Dataset Information

Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries.

ABSTRACT: Private for-profit outlets are important treatment sources for malaria in most endemic countries. However, these outlets constitute only the last link in a chain of businesses that includes manufacturers, importers and wholesalers, all of which influence the availability, price and quality of antimalarials patients can access. We present evidence on the composition, characteristics and operation of these distribution chains and of the businesses that comprise them in six endemic countries (Benin, Cambodia, Democratic Republic of Congo, Nigeria, Uganda and Zambia).We conducted nationally representative surveys of antimalarial wholesalers during 2009-2010 using an innovative sampling approach that captured registered and unregistered distribution channels, complemented by in-depth interviews with a range of stakeholders. Antimalarial distribution chains were pyramidal in shape, with antimalarials passing through a maximum of 4-6 steps between manufacturer and retailer; however, most likely pass through 2-3 steps. Less efficacious non-artemisinin therapies (e.g. chloroquine) dominated weekly sales volumes among African wholesalers, while volumes for more efficacious artemisinin-based combination therapies (ACTs) were many times smaller. ACT sales predominated only in Cambodia. In all countries, consumer demand was the principal consideration when selecting products to stock. Selling prices and reputation were key considerations regarding supplier choice. Business practices varied across countries, with large differences in the proportions of wholesalers offering credit and delivery services to customers, and the types of distribution models adopted by businesses. Regulatory compliance also varied across countries, particularly with respect to licensing. The proportion of wholesalers possessing any up-to-date licence from national regulators was lowest in Benin and Nigeria, where vendors in traditional markets are important antimalarial supply sources.The structure and characteristics of antimalarial distribution chains vary across countries; therefore, understanding the wholesalers that comprise them should inform efforts aiming to improve access to quality treatment through the private sector.

SUBMITTER: Palafox B

PROVIDER: S-EPMC3974780 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries.

Palafox Benjamin B Patouillard Edith E Tougher Sarah S Goodman Catherine C Hanson Kara K Kleinschmidt Immo I Rueda Sergio Torres ST Kiefer Sabine S O'Connell Kathryn A KA Zinsou Cyprien C Phok Sochea S Akulayi Louis L Arogundade Ekundayo E Buyungo Peter P Mpasela Felton F Chavasse Desmond D

PloS one 20140403 4

<h4>Background</h4>Private for-profit outlets are important treatment sources for malaria in most endemic countries. However, these outlets constitute only the last link in a chain of businesses that includes manufacturers, importers and wholesalers, all of which influence the availability, price and quality of antimalarials patients can access. We present evidence on the composition, characteristics and operation of these distribution chains and of the businesses that comprise them in six endem ...[more]

PMID: 24699934

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Project description:BackgroundArtemisinin-based combination therapy (ACT) is the first-line malaria treatment throughout most of the malaria-endemic world. Data on ACT availability, price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality-assured ACT supply. This paper presents supply side data from ACTwatch outlet surveys in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia.MethodsBetween March 2009 and June 2010, nationally representative surveys of outlets providing anti-malarials to consumers were conducted. A census of all outlets with the potential to provide anti-malarials was conducted in clusters sampled randomly.Results28,263 outlets were censused, 51,158 anti-malarials were audited, and 9,118 providers interviewed. The proportion of public health facilities with at least one first-line quality-assured ACT in stock ranged between 43% and 85%. Among private sector outlets stocking at least one anti-malarial, non-artemisinin therapies, such as chloroquine and sulphadoxine-pyrimethamine, were widely available (> 95% of outlets) as compared to first-line quality-assured ACT (< 25%). In the public/not-for-profit sector, first-line quality-assured ACT was available for free in all countries except Benin and the DRC (US$1.29 [Inter Quartile Range (IQR): $1.29-$1.29] and $0.52[IQR: $0.00-$1.29] per adult equivalent dose respectively). In the private sector, first-line quality-assured ACT was 5-24 times more expensive than non-artemisinin therapies. The exception was Madagascar where, due to national social marketing of subsidized ACT, the price of first-line quality-assured ACT ($0.14 [IQR: $0.10, $0.57]) was significantly lower than the most popular treatment (chloroquine, $0.36 [IQR: $0.36, $0.36]). Quality-assured ACT accounted for less than 25% of total anti-malarial volumes; private-sector quality-assured ACT volumes represented less than 6% of the total market share. Most anti-malarials were distributed through the private sector, but often comprised non-artemisinin therapies, and in the DRC and Nigeria, oral artemisinin monotherapies. Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector.ConclusionsThese standardized, nationally representative results demonstrate the typically low availability, low market share and high prices of ACT, in the private sector where most anti-malarials are accessed, with some exceptions. The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries. The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria.

