Uganda outlet report 2010
Data were collected between 15th November and 17th December 2010. A total of 11,369 outlets with the potential to stock antimalarials were approached by the study teams. Of these, 216 outlets were not screened for various reasons: 13 providers refused to be interviewed; 102 outlets were not open at the time of the survey visits; 36 outlets had closed down permanently; in 29 outlets an eligible respondent - the person that is most knowledgeable about the stock - was absent; and 36 outlets were unable to be interviewed for other reasons. Overall, 11,153 outlets agreed to participate in the outlet survey and were screened. Of these, 2,511 outlets met the screening criteria and an interview was conducted; a further 79 outlets met the screening criteria but could not be interviewed (1 outlet was not open at the time; 18 outlets refused the full interview; in 39 outlets the timing was not convenient; and 21 outlets were not interviewed for other reasons). Of the 2,511 completed or partially completed interviews, 91 reported having stocked antimalarials at any point in the three months prior to the interview although not at the time of interview, and 2,420 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 (CMDs, 5%) and general retailers (<1%) (Figure 1). General retailers included grocery stores, dukas, merchandise stores and kiosks. On the day of interview, antimalarials were available in 97% of public health facilities and 95% of private not-for-profit health facilities screened. Excluding CMDs, 96% of public/not-for-profit sector outlets reported antimalarials in stock on the day of interview. Due to the large number of general retailers in the census, antimalarials were available in only 14% of private sector outlets screened; this figure rises to 90% if the general retailer category is excluded.
Outlet types stocking animalarials
More than half of all outlets with antimalarials in stock were drug stores (59%); just over 1 in 5 antimalarial stockists were private for-profit health facilities. In total, 8% of outlets stocking antimalarials were in the private for-profit sector.
Availability of different antimalarial classes
Among outlets stocking antimalarials on the day of interview there continues to be a stark difference between the availability of first-line quality-assured ACT (FAACT) in the public and private for-profit sectors (70% and 10% respectively). Only 1 in 10 for-profit health facilities had FAACT in stock (11%), compared to 87% of public health facilities. Non artemisinin therapies were widely available in the for-profit sector (>85% for all outlet types). In contrast, oral artemisinin monotherapies were found in only 5% of pharmacies and <1% of drug stores.
Availability of diagnostic blood testing
Among outlets stocking antimalarials in the past three months, 32% of public/not-for-profit outlets reported having diagnostic testing available, compared to 14% of outlets in the private for-profit sector. Although few drug stores provided diagnostic tests, 47% of for-profit health facilities and 24% of pharmacies had tests available. When testing was available, microscopy was more common than RDTs in both sectors overall. RDTs were available in 1 in 5 pharmacies (22%).
Price of antimalarials
The median price of FAACT in public health facilities was $0.00 (IQR: 0.00, 0.00; n=2,287), compared to $2.65 in the private for-profit sector (IQR: 1.32, 3.53; n=448). 100% of FAACT distributed in the public/not-for-profit sector was done so free of cost (by volume for 7 days before interview, Table A.4). The median price of the most popular non-ACT by volume, Sulfadoxine-Pyrimethamine (SP), was $0.66 at private outlets (IQR: 0.44, 0.66; n=1,186).
Volumes of antimalarials sold/distributed
60% 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 40% of antimalarial volumes. 38% of total antimalarial volumes were from public/not-for-profit sector FAACT, and 14% from SP distributed in the public/not-for-profit sector. In the private sector, non-artemisinin therapies made up the largest proportion of the market share, followed by non-QA ACTs. Oral artemisinin monotherapies represented less than 0.01% of total market share.
Overall, 71% 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 private outlets (95% vs. 74%). Knowledge of the correct first-line treatment in drug stores – the source of 26% of antimalarials by volume (see above) – was 75%.
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 Uganda from November to December 2010. This report also serves to provide baseline data as part of the independent evaluation for Phase 1 Affordable Medicines Facility – malaria (AMFm).
