS1 OS2 OS1 OS2

Microscopic Blood Testing Facilities Rapid Diagnostic Tests

11.7 915.6 15.3

0

10

20

30

40

50

60

70

80

90

100

OS1 OS2 OS1 OS2

Microscopic Blood Testing Facilities Rapid Diagnostic Tests

%

%

PRICE OF ANTIMALARIALS: In public health facilities, the price of first line treatment was free of charge. Few differences were observed over time in the private sector, the most popular treatment, SP, remained 18 times less expensive than the first line treatment.

Figure 7. Median Price of a Full Adult Course Antimalarial Treatment in Private Health Sector

VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: Most first line treatment in Zambia, is distributed in the public sector (~16%). N-AMTs distributed in this sector is largely SP, presumable for intermittent preventive treatment in pregnant women. Less than 10% of ACTs were distributed in the private sector. Slight decreases were observed in the follow up survey of this antimalarial class.

Figure 8. Relative Volumes of Full Course Adult Treatments Sold/Distributed in

the Past Week

35000 35000

2000 2000

3160029850

0

5000

10000

15000

20000

25000

30000

35000

40000


Firstline Treatment Most Popular Treatment (SP) Oral Artemisinin Monotherapy

15.6 17.48.1 5.7

6.32.3

33.223.5

3.9

3.5

31.4 47.2

0.0

0.0 0.4

0.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

OS1 OS2 OS1 OS2

Public Private

First Line (AL 20/120) Other ACTs

SP Non-artemisinin therapies

Oral artemisinin monotherapies Non-oral artemisinin monotherapies

US $

%

PROVIDER KNOWLEDGE: Provider knowledge in the public sector was generally high and higher at follow up with 94% of providers knowing the first line treatment. Among providers that knew the first line treatment, knowledge of the dosing regimen was quite high. Slight increases were observed in the private sector, though knowledge of the first line treatment was lower (60%). Improvements were found over time in the proportion of providers that knew the correct child dosing regimen (88%).

Figure 9. Provider Knowledge of Recommended First-Line Treatment and Dosing Regimen within the Public Health

Sector

Figure 10. Provider Knowledge of Recommended First-Line Treatment and Dosing Regimen within the Private Health

Sector

88.693.8 100 99.4 99.1 99.4

0

10

20

30

40

50

60

70

80

90

100


Knows Firstline Treatment Knows correct adult dosing regimen Knows correct child dosing regimen

59.767.7

82.892.4

75.0

88.3

0102030405060708090

100


Knows Firstline Treatment Knows correct adult dosing regimen Knows correct child dosing regimen

%

%

Country Background

Zambia is located in Southern Africa sharing borders with Angola, Democratic Republic of Congo, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe. The population is approximately 11.8 million of which an estimated 65% live in rural areas. The per capita gross domestic product is $1,500 and over 80% of the population lives below the poverty line.1 One in six children dies in Zambia before reaching their fifth birthday, with malaria acting as a key driver of child mortality.2 In 2007, the country had approximately 4.3 million clinically diagnosed cases of malaria reported via the health management information system (HMIS), accounting for 36% of outpatient visits, 48% of disease burden among children under five, and up to 20% maternal mortality.3 Epidemiology and Malaria Control Strategies

Malaria transmission is seasonal in Zambia occurring mainly from November to May.4 Despite widespread endemicity, certain areas of the country can be characterized as hyperendemic, mesoendemic, or epidemic prone. The predominant parasite is P. falciparium which accounts for about 95% of all infections.5 The National Malaria Control Strategy identifies pregnant women and children under five as the population groups most at risk. Key malaria prevention and treatment interventions include distribution of long-lasting insecticide treated nets (LLINs) through campaigns, antenatal clinics (ANCs), the commercial sector, and vulnerable populations such as people living with HIV/AIDS and the poorest of the poor; indoor residual spraying (IRS) in urban and peri-urban areas; intermittent preventive treatment for pregnant women (IPTp) through ANCs; and administration of ACTs through health facilities with increasing focus on confirmed diagnosis using microscopy or rapid diagnostics tests (RDTs).6 National Treatment Policy

Zambia was the first African country, in 2002, to adopt artemisinin-based combination therapy (ACT) as the first line treatment for uncomplicated malaria7, selecting artermether lumifantrine (AL). SP is the alternative first line treatment in pregnant women and children less than 5 kg; and oral quinine is the second line treatment in cases of failure of first line drugs in all age groups. Severe malaria is treated with quinine. In Zambia, ACTs are classified as prescription-only medications and are therefore not sold legally through unregistered private sector providers; their availability has therefore remained largely limited to the public sector, registered pharmacies and private clinics. 8 The National Malaria Control Centre (NMCC) recommends parasitological diagnosis for all patients with suspected malaria at hospitals and health centres with laboratory facilities. Clinical diagnosis is recommended where laboratory facilities are not available. Children under five years of age are treated based on laboratory diagnosis in health facilities where available, otherwise are evaluated and treated according to the algorithm of the Integrated Management of Childhood Illness (IMCI). Antimalarial Treatment Distribution and Delivery

The main provider of health care services in Zambia is the public health care system which is a tiered system comprising more than 1000 health facilities9 (hospitals, health centres and health posts). Other health service providers include privately owned hospitals and clinics; mission hospitals and clinics, which are coordinated by the Churches Health Association of Zambia (CHAZ); and health facilities run by Non-Governmental Organizations (NGOs).10

1 CIA (2009). CIA World Factbook: Zambia. https://www.cia.gov/library/publications/the-world-factbook/geos/za.html.

2 UNICEF (2009). State of the World’s Children.

3 Zambia MOH, National Malaria Control Centre. (2005). “A 5 year strategic plan: A road map for impact in malaria in Zambia 2006-2010”.

