Uganda outlet report 2011
Data were collected between November 8th 2011 and December 12th 2011. A total of 16,521 outlets were approached. Of these, 314 outlets were not screened for various reasons: 51 providers refused to be interviewed; 47 outlets were closed down permanently; 120 outlets were not open at the time of the survey visit; in 63 outlets, providers were not available for interview at the time of the survey visit; 24 providers were unable to be interviewed for other reasons. Overall, 16,207 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 3,285 outlets met our screening criteria; however, interviews could not be conducted for 58 outlets. Of the 3,227 interviews conducted, 89 reported having stocked antimalarials at any point in the three months prior to the interview and 3,138 outlets stocked antimalarials at the time of the interview.
Availability of any antimalarial
Stocking rates of any antimalarial varied by outlet type. In the public/not-for-profit sector, 99% of public health facilities and 94% of private not for-profit facilities had at least one antimalarial in stock on the day of interview. Of CHWs, who according to government policy may treat using antimalarials, 11% stocked an antimalarial. There was variation in the private for-profit sector. Over 90% of private for-profit facilities, pharmacies and drug stores stocked antimalarials. This is in contrast to 0.4% of the 11,931 general retailers that were surveyed.
Outlet types stocking antimalarials
Drug stores were the most common type of outlet stocking antimalarials, followed by private for-profit health facilities, community health workers, and public health facilities.
Availability of different classes of antimalarials
Among facilities that stocked antimalarials on the day of the survey, overall quality-assured ACT (QA ACT) availability in 2011 was 67%. In public health facilities that stocked antimalarials, QA ACT availability was 92%. QA ACT availability was also high among private not-for-profit outlets (80%) but lower among community health workers (CHWs) (55%). In the private for-profit sector, availability was 63%. However, there was considerable variation within the private for-profit sector. QA ACT availability was higher in pharmacies (96%) than in private for-profit facilities (77%), general retailers (74%) or drug stores (60%). Availability of QA ACTs with the AMFm logo was much higher than that of QA ACTs without the logo overall (58% vs. 16%), in both public health facilties (83% vs. 42%) and in the private for-profit sector (61% vs. 8%). Availability of QA ACTs with the logo was higher in outlets in urban versus in rural areas (70% vs. 55%). Availability of non-quality-assured ACTs was 28% (data not shown). Non-quality-assured ACTs were more commonly found in urban than in rural outlets in both 2010 and 2011. Availability of oral artemisinin monotherapy (AMT) was negligible in both surveys.
Availability of diagnostic blood testing
Of outlets stocking antimalarials in the last three months, 96% of private not for-profit facilities, 75% of public health facilities and 70% of CHWs reported offering any testing services. There was variation in the private sector: 55% of private for-profit facilities, 31% of pharmacies and 7% of drugs stores stocked tests, while no general retailers had tests available.
Price of antimalarials
In the public and private not-for-profit sectors and for CHWs, the median price of QA ACTs was US Dollar (USD) 0.00, reflecting the policy of free ACT provision. In the private for-profit sector, the median QAACT price was USD 1.96 in urban and rural areas, and USD 1.96 overall. The median price for QA ACTs was much higher than the recommended retail price (RRP), which was USD 0.47. The median price in private for-profit outlets for a QA ACT carrying the AMFm logo was USD 1.96 per AETD. This is 3.3 times the median price of the most popular antimalarial thatis not a QA ACT, SP, in tablet form (USD 0.59). There was no difference in the private for-profit sector between the median price of QA ACTs with and without the AMFm logo overall, although in urban areas the price of QA ACTs without the AMFm logo was USD 2.74.
Volumes of antimalarials sold/distributed:
Overall market share of QA ACTs was 57% in 2011, with non-artemisinin therapies (nAT) accounting for 31% of the overall market share. In private not-for-profit outlets, the QA ACT market share was 51%. In the private for-profit sector, the QAACT market share was 39%. In public health facilities, QA ACT market share was 81%, with nATs accounting for 18% of market share in public health facilities. QA ACTs with the AMFm logo accounted for 76% of all QA ACTs sold or distributed across all outlets, and 88% of QA ACT volumes in private for-profit outlets. The private for-profit sector was responsible for 53% of all antimalarials sold or distributed in 2011.
Overall, 78% of providers were able to correctly state artemether-lumefantrine (AL) as the recommended first-line treatment for uncomplicated malaria in Uganda. Knowledge was higher among providers at public/not-for-profit outlets, compared to the private for-profit sector (94% vs. 75% respectively). Knowledge was lowest among general retailers (25%). There were few differences in providers’ ability to state the recommended first-line treatment for children or adults.
The ACTwatch Outlet Survey involves quantitative research at the outlet level in ACTwatch countries (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo [DRC]). Other elements of ACTwatch research 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 between November 8th 2011 and December 12th 2011 and also serves as the endline for the Affordable Medicines Facility – malaria (AMFm) Phase I Independent Evaluation.
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 are also collected. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials.
Overview of the independent evaluation process
The independent evaluation (IE) is part of a multi-faceted monitoring and evaluation framework developed for Phase 1 of the Affordable Medicines Facility – malaria (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 Artemisinin-based Combination Therapy (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 conduct the IE. The IE was carried out in all of the currently operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and Zanzibar), and Uganda). In addition, the Global Fund contracted with Data Contributors (DCs) that were responsible for in-country fieldwork, data analysis and country reports. These institutions are Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de Recherche pour le Développement Humain (CRDH).
The ACTwatch Project, which is part of PSI, was responsible for the work in Kenya, Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health Institute) and Zanzibar, through funding from both the Bill and Melinda Gates Foundation and the Global Fund. This work was carried out as part of their existing portfolio and funding stream provided by the Bill and Melinda Gates Foundation for work in Nigeria, Madagascar, and Uganda. DNDi subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, to undertake the work in Ghana. CRDH subcontracted with the Centre International d'Etudes et de Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.
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 current report is based on the endline assessment in Uganda, conducted by PSI/ACTwatch. The results of the baseline survey can be found in the Uganda 2010 outlet survey report (ACTwatch, 2010) and for all pilots in the Multi-Country Baseline Report (Independent Evaluation Team, 2011). Analysis of changes between baseline and endline outlet surveys will be presented in the Multi-Country Endline Report (Independent Evaluation Team, 2012), together with the data that the IE team has compiled from national household surveys. In addition, country case studies on context/process were conducted by the IE, and these case studies are summarized in the present report.
Endline outlet survey methods
A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were sub-counties/parishes, with an average of 10,000 to 15,000 inhabitants. In Uganda, 44 clusters (urban [18 clusters] and rural [26 clusters]), were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular sub-district (sub-county/parish in Uganda) is selected is proportional to its population size. The sample size was powered to detect a change of 20% percentage points in availability of quality-assured ACTs between baseline and endline 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; 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 (CHWs) in other countries). Refer to the Appendix 8.5 for definitions and numbers of each type of outlet included in the analysis.
A structured endline questionnaire was developed, which included questions to measure indicators for the Independent Evaluation. 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. Data quality control tools used in the field were based on those implemented by ACTwatch for the baseline survey. A paper questionnaire was used to collect data.
To ensure a high level of data quality, standardized guidelines were used to clean the data. For the analysis, the ACTwatch team used a standardized tabulation plan for all ACTwatch tables presented in this report and analysis “do files” in STATA, which produced all the required ACTwatch indicators. In addition, the IE team provided a tabulation plan for all IE tables presented in this report, and analysis “dofiles” in STATA, which produced all the required indicators and automatically generated the IE tables. All analysis was run using STATA version 11, recording results in a log file.