Cambodia outlet report 2009
Data were collected from 9th June to 8th July 2009. A total of 7,833 outlets were sampled (Zone 1 and 2 [multi-drug resistance is suspected or confirmed], N=3,912 Zone 3, N=3,611;). 406 outlets were excluded from the analysis; they were either not open during the survey visit, did not have an eligible respondent available, or refused to participate. Therefore, 7,427 outlets were included in the analysis. Of these, 1,019 outlets stocked antimalarials at any point in the three months prior to the interview, and 865 outlets stocked antimalarials at the time of the interview.
Availability of antimalarials
The ACT ASMQ was available in most public health facilities (82%), and nearly half of pharmacies/clinics (44%) and drug stores (44%). Other ACTs (DHQ+PPA and A+PPQ) were less commonly available (public health facilities, 5%s; pharmacies/clinics, 14%; drug stores, 6%; mobile providers, 3%). Oral artemisinin monotherapy was not commonly available in the public (2%) or private sectors (pharmacy/clinics, 9%; drug stores, 14%; mobile providers, 4%; grocery stores, 2%; village shops, 1%). Non-artemisnin monotherapy – most commonly chloroquine – was available in about half of all public health facilities (49%), but less commonly available in pharmacies/clinics (15%), drug stores (16%), mobile providers (14%), grocery stores (4%) and village shops (2%).
Availability of diagnostic blood testing
Of outlets stocking antimalarials in the last three months, 59% (N=1,015) reported offering diagnostic testing services of some kind. 24% of outlets had microscopic blood testing while 45% offered rapid diagnostic tests (RDTs). RDTs were available in most antimalarial-stocking public health facilities (75%), and in more than half of pharmacies/clinics (58%). Fewer than half of antimalarial-stocking drug stores (39%), mobile providers (42%) and grocery stores (34%) stocked RDTs. Microscopy was less commonly available with public health facilities (16%) as well as in the private sector (38% pharmacies/clinics; 32% drug stores; 45% mobile providers; 4% grocery stores).
Price of antimalarials
In public health facilities, nearly all antimalarials, including ASMQ and DHA+PPQ, were available for free. In the private sector, the median price of ASMQ is much higher than the median price of chloroquine (the most popular non-artemisinin monotherapy), and lower than the price of other ACTs (DHA+PPQ and A+PPQ) and oral artemisinin monotherapy. For example, at pharmacies/clinics, the median price of ASMQ was $0.94 as compared with $1.85 for other ACTs and $2.64 for oral artemisinin monotherapy.
Volumes of antimalarials sold/distributed
The relative volumes of adult equivalent treatment doses for each antimalarial reportedly sold or distributed in the week preceding the survey in the public and private sectors provides a picture of the total antimalarial market in Cambodia. About 70% of antimalarials move through the private sector – including pharmacies/clinics (32%), drug stores (13%), mobile providers (15%), grocery stores (7%) and village shops (6%). Most antimalarials sold/distributed in Cambodia are ACTs, including public sector ASMQ, A+M (28%), private sector ASMQ, Malarine (33%), and other ACTs, which include DHA+PPQ and A+PPQ (11%). Oral artemisinin monotherapy accounts for 6% and non-artemisinin monotherapy (largely chloroquine) for 20% of all antimalarials sold/distributed in Cambodia.
Overall, 76% of providers were able to correctly state that ASMQ is the recommended first-line treatment for uncomplicated malaria in Cambodia. Knowledge was highest among providers at public health facilities and pharmacies/ clinics; 90% or more of providers at such facilities were able to correctly identify the first-line treatment for P. falciparum malaria. Roughly three-quarters of respondents at drug stores or mobile providers knew the first-line treatment. Knowledge was lowest among providers at grocery stores (64%) and village shops (47%).
The outlet survey is one of ACT watch’s three 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 are presented first, followed by indicators presented across outlet categories, high/low stratum 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 across two malaria-endemic strata, zone 1&2 (malaria drug resistance (MDR) suspected/confirmed) and zone 3 (MDR free), in Cambodia. Sampling was conducted using a one-stage probability proportion to size (PPS) cluster design, with the measure of size being the relative sub-district population. Oversampling of public health facilities was conducted in districts surrounding the selected sub-districts. 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 referral hospitals, health centres and posts, village malaria workers, and village health volunteers); 2) pharmacies/clinics (pharmacies, clinical pharmacies, cabinets, and private clinics/health providers); 3) drug stores; 4) mobile providers; 5) grocery stores; and 6) village shops [see Appendix A for definitions and numbers of each type of outlet].
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 StataCorp. 2009 (Stata Statistical software: Release 11. College station, TX: StataCorp LP). Given that PPS sampling was used, the data is weighted at analysis to minimize bias that could be introduced where clusters are very different in size. Weighting the data allows the analysis to be adjusted to better represent the population. Survey settings were incorporated to account for clustering of the outlets within the districts.