4 WHO (2008). World Malaria Report 2008. WHO/HTM/GMP/2008.1.

5 Zambia MOH (2002). Press release on the malaria treatment policy change in Zambia.

6 PMI (April 2009). Country Profile: Zambia. http://www.fightingmalaria.gov/countries/profiles/zambia_profile.pdf.

7 Sipilanyambe, N. et al. (2008). “From chloroquine to artemether-lumefantrine: the process of drug policy change in Zambia”. Malar Journal, 7:25.

8 Zambia MOH, National Malaria Control Centre. (2005). “A 5 year strategic plan : A road map for impact in malaria in Zambia 2006-2010”.

9 Central Board of Health, Government of Zambia (2002). Health Institutions in Zambia: A Listing of Health Facilities According to Levels and Locations.

10 Ministry of Health, Government of Zambia (2005). National Health Strategic Plan 2006-2010.

As part of Zambia’s Global Fund to Fight AIDS, Tuberculosis and Malaria implementation (GFATM), ACT treatment has been procured and is made available in the public sector free of charge. AL has been distributed to health facilities since the end of 2004. In order to ensure rational use of these drugs, the GFATM also supported procurement and distribution of RDTs, microscopes and training of health workers. Round 1 provided enough ACTs to cover 28 out of the 72 districts in Zambia, and Round 4 included support for the 28 districts and scale up to the remainder of the districts using existing delivery mechanisms that include IMCI, community health workers (CHW) and pharmacies. As of November 2008, 11 districts have started community based treatment of malaria with ACTs. ACT delivery in Zambia is also supported by financing from other donors. The World Bank Malaria Booster project provides health system strengthening to improve service delivery, small grants for community-level malaria control, and funding to the MOH/NMCC. In 2009, the United States President’s Malaria Initiative (PMI) began to procure AL for children under five and strengthen Zambia’s logistics and commodity delivery systems. UNITAID supplies 1.1 million ACT doses for community distribution. Department for International Development (DfID) has provided funds to redesign Zambia’s peripheral supply chain distribution system in collaboration with JSI/DELIVER and the World Bank. Malaria Financing

Malaria prevention and treatment in Zambia is largely supported by international and bi-lateral donors. As noted above, the key malaria partners include the GFATM, World Bank, PMI, UNITAID, and DfID. The NMCC received $39.2 million during the GFATM Round 1, $42.7 million during GFATM Round 4, and $17.7 million during GFATM Round 7 for a range of malaria prevention and treatment interventions. The World Bank provided $20 million through its 2005-2010 Malaria Health Booster program for health systems strengthening and small community grants. PMI awarded $9.5 million in fiscal year 2007, $14.8 million in 2008, and $14.7 million in 2009 to support LLINs, ACTs, IRS, IPTp, and monitoring and evaluation. UNITAID contributed 1.1 million ACT doses.

Results

Study-wide Trends: 2008 vs. 2009

Availability of Antimalarials11 Public sector Private sector Total


% % % % % %

Proportion of outlets that had: N=135 N=202 N=2153 N=3645 N=2288 N=3840

Antimalarials in stock at the time of survey visit

92.6a 86.6a 12.3a 7.3b 17.0a 11.5b

Among those outlets that had AMs in stock, proportion that had

N=125 N=175 N=265 N=267 N=390 N=442

First-line treatment (AL) 89.6a 89.7a 27.9a 29.6a 47.7a 53.4a

WHO approved ACT 89.6a 89.1a 23.0a 27.0a 44.4a 51.6b

Nationally registered ACT 89.6a 87.4a 21.1a 26.2a 43.1a 50.5b

Non-WHO/nationally registered ACT 4.0a 6.3a 21.5a 20.2a 15.9a 14.7a

Non-artemisinin therapy 98.4a 96.6a 97.4a 97.8a 97.7a 97.3a

Chloroquine 0.8a 0.0a 21.1a 21.3a 14.6a 12.9a

Sulfadoxine-Pyrimethamine (SP)

86.4a 65.1b 78.5a 82.0a 81.0a 75.3b

Second-line treatment (Quinine)

86.4a 92.0a 19.6a 19.1a 41.0a 48.0b

Quinine Injection 37.6a 50.9b 6.8a 6.7a 16.7a 24.2b

Artemisinin monotherapy 4.0a 3.4a 22.3a 15.0b 16.4a 10.4b

Oral artemisinin monotherapy 1.6a 1.7a 18.1a 8.6b 12.8a 5.9b

Non Oral artemisinin monotherapy

3.2a 1.7a 13.2a 10.1a 10.0a 6.8a

N=111 N=161 N=222 N=248 N=333 N=409

A WHO approved or nationally registered ACT as the most distributed antimalarial, by volume of sales/distribution in the past week

31.5a 51.6b 6.8a 6.5a 15.0a

24.2b

11 Statistical difference is labeled with a superscript, a or b (p<0.05). proportions or medians that are both labeled

with the superscript `a’ do not differ significantly from one another according to a chi-squire or Mood’s median test,

respectively with a type 1 error rate of 0.05.

