Zambia outlet report 2011
Data were collected from 17th March to 22nd May 2011. A total of 6,701 outlets were approached. Of these, 1,265 outlets were not screened for various reasons: in 33 outlets, eligible respondents were not available; 373 outlets were not open at the time of the survey visit; 830 outlets were closed down permanently; in 19 outlets, providers refused; and in 10 outlets, providers were unable to be interviewed for ‘other’ reasons. Overall, 5,436 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 891 outlets met our screening criteria and were interviewed. Of the 861 completed interviews, 80 reported having stocked antimalarials at any point in the three months prior to the interview and 781 outlets stocked antimalarials at the time of the interview.
Availability of antimalarials
Stocking rates of any antimalarial varied by outlet type. In the public/not for-profit sector, 98.4% of outlets had at least one antimalarial in stock on the day of the interview, with 98.2% of public health facilities stocking antimalarials. In the private sector, 93.8% of the private for-profit health facilities, 96.3% of the pharmacies, and 85.8% of drug stores stocked antimalarials on the day of the interview. Stocking rates were very low among general retailers (3.1%)
Outlet types stocking antimalarials
Public health facilities were the most common type of outlet stocking antimalarials (45%), followed by general retailers (27%) and then drug stores (16%).
Availability of different classes of antimalarials
Among outlets stocking antimalarials on the day of interview there is a substantial difference between the availability of Quality Assured ACT (QA ACT) in the public/not for-profit sector and the private sector (93.0% and 20.1% respectively). In the private sector, 65.9% of pharmacies and 56.3% of private for-profit facilities stocked QA ACTs. Fewer than 20% of drug stores had a QA ACT in stock. Non-artemisinin therapies were universally available in the public/not-for-profit and private sector (>90% for all outlet types). Oral AMT was rarely available and only present in pharmacies and drug stores.
Availability of diagnostic testing
Among outlets stocking antimalarials in the past three months, 81.5% of the outlets in public/not for-profit sector had diagnostic testing available, compared to only 14.9% outlets in the private sector. There was variation in availability of microscopic tests versus RDTs by outlet type.
Median QA ACT price in the public/not-for-profit sector was $0.00 [n=772]. The median QA ACT price in the private sector was $5.36 [n=259]. QAACTs were most expensive in the private-for-profit health facilities $12.86 [n=34] and pharmacies $10.70 [n=137]. In comparing the median price of SP, the most popular antimalarial, first-line ACT (FAACT) was 10.9 times more expensive than SP in the private sector. QA ACTs were 1.4 times more expensive than FAACTs in the private sector.
Volumes of antimalarials sold/distributed
Over 80% of antimalarials sold/distributed in the 7 days before the survey were through the public/not for-profit sector, while the private sector in Zambia comprised 16% of antimalarial volumes. In the public/not-for-profit sector, QA ACTs comprised most of the antimalarial volume, followed by SP. Almost all antimalarials sold in the private sector were non-artemisinin therapies. Volumes of oral artemisinin monotherapies were rare (<0.01%).
Overall, 58.7% of providers interviewed were able to correctly state AL as the recommended first-line treatment for uncomplicated malaria (data not shown). Knowledge was higher in the public/not for-profit sector than the private sector (98.3% and 48.3% respectively). Knowledge was highest in public health facilities (98.5%), private health facilities (91.3%), and private not for-profit facilities (96.7%). Knowledge of adult dosing regimens for AL was generally higher than child dosing regimens, however exceptions were found for drug stores and general retailers.
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). 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 Zambia from the 17th March to 22nd May 2011. 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 that could sell or provide antimalarials to consumer was taken through a census approach in 38 wards across two strata (urban and rural areas) in Zambia. A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were wards, with an average of 10,000 to 15,000 inhabitants. Clusters were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular commune 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 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 are as follows: 1) public health facilities (1st, 2nd, and 3rd level hospital, hospital affiliated health centre, urban health centre, rural health centre, and health post); 2) not-for-profit health facilities (NGO/mission hospital); 3) pharmacies (pharmacies licensed by the Pharmaceutical Regulatory Authority); 4) drug stores; 5) private health facilities (private hospital, private clinic, and surgery); 6) general retailers (grocery store, super/mini markets/petrol stations, kiosk/tuck shop, kantemba/market stand, and container). Refer to the appendices for definitions and numbers of each type of outlet included in the analysis.
Four questionnaire modules were administered to participating outlets: 1) Screening questionnaire, 2) Antimalarial audit sheet, 3) Rapid diagnostic test (RDT) audit sheet and 4) Provider questionnaire. For all outlets, trained interviewers administered the screening questionnaire to collect information on 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, manufacturer, and generic names, strengths of the active ingredients, whether the outlet experienced stock-outs of the drug, whether the drug was expired, amount sold in the last week, and price sold to the consumers. In addition, interviewers collected information on the availability and price of microscopic tests and RDTs. An RDT audit sheet was administered where information on the brand name and manufacturer, amount sold in the last week, and price sold to consumers was obtained. Among outlets that stocked antimalarials at the time of the interview or the past three months, the interviewer collected information on provider’s demographics, knowledge, and perceptions. Interviewers also observed the storage conditions of medicines.
Several validation and data checking steps occurred during and after data collection. Double data entry was conducted using Microsoft Access (Microsoft Corporation, Seattle, WA, USA). Data were cleaned and analyzed using Stata version 11 (College Station, StataCorp LP., Texas, USA).