Zambia outlet report 2008
Data were collected between 18th October 2008 and 8th January 2009. A total of 2,460 outlets were sampled (by strata: urban, N=1,917; rural, N=543). 11 providers refused to be interviewed; 68 outlets were permanently closed; 82 outlets were not open at the time of the survey visit; in 11 outlets, providers were not available for interview at the time of data collection. These outlets were excluded from the analysis. Overall, 2,288 providers agreed to participate in the ACTwatch outlet survey. Of these, 425 outlets stocked antimalarials at any point in the three months prior to the interview, and 390 outlets stocked antimalarials at the time of the interview.
Availability of antimalarials
The census of outlets found that 17.0% had antimalarials in stock. 8.1% of outlets stocked the recommended first-line treatment for uncomplicated malaria, artemether-lumefantrine (AL), 20mg/120mg. While the majority of public health facilities and Part One pharmacies stocked the first-line treatment (83.0% and 79.6% respectively), availability in private health facilities was lower (56.8%). Although 87.5% of drug stores stocked AMs, only 6.2% carried the first-line treatment; they were much more likely to stock non-artemisinin therapies (86.2%). Overall, non-artemisinin therapies such as chloroquine and SP were more commonly stocked than was the first-line treatment. Few groceries and Other Outlets had antimalarials of any kind in stock; when they did stock antimalarials, they were nearly always non-artemisinin therapies.
Availability of diagnostic blood testing
Of outlets stocking antimalarials in the last three months, 42.9% offered diagnostic testing services of some kind. 26.5% of outlets had microscopic blood testing while 38.2% offered rapid diagnostic tests (RDTs). Diagnostic testing was available at 91.0% of public health facilities, mostly through RDTs, and at 85.7% of private health facilities, mostly through microscopy. 31.8% of Part One pharmacies offered some diagnostic testing service. Availability of diagnostic tests in drug stores, groceries and Other Outlets was very low (<1%).
Price of antimalarials
In Zambia, public health facilities distributed antimalarials free of cost. Overall, 48.3% of the first-line treatment, AL, was distributed free of cost (by volume of adult treatments). Among outlets that sold antimalarials for a price, the median price of the first-line treatment was $7.51. In comparison, the median price of the most popular antimalarial, sulfadoxine-pyrimethamine (SP) was $0.43, less than one-seventeenth the price of AL. WHO approved ACTs were 18 times more expensive than SP. When sold for a price, the first-line treatment was also consistently more expensive than the international reference price of AL 20mg/120mg. Less than a quarter of all outlets (21.9%) offered credit to consumers for the purchase of antimalarials.
Volumes of antimalarials sold/distributed
The most frequently sold or distributed class of antimalarials was non-artemisinin therapies (79.0%). 20% of all antimalarial distribution was ACTs, of which the first-line treatment accounted for 15.5%. 45.9% of the first-line treatment was distributed by public health facilities, and 34.8% was distributed by Part One pharmacies. Oral artemisinin monotherapies accounted for 1% of all antimalarial sold/distributed. In Zambia, the antimalarial market was almost equally split between the public and private sectors. Part One pharmacies, drug stores, and private health facilities account for over 88% of private sector distribution.
Overall, 68.9% of providers were able to correctly state that AL is the recommended first-line treatment for uncomplicated malaria in Zambia. Knowledge in public health facilities – the outlets responsible for 49% of AM distribution – was relatively high, with more than 88% of providers able to correctly identify the first-line treatment. Of the key outlet types for AM distribution, knowledge was significantly lower among providers in drug stores, compared with public and private health facilities, and Part One pharmacies. Among those providers who knew AL was the recommended first-line treatment for uncomplicated malaria, 89.8% were able to correctly state the dosing regimen of AL for an adult; 84.9% were able to correctly state the dosing regimen for a two-year old child. Providers in public health facilities, Part One pharmacies, and private health facilities had similarly high levels of knowledge of AL dosing regimens. Knowledge among drug store providers was significantly lower than that of providers in public health facilities and Part One pharmacies.
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 and urbanisation.
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/wards across two strata, urban and rural areas, in Zambia. Sampling was conducted using a one-stage probability proportional to size (PPS) cluster design, with the measure of size being the relative sub-district/ward population. 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 (government health facilities, hospitals, health posts); 2) Part One pharmacies (pharmacies licensed by the Pharmaceutical Regulatory Authority); 3) drug stores; 4) private health facilities (private hospitals, clinics, and surgeries); 5) grocery stores; and 6) other outlets (kiosks, containers, kantembas, and super/mini markets and petrol stations). Oversampling of public health facilities and Part One pharmacies was conducted in districts surrounding the selected sub-districts/wards.
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).