Uganda outlet report 2009
Data were collected between 16th March and 7th April 2009. A total of 5,432 outlets with the potential to stock antimalarials were approached by the study teams. Of these, 165 outlets were not screened for various reasons: 64 providers refused to be interviewed; 48 outlets were not open at the time of the survey visits; in 34 outlets an eligible respondent - the person that is most knowledgeable about the stock - was absent; and 19 outlets were unable to be interviewed for other reasons. Overall, 5,267 outlets agreed to participate in the outlet survey and were screened. Of these, 1,278 outlets met the screening criteria and were interviewed. Of the 1,277 completed interviews, 52 reported having stocked antimalarials at any point in the three months prior to the interview and 1,225 outlets stocked antimalarials at the time of the interview.
Availability of any antimalarial
Antimalarials were available in over 85% of screened outlets, with the exception of community medicine distributors (40%) and general retailers (<1%) (Figure 1). General retailers include grocery stores, dukas, merchandise stores and kiosks. On the day of interview, any antimalarial was available in over 95% of public health facilities and 89% of private not for-profit health facilities screened. Due to the large number of general retailers in the census, antimalarials were available in only 14% of the private sector; this figure rises to 96% if the general retailer category is excluded.
Outlet types stocking antimalarials
Half of all outlets with antimalarials in stock were drug stores, followed by private for-profit health facilities (23%). In total, 77% of outlets stocking antimalarials were in the private sector.
Availability of different antimalarial classes
Among outlets stocking antimalarials on the day of interview there is a large difference between the availability of first-line quality assured ACT (FAACT) in the public/not for profit sector and the private sector (73% and 8% respectively). Fewer than 1 in 10 for-profit health facilities had FAACT in stock, compared to over 75% of public health facilities. Non artemisinin monotherapies were universally available in the private sector (>98% for all outlet types). Alarmingly, 90% of pharmacies and 24% for-profit health facilities stocked oral artemisinin monotherapies; this class of drug was found in <1% of public health facilities.
Availability of diagnostic blood testing
Among outlets stocking antimalarials in the past three months, 33% of public/not for-profit outlets reported having diagnostic testing available, compared to 18% of outlets in the private for-profit sector. Levels of availability were similar in public and private for-profit health facilities (45% and 48%), but low in other private sector outlets (pharmacies 11%, drug stores 5%). When testing was available, microscopy was generally more common than rapid diagnostic tests (RDTs).
Price of antimalarials
The median price of FAACT in public health facilities was $0.00 [n=681], compared to $4.36 [n=81] in the private sector. 100% of FAACT distributed in the public/not for-profit sector was done so free of cost, compared to 18% in the private sector (by volume for 7 days before interview, Table A.4). The median price of the most popular antimalarial by volume, SP, was $0.48 in the private sector. Oral artemisinin monotherapy in the private sector ranged from $7.00-$9.00 according to outlet type.
Volumes of antimalarials sold/distributed
43% of antimalarials sold/distributed in the 7 days before the survey were through the public/not for-profit sector, while the private sector in Uganda comprised 57% of antimalarial volumes. 22% of total volumes were from SP distributed in the public/not for-profit sector. Across Uganda, public/not for profit FAACT comprised 17% of the total volumes. Almost all antimalarials sold in the private sector were non-artemisinin monotherapies (53% of total volumes; 93% of private sector volumes). In total, 0.7% of recent antimalarial sales were of oral artemisinin monotherapies, the majority (0.6% of the total) moving through the private sector.
Overall, 68% of providers interviewed correctly stated AL as the recommended first-line treatment for uncomplicated malaria in Uganda. By sector, knowledge was significantly higher in public/not for profit outlets than the private sector (93% vs. 60%). Knowledge of the correct first-line treatment in drug stores – the source of 34% of antimalarials by volume (see above) – was only 58%.
The ACTwatch Outlet Survey, one of the ACTwatch project components, involves quantitative research at the outlet level in ACTwatch countries (Benin, Cambodia, the Democratic Republic of Congo [DRC], 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 Uganda from the 16th of March to the 7th of April 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. 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 38 clusters across Uganda; clusters being defined as sub-counties. 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 and registered pharmacies 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 were: 1) public health facilities (national/regional referral hospitals, district hospitals, health centres [county, sub-county and parish level]); 2) private not for-profit health facilities (mission and Non-Governmental Organisation [NGO] health facilities); 3) private for-profit health facilities (private clinics, domiciliaries and midwives); 4) pharmacies; 5) drug stores; 6) general retailers (groceries, dukas and general merchandise store and kiosks; and 7) community medicine distributors (analogous to community health workers in other countries). 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, and 3) a provider module. For all outlets, trained interviewers administered the screening module to collect information on the outlet type andlocation, 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).