Overview of the independent evaluation process
The independent evaluation is part of a multi-faceted monitoring and evaluation framework developed for AMFm. It is intended to assess whether, and to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent evaluation will be summarized in a report to be considered by the Global Fund Board at the end of Phase 1. The four main objectives of AMFm are: (i) to increase ACT affordability, (ii) to increase ACT availability, (iii) to increase ACT use, including among vulnerable groups, and (iv) to “crowd out” other oral antimalarials by gaining market share.
Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene and Tropical Medicine (LSHTM) to carry out the Independent Evaluation (IE) in all of the currently operational Phase 1 countries (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda, and Zanzibar). In addition, the Global Fund contracted ACTwatch to conduct the baseline survey in Uganda.
The IE is based on a non-experimental design with a pre- and post-test intervention assessment in which each participating country is treated independently as a case study. In addition to measuring the changes in key indicators pre- and post-intervention, the evaluation includes an assessment of the implementation process and a comprehensive documentation of the context both to inform assessments about causality and to aid in generalizability to other contexts.
The baseline/pre-intervention assessment relied on primary data collected from outlet surveys, in-depth interviews with key stakeholders involved in the drug supply chain in the country, and a review of documents. The data from outlet surveys and contextual information come from the country reports. In addition, the IE team compiled data (not included in this report) from national household surveys (DHS, MICS, MIS, and ACTwatch) to provide information on the use of antimalarials in the general population.
A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were sub-counties (and parishes in Kampala), with an average of 10,000 to 15,000 inhabitants. In Uganda, 39 clusters were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular sub-county is selected is proportional to its population size. Oversampling of public health facilities and registered pharmacies was conducted to ensure adequate representation of these outlet types in the survey. The sample size was powered to detect a change of 20% percentage points in availability of quality-assured ACTs between baseline and end line in rural and urban areas.
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 (government hospitals, health centres, health posts, 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, domiciliaries and midwives); 4) registered pharmacies; 5) unregistered, informal drug stores; 6) groceries, dukas and general merchandise stores; 6) kiosks; and 7) community medicine distributors (CMDs) (analogous to community health workers in other countries). Refer to the Appendix for definitions and numbers of each type of outlet included in the analysis.
Using a structured questionnaire, fieldworkers recorded the outlets’ basic details and then asked a screening question about the availability of antimalarials to decide whether to proceed with the full interview or not. The questionnaire was administered to a senior person at the outlet to collect data on outlet identification, outlet characteristics, provider knowledge, antimalarials and rapid diagnostic tests (RDTs) stocked and stock outs of quality-assured ACTs. They recorded information on “audit sheets” on all antimalarials and RDT products stocked in terms of their price and volume sold in the past week.
A generic data entry program was developed by the IE in CSpro and then adapted for Uganda by the IE team. To ensure a high level of data quality, after the standard verification with double entry, ACTwatch performed additional cleaning using a detailed guideline provided by the IE team.
For the analysis, the Independent Evaluators provided a tabulation plan for all tables presented in this report, and analysis do-files in STATA, which produced all the required indicators and automatically generated the tables. This analysis plan drew on the ACTwatch analysis approach, enabling comparability between ACTwatch and IE indicators presented in this report, and those ACTwatch indicators collected in prior survey rounds. ACTwatch adapted these analysis files to the country setting and ran the analysis using STATA version 11, recording results in a log file.
Implementation process and context information
One aim of the independent evaluation is to document the contextual factors that may influence the effectiveness of AMFm and the implementation process to be able to assess the degree to which the intervention (price reductions through negotiations with manufacturers, a subsidy in the form of a buyer co-payment, and supporting interventions) has been implemented. At the baseline, ACTwatch collected two sets of context data: the first on background information and the second on key events prior to or during data collection. This was done with the review of key documents and interviews with key stakeholders in the implementation of the program.