Cambodia outlet report 2013
Availability of antimalarials
The percentage of public health facilities and CHWs with at least one antimalarial in stock on the day of the survey increased between 2009 and 2011 and remained high in 2013 (public health facilities, 82%; CHWs, 88%). Private sector stocking of antimalarials declined between 2009 and 2011 and remained relatively low in 2013. The percentage of public health facilities and CHWs with at least one antimalarial in stock on the day of the survey increased was high across research domains. However, antimalarial availability among private sector outlets was significantly lower in Zone 1 as compared with Zone 2 and Zone 3 & ‘No zone.’ The percentage of antimalarial-stocking public health facilities and CHWs with at least one ACT in stock on the day of the survey remained higher than 95% over time. ACT availability in the private sector was variable over time and across outlet types. In 2013, most antimalarial-stocking private health facilities (90%), pharmacies (95%), drug stores (70%) and itinerant drug vendors (79%) had ACT in stock. ACT availability was lower among general retailers (17%). The percentage of antimalarial-stocking outlets with at least one ACT in stock on the day of the survey was similar among public and private outlets across research domains, with the exception of lower ACT availability among drug stores in Zone 1 (53%) as compared with Zone 2 (88%) and Zone 3 & ‘No zone’ (68%).
The percentage of antimalarial-stocking outlets with the ACT DHA-PPQ in stock on the day of the survey increased across survey rounds. In 2013, most antimalarial-stocking public health facilities (85%), CHWs (95%), private health facilities (65%), and pharmacies (72%) had DHA-PPQ in stock. Availability was lower among drug stores (42%), general retailers (14%), and itinerant drug vendors (47%).
The percentage of antimalarial-stocking public health facilities and CHWs with the ACT ASMQ in stock on the day of the survey decreased between 2009 and 2013 to 69% and 24% respectively. ASMQ availability among antimalarial-stocking private outlets increased over time to approximately half of private health facilities (46%) and pharmacies (51%), and 36% among itinerant drug vendors. ASMQ availability remained low among general retailers over time (4% in 2013).
Oral artemisinin monotherapy
The percentage of private sector antimalarial-stocking outlets with oral artemisinin monotherapy in stock on the day of the survey decreased over time. In 2013, availability was limited to 0.6% among private for-profit health facilities, and 5.2% among itinerant drug vendors.
The majority of antimalarial-stocking outlets were private sector outlets across survey rounds. Private sector market composition shifted over time towards increasing contribution from formal regulated private sector outlet types (private for-profit health facilities and pharmacies), and declining contribution from informal unregulated private outlet types (drug stores, general retailers, and itinerant drug vendors). Antimalarial market composition varied across research domains in 2013. Most antimalarial-stocking outlets in Zone 1 were CHWs (75%) and private sector outlets accounted for less than 20% of the market composition. In Zone 2, the private sector accounted for approximately 60% of antimalarial-stocking outlets, and CHWs for over one-third (37%) of the market composition. In the third research domain comprised of Zone 3 and ‘No zone’ areas, nearly all antimalarial-stocking outlets were private sector outlets.
Availability of blood testing
The percentage of antimalarial-stocking outlets with malaria blood testing available (RDT or microscopy) remained high over time among public and private health facilities and CHWs. In 2013, over 90% of antimalarial-stocking public health facilities and CHWs had malaria blood testing available. Trends in blood testing availability among other outlet types suggest a decline in availability over time.
Antimalarial market share
At national level, 60% of all antimalarials sold or distributed in the week preceding the survey were distributed through private sector outlets including pharmacies (20%), itinerant drug vendors (14%), and private for-profit facilities (12%). The majority of antimalarials sold/distributed were ACTs including DHA-PPQ (63%) and ASMQ (24%). Non-artemisinin monotherapy accounted for only 13% of the market share, and there was no reported sale/distribution of oral artemisinin monotherapy. Public sector market share differed across research domains, ranging from 93% in Zone 1 to 35% in Zone 3 & ‘No zone.’ The non-artemisinin therapy distributed in Zone 1 is atavoquone proguanil, while in Zone 3 & ‘No zone,’ non-artemisinin therapy distributed by the private sector was primarily chloroquine.
This country reference document is a detailed presentation of the 2013 national ACTwatch outlet survey (OS) conducted in Cambodia. The 2013 OS follows previous survey rounds conducted by ACTwatch in Cambodia in 2009 and 2011.
ACTwatch antimalarial market monitoring in Cambodia from 2009 to present has been implemented in the context of recent policy and strategy changes designed and implemented to improve coverage of appropriate case management and address the threat of artemisinin drug resistance. These include:
- Shifts in first-line therapy for Plasmodium falciparum (Pf)and Plasmodium vivax (Pv). The first-line therapy for Pfchanged from the artemisinin-based combination therapy (ACT) artesunate mefloquine (ASMQ) to ASMQ or dihydroartemisinin piperaquine (DHA-PPQ) in 2012 following targeted use of DHA-PPQ since 2009 in artemisinin resistance containment areas. Malaria case management using ASMQ or DHA-PPQ should also include treatment with primaquine (PQ). Atovaquone proguanil (Malarone) is authorized for use in geographic areas with artemisinin tolerance (Zone 1). The first-line therapy for Pv changed from chloroquine to DHA-PPQ plus PQ in 2012.
- Scale up of malaria rapid diagnostic tests (RDT) to facilitate confirmatory testing before antimalarial treatment.
- Efforts to improve access to appropriate fever case management through scale up of the Village Malaria Worker (VMW) program. Malaria blood testing and treatment are provided free-of-charge through VMWs.
- Banning the sale of oral artemisinin monotherapy in 2009.
- Increased regulation of private sector sale of antimalarials and RDTs.
Many malaria control and elimination strategies in Cambodia are targeted to geographic areas according to the presence, absence, or risk of infection with artemisinin-resistant Pf. The National Centre for Entomology, Parasitology and Malaria Control (CNM) has stratified the country into four zones: 1) Zone 1 - areas where artemisinin tolerance has been detected; 2) Zone 2 - areas with no evidence of drug tolerance but considered at risk (known as a ‘buffer’ area); 3) Zone 3 - malaria endemic provinces with relatively high malaria prevalence; and 4) ‘No zone’ – malaria endemic provinces with relatively low malaria prevalence. Information on the Cambodia context is provided in Annex 2.
The ACTwatch outlet surveys conducted in 2009, 2011, 2013, and planned for 2015 are designed to monitor key antimalarial market indicators at national level and across three research domains defined by the CNM stratification: Zone 1, Zone 2, and Zone 3 plus ‘No zone.’ ACTwatch outlet survey findings can inform ongoing monitoring, evaluation, and adjustment to policy, strategy, and funding decisions to strengthen malaria case management and contain artemisinin resistance.