Responsibly improving access to ACTs in the private sector

Transcription

1 Responsibly improving access to ACTs in the private sector Concept and study findings October 1-2, 2007 Kampala, Uganda

2 Why are we here? To collectively define how to provide subsidized antimalarials by engaging the private sector To develop the roadmap for the MoH Uganda-MMV private sector intervention

3 ACT access gap exists in the Ugandan private sector Free ACTs available through public sector ACTs unavailable through the private sector Too expensive Prescription only status excludes informal sector Private sector key provider of treatment 60-80% of Ugandans seek fever / malaria treatment through private sector Serves as back-up source of ACTs in event of stock-outs in public sector

4 First step in February 2007: MOH-MMV consultative meeting to define engagement with private sector Active participation from all stakeholders Led by Ministry of Health National Malaria Control Programme Pharmacy department National Medical Stores National Drug Authority WHO MMV AFFORD, Malaria Consortium, MSH MU-IPH, PSI, Media and others

5 Unanimous support for an intervention To provide a highly subsidized ACT through the private sector Target all age groups (go beyond under 5s) Align National Drug Authority policies with proposed intervention Contain strong monitoring and evaluation component Address issues of sustainability in design Embed within existing systems Task Force Secretariat created to work out details (MoH, NDA, WHO, MMV, MSH)

6 Goals of the MoH-MMV intervention To reduce malaria related morbidity, disability and death To inform national policy / international community on scaling up provision of subsidized ACT through the private sector

7 Conduct intervention in two phases SUDAN Phase 1: Eastern Districts Intervention districts: Palisa, Budaka, Kamuli, Kaliro Control district: Soroti Phase 2: Western / Central Districts Intervention districts: Kamwenge, Kabarole Control district: Mubende DEMOCRATIC REPUBLIC CONGO Kase se Kabarol e Bushen yi Rukungir i Kanung Ntunga u mo Kabal Kisore o RWANDA Fort Portal Kamwen ge Ibanda Kyenjoj o Mbarara Kiruhura Isingir o Aru a Neb bi Hoim a Kibaal e Yumbe Sembab ule Mubend e Raka i = Intervention district Moyo Adjuma ni Masin di Kibog a Masak a Mpig i Nakase ke TANZANIA Gulu Apa c Kalanga la Kitgum Pader Lira Kmaid o Kotido Katakw i Morot o Nakapiripirit Soro ti Kum Buk i ede Nakasong Pallis a Sironk ola Kamuli a Mle o Kaliro Knga Butale Luwero Igang ja Toror Jinjaa Bugir o i Mayug Busi Mukon e a KAMPALA o KENYA Wakiso Budak a = Control district Kapchorw a

8 District selection criteria Different transmission settings (high and low/medium) No other major malaria pilot on-going District borders within Uganda Any drug leakage stays within Uganda Not over-studied areas Homogeneous populations with similar dialects who can understand each other 2 languages or less can be used for IEC purposes Predominantly rural populations underserved with health services, more stable, more cooperative constitute the majority of Ugandan population

9 Preparatory phase: Understand the reality in study districts June September 2007 The Antimalarial market (supply) Who sells antimalarials? What type of outlet? What type of antimalarials are sold? What price? Where do the drugs come from? Patients (demand) What drives choice of outlet and antimalarial? What is their experience with treatment? How can their access to treatment be improved?

10 Similar findings emerged from the supply and demand side studies Presentation focuses on selective findings: Health seeking behaviour Availability of antimalarials Prices Supply chain Drivers of choice Communities views on the intervention

11 Findings Caregivers well informed on signs of malaria. What do they do in event of fever?

12 Fever alone does not trigger treatment seeking Perception of treating only if other symptoms emerge % Kamuli (N=876) Pallisa (N=855) Soroti (N=885) Should only give antimalarial if they have other symptoms of malaria

13 Less than a third get treatment within the 24 hour window Proportion of children under 5 with fever in last 2 weeks who received any antimalarial % Kamuli (N=711) Pallisa (578) Soroti (545) 24 hrs from onset of fever 48 hrs from onset of fever

14 Most children continue to be treated with ineffective drugs Proportion of children under 5 with fever in last 2 weeks who received ACT 20 % Kamuli (N=711) Pallisa (N=578) Soroti (N=545) Within 24 hours Within 48 hours

15 What can we do? Need a series of interventions to ensure the right response i.e. Prompt health seeking Right drugs Complete course

16 Findings Where do people turn to for treatment?

17 Source of antimalarials varies significantly by study district (supply side perspective) Proportion of outlets per sector found Formal sector Informal sector Public CDD Pharmacy NGO Drug shop* Clinic Retail store** Market Kamuli 9% 0% 1% 7% 28% 10% 45% 0% Pallisa 30% 19% 0% 7% 29% 5% 8% 2% Soroti 18% 0% 1% 7% 51% 10% 12% 1% * licensed **unlicensed

18 Outlets well-dispersed across districts with clustering around trading centres Census of outlets done in shaded areas 18

19 Private sector is the most important source of antimalarials for caregivers Source of first treatment/advice at onset of fever % Kamuli (N=353) Pallisa (N=228) Soroti (N=395) Gov Hosp Health Centre Private hosp/clinic/pharmacy/drug shop CMD

20 What can we do? Ensure affordable ACTs available where caregivers seek treatment

21 Findings What is on the shelves? At what price? How does it get there?

22 CQ is the most stocked of the 164 antimalarials found On the market in the 6 districts # % Chloroquine 37 23% Quinine 30 18% Artemisinin monotherapy 31 19% SP 28 17% ACT 16 10% AQ 12 7% others 10 6% Total 164 Apac, Kabarole, Kampala, Kamuli/Kaliro, Pallisa/Budake, Soroti