Public sector Private sector Total

Disruption in Stock, Storage Conditions & Blood Testing


N=133 N=178 N=292 N=298 N=425 N=470

No disruption in stock in the past three months

68.4a 57.9b 44.9a 50.3a 52.2a 53.2a

N=122 N=173 N=97 N=111 N=219 N=284

No disruption in stock of the first-line treatment in the past three months

77.9a 72.8a 59.8a 60.4a 69.9a 68.0a

N=125 N=175 N=263 N=267 N=388 N=442

Expired stock of any antimalarial 2.4a 2.3a 3.8a 0.7b 3.4a 1.4a

N=112 N=157 N=74 N=79 N=186 N=236

Expired stock of first-line treatment (AL)

1.8a 1.9a 2.7a 0.0a 2.2a 1.3a

N=123 N=169 N=256 N=261 N=379 N=430

Expired stock of non-artemisinin therapy

0.8a 0.6a 2.7a 0.8a 2.1a 0.7a

N=5 N=6 N=59 N=40 N=64 N=46

Expired stock of artemisinin monotherapy

0.0 0.0 0.0 0.0 0.0 0.0

N=119 N=176 N=280 N=291 N=399 N=467

Acceptable storage conditions for medicines

94.1a 84.7b 94.6a 94.2a 94.5a 90.6b

N=133 N=177 N=274 N=294 N=407 N=465

Microscopic blood testing facilities 57.1a 44.1b 11.7a 9.0a 26.5a 22.4a

N=133 N=177 N=270 N=287 N=403 N=464

Rapid diagnostic tests 84.2a 89.3a 15.6a 15.3a 38.2a 43.5a

Price of Antimalarials Public sector Private sector Total


Distribution of free drugs: % % % % % %

Proportion of first-line ACTs distributed free of cost (by volumes of adult treatments)

98.1 99.6 0.0 13.9 65.2 78.6

Median price of a full course of tablet

AETD12:

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

First-line treatment (AL) 0.0a 0.0a 35000.0a 35000.0a 0.0a 0.0b

WHO approved ACT 0.0a 0.0a 36000.0a 40000.0a 0.0a 0.0b

Nationally registered ACT 0.0a 0.0a 35000.0a 40000.0a 0.0a 0.0a

Non-WHO/nationally registered ACT 17500.0a 0.0a 37500.0a 39500.0a 36500.0a 39000.0a

Non-artemisinin therapy 0.0a 0.0a 2419.4a 2419.4a 1500.0a 1500.0a

Oral artemisinin monotherapy 0.0a 0.0a 31600.0a 29850.0a 29600.0a 26200.0a

SP, the ‘most popular’ non-ACT antimalarial treatment in Zambia

0.0a 0.0a 2000.0a 2000.0b 1500.0a 1500.0a

Median price of a full course AETD

relative to SP, the ‘most popular’ non-

ACT antimalarial treatment in Zambia:

Ratio Ratio Ratio Ratio Ratio Ratio

First-line treatment (AL) n/a n/a 17.5 17.5 n/a n/a

WHO approved ACT n/a n/a 18.0 20.0 n/a n/a

Nationally registered ACT n/a n/a 17.5 20.0 n/a n/a

Non-WHO/nationally registered ACT n/a n/a 18.8 19.8 24.3 26

Median price of a full course of tablet

AETD relative to the minimum legal

daily wage in Zambia Kwacha

(10491.49, 12020.56):


First-line treatment (AL) n/a n/a 3.3 2.9 n/a n/a

WHO approved ACT n/a n/a 3.4 3.3 n/a n/a

Nationally registered ACT n/a n/a 3.3 3.3 n/a n/a

Non-WHO/nationally registered ACT n/a n/a 3.6 3.3 3.5 3.2


Median price of a firstline AETD

relative to international reference

price in Kwacha (9885.32, 11326.04)

n/a n/a 3.5 3.1 n/a n/a

% % % % % %

-- -- N=269 N=278 N=269 N=278

Proportion of outlets that offer credit

to consumers for antimalarials -- -- 21.9a 25.5a 21.9a 25.5a

12 Prices for oral AETD are reported. Comparisons of non-oral AETD are included as an appendix (see appendix C).

P a g e | 20

www.ACTwatch.info Outlet Survey Report (Round 2), Zambia, 04/09 – 07/09

Public sector Private sector Total


Volumes of full course sold or distributed in the past week

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean per

outlet

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean

per

outlet

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean

per

outlet

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean per

outlet

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean per

outlet

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Mean

per

outlet

Each antimalarial category as a

proportion of the total volume

of all antimalarials sold or

distributed in the past week:

