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Benjamin Palafox Department of Global Health & Development London School of Hygiene & Tropical Medicine

Mapping the private sector distribution chain to understand barriers and opportunities for improved access to antimalarials in six low-income countries in Africa and South-East Asia. Benjamin Palafox Department of Global Health & Development London School of Hygiene & Tropical Medicine.

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Benjamin Palafox Department of Global Health & Development London School of Hygiene & Tropical Medicine

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  1. Mapping the private sector distribution chain to understand barriers and opportunities for improved access to antimalarials in six low-income countries in Africa and South-East Asia Benjamin Palafox Department of Global Health & Development London School of Hygiene & Tropical Medicine

  2. Background • Artemisinin-based combination therapies (ACTs) • highly effective, recommended treatment for Pf malaria • 228 million doses are needed to treat Pf cases; approx. 100 million doses distributed per annum (2010 RBM) • Despite free or highly subsidised provision, limited access and availability of ACTs in public sector has resulted in poor coverage • 3%-21% of febrile children in Africa receive ACT (2011 ACTwatch HH) • Many seek treatment from private sector retailers • >50% for under-5s in 6 ACTwatch countries (but only 22% in Zambia) (2011 ACTwatch HH) • Retail prices for ACT are 5-23 times higher than those of older, less effective antimalarials (e.g. CQ, SP) (2011 ACTwatch OS) • Most retail customers purchase less effective antimalarials, or painkillers • Use of oral artemisinin monotherapies also common  resistance

  3. What is ACTwatch? Cambodia Nigeria Benin Uganda DRC 5 year, 7 country project Funded by the BMGF Objective Provide policy makers with evidence on trends in availability, price, and use of antimalarials Zambia Madagascar Partnership PSI, LSHTM and MoHs www.ACTwatch.info 3

  4. Outlet & Supply Chain Survey Methods: • Randomly selection of clusters with PPS • Census conducted of all outlets with the potential to stockantimalarials • Over-sampling of public health facilities and pharmacies • Audit conducted of all antimalarials in stock • Product details, price, volumes • Sampling frame of wholesalers created by tracing the distribution chain starting from the bottom and working up • All outlets asked for the name & address of top 2 antimalarial suppliers (terminal wholesalers) • Terminal wholesalers asked for their suppliers (intermediate wholesalers), and so on, until top of the chain is reached price availability volumes price availability volumes www.ACTwatch.info 4

  5. Relative volumes of antimalarials sold/distributed by sector & antimalarial type * For any artesunate+mefloquine product in Cambodia (as there is no quality-assured artesunate+mefloquine product)

  6. Median retail price (IQR) for full adult equivalent antimalarial treatments in the private sector * For any artesunate+mefloquine product in Cambodia (as there is no quality-assured artesunate+mefloquine product) www.ACTwatch.info

  7. Supply Chain Study Results from Benin, Cambodia, DRC, Nigeria, Uganda & Zambia Market-level forces • Rationale: Price & availability of antimalarials in the private retail sector are expected to be strongly influenced by wholesalers at higher levels of the distribution chain, as well as by market level factors

  8. Private sector antimalarial availability: • wholesale vs. retail level+ + Of those stocking at least one antimalarial drug; * For any artesunate+mefloquine product in Cambodia (as there is no quality-assured artesunate+mefloquine product) www.ACTwatch.info

  9. Median wholesale mark-up (% & absolute) by antimalarial type

  10. Median retail mark-up (% & absolute) by antimalarial type

  11. Wholesaler Characteristics:Qualifications, Licensing & Storage +In Uganda this includes wholesalers who had a recently valid pharmacy license (i.e. Expired Nov or Dec 2008) as licences for 2009 were still being processed by the authorities at the time of data collection

  12. Discussion • To increase the ACTs use in the private sector, consumer availability must increase and end-user prices must decrease • As wholesale and retail mark-ups on ACTs are generally reasonable, decreases in end-user price would require decreases in factory gate prices • Affordable Medicines Facility–malaria (AMFm), and other subsidy interventions, may help to achieve this • AMFm pilots began in 2010, including in some ACTwatch countries  possible changes in ACT price and availability • Price regulation could help  difficult to implement • Bans on sale of artemisinin monotherapies must be more vigorously enforced

  13. ACTwatch Advisory Committee • Mr. Suprotik Basu • Mr. Rik Bosman • Ms. Renia Coghlan • Dr. Thom Eisele • Mr. Louis Da Gama • Dr. Paul Lalvani • Dr. RamananLaxminaravan • Dr. Matthew Lynch • Dr. Bernard Nahlen • Dr. Jayesh M. Pandit • Dr. Melanie Renshaw • Mr. Oliver Sabot • Ms. RimaShretta • Dr. Rick Steketee • Dr. Warren Stevens • Dr. Gladys Tetteh • Dr. Nick White • Dr. PrashantYadav • Dr. ShunmayYeung The ACTwatch Group: • Benin • Dr. Mariam Oke Sopoh • Dr. Cherifatou Bello Adjibabi • Ms. Martine-Esther Tassiba • Mr. Cyprien Zinsou • Mr. Leger Foyer • Mr. GhyslainGuedegbe • Ms. S Le Fevre • Cambodia • Dr. Socheat Duong • Dr. NguonChea • Dr. Sim Kheng • Mr. Sochea Phok • Ms. Dianna Long • Ms. Mean Phou • Ms. Henrietta Allen • Mr. Sarath Mak • Mr. Chris Jones • DRC • Ms. S Kutumbakana Kimwesa • Dr. Jean Angbalu Agbango • Dr. Louis-Daniel Akulayi • Dr. Godefroid Mpanya Ilunga • Ms. Theresa Tapsoba • Mr. Willy Mpwate Nsuele • Madagascar • Dr. B F Ramarosandratana • Dr. Nivo Hanitra Rasoanarivo • Mr. Jacky Raharinjatovo • Ms. Iarimalanto Rabary • Mr. Brian McKenna • Nigeria • Dr. Bala Audu • Dr. Emmanuel Ezedinachi • Dr. Ayotunde R. O. Momodu • Ms. Ekundayo D. Arogundade • Dr. Jennifer Anyanti • Mr. Bright Ekweremadu • Dr. UwemInyang • Dr. Akinpelumi Abiodun • Uganda • Dr. Dennis Rubahika • Dr. George Mukhone • Mr. Simon Sensalire • Mr. Peter Buyungo • Dr. Susan Mpanga Mukasa • Zambia • Mr. Muyamwa Mainga • Dr. Mulakwa Kamuliwo • Zambia (cont) • Mr. Busiku Hamainza • Mr. Felton Mpasela • Mr. Richard Harrison • Mr. Nicholas Shiliya • ACTwatch Central - PSI • Dr. Des Chavasse • Dr. Steven Chapman • Dr. Kathryn O'Connell • Ms. Tanya Shewchuk • Ms. Tsione Solomon • Mr. Erik Munroe • Mr. Stephen Poyer • Ms Hellen Gatakaa • Mr. Illah Evance • Mr. Julius Ngigi • Dr. Megan Littrell • Ms. Michelle Geiss • ACTwatch Central - LSHTM • Dr. Kara Hanson • Dr. Catherine Goodman • Mr. Benjamin Palafox • Ms. Sarah Tougher • Ms. Edith Patouillard • Dr. Immo Kleinschmidt www.ACTwatch.info 13

  14. www.actwatch.info • Household, Outlet, Supply Chain reports Malaria Journal • Study Design • Outlet Survey • Household Survey • Cambodia

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