DR Congo outlet report 2009
Data were collected between August 10th and October 27th, 2009. A total of 3,814 outlets were approached. Of these, 99 outlets were not screened for various reasons: 43 providers refused to be interviewed; 36 outlets were closed down permanently; 14 outlets were not open at the time of the survey visit; in 5 outlets, providers were not available for interview at the time of survey visit; and 1 provider were unable to be interviewed for other reasons. Overall, 3,715 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 1,407 outlets met the screening criteria and were interviewed. Of the 1,407 completed interviews, 32 reported having stocked antimalarials at any point in the three months prior to the interview and 1,375 outlets stocked antimalarials at the time of the interview.
Availability of any antimalarials
Antimalarials were available in over 95% of screened outlets, with the exception of private for profit health facilities (76%) and general retailers (2%). General retailers are boutiques, kiosks and market stalls and were included in the survey to verify an assumption that such outlets in DRC do not generally stock antimalarials. On the day of interview, any antimalarial was available in 97% of public and private not for-profit outlets, and 97% of drug stores. Antimalarials were available in 25% of private sector outlets screened; this figure rises to 90% if the general retailer category is excluded.
Outlet types stocking antimalarials
Drug stores were overwhelmingly the most common type of outlet stocking antimalarials: an estimated 59% of all outlets with antimalarials in stock were drug stores. In total, 83% of outlets stocking antimalarials were in the private sector.
Availability of different classes of antimalarials
Among outlets stocking antimalarials, first-line quality assured ACT (FAACT) was more commonly available in the public/not for profit sector compared to the private sector (76% vs. 26%). Only 1 in 4 drug stores stocked FAACT, compared to 3 in 4 public/not for-profit outlets. Stocking rates of non-artemisinin monotherapies were above 90% for all outlet categories. Oral artemisinin monotherapy was observed more often in for-profit outlets (41%) than in public/not for-profit outlets (10%). Half of all drug stores with antimalarials in stock stocked oral artemisinin monotherapy.
Availability of diagnostic blood testing
Among outlets stocking antimalarials in the past three months, 81% of public/not for-profit outlets reported having diagnostic testing available, compared to 21% of outlets in the private for-profit sector. In the private sector testing was almost wholly restricted to for-profit health facilities: only 2% of drug stores provided any testing. In the public/not for-profit sector microscopy was twice as common as RDTs; 1 in 3 public/not for-profit outlets had RDTs in stock on the day of interview.
Price of antimalarials
The median price of FAACT in public health facilities was $0.61 [n=160], compared to $1.75 [n=253] in the private sector. 37% of FAACT distributed in the public/not for profit sector was done so free of cost, compared to 1% in the private sector (by volume for 7 days before interview, data not shown). The median price of the most popular antimalarial, SP, at private outlets was $0.36 [n=1,258], 5 times cheaper than private-sector FAACT. Oral artemisinin in private outlets regularly retailed for over $3.00 for an adult tablet course.
Volumes of antimalarials sold/distributed
The private sector in DRC dominated the antimalarial market, representing over 70% of antimalarials distributed in the 7 days before the survey. Drug stores alone accounted for almost 60% of the total volumes sold/distributed. Most antimalarials distributed in the public sector were SP or FAACT. 4 out of every 5 treatments distributed were non-artemisinin therapies, mainly SP (44%), amodiaquine (20%) and quinine (17%). In total FAACT comprised 8% of antimalarials distributed, a figure comparable with the volume of oral artemisinin monotherapy distributed (7%).
Overall, 48% of providers interviewed correctly stated ASAQ as the recommended first-line treatment for uncomplicated malaria in the DRC. By sector, knowledge was significantly higher in public/not for-profit outlets than private outlets (76% vs. 42%). Knowledge of adult and child dosing regimens for ASAQ followed the same trends as first-line knowledge: around 70% of public/not for-profit providers described the correct regimens, compared to 28% of private sector providers.
The ACTwatch Outlet Survey, one of the ACTwatch project components, involves quantitative research at the outlet level in ACTwatch countries (Benin, Cambodia, Democratic Republic of Congo, Madagascar, Nigeria, Uganda and Zambia). Other elements of ACTwatch include Household Surveys led by Population Services International (PSI) and Supply Chain Research led by the London School of Hygiene & Tropical Medicine (LSHTM). This report presents the results of a cross-sectional survey of outlets conducted in DRC from August to October 2009. The objective of the outlet survey 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. Price and availability data on diagnostic testing services is also collected. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials. A nationally representative sample of all outlets with the potential to sell or provide antimalarials to a consumer was taken through a census approach in 76 clusters across DRC; clusters being defined as Health Areas (aire de santé). Sampling was conducted using a stratified one-stage probability proportion to size (PPS) cluster design, with the measure of size being the relative cluster population. Oversampling of public health facilities, registered pharmacies and drug stores was conducted to ensure adequate representation of these outlet types in the survey. The inclusion criteria for this study were outlets that stocked an antimalarial at the time of survey or had stocked antimalarials 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 hospitals, health centres, dispensaries, village health units, and other government health facilities); 2) private not for-profit health facilities (mission and NGO health facilities); 3) private for-profit health facilities (private clinics and hospitals); 4) registered pharmacies; 5) unregistered, informal drug stores; 6) boutiques and kiosks; 6) market stalls; and 7) itinerant drug vendors (hawkers). Refer to the appendices for definitions and numbers of each type of outlet included in the analysis.
Three questionnaire modules were administered to participating outlets: 1) screening module, 2) audit module, and 3) provider module. For all outlets, trained interviewers administered the screening module 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 module 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, perceptions, and medicine storage conditions using the provider module. 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 were analysed using Stata 11 (Stata Corp, College Station, TX).