% %

%

%

%

%

First-line treatment (AL) 29.6 39.2 17.1 10.2 23.7 23.1

WHO approved ACT 29.6 39.2 13.3 8.2 21.9 21.9

Nationally registered ACT 29.3 38.9 12.4 6.7 21.3 21.0

Non-WHO/nationally

registered ACT 0.0 0.1 16.1 5.8 7.6 3.3

Non-artemisinin therapy 70.3 60.7 66.4 84.9 68.5 74.2

Chloroquine 0.0 0.0 2.9 1.7 1.4 0.9

Sulfadoxine-

Pyrimethamine (SP) 62.9 52.9

58.5 78.4 60.8 67.1

Second-line

treatment (Quinine) 7.4 7.8 0.9 2.5 4.4 4.8

Oral artemisinin monotherapy 0.0 0.0 2.3 0.6 1.1 0.3

Non-oral AMT 0.0 0.0 0.8 0.3 0.4 0.1

P a g e | 21


Provider Knowledge and Perceptions Public sector Private sector Total


% % % % % %

Proportion of providers that: N=132 N=177 N=283 N=291 N=415 N=468

Correctly state the recommended first-line treatment for uncomplicated malaria

88.6a 93.8a 59.7a 67.7b 68.9a 77.6b

N=116 N=166 N=169 N=197 N=285 N=363

Correctly state the dosing regimen of the first-line treatment for an adult

100a 99.4a 82.8a 92.4b 89.8a 95.6b

N=116 N=165 N=168 N=196 N=284 N=361

Correctly state the dosing regimen of the first-line treatment for a two year old

99.1a 99.4a 75.0a 88.3b 84.9a 93.4b

-- -- N=286 N=290 N=419 N=467

Can list at least one health danger sign in a child that

requires referral to a public health facility: -- -- 66.4a 79.3b 66.4a 78.7b

Convulsions -- -- 33.9a 36.2a 39.6a 25.7b

Vomiting -- -- 50.0a 67.9b 48.7a 45.6a

Unable to drink/breastfeed -- -- 7.7a 19.0b 9.3a 12.6a

Excessive sleep/difficult to wake up -- -- 2.8a 2.4a 2.1a 1.5a

Unconscious/coma -- -- 4.9a 4.5a 6.9a 3.0b

N=132 N=177 N=278 N=285 N=410 N=462

Agree with the statement, “Most customers request an antimalarial by brand name or generic name.”

16.7a 9.6a 67.6a 54.0b 51.2a 37.0b

N=133 N=176 N=279 N=289 N=412 N=465

Agree with the statement, “I decide which antimalarial medicine most customers receive.”

67.7a 58.5a 38.0a 23.9b 47.6a 37.0b

P a g e | 22


Outlet Survey 2: Comparisons by Outlet Type

Availability of Antimalarials Public Health Facility

Part One Pharmacy

Drug Store


Grocery Store

Other Outlet

Total

% % % % % % %

Proportion of outlets that had: N=202 N=56 N=202 N=48 N=2236 N=1096 N=3840

Antimalarials in stock at the time of survey visit

86.6 91.1 62.9 79.2 2.1 0.5 11.5

Among those that had AMs in stock, proportion of outlets that had:

N=175 N=51 N=127 N=38 N=46 N=5 N=442

First-line treatment (AL) 89.7 80.4 15.0 47.4 2.2 0.0 53.4

WHO approved ACT 89.1 68.6 15.0

44.7

2.2

0.0

51.6

Nationally registered ACT 87.4 68.6 15.0 39.5 2.2 0.0 50.5

Non-WHO/nationally registered ACT 6.3 78.4 3.1 26.3 0.0 0.0 14.7

Non-artemisinin therapy 96.6 98.0 97.6 95.4 97.8 100.0 97.3

Chloroquine 0.0 9.8 21.3 5.3 50.0 0.0 12.9

Sulfadoxine-Pyrimethamine (SP) 65.1 86.3

89.8 86.8

50.0

100.0

75.3

Second-line treatment (Quinine) 92.0 54.9 2.4 52.6 0.0 0.0 48.0

Quinine injection 50.9 15.7 0.0 26.3 0.0 0.0 24.2

Artemisinin monotherapy 3.4 52.9 0.8 28.9 0.0 20.0 10.4

Oral artemisinin monotherapy 1.7 37.3 0.8 5.3 0.0 20.0 5.9

Non-oral artemisinin

monotherapy

1.7 31.4 0.0 26.3 0.0 20.0 6.8

N=161

N=48

N=118

N=36

N=41

N=5

N=409

A WHO approved or nationally registered ACT as the most distributed antimalarial, by volumes of sales/distribution in the past week

