Travor Mabugu BPharm (HONS), MSc, MPS

1. Cost Analysis of Management of Malaria Using ACT in the Private Sector of Zimbabwe: a Regulatory Implication Travor Mabugu BPharm (HONS), MSc, MPS School of Pharmacy, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe, Health Economics and Policy Research Initiative. ICIUM Conference presentation, Turkey. 14-18 November

2. Outline • Background • Introduction • Objectives • Methodology • Results • Implications of Results • Future research focus • Background • Introduction • Methodology • Results • Conclusion • Future research focus ICIUM Conference presentation, Turkey. 14-18 November

3. Burden of disease • Over 50% of the population of Zimbabwe are at risk of Malaria • 3rd commonest cause of mortality & morbidity in Zimbabwe, coming after HIV/AIDS & TB across all age groups • 1.5million malaria episodes are reported per year and associated mortality of 1000 • Malaria accounts for 30% out patients visits and 40% hospital admissions ICIUM Conference presentation, Turkey. 14-18 November

4. Intervention strategies • Intervention strategies include: • Preventative strategies e.g. vector control, prophylactic measures etc • Treatment strategies e.g. use of medicines such as ACTs • The decision to adopt ACTs in Zimbabwe was made in 2004, implementation was delayed for more than 3years due to resource constraints • During which combination therapy of Chloroquine and Sulphadoxine/pyrimethamine was used • To date ACTs are now being used as first line treatment of uncomplicated Malaria ICIUM Conference presentation, Turkey. 14-18 November

5. ACT policy • Most African countries adopted the use of ACTs for management of uncomplicated malaria mainly because; • Efficacy reasons • Increased resistance to traditional regimens (WHO, 2002) • Two major pitfalls are associated with this adoption; • Even though CEA studies favoured the move Coleman et al, 2004; Morel et al, 2005), this never meant that there are cheaper • Confirmatory parasitological test comes as a condition to ACT initiation. (WHO, 2009) • This hence pauses some barriers to access • Financial barriers (chief) ICIUM Conference presentation, Turkey. 14-18 November

6. Barriers to access Malaria Treatment Facility level factors Patient level factors Health system factors ICIUM Conference presentation, Turkey. 14-18 November

7. Primary focus of the study RDTs versus Microscopy Doctor, Pharmacist versus no consultation CQ&SP versus ACTs (AL) ICIUM Conference presentation, Turkey. 14-18 November

8. Regulatory effects ICIUM Conference presentation, Turkey. 14-18 November

9. Aim To analyze the variation in cost in the management of uncomplicated malaria using the recently introduced ACT in contrast to the old regimen Chloroquine (CQ)& Sulfadoxine and Pyrimethamine (SP) ICIUM Conference presentation, Turkey. 14-18 November

10. Specific objectives • To obtain a cost estimate (patient perspective) for the management of uncomplicated adult malaria case at the following levels: • Consultation • Diagnostic (parasitological) • Medicine costs ICIUM Conference presentation, Turkey. 14-18 November

11. Possible routes of care ACTs or CQ&SP ICIUM Conference presentation, Turkey. 14-18 November

12. Sub-analysis • We also assessed malaria care seeking behaviours by potential patients. • Exit patient interviews • Retail/community pharmacies • Target areas • Harare – Metropolitan • Karoi and Bindura - Non-Metropolitan centres ICIUM Conference presentation, Turkey. 14-18 November

13. Methodology • Activity Based Costing was conducted in stages • Identification of activities of consumption of care • Identification of resource use per activity • Valuation of each activity (patient perspective) • Aggregation of total cost of consumption of care • Patient perspective to costing was taken • Limited to out of pocket expenditure • Time horizon (for costing) • Restricted to episode of malaria. ICIUM Conference presentation, Turkey. 14-18 November

14. Methodology • Operational definition • Access was defined as position in which the antimalarial was in the hands of the consumer (ready for consumption) • A function of availability and affordability and acceptability • Limitation of the definition • We did not track benefits or outcomes of consumption of care • For costing purposes this was adequate ICIUM Conference presentation, Turkey. 14-18 November

15. ACTs versus CQ-SP total costs ICIUM Conference presentation, Turkey. 14-18 November

16. Variation in total cost of care by ACTs category ICIUM Conference presentation, Turkey. 14-18 November

17. ICIUM Conference presentation, Turkey. 14-18 November

18. Patient level effects • 40.2% of patients who took ACTs did not seek a physician • Access of ACTs was restricted due to regulatory barrier • 55% did not have a confirmatory diagnosis • Wastage, resistance due to uncontrolled use • 14.8% accessed it as a Pharmacy (P) drug • 87.5% of patients who took CQ-SP did not seek a physician ICIUM Conference presentation, Turkey. 14-18 November

19. Decision Process 13.38 19.48 45.60 ICIUM Conference presentation, Turkey. 14-18 November

20. Average cost of care ICIUM Conference presentation, Turkey. 14-18 November

21. National Implications • Low uptake of the Anti-malarials • Financial barriers are created by the regulatory framework • However these need to be weighed against various issues; • Knowledge gap (patient level) • Uncontrolled access – risk of resistance development • Management of limited and expensive commodities ICIUM Conference presentation, Turkey. 14-18 November

22. Future Research focus • Regulatory policies creates financial barriers to access • These need to weighed in line with positive implications of such regulatory measures e.g. Wasting resources, resistance etc • Hence net benefits would be ideal indicators of the implications of regulation • Training of pharmacists, Community health workers on use of RDTs could be a possible solution. ICIUM Conference presentation, Turkey. 14-18 November

23. Thank youTatendaSiyabonga ICIUM Conference presentation, Turkey. 14-18 November