Madagascar outlet report 2010

Data were collected between 27th April and 21st June 2010. A total of 7,221 outlets were approached. Of these, 452 outlets were not screened for various reasons: 38 providers refused to be interviewed; 103 outlets were closed down permanently; 251 outlets were not open at the time of the survey visit; in 14outlets, providers were not available for interview at the time of survey visit; 46 providers were unable to be interviewed for other reasons. Overall, 6,769 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 2,642 outlets met our screening criteria; however, interviews could not be conducted for 26 outlets. Of the 2,616 interviews conducted, 202 reported having stocked antimalarials at any point in the three months prior to the interview and 2,414 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, 97% of public health facilities had at least one antimalarial in stock on the day of interview, whereas the figure was 81% in private not for‐profit facilities. Of community health workers, who according to government policy may treat using antimalarials, 27% stocked an antimalarial. There was substantial variation in the private sector. More than 88% of private for‐profit facilities, and almost 100% of pharmacies and 97% of drugs stores, stocked antimalarials. This is in contrast to 31% of general retailers.

Outlet types stocking antimalarials

General retailers were the most common type of outlet stocking antimalarials, followed by community health workers (10%), public health facilities and then drug stores (dépôt de médicament).

Availability of different classes of antimalarials

First‐line quality assured ACTs (FAACTs) were far more readily available in the public/not for‐profit sector compared to the private sector (92% compared to 8%). Availability of FAACTs was less than 60% in all private sector categories, and very low for general retailers (<3%). The private sector had the highest stocking rates of nonartemisinin therapies (mainly chloroquine [CQ]). Non‐artemisinin therapies available in the public sector were typically Sulfadoxine‐Pyrimethamine (SP) and quinine (data not shown). Artemisinin monotherapies were only observed in private for‐profit facilities, and were very rare.

Availability of diagnostic blood testing

Of outlets stocking antimalarials in the last three months, 88% of public health facilities reported offering any rapid diagnostic testing (RDT) services. While one in three private not for‐profit facilities offered RDTs, availability of RDT services was less than 15% across all outlet types in the private sector. Few (<5%) facilities outside the public sector provide microscopic testing.

Price of antimalarials

Most public health facilities and private not-for profit health facilities distributed antimalarials free of cost (93.3% and 100% respectively [data not shown]). In the private sector, the median price of FAACTs was $0.14 (IQR, $0.09‐$0.56) due to the presence of a socially marketed  ACT in the market. Much higher AETD prices were observed in pharmacies ($7.68, IQR $0.19‐$32.48). The median price of the most popular antimalarial, (CQ), at private outlets was $0.35 (IQR, $0.28‐$0.35).

Volumes of antimalarials sold/distributed

The private sector dominated the antimalarial market, representing 82% of antimalarials distributed. Drug stores (dépôt de médicament) and general retailers accounted for 70% of the total volumes sold/distributed, while the public/not for-profit sector accounted for less than 20% of the total. Most antimalarials distributed in the public sector were ACTs or SP.Over 85% of all treatments distributed were non‐artemisinin therapies, mainly CQ (57%) and SP (27%). FAACTs comprised only 12% of all antimalarials distributed.

Provider knowledge

Overall, 23% of providers were able to correctly state ASAQ as the recommended first‐line treatment for uncomplicated malaria in Madagascar. Knowledge was higher among providers at public/not for‐profit outlets, compared to the private sector (72% vs. 12% respectively). Providers were more likely to be able to correctly state the dosing regimen of ASAQ for a child versus an adult.

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 Madagascar between the end of April and June 2010 and also serves as the baseline for the Affordable Medicines Facility – malaria (AMFm) Phase I Independent Evaluation, for which some additional indicators are presented.

Overview of the AMFm independent evaluation process

The independent evaluation 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 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).The baseline of the AMFm 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. ACTwatch provided data for Kenya, Madagascar, Nigeria, Tanzania mainland, Uganda, and Zanzibar.

Baseline outlet surveys were carried out in 8 pilots in 7 countries with the objectives of assessing availability, affordability, and market share of co‐paid ACTs in rural and urban areas in each of the seven participating countries. The Independent Evaluation uses outlet survey data from two groups: 1) those in which nationally representative outlet surveys have been conducted under the ACTwatch program (Madagascar and Nigeria), and 2) those in which new outlet surveys were conducted under the AMFm Phase 1 IE (Ghana, Kenya, Niger, Tanzania mainland, Uganda and Zanzibar). The surveys were conducted in all the countries between August 2009 and December 2010.

Madagascar Outlet Survey Methods

A nationally representative sample of all outlets that could sell or provide antimalarials to a consumer was taken through a census approach in 38 clusters across two malaria‐endemic strata, urban and rural, in Madagascar. A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were communes, 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, pharmacies and drug stores (dépôt de médicament) was conducted in administrative districts surrounding the selected clusters. The sample size was powered to detect a change of 20% percentage points in availability of ACTs over


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 hospitals and health centres); 2) pharmacies (pharmacies licensed by the National Drug Authority and Pharmacists’ Council) 3) drug stores (depot de medicament) (licensed by the National Drug Authority and Pharmacists’ Council); 4) private health facilities (private clinics, private practices, NGO health centres and dispensaries); 5) grocery stores (épicerie [small groceries], épibars [small groceries with bars] and épi gargotes [small groceries with food stalls]);6) Community health workers (Agent de Santé à Base Communautaire and Agent de Vente à Base Communautaire); and 7) other outlets (gargotes [food stalls with sit‐down eating areas], bars, and other outlets).

Data were collected using Personal Digital Assessments (PDAs). Three questionnaire modules were administered to participating outlets: 1) Screening Module, 2) Audit sheet and 3) Provider Module. For all outlets, trained interviewers administered the screening module 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 also observed outlet licensing and storage conditions of medicines using the provider module.

To ensure a high level of data quality, ACTwatch performed cleaning using standard ACTwatch guidelines. For the analysis, the Independent Evaluators provided a tabulation plan for all tables presented in this report for the IE indicators, and analysis do‐files in STATA, which produced all the required indicators and automatically generated the tables. ACTwatch adapted these analysis files to the country setting and ran the analysis using STATA version 11, recording results in a log file. Additional analysis for other ACTwatch specific indicators was conducted by ACTwatch following standard guidelines.

Madagascar 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. 

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