51.6 12.5 1.7 19.4 2.4 0.0 24.2

P a g e | 23


Disruption in Stock, Storage Conditions & Blood Testing


Part One

Pharmacy

Drug Store


Grocery Store

Other Outlet

Total

% % % % % % %

N=178 N=51 N=143 N=39 N=53 N=6 N=470

No disruption in stock in the past three months

57.9 39.2 49.0 46.2 67.9 50.0 53.2

N=173 N=48 N=30 N=27 N=4 2 N=284

No disruption in stock of first-line treatment in the past three months

72.8 77.1 46.7 59.3 0.0 0.0 68.0

N=175 N=51 N=127 N=38 N=46 N=5 N=442

Expired stock of any antimalarial 2.3 0.0 1.6 0.0 0.0 0.0 1.4

N=157 N=41 N=19 N=18 N=1 N=0 N=236

Expired stock of first-line treatment (AL) 1.9 0.0 0.0 0.0 0.0 0.0 1.3

N=169 N=50 N=124 N=37 N=45 N=5 N=430

Expired stock of non-artemisinin therapy 0.6 0.0 1.6 0.0 0.0 0.0 0.7

N=6 N=27 N=1 N=11 N=0 N=1 N=46

Expired stock of artemisinin monotherapy

0.0 0.0 0.0 0.0 -- -- 0.0

N=176 N=51 N=142 N=39 N=53 N=6 N=467

Acceptable storage conditions for medicines

84.7 100.0 93.0 97.4 90.6 83.3 90.6

N=177 N=50 N=141 N=39 N=52 N=6 N=465

Microscopic blood testing facilities 44.1 4.0 0.7 59.0 0.0 0.0 22.4

N=177 N=50 N=141 N=38 N=52 N=6 N=464

Rapid diagnostic tests 89.3 26.0 2.1 73.7 0.0 0.0 43.5

P a g e | 24


Price of Antimalarials Public Health Facility

Part One Pharmacy

Drug Store Private Health Facility

Grocery Store

Other Outlet

Total

Distribution of free drugs: % % % % % % %

Proportion of first-line ACTs distributed free of cost (by volumes of adult treatments)

99.6

0.0

0.0

29.2

0.0 --

78.6

Median price of a full course of tablet AETD: Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

First-line treatment (AL) $0.00 $6.55 $4.68 $8.42 $-- $-- $0.00

WHO approved ACT $0.00 $8.70

$4.68

$8.42

$--

$--

$0.00

Nationally registered ACT $0.00

$8.98 $4.68 $8.70 $-- $-- $0.00

Non-WHO/nationally registered ACT $0.00 $7.02

$--

$9.17 $-- $-- $7.30

Non-artemisinin therapy $0.00 $0.84 $0.45 $0.56 $0.45 $0.48 $0.28

Oral artemisinin monotherapy $0.00 $4.94 $6.29 $-- $-- $-- $4.90

SP, the ‘most popular’ non-ACT antimalarial treatment in Zambia $0.00 $0.37 $0.37 $0.37 $0.34 $0.47 $0.28

Median price of a full course AETD relative to SP, the ‘most popular’ non-ACT

antimalarial treatment in Zambia: Ratio Ratio Ratio Ratio Ratio Ratio Ratio

First-line treatment (AL) n/a 17.7 12.6 22.8 -- -- n/a

WHO approved ACT n/a 23.5 12.6 22.8 -- -- n/a

Nationally registered ACT n/a 24.3 12.6 23.5 -- -- n/a

Non-WHO/nationally registered ACT n/a 20.0 n/a 24.8 -- -- 26.1

Median price of a full course of tablet AETD relative to the minimum legal

daily wage in Zambia ($2.25): Ratio Ratio Ratio Ratio Ratio Ratio Ratio

First-line treatment (AL) n/a 2.9 2.1 3.7 -- -- n/a

WHO approved ACT n/a 3.9 2.1 3.7 -- -- n/a

Nationally registered ACT n/a 4.0 2.1 3.9 -- -- n/a

Non-WHO/nationally registered ACT n/a 3.1 n/a 4.1 -- -- 3.2

Ratio Ratio Ratio Ratio Ratio Ratio Ratio

Median price of a Firstline AETD relative to international reference price

($2.12) n/a 3.1 2.2

4.0

-- --

n/a

% % % % % %

N=50 N=134 N=35 N=53 N=6 N=278

Proportion of outlets that offer credit to consumers for antimalarials -- 14.0 28.4 42.9 17.0 33.3 25.5

P a g e | 25


Volumes of Antimalarials Sold/Distributed


Part One Pharmacy

Drug Store Private Health Facility

Grocery Store Other Outlet Total

Volumes of full course AETDs (all

dosage forms) sold or distributed in the

past week:

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Each antimalarial category as a

proportion of the total volume of all

antimalarials sold or distributed in the

past week:

% % % % % % %

First-line treatment (AL) 39.2 19.3 1.6 18.6 0.3 0.0 23.1

WHO approved ACT 39.2 11.4 1.6 23.0 0.3 0.0 21.9

Nationally registered ACT 38.9 11.4 1.6 23.0 0.3 0.0 21.0

Non-WHO/nationally registered ACT 0.1 16.1 0.1 9.0 0.0 0.0 3.3

Non-artemisinin therapy 60.7 69.9 97.7 67.3 99.9 1.0 74.2

Chloroquine 0.0 0.1 2.1 0.5 8.7 0.0 0.9

Sulfadoxine-Pyrimethamine (SP) 52.9 59.3 93.0 62.2 90.6 1.0 67.1

Second-line treatment (Quinine) 7.8 6.9 0.1 3.2 0.0 0.0 4.8

Oral artemisinin monotherapy 0.0 1.2 0.6 0.1 0.0 0.0 0.3

Non Oral AMT 0.0 0.5 0.0 0.5 0.0 0.0 0.1

P a g e | 26


Provider Knowledge and Perceptions


Part One Pharmac

y

Drug Store


Grocery Store

Other Outlet

Total

% % % % % % %

Proportion of providers that: N=177 N=51 N=142 N=39 N=53 N=6 N=468


93.8 88.2 66.9 89.7 34.0 66.7 77.6

N=166

N=45

N=95

N=35

N=18

N=4

N=363

Correctly state the dosing regimen of the first-line treatment for an adult

99.4 100.0 92.6 100.0 61.1 75.0 95.6

N=165

N=45

N=94

N=35

N=18

N=4

N=361


99.4 95.6 87.2 100.0 61.1 50.0 93.4

-- N=51 N=142 N=39 N=52 N=6 N=290

Can list at least one danger sign in a child that requires referral to a public health facility:

