Uganda outlet report 2008
Data were collected between 20th September and 22nd October 2008. A total of 1,369 outlets were sampled. 32 providers refused to be interviewed; 49 outlets were not open at the time of the survey visits (up to three visits before exclusion); in 18 outlets an eligible respondent, a person that is the most knowledgeable about the stock, sales, and prices of antimalarials, and who also has primary contact with customers, could not be identified; and 35 outlets were unable to be interviewed for other reasons. These outlets were excluded from the analysis. Overall, 1,235 providers agreed to participate in the ACTwatch outlet survey. Of these, 658 outlets stocked antimalarials at some point in the three months prior to the interview, and 632 outlets stocked antimalarials at the time of the interview.
Availability of antimalarials
The census of outlets found that 51.2% had antimalarials in stock. 28.0% of outlets stocked the recommended first-line treatment for uncomplicated malaria, artemether-lumefantrine (AL), 20mg/120mg. The majority of public health facilities (82.8%) stocked the first-line treatment. Availability of antimalarials in “other” outlets was low (≤1%). With the exception of “other outlets”, the availability of non-artemisinin therapy was high in all outlet types (86.2%-94.6%).
Availability of diagnostic blood testing
Overall, 30.2% of outlets stocking antimalarials in the last three months had microscopic blood testing and 10.8% had rapid diagnostic tests (RDTs). Diagnostic testing was available mostly through microscopy at private health facilities (51.6%) and public health facilities (43.6%). In comparison, RDTs were available at 19.0% of private health facilities, 13.7% of public health facilities, and 10.7% of Part One pharmacies.
Price of antimalarials
In Uganda’s public health facilities, the first-line ACT, WHO approved ACTs and nationally registered ACTs, were mostly distributed for free, thus the median price is zero. Among outlets that sold ACTs for a price, the first-line treatment was 11.2 to 12.6 times more expensive than the most popular antimalarial, sulfadoxine-pyrimethamine (SP), and around 3 times more expensive than the international reference price for artemether-lumefantrine (AL). Over half of all outlets (60.1%) offered credit to consumers.
Volumes of antimalarials sold/distributed
The private sector is the dominant channel in Uganda accounting for 70.6% of all sales/ distribution of antimalarials. Yet, ACTs account for less than 1% of private sector distribution, while non-artemisinin therapies comprise 98.9%. Of the private sector, drug stores are the dominant component of the market. The first-line treatment ACT [AL] comprises just 14.1% of all antimalarial distribution through the public sector. Study-wide, AL comprises only 4.3% of all antimalarial distribution.
Overall, 79.7% of providers were able to correctly state the recommended first-line treatment for uncomplicated malaria in Uganda. Knowledge was highest among providers at public health facilities, with 92.5% able to state that AL was the recommended first-line treatment. Knowledge was lowest among providers at drug stores (60.4%), the outlet type responsible for largest antimalarial distribution by volume. Figure 5. Provider Knowledge of Recommended First-Line Treatment Knowledge of the correct dosing regimens (among those providers who knew that AL was the recommended first-line treatment for uncomplicated malaria) was high. Overall, 97.2% and 94.0% of providers were able to correctly state the dosing regimens of AL for an adult and for a two year old, respectively.
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, high/low endemicity and urbanisation. Methods: 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 strata, low and high malaria endemicity, in Uganda. Sampling was conducted using a one-stage probability proportional 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 (national, district, and regional government hospitals, health centres, and community health distributors); 2) Part One pharmacies (pharmacies licensed by the National Drug Authority); 3) private health facilities (private clinics, domiciliaries, NGO health centres, missionary health centres, and midwives); 4) drug stores and; 5) other outlets (grocery stores, dukas, general merchandise stores, and traditional healers) [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., Chigaco, IL, USA).