Cambodia outlet report 2011

Availability

When observing stocking rates for all public health facilities and village malaria workers, availability of ACTs in 2011 was around 86% and 91% respectively. In the private for-profit sector, overall availability of ACTs was lower. Less than one third of pharmacies (29%), drugs stores (18%) or mobile providers (15%) stocked ACTs. Availability of non-artemisinin therapies in the private sector was similar to ACT availability, with 20% of pharmacies, drugs stores and 14% of mobile providers stocking non-artemisinin therapies. Few general retailers stocked any antimalarials (1%). Oral artemisinin monotherapies were available in 0.2% of public not-for-profit sector and 1.6% of the private sector.

Availability of any ACT was high for the public not for-profit sector antimalarial stocking outlets, across all three domains (91%-99%). However, there was variation in availability for different types of ACTs in the public not for-profit sector. DHA-PPQ was significantly more available in domain 1 (91%) (where it is the first line treatment) as compare to zone 2 (40%) or zone 3 (10%). In contrast, ASMQ was rarely available in the public not for-profit sector in zone 1 (0.4%), as compared to domain 2 (64%) and domain 3 (88%). In the private sector, there were few differences in availability of any Malarine across domains (42%-55%) or DHA-PPQ (3%-11.2%).

While there was little change in ACT availability between 2009 and 2011 the public not for-profit sector (96% to 97%), there were substantial declines in the private sector (from 63% in 2009 to 49% in 2011) of private sector outlets stocking antimalarials. Availability of non-artemisinin therapy increased (46% to 57% of private sector outlets stocking antimalarials). While 20% of outlets stocking antimalarials in the private sector stocked oral artemisinin monotherapy in 2009, this decreased to 4.2% in 2011.

Price

ACT treatments were free in public health facilities and village malaria workers. In the private sector, the price of ACTs was $2.03. The price of Malarine, the private sector socially-marketed ACT, was sold nationally at a subsidized price in the private sector ($1.63). Where DHA-PPQ was found in the private sector, this cost $7.20. The price of the most popular antimalarial, chloroquine, was less expensive than either Malarine or DHA-PPQ, at $0.74.

Market share

Market share data highlight the dominant role of the private sector in both 2009 and 2011, where around 70% of all antimalarials pass through the private sector. However, there were changes over time in terms of the volumes of ACTs and non-artemisinin therapies sold. In the private sector in 2009, ACTs comprised of 43% of the volumes while non-artemisinin therapy comprised of 19% of antimalarials sold or distributed in the last week. In contrast, in 2011, most of the antimalarials sold through the private sector were non-artemisinin therapies in 2011 (47%) as compared to ACTs (14.5%). In 2009, there were concerning amounts of oral artemisinin monotherapies in the private sector (6% of the total market) but in 2011, this decreased to <1%.

ACTs comprised of 70% of the total volume of antimalarials distributed across all sectors in 2009. This decreased to 41% in 2011.

Provider knowledge

Provider knowledge was lower in the private sector (50%) than in the public not for-profit sector (93%). Other studies have shown that medicine seller knowledge of drugs and doses, particularly in the private sector, is often poor [13, 15, 16]

Diagnostic testing

Diagnostic testing with a microscopic test cost $0.74 in the private sector and $0.49 for an RDT. Almost one in four facilities stocked a microscopic test in the private sector, and 44% of facilities stocked RDTs. In the public not for-profit sector, 22% of public health facilities stocked microscopic blood tests and 94% stocked RDTs. Almost all village malaria workers stocked RDTs (97%).

This report presents the results of a cross-sectional survey of outlets conducted in Cambodia between June and August 2011.

The objective of the outlet survey is to monitor levels and trends in the availability, price, and volumes of antimalarials sold, and providers’ perceptions and knowledge of antimalarial medicines at different public/not for-profit and private sector outlets. Price and availability data on diagnostic testing services are also collected. This report presents indicators on availability, price, and volumes of antimalarial medicines sold, as well as availability and price of diagnostic tests in outlets. The study also reports on provider knowledge of antimalarials and other provider perceptions.

A nationally representative sample of all outlets that could sell or provide antimalarials to a consumer was taken through a census approach in 113 communes across three malaria-endemic domains in Cambodia. Sampling was conducted using a one-stage probability proportion to size (PPS) cluster design, with the measure of size being the relative commune population. Oversampling of public health facilities was conducted in districts surrounding the selected communes. Domains were defined using the Cambodia National Centre for Parasitology, Entomology, and Malaria Control’s (CNM) artemisinin-resistance containment zoning, specifically:

  • Domain 1 = Zone 1, artemisinin tolerance confirmed
  • Domain 2 = Zone 2, artemisinin tolerance suspected/buffer area
  • Domain 3 = Zone 3, artemisinin tolerance free; and areas without a zone designation

A probability sample of 32 communes out of 45 were selected from domain one, 32 out of 228 from domain two, and 49 out of 928 from domain three, giving a total of 113 sub-districts. Outlet inclusion criteria for this study included outlets that 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 (referral hospitals, health centres or sub-health centres, former district hospitals, health posts, and village malaria workers); 2) private not for-profit health facilities (hospitals and clinics operated by non-governmental or religious organizations); 3) private for-profit health facilities (private hospitals, clinics, poly clinics, depot A and B, and cabinets); 5) pharmacies (clinical pharmacies and pharmacies); 6) drug stores; 7) general retailers (grocery stores, village shops); and 8) mobile providers (itinerant providers without a physical location).

Using a structured questionnaire, fieldworkers recorded the outlets’ basic details and then asked a screening question about the availability of antimalarials to determine if the outlet was eligible to be administered the full questionnaire. The questionnaire was administered to a senior person at the outlet to collect data on outlet identification, outlet characteristics, provider knowledge, availability of antimalarials and rapid diagnostic tests (RDTs), stock-outs of antimalarials and availability of cocktails. They recorded information on “audit sheets” for all antimalarials and RDT products stocked in terms of their price and volume sold in the past week.

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). The data was weighted at the analysis stage. Survey settings were incorporated to account for clustering of the outlets within the districts.

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