Project description:The private for-profit sector is an important source of treatment for malaria. However, private patients face high prices for the recommended treatment for uncomplicated malaria, artemisinin combination therapies (ACTs), which makes them more likely to receive cheaper, less effective non-artemisinin therapies (nATs). This study seeks to better understand consumer antimalarial prices by documenting and exploring the pricing behaviour of retailers and wholesalers. Using data collected in 2009-10, we present survey estimates of antimalarial retail prices, and wholesale- and retail-level price mark-ups from six countries (Benin, Cambodia, the Democratic Republic of Congo, Nigeria, Uganda and Zambia), along with qualitative findings on factors affecting pricing decisions. Retail prices were lowest for nATs, followed by ACTs and artemisinin monotherapies (AMTs). Retailers applied the highest percentage mark-ups on nATs (range: 40% in Nigeria to 100% in Cambodia and Zambia), whereas mark-ups on ACTs (range: 22% in Nigeria to 71% in Zambia) and AMTs (range: 22% in Nigeria to 50% in Uganda) were similar in magnitude, but lower than those applied to nATs. Wholesale mark-ups were generally lower than those at retail level, and were similar across antimalarial categories in most countries. When setting prices wholesalers and retailers commonly considered supplier prices, prevailing market prices, product availability, product characteristics and the costs related to transporting goods, staff salaries and maintaining a property. Price discounts were regularly used to encourage sales and were sometimes used by wholesalers to reward long-term customers. Pricing constraints existed only in Benin where wholesaler and retailer mark-ups are regulated; however, unlicensed drug vendors based in open-air markets did not adhere to the pricing regime. These findings indicate that mark-ups on antimalarials are reasonable. Therefore, improving ACT affordability would be most readily achieved by interventions that reduce commodity prices for retailers, such as ACT subsidies, pooled purchasing mechanisms and cost-effective strategies to increase the distribution coverage area of wholesalers.

Project description:BackgroundPrivate sector malaria programmes contribute to government-led malaria elimination strategies in Cambodia, Lao PDR, and Myanmar by increasing access to quality malaria services and surveillance data. However, reporting from private sector providers remains suboptimal in many settings. To support surveillance strengthening for elimination, a key programme strategy is to introduce electronic surveillance tools and systems to integrate private sector data with national systems, and enhance the use of data for decision-making. During 2013-2017, an electronic surveillance system based on open source software, District Health Information System 2 (DHIS2), was implemented as part of a private sector malaria case management and surveillance programme. The electronic surveillance system covered 16,000 private providers in Myanmar (electronic reporting conducted by 200 field officers with tablets), 710 in Cambodia (585 providers reporting through mobile app), and 432 in Laos (250 providers reporting through mobile app).MethodsThe purpose of the study was to document the costs of introducing electronic surveillance systems and mobile reporting solutions in Cambodia, Lao PDR, and Myanmar, comparing the cost in different operational settings, the cost of introduction and maintenance over time, and assessing the affordability and financial sustainability of electronic surveillance. The data collection methods included extracting data from PSI's financial and operational records, collecting data on prices and quantities of resources used, and interviewing key informants in each setting. The costing study used an ingredients-based approach and estimated both financial and economic costs.ResultsAnnual economic costs of electronic surveillance systems were $152,805 in Laos, $263,224 in Cambodia, and $1,310,912 in Myanmar. The annual economic cost per private provider surveilled was $82 in Myanmar, $371 in Cambodia, and $354 in Laos. Cost drivers varied depending on operational settings and number of private sector outlets covered in each country; whether purchased or personal mobile devices were used; and whether electronic (mobile) reporting was introduced at provider level or among field officers who support multiple providers for case reporting.ConclusionThe study found that electronic surveillance comprises about 0.5-1.5% of national malaria strategic plan cost and 7-21% of surveillance budgets and deemed to be affordable and financially sustainable.

Project description:BackgroundDespite the growing interest in the private health sector in low- and middle-income countries, little is known about physicians working outside the public sector. The present work adopts a mixed-methods approach to explore characteristics, working patterns, choices, and motivations of the physicians working exclusively for the private sector in the capital cities of Cape Verde, Guinea Bissau, and Mozambique. The paper's objective is to contribute to the understanding of such physicians, ultimately informing the policies regulating the medical profession in low- and middle-income countries.MethodsThe qualitative part of the study involved 48 interviews with physicians and health policy-makers and aimed at understanding the practice in the three locations. The quantitative study included a survey of 329 physicians, and multivariate analysis was conducted to analyse characteristics, time allocation, earnings, and motivations of those physicians working only for the private sector, in comparison to their public sector-only and dual practice peers.ResultsOur findings showed that only a limited proportion of physicians in the three locations work exclusively for the private sector (11.2%), with members of this group being older than those practicing only in the public or in both sectors. They were found to work fewer hours per week (49 hours) than their public (56 hours) and dual practice peers (62 hours) (P <0.001 and P?=?0.011, respectively). Their median earnings were USD 4,405 per month, with substantial variations across the three locations. Statistically significant differences were found with the earnings of public-only physicians (P <0.001), but not with those of the dual practice group (P?=?0.340). The qualitative data from the interviews showed private-only physicians' preference for an independent and more flexible work modality, and this was quoted as a determining factor for their choice of sector. This group appears to include those working in the more informal sector, and those who decided to leave the civil service following a disagreement with the public employer.ConclusionsThe study shows the importance of understanding the relation between health professionals' characteristics, motivations, and their engagement with the private sector to develop effective policies to regulate the profession. This may ultimately contribute to achieving universal access to medical services in low- and middle-income countries.