23 CQ is by far the cheapest antimalarial Across all sectors and districts Cost/course (Ush) Chloroquine tablets Amodiaquine tablets Chloroquine injection 3,200 4,200 Quinine tablets 3,200 4,200 SP Quinine injection ACT 10,000 15,000 Artemisinin monotherapy oral 5,500 35,000 Artemisinin monotherapy injection 9,000 23,000 Prices vary by brand rather than between outlets except clinics

24 Patient price can be 2-4 times the manufacturers price Taxes and margins Imported Insurance and freight 10-17% NDA 2% Clearance & finance/banking charges 2% Importer (higher for single source products) 20-70% Wholesaler 2-30% Retailer typically Pharmacy 125% Drug Shop 85% Clinic 250% TOTAL Pharmacy % Drug Shop % Clinic %

25 The supply chain in Kampala is relatively simple

26 But increases in complexity outside the capital International Manufacturer Local Manufacturer Importer/LTA NMS JMS Wholesaler Wholesaler Kampala District Wholesaler Neighboring District Public Mission Pharmacy Drug Store Clinic Store Market Licensed Unlicensed

27 What can we do? Introduce a maximum recommended retail price for the subsidized ACT to be affordable (limit profiteering) Provide incentives to the trade to ensure stocking Identify the most efficient distribution chain to ensure: the subsidized ACT reaches most outlets in the intervention areas does not leak to adjacent areas

28 Findings What guides choice of antimalarials?

29 A combination of factors Price Even for the low price medicines, only half customers purchase a full course of anti-malarials Many outlets provide credit or recommend a cheaper alternative Provider recommendation Steps when selling medicine? People come and ask me if I have chloroquine, they give me money and I give them tablets equivalent to their money (Retailer) Perception of effectiveness I mostly dispense chloroquine because it is the one which basically works for them (private nurse) We dispense chloroquine and Fansidar tablets quite often because it is what they want and it cures them (shopkeeper)

30 What can we do? Create awareness among providers and caregivers of the value of ACTs and subsidized price

31 Findings What do communities think about getting a subsidized ACT through the private sector?

32 Communities welcome the concept of getting a subsidized ACT through the private sector if prices are low people will be willing to buy these new medicines for malaria (community member) It will enable people to get treatment within 24 hours. Those who don t want to come to health units can now get drugs elsewhere (government nurse) I like it because the medicines will be near and easy to access. Transport costs for those who may be coming from far will also be reduced (retailer)

33 The Intervention An overview of the concept Incorporating comments from the deep dive workshop (September 26-27, 2007)

34 Specific objectives of the intervention Supply side Availability of the subsidized ACT in most outlets Improved management of malaria in the private sector Dispensing the right drug, in right dosage, at the right price (subsidized) with adequate information to ensure correct use Demand side Prompt and appropriate health seeking behaviour Good compliance with treatment schedules

35 Key activities: Establishing the right policy framework Allow the pilot to move forward Provide limited deregulation of the subsidized ACT (OTC status) Use existing regulated outlets Define additional outlets authorized to stock subsidized ACT Facilitate regularization of unlicensed outlets address issues of QA (storage and temperature control, etc.) Grant approval for repackaged ACT CMDs remain in public sector with close monitoring

36 Key activities: Ensuring sound supply chain management Keep it simple: Start with few prequalified FDCs* and add new FDCs as they become prequalified Ensure adequate stocks through existing supply chain Initially some direct supply Subsequently tender for launch of few distributors to supply pilot areas *Fixed dose combination

37 Key activities: Ensuring sound supply chain management Provide incentives to trade to ensure stocking at a large number of outlets within easy reach of communities Introduce maximum recommended retail price to avoid profiteering

38 Key activities: Launching a strong marketing campaign Repackage the subsidized ACT to create an umbrella brand strong government ownership of umbrella brand allows inclusion of more ACTs under the same brand in line with changes to national policy facilitates customer choice ensures stocking by the trade improves compliance with clear user instructions Manufacturers remain responsible for pharmacovigilance and PMS with NDA

39 What is an umbrella brand?

40 Key activities: Launching a strong marketing campaign (contd.) Promote options for treatment in public and private sectors Design effective communications to generate demand and change behaviour Private sector (to stock subsidized ACT and dispense correctly) Care givers (to seek timely treatment and provide ACTs correctly)

41 Key activities: Provider Training Ensure improved management of malaria in the private sector Correct dispensing of ACTs Recognize warning signs to ensure prompt referral Establish links between the public and private sector providers Test out different models of training

42 Key activities: Monitoring and evaluation Geographical access Is the subsidized product on the shelves? At what types of outlets? How far from communities? Is private sector distribution of ACTs synergistic to home based management of fever? Trade stocking /dispensing patterns Has the subsidized product displaced currently used antimalarials? Are ACTs being correctly dispensed? Use Are ACTs being correctly taken?

43 Key activities: Monitoring and evaluation Safety How safe is the wider distribution Financial access What price are consumers paying? Equity Is it being purchased by the poor? Health impact Has the proportion of children receiving prompt treatment with ACTs increased? Has school absenteeism fallen? Has the occurrence of severe malaria decreased?

44 Where do we go to from here? MoH-MMV Taskforce secretariat will oversee: Development of a roadmap and workplan based on input from the workshops Establishment of transparent processes for implementation Start work Workplan to be approved by Case Management Committee, ICCM and HIPAC