Madagascar outlet report 2008

Data were collected between 28th November 2008 and 8th January 2009. A total of 5,285 outlets were sampled. 22 providers refused to be interviewed; 26 outlets were closed down permanently; 213 outlets were not open at the time of the survey visit; in 19 outlets, providers were not available for interview at the time of survey visit; 39 providers were unable to be interviewed for other reasons. These outlets were excluded from the analysis. Overall, 4,966 providers agreed to participate in the ACTwatch outlet survey. Of these, 1,954 outlets stocked antimalarials at any point in the three months prior to the interview, and 1,851 outlets stocked antimalarials at the time of the interview.

Availability of antimalarials

The census of outlets found that 37.3% had antimalarials in stock. One‐quarter of these, or 9.6% of all outlets, stocked the recommended first‐line treatment for uncomplicated malaria, artesunateamodiaquine (ASAQ), 50mg/153mg. While a majority of public health facilities (85.6%) stocked the first‐line treatment, fewer than half of all other types of outlets did so. Non‐artemisinin therapies such as chloroquine and SP were much more commonly stocked overall than the first‐line treatment. Over 90% of outlets with antimalarials in stock, or 34.4%

of all outlets, had non‐artemisinin therapies in stock. Only at public health facilities and community agents was the first‐line treatment, ASAQ, more commonly available than non‐artemisinin therapies. Few community agents, groceries, and Other Outlets had antimalarials of any kind in stock; when groceries or Other Outlets did stock antimalarials, they were nearly always non‐artemisinin therapies.

Availability of diagnostic blood testing

Of outlets stocking antimalarials in the last three months, 18.5% reported offering diagnostic testing services of some kind. 3.0% of outlets had microscopic blood testing while 18.0% offered rapid diagnostic tests (RDTs). Diagnostic testing was available at 86.4% of public health facilities and at 46.2% of private health facilities, mostly through RDTs. Other than public or private health facilities, very few outlets (≤1.7%) offered diagnostic testing of any kind.

Price of antimalarials

Public health facilities, private health facilities, and community agents mostly distributed antimalarials free of cost. Overall, 92.5% of the first‐line treatment, ASAQ, was distributed free of cost (by volume of adult treatments). Among outlets that sold antimalarials for a price, the median price of the first‐line treatment was $4.04. In comparison, the median price of the most popular antimalarial, sulfadoxine‐pyrimethamine (SP), at outlets that sold antimalarials was $0.38, less than one‐tenth the price of ASAQ. WHO approved and nationally registered ACTs were over 25 times more expensive than SP. The first‐line treatment was also consistently more expensive than the international reference price of ASAQ 50mg/153mg. Less than a quarter of outlets (23.8%) offered credit to consumers for the purchase of antimalarials.

Volumes of antimalarials sold/distributed

Nearly 95% of all full adult treatments distributed were non‐artemisinin therapies. Nonartemisinin therapies used in Madagascar were mostly SP (50.9%) and chloroquine (46.6%).

Only 5.6% of all antimalarial distribution was ACTs, of which the first‐line treatment accounted for only 1%. The majority of ACTs (68.2%) were sold/distributed by Part One pharmacies. The first‐line ACT was mainly distributed by public health facilities.

In Madagascar, the private sector dominated the antimalarial market. 92% of antimalarials were sold/distributed through private outlets. Part One pharmacies distributed nearly 60% of all antimalarials. Groceries accounted for another 22.9% of the market.

Provider knowledge

Overall, 30.2% of providers were able to correctly state that ASAQ is the recommended first‐line treatment for uncomplicated malaria in Madagascar. Knowledge was highest among providers at health facilities; 89.2% of providers in public health facilities and 76.1% of private health facility providers were able to correctly identify the first‐line treatment. At Part One pharmacies and groceries – the outlets responsible for 80% of drug distribution – knowledge was lower. 59.1% of providers at Part One pharmacies could correctly state the first‐line treatment. At groceries, only 3.1% of providers knew the first‐line treatment was ASAQ. Among those providers who knew ASAQ is the recommended first‐line treatment for uncomplicated malaria, 62.3% were able to correctly state the dosing regimen of ASAQ for an adult; 79.6% were able to correctly state the dosing regimens for a two‐year old child. Providers consistently had better knowledge of child dosing regimens than those for adults. Knowledge of both treatment regimens was highest amongst providers at public health facilities. Even among providers in groceries that knew ASAQ is the first‐line treatment, knowledge about correct dosing regimens was low.

The outlet survey is one of the ACTwatch 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 and urbanisation.

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, urban and rural, in Madagascar. 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 and Part One pharmacies 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 hospitals and health centres); 2) Part One pharmacies (pharmacies licensed by the National Drug Authority and Pharmacists’ Council); 3) private health facilities (private clinics, private practices, NGO health centres and dispensaries); 4) grocery stores (épicerie [small groceries], épi bars [small groceries with bars] and épi gargotes [small groceries with food stalls]); 5) Community Agents (Agent de Santé à Base Communautaire and Agent de Vente à Base Communautaire); and 6) other outlets (gargotes [food stalls with sit‐down eating areas], bars, and other outlets) [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 SPSS 17.0 (SPSS Inc., Chicago, IL, USA).

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