Project description:BackgroundSeveral interventions have been put in place to promote access to quality malaria case management services in Uganda's private sector, where most people seek treatment. This paper describes evidence using a mixed-method approach to examine the role, readiness and performance of private providers at a national level in Uganda. These data will be useful to inform strategies and policies for improving malaria case management in the private sector.MethodsThe ACTwatch national anti-malarial outlet survey was conducted concurrently with a fever case management study. The ACTwatch nationally representative anti-malarial outlet survey was conducted in Uganda between May 18th 2015 and July 2nd 2015. A representative sample of sub-counties was selected in 14 urban and 13 rural clusters with probability proportional to size and a census approach was used to identify outlets. Outlets eligible for the survey met at least one of three criteria: (1) one or more anti-malarials were in stock on the day of the survey; (2) one or more anti-malarials were in stock in the 3 months preceding the survey; and/or (3) malaria blood testing (microscopy or RDT) was available. The fever case management study included observations of provider-patient interactions and patient exit interviews. Data were collected between May 20th and August 3rd, 2015. The fever case management study was implemented in the private sector. Potential outlets were identified during the main outlet survey and included in this sub-sample if they had both artemisinin-based combination therapy (ACT) [artemether-lumefantrine (AL)], in stock on the day of survey as well as diagnostic testing available.ResultsA total of 9438 outlets were screened for eligibility in the ACTwatch outlet survey and 4328 outlets were found to be stocking anti-malarials and were interviewed. A total of 9330 patients were screened for the fever case management study and 1273 had a complete patient observation and exit interview. Results from the outlet survey illustrate that the majority of anti-malarials were distributed through the private sector (54.3%), with 31.4% of all anti-malarials distributed through drug stores and 14.4% through private for-profit health facilities. Availability of different anti-malarials and diagnostic testing in the private sector was: ACT (80.7%), quality-assured (QA) ACT (72.0%), sulfadoxine-pyrimethamine (SP) (47.1%), quinine (73.2%) and any malaria blood testing (32.9%). Adult QAACT ($1.62) was three times more expensive than SP ($0.48). The results from the fever case management study found 44.4% of respondents received a malaria test, and among those who tested positive for malaria, 60.0% received an ACT, 48.5% received QAACT; 14.4% a non-artemisinin therapy; 14.9% artemether injection, and 42.5% received an antibiotic.ConclusionThe private sector plays an important role in malaria case management in Uganda. While several private sector initiatives have improved availability of QAACT, there are gaps in malaria diagnosis and distribution of non-artemisinin monotherapies persists. Further private sector strategies, including those focusing on drug stores, are needed to increase coverage of parasitological testing and removal of non-artemisinin therapies from the marketplace.

Project description:IntroductionTo accelerate progress to reach the sustainable development goals for ending preventable maternal, newborn and child deaths, it is critical that both the public and private health service delivery systems invest in increasing coverage of interventions to sustainably deliver quality care for mothers, newborns and children at scale. Although various approaches have been successful in high-income countries, little is known about how to effectively engage and sustain private sector involvement in delivering quality care in low-income and middle-income countries. Our systematic review will examine private sector implementation of quality care for maternal, newborn and child health (MNCH) and the impact of this care. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for protocols.Methods and analysisFollowing the PRISMA approach, this systematic review will include quantitative, qualitative and mixed-methods studies addressing the provision of quality MNCH care by private sector providers. Eight databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, Web of Science) and two websites will be searched for relevant studies published between 1 January 1995 and 30 June 2019. For inclusion, studies in low-income and middle-income countries must examine at least one of the following critical outcomes: maternal morbidity or mortality, newborn morbidity or mortality, child morbidity or mortality, quality of care, experience of care and service utilisation. Depending on the data, analyses could include meta-analysis, descriptive quantitative statistics, narrative synthesis and thematic synthesis. Quality will be assessed using tools for qualitative and quantitative studies.Ethics and disseminationFormal ethical approval is not required for this research, as the secondary data are not identifiable. Findings from this review will be used to develop models for effective collaboration of the private and public sectors in implementing quality of care for MNCH. In addition to publishing our findings in a peer-reviewed journal, the findings will be shared through the Quality of Care Network, relevant mailing lists, webinars and social media.Prospero registration numberCRD42019143383.

Dataset Information

Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries.

Publications

Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries.

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