Madagascar outlet report 2011

Data were collected between the 7th of November 2011 and the 7th of January 2012. A total of 10,723 outlets were approached. Of these, 682 outlets were not screened for various reasons: 13 providers refused to be interviewed; 283 outlets were closed down permanently; 236 outlets were not open at the time of the survey visit; in 139 outlets, providers were not available for interview at the time of the survey visit; 11 providers were unable to be interviewed for other reasons. Overall, 10,041 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 2,854 outlets met our screening criteria; however, interviews could not be conducted for 48 outlets. Of the 2,806 interviews conducted, 435 reported having stocked antimalarials at any point in the three months prior to the interview and 2,371 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 and 82% of private not-for-profit facilities had at least one antimalarial in stock on the day of interview. Of community health workers, who according to government policy may treat using antimalarials, 12% stocked an antimalarial. There was substantial variation in the private sector. More than 71% of private for-profit facilities, 93% of pharmacies and 96% of drugs stores, stocked antimalarials. This is in contrast to 21% of general retailers.

Outlet types stocking antimalarials

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

Availability of different classes of antimalarials

Among facilities that stocked antimalarials at any time in the three months preceding the survey, overall QA ACT availability