Myanmar outlet report 2012
Data collection ran from 1st March 2012 to 30th May 2012. A total of 3,746 outlets were approached for inclusion in the study. 88 outlets were not screened for various reasons, including temporarily closure of outlet and no appropriate person available for interview, and the remaining 3,658 outlets were screened. Among the 3,658 outlets, 1,359 were found stocking any antimalarials on the day of interview (1256) or had stocked in the past 3-months (103). However, 85 outlets were not interviewed for reasons such as no appropriate person available for interview or inconvenient time for the full interview (53), not open at the time of return visits (10), and refused to participate (22). A total of 1,274 outlets completed interviews: 92 outlets reported having stocked antimalarials at any point in the three months period prior to the interview and 1,182 outlet reported stocking antimalarials at the time of the interview.
AVAILABILITY OF ANY ANTIMALARIAL:
On the day of interview 32% of outlets screened reporting having at least one antimalarial in stock, including 82% of private health facilities, 79% of pharmacies, 55% of itinerant drug vendors, 15% of general retailers and 73% of health workers. Availability was relatively low among general retailers (village stores, grocery stores) though they are the most numerous outlet types in the census.
OUTLET TYPES STOCKING ANTIMALARIALS:
On the day of interview 1256 outlets were found to stock at least one antimalarial. General retailers topped the list, followed by health workers.
AVAILABILITY OF DIFFERENT CLASSES OF ANTIMALARIALS:
Among outlets stocking antimalarials on the day of interview patterns of antimalarial availability differed by type of outlet. In two categories of outlets - private health facility and health worker - availability of any ACT was relatively high. These two outlet types usually charge the consumer a consultation fee in addition to the drug cost. Pharmacies and general retailers rarely stocked ACT but very high proportion of pharmacies (85%) and general retailers (80%) stocked oral artemisinin monotherapy. Health workers reported the highest stock of first-line quality assured ACT (FAACT) (76%). Among itinerant drug vendors non-artemisinin therapy was the most commonly stocked class of antimalarials (83%), while fewer than 1 in 10 stocked any ACT.
AVAILABILITY OF DIAGNOSTIC BLOOD TESTING:
Among outlets stocking antimalarials in the past three months, availability of diagnostic blood testing facilities was low except among health workers (70%) and private health facilities (54%). Microscopic testing was rare; only 4% of private health facilities reported have microscopic testing available.
PRICE OF ANTIMALARIALS:
At the time of data collection health workers [n=219] reported providing QA ACT and chloroquine free of charge. The median price of one course of adult equivalent treatment dose of QA ACT in private health facilities was [n=115] 1,000 Kyats and 2,500 Kyats in general retailers. Very few pharmacies and itinerant drug vendors stocked ACT and median price was not available from them.
VOLUMES OF ANTIMALARIALS SOLD/ DISTRIBUTED:
Overall, private sector market share was dominated by oral artemisinin monotherapy (33%) and non-artemisinin therapies (38%). The private sector market share for ACT was 23%. Oral artemisinin monotherapy market share ranged from 17% (health worker) to 48% (pharmacy) and was present in all outlet types. In contrast, quality assured ACTs only comprised substantial fractions of the market share in private health facilities and among health workers.
DISTRIBUTION OF MARKET SHARE OF ORAL ARTEMISININ MONOTHERAPY, BY BRAND:
Artesunate and Artemether had roughly 60% and 40% market share. AA Artesunate (24%) and AA Artemether (10%) distributed by AA Medical Products Co. Ltd together captured 34% of the share of oral artemisinin monotherapy market.
Overall, 22% of providers interviewed were able to correctly state AL as the recommended first-line treatment for uncomplicated malaria in Myanmar. Providers in private facilities and health workers reported significantly higher knowledge than the retailers in pharmacies or itinerant drug vendors or general stores.
The practice of cutting the strip and selling partial pack or individual tablets is more common at pharmacies and general stores. Over 90% of the private health facilities and 80% of health workers reported that they did not cut out blisters or sell partial doses.
Financing for malaria control has increased substantially over the last decade, facilitating significant progress towards international targets for prevention and treatment. Increased coverage of at-risk populations with vector control as well as effective case management with artemisinin combination therapy (ACT) is contributing to substantial reductions in malaria cases and deaths. The spread of artemisinin resistance in P. falciparum malaria parasites would threaten recent malaria control progress across endemic countries.
Factors believed to be contributing to emerging drug resistance include the unregulated sale of artemisinin monotherapies; limited access to ACTs; co-blistered ACTs that are not co-formulated (facilitating continued use of artemisinin monotherapy); and ubiquitous counterfeit and substandard drugs. Serious efforts to contain drug resistance are currently underway along the Cambodia-Thai border.
The MARC is a comprehensive set of interventions, including prevention programs, increased testing and treatment through public and non-governmental providers, and replacement of artemisinin monotherapy in the private sector with ACT. PSI has received funding from UK Department for International Development (DFID), the Bill and Melinda Gates Foundation (BMGF) and Good Ventures, for Artemisinin Monotherapy Replacement Malaria Project (AMTR) for 3 years, to contribute to the goal of the Myanmar Artemisinin Resistant Containment program (MARC). Within the MARC framework, PSI will work with private sector suppliers and providers throughout Myanmar to rapidly replace widely available artemisinin monotherapy with highly subsidized, quality assured ACTs. Broad reaching behavior change communications (BCC) targeting both consumers and providers will support supply chain activities and together will halt the spread of artemisinin resistance in the region.
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.
To conduct this outlet study PSI/Myanmar adapted the ACTwatch Outlet Survey, one of the components of the ACTwatch project. This report presents the results of a cross-sectional survey of outlets conducted in Myanmar from March to May 2012.
A nationally representative sample of all private outlets with the potential to sell or provide antimalarials to a consumer was taken through a census approach in 61 wards in the urban domain and 65 village tracts in the rural domain, giving a total of 122 wards and 130 village tracts across Myanmar including both the project intervention and control areas. The cluster was defined as wards in urban and village tract in rural areas. Sampling was conducted using a two-stage probability proportion to size (PPS) cluster design, with the measure of size being the relative cluster population.
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) private health facilities, private clinics (may or may not be affiliated with a franchise network) and hospitals; 2) registered pharmacies; 3) itinerant drug vendors (hawkers); 4) general retailers (village stores, groceries, and general stores); and 5) community health workers providing treatment outside of the public health facilities. Please 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) a screening module, 2) an audit module (antimalarial audit sheets and RDT audit sheets), and 3) a provider module. For all outlets, trained interviewers administered the screening module to collect information on the outlet type and location, 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 a CSPro database system designed with in-built checks for consistency and range values. Verification of the first and second entries was done and corrections on mismatched records done until a final verified data was achieved.
Data analysis was conducted in Stata 11.0 (Stata Corp College Station, TX) and included descriptive summaries and comparisons between urban and rural, and intervention and controls areas.