--

78.4 78.2 84.6 78.8 83.3 79.3

Convulsions -- 49.0 29.6 48.7 30.8 50.0 36.2

Vomiting -- 70.6 71.1 53.8 67.3 66.7 67.9

Unable to drink/breastfeed -- 5.9 19.0 28.2 23.1 33.3 19.0

Excessive sleep/difficult to

wake up --

2.0 1.4 0.0 7.7 0.0 2.4

Unconscious/coma -- 9.8 0.7 17.9 0.0 0.0 4.5

N=177 N=51 N=138 N=39 N=51 N=6 N=462


9.6 51.0 60.9 10.3 68.6 83.3 37.0

N=176 N=51 N=140 N=39 N=53 N=6 N=465


58.5 27.5 15.7 76.9 1.9 33.3 37.0

P a g e | 27


Outlet Survey 2: Comparisons by Urban vs. Rural Areas

Availability of Antimalarials13 Urban Rural Total

% % %

Proportion of outlets that had: N=2915 N=925 N=3840

Antimalarials in stock at the time of survey visit 10.8 13.6 11.5

Among those that had AMs in stock, proportion of outlets that had: N=316 N=126 N=442

First-line treatment (AL) 50.3 61.1 53.4


Nationally registered ACT 46.5 60.3 50.5

Non-WHO/nationally registered ACT 19.3 3.2 14.7

Non-artemisinin therapy 97.2 97.6 97.3

Artemisinin monotherapy 13.0 4.0 10.4

Oral artemisinin monotherapy 7.3 2.4 5.9

N=288 N=121 N=409

A WHO approved or nationally registered ACT as the most distributed antimalarial, by volumes of sales/distribution in the past week

19.1 36.4 24.2

N=339 N=131 N=470

No disruption in stock in the previous three months 51.9 56.5 53.2

N=194 N=90 N=284

No disruption in first-line treatment stock in the previous three months 69.6 64.4 68.0

N=316 N=126 N=442

Expired stock of any antimalarial 1.3 1.6 1.4

N=337 N=130 N=467

Acceptable storage conditions for medicines 92.3 86.2 90.6

N=335 N=130 N=465

Microscopic blood testing facilities 22.7 21.5 22.4

N=334 N=130 N=464

Rapid diagnostic tests 35.0 65.4 43.5

13 Statistical difference is labeled with a superscript, a or b (p<0.05). Proportions or medians that are both labeled with

the superscript `a’ do not differ significantly from one another according to a chi-squire or a Mood’s median test,

respectively, with a type 1 error rate of 0.05.

P a g e | 28


Price of Antimalarials Urban Rural Total

Distribution of free drugs: % % %

Proportion of first-line ACTs distributed free of cost (by volumes of adult

treatments) 68.1 98.7 78.6

Median price of a full course of tablet AETD of: Median

(N of AMs)

Median

(N of AMs) Median

(N of AMs)

First-line treatment (AL) $0.00

$0.00

$0.00

WHO approved ACT $0.00 $0.00 $0.00

Nationally registered ACT $0.00 $0.00 $0.00

Non-WHO/nationally registered ACT $7.40

$0.00

$7.30

Non-artemisinin therapy $0.37

$0.00

$0.28

Oral artemisinin monotherapy $4.94 $0.00 $4.90

SP (the ‘most popular’ non-ACT antimalarial treatment in Zambia) $0.37

$0.00

$0.28

Median price of a full course AETD ACT relative to SP (the ‘most popular’ non-ACT

antimalarial treatment in Zambia): Ratio Ratio Ratio

First-line treatment (AL) n/a n/a n/a

WHO approved ACT n/a n/a n/a

Nationally registered ACT n/a n/a n/a

Non-WHO/nationally registered ACT 20.0 n/a 26.1

Median price of a full course of tablet AETD ACT relative to the minimum legal

daily wage ($2.25): Ratio Ratio Ratio

First-line treatment (AL) n/a n/a n/a

WHO approved ACT n/a n/a n/a

Nationally registered ACT n/a n/a n/a

Non-WHO/nationally registered ACT 3.3 n/a 3.2

Ratio Ratio Ratio

Median price of a full course first line AETD relative to the international reference

price ($2.12) n/a n/a n/a

% % %

N=238 N=40 N=278

Proportion of outlets that offer credit to consumers for antimalarials 26.1 22.5 25.5

P a g e | 29


Volumes of Antimalarials Sold/Distributed Urban Rural Total

Volumes of full course AETDs (all dosage forms) sold or

distributed in the past week:

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

Number

of outlets

that

stocked

each

category

of AM

Total

number of

full course

adult

treatments

First-line treatment (AL) 1638 147 845 97 2483

WHO approved ACT 1519 129 845 97 2364

Nationally registered ACT 1419 123 853 97 2258

Non-WHO/nationally registered ACT 353 82 0.0 0.0 353

Non-artemisinin therapy 6298 418 1693 109 7991

Oral artemisinin monotherapy 21 13 14 3 35

Non Oral AMT 13 25 2 2 15

Each antimalarial category as a proportion of the total

volume of all antimalarials sold or distributed in the past

week:14

% % %

First-line treatment (AL) 19.9 33.1 23.1


Nationally registered ACT 17.3 33.4 21.0

Non-WHO/nationally registered ACT 4.3 0.0 3.3

Non-artemisinin therapy 76.6 66.3 74.2

Oral artemisinin monotherapy 0.3 0.5 0.3

Non Oral AMT 0.2 0.1 0.1

14

Percentages total more than 100% in each column because ACTs that are WHO approved, nationally registered, and the first-line treatment are not mutually exclusive.

