PROVIDING MALARIA MARKET Robi Okara Malaria and ......psi.org ACTwatch is a multi-country research project designed to fill evidence gaps on malaria diagnostics, antimalarial medicines

MALARIA MARKET EVIDENCE

PROVIDING MALARIA MARKET EVIDENCE THROUGH THE

ACTwatch PROJECT

Robi OkaraMalaria and Child Survival Associate

Whitefield Place, School LaneP.O Box 14355-00800Nairobi, Kenya

Tel: +254 20 4440125/6/7/8Cell: +254 737 814 [email protected] psi.org

ACTwatch is a multi-country research project designed to fill evidence gaps on malaria diagnostics, antimalarial medicines and fever case management in the private and public health sectors. Standardized tools and approaches are employed to provide comparable data across countries and over time.

ACTwatch was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently implemented in 10 countries (see Figure 1) with funding from the BMGF, UNITAID, and the DFID.

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. ACTwatch monitors 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.

An important part of our work is to ensure that policy makers and other stakeholders at national and international levels have access to ACTwatch findings through dissemination of the results. We share our results through our website: www.actwatch.info, as well as through presentations at national and international meetings. Study designs, questionnaires and reports are available on our website or by request.

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KENYA

ZAMBIA

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NIGERIABENIN

UGANDA

MYANMAR

CAMBODIA

Figure 1: ACTwatch Project Countries

Inform strategies to improve malaria case management in the private sectorPrivate sector providers play a significant role in the management of suspected malaria cases in many endemic countries. These providers include regulated outlets such as pharmacies and unregulated outlets including drug shops and retail outlets.

ACTwatch outlet surveys document the private sector market share relative to the public sector, and provide information on antimalarial availability, distribution and price among private sector outlets. For example, in Kinshasa (the Democratic Republic of the Congo), most antimalarial-stocking outlets are drug shops (Figure 2) and these outlets distribute nearly 90% of all antimalarials (Figure 3).

Most antimalarials distributed by drug shops are non-artemisinin therapy (SP, quinine) and non-quality-assured ACT. Information about private sector readiness and performance can be used to inform and monitor strategies to improve malaria diagnosis and treatment.

ACTwatch Evidence is used to:

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Figure 2: Antimalarial market composition, ACTwatch Outlet Survey, Kinshasa 2013

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Monitor the implementation of drug policy shiftsACTwatch outlet surveys provide evidence to inform, monitor and evaluate changes in drug policy and strategies for policy implementation and scale-up. For example, policy and strategy changes have recently been implemented in Cambodia to improve coverage of appropriate case management and address the threat of artemisinin drug resistance. Cambodia began using ACT for P. falciparum (Pf) in 2000. The first-line treatment for Pf was artesunate mefloquine (ASMQ) and public and private sector strategies were used to increase appropriate case management coverage using ASMQ. Artemisinin resistance containment policies and strategies implemented in resistance

risk areas of Cambodia (Zone 1) included introduction of the ACT dihydroartemisinin piperaquine (DHA PPQ) in 2009. In 2012, the first-line treatment for both Pf and P. vivax infections was changed to either DHA PPQ or ASMQ. Policy changes also include a ban of oral artemisinin monotherapy (oAMT) in 2009 enforced through multiple strategies. Trend data from ACTwatch outlet surveys conducted in 2009, 2011 and 2013 (Figure 4) show the decline in availability of oAMT and the successful introduction and scale up of DHA-PPQ in both the public and private health sectors.

Figure 3: Antimalarial market share, ACTwatch Outlet Survey, Kinshasa 2013

Figure 4: Availability of oral artemisinin monotherapy (oAMT) and first-line ACT, ACTwatch Outlet Surveys 2009-2013, Cambodia

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Assess the impact of ACT co-payment mechanisms

Public and private sector first-line buyers in 7 countries had access to highly subsidized quality-assured ACT (QAACT) from 2010-2013 through the Global Fund co-payment mechanism (Affordable Medicines Facility, malaria - AMFm. Outlet surveys conducted by ACTwatch in a subset of these countries track the availability, price and market share for co-paid (green leaf) ACTs in the public and private health sectors. Trend data from Nigeria and Uganda show the increasing QAACT relative market share over time (Figure 5), and the decrease in median price of QAACT (Figure 6).

Figure 5: Antimalarial market share, ACTwatch Outlet Surveys, Nigeria 2009-2013, Uganda 2010-2013

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Catalogue antimalarial medicines and rapid diagnostic tests (RDTs) on the market

Figure 7: Availability of malaria rapid diagnostic tests among antimalarial- stocking outlets, ACTwatch Outlet Surveys, Nigeria 2009-2013, Uganda 2010-2013

For more information on ACTwatch, please contact Dr. Megan Littrell, Principle Investigator [email protected] or visit www.actwatch.info

Inform and monitor the scale-up of malaria RDTs in the public and private health sectors In 2010, the WHO released new guidance stipulating confirmatory testing for malaria infection prior to treatment. National policies and strategies were subsequently implemented to achieve scale-up. ACTwatch outlet surveys have been tracking availability and price of malaria blood testing. Trend data show the increasing availability of malaria rapid diagnostics tests among both public and private sector outlets in countries such as Nigeria and Uganda (Figure 7).

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ACTwatch outlet surveys include complete antimalarial drug and RDT audits. Information captured includes: formulation, active ingredients, strengths, brand names, manufacturers, country of manufacturer, and package size. Audit information is used to classify commodities into categories relevant for monitoring policies and strategies. These include first-line treatment (for uncomplicated and severe malaria), quality-assured and non-quality-assured drugs, and nationally-registered and non-nationally-registered drugs. Malaria medicine and RDT audit information is available through searchable databases available at www.actwatch.info or by request.