P a g e | 30


Provider Knowledge and Perceptions Urban Rural Total

% % %

Proportion of providers that: N=337 N=131 N=468


77.2 78.6 77.6

N=260

N=103

N=363

Correctly state the dosing regimen of the first-line treatment for an adult 96.5 93.2 95.3

N=259

N=102

N=361


93.4 93.1 93.4

N=247 N=43 N=290

Can list at least one danger sign in a child that requires referral to a public

health facility: 79.4 79.1 79.3

Convulsions 37.2 30.2 36.2

Vomiting 69.2 60.5 67.9

Unable to drink/breastfeed 18.6 20.9 19.0

Excessive sleep/difficult to wake up 1.2 9.3 2.4

Unconscious/coma 4.9 2.3 4.5

N=334 N=128 N=462


42.2 23.4 37.0

N=335 N=130 N=465


31.6 50.8 37.0

P a g e | 31


Outlet Survey 2: Staff and Outlet Characteristics

Study-wide

%

Proportion of outlets: N=468

with a staff member that has completed primary school education 98.9

N=462

with a staff member that has completed secondary school education 93.7

N=457

that have received government or NGO training within the past two years 44.9

N=462

that have staff with a health related qualification 73.4

N=468

that store medicines in dry areas 95.5

N=468

that store medicines out of direct sunlight 99.6

N=467

that do not keep medicines on the floor 95.3

N=290

that report having a pharmacy, clinic, NGO or missionary license 38.6

N=284

where a license was observed by the interviewer 47.9

P a g e | 32


Appendix A: Zambia Outlet Type Descriptions

Outlet Type N Description

Public Health Facility 202

Third-level hospital 7 These are government health facilities providing free prescription medicine, medical consultations, and diagnosis. Health centres serve a catchment area of between 10,000 (rural) to 50,000 (urban) residents. They are staffed by a nurse or clinical officer. First-level hospitals accept referrals from local health centres and health posts. They serve populations of between 80,000 and 200,000 people with surgical, obstetric and diagnostic services. At the provincial level, second-level hospitals typically offer services in internal medicine, gynecology, psychiatry and intensive care. Third-level hospitals serve a catchment of 800,000 people and expand upon provincial level services, while also serving as training and research institutions.

Second-level hospital (Provincial level)

5

First-level hospital (District-level) 20

Hospital affiliated centre 3

Urban health centre 76

Rural health centre 76

Health post 15

Part One Pharmacy 56

Part One pharmacy 56

Pharmacies that are licensed by the Pharmaceutical Regulatory Authority (PRA) and sell prescription medicine at a commercial rate. Part One pharmacies are manned by pharmacists and qualified health practitioners. They sell all classes of medicines. In addition to being regulated by the PRA, they are also required to have a trading license from the local council. These pharmacies may also sell cosmetics.

Drug Store 202

Drug store 202

Drug stores sells medicines at a commercial rate, but differ from pharmacies in a number of aspects: 1) Drug stores are usually smaller than pharmacies; 2) they are not regulated by the Pharmaceutical Regulatory Authority, and instead are licensed by the local government board (however, an unknown proportion operate without a license); 3) they are only permitted to sell over the counter medicines; 4) they are not guaranteed to be manned by qualified health dispensers/practitioners, and are sometimes manned by relatives of qualified health dispensers or someone with only basic education or knowledge about medicines.

Private Health Facility 48

Private hospitals 4

Private hospitals sell medicines at a commercial rate and are manned by qualified health dispensers/practitioners, who are registered with the medical council. These facilities are regulated by the Pharmaceutical Regulatory Authority. They have a hospital license and can admit patients for more than 48 hours.

Private clinic 36

Private clinics sell medicines at a commercial rate and are manned by qualified health dispensers/practitioners, who are registered with the medical council. As with private hospitals, they are regulated by the Pharmaceutical Regulatory Authority. Private clinics have a clinic license, and differ from hospitals in that they can admit patients for a maximum of 48 hours.

Surgery 8

Surgeries are also manned by qualified health practitioners who are registered with the medical council. They have a clinic license and offer certain specialized services, but they are not allowed to admit patients. They are most common in urban areas.

P a g e | 33


Grocery Store 2,236

Grocery store 2,236 Small businesses that sell fast moving consumer goods including food, beverages, and household products. These outlets commonly sell antipyretics.

Other Outlet 1,096

Kiosk 23 Small businesses, made from temporary wooden structures, which sell fast moving consumer goods. They may also sell medicines. Kiosks are usually found near schools, colleges and universities.

Kantemba 982 These are similar to kiosks but have a more permanent structure. They are twice the size of a phone booth with walls made from metal.

Super/Mini market or Petrol station

44 Express stores at filling stations. Small businesses which sell general groceries; they may stock some medicines such as such as antipyretics or cough syrups.

Container 37

This is a shipment container that has been turned into a shop. They have commodities that can also be found in grocery stores but may also sell over the counter medicines. Containers need to obtain a trading license from the local council.

Mobile provider 5

These are street hawkers who sell a variety of items, which may include medicines. They typically operate in residential areas and at road junctions. In residential zones, hawkers mostly target low income and rural areas. In urban zones, they may have a hawker’s license under the local council.

Pharmacy/Chemist (not registered)

2

Other 3 Other outlet types that did not fit into any of the aforementioned outlet types. These were largely market stands and stalls.

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Appendix B: First-Line ACT and Nationally Registered ACTs

Government recommended first-line treatment for uncomplicated malaria

Generic Name Strength Dosage Form

Artemether/Lumefantrine 20mg/120mg Tablet

Recommended treatment regimen for the government recommended first-line treatment for uncomplicated

malaria15

Body weight in kg (age) # Tablets, Day 1

0hr 8hr

# Tablets, Day 2

24hr 36hr

# Tablets, Day 3

48hr 60hr

5 -14 kg (2 months to 5 years) 1 1 1 1 1 1

15-24 kg (6 to 8 years) 2 2 2 2 2 2

25-34 kg (9 to 11 years) 3 3 3 3 3 3

35 kg (12 years and above) 4 4 4 4 4 4

Complete list of Zambia’s nationally registered ACTs as of September 2008

Generic Name Strength Dosage Form

Brand name

Manufacturer Country of

Manufacture

Artemether/Lumefantrine 20mg/120mg Tablet Coartem Novartis Switzerland

Artemether/Lumefantrine 20mg/120mg Tablet Co-Max Universal

Corporation Ltd Kenya

Artesunate/Sulphadoxine/ Pyrimethamine

50mg/500mg/25mg Tablet Sulfamon

Plus Cipla India

15

Central Board of Health (Zambia): Guidelines for the diagnosis and treatment of malaria in Zambia. Central Board of Health, Lusaka. Third edition (undated).

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Appendix C: Study-wide tablet/non tablet AETD prices

Price of tablet/non tablet

AETDs OS2

Tablets Suppository Oral

Liquids Injectables Other Total

Distribution of free drugs: % % % % % %

Proportion of first-line ACTs

distributed free of cost (by volumes

of adult treatments)

78.6 -- --

--

--

78.6

Median price of a full course tablet

AETD:

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

Median (N of AMs)

First-line treatment (AL) $0.00 -- -- -- -- $0.00

WHO approved ACT $0.00 -- -- -- -- $0.00

Nationally registered ACT $0.00 -- -- -- -- $0.00

Non-WHO/nationally registered ACT $7.30 -- $14.72 -- -- $8.80

Non-artemisinin therapy $0.28 -- $3.37

$0.00

-- $0.28

Oral artemisinin monotherapy $4.90 -- $13.01 -- -- $7.96

SP (the ‘most popular’ non-ACT

antimalarial treatment in Zambia) $0.28 --

$2.81 -- --

$0.37

Median price of a full course AETD

ACT relative to SP (the ‘most

popular’ non-ACT antimalarial

treatment in Zambia):


First-line treatment (AL) n/a -- -- -- -- n/a

WHO approved ACT n/a -- -- -- -- n/a

Nationally registered ACT n/a -- -- -- -- n/a

Non-WHO/nationally registered ACT 26.1 -- 5.2 -- -- 23.8

Median price of a full course of an

AETD ACT relative to the minimum

legal daily wage ($2.25):


First-line treatment (AL) n/a -- -- -- -- n/a

WHO approved ACT n/a -- -- -- -- n/a

Nationally registered ACT n/a -- -- -- -- n/a

Non-WHO/nationally registered ACT 3.2 -- 6.5 -- -- 3.9


Median price of firstline AETD

relative to the international

reference price ($2.12)

n/a -- --

--

--

n/a

% % % % % %

N=287 -- N=6 N=4 -- N=297

P a g e | 36


Proportion of outlets that offer

credit to consumers for antimalarials 24.0 -- 33.3

75.0

--

24.9

P a g e | 37

Volumes of AETDs sold/distributed by dosage form

Tablets Suppository Oral Liquids Injectables Other Total

Total number of full course adult

equivalent tablet treatments











Each antimalarial category

as a proportion of the total

volume of all antimalarials

sold or distributed in the

past week

%

%

%

%

%

First-line treatment (AL) 23.5 -- -- -- -- 23.1

WHO approved ACT 22.3 -- -- -- -- 21.9

Nationally registered ACT 21.3

-- -- -- -- 21.0

Non-WHO/nationally

registered ACT 2.5

-- 59.2 -- -- 3.3

Non-artemisinin therapy 74.7 -- 33.8 83.9 -- 74.2

Chloroquine 0.9 -- -- 6.8 -- 0.9

Sulfadoxine-

Pyrimethamine

(SP)

68.1 -- 21.1 -- -- 67.1

Second-line

treatment

(Quinine)

4.6 -- 4.9 24.6 -- 4.8

Oral Artemisin

monotherapry 0.2 -- 7.0 -- -- 0.3

P a g e | 38


Documents

Outlet Survey Report Zambia 2009 - ACTwatch · Acknowledgements ACTwatch is funded by the Bill and Melinda Gates Foundation. This study was implemented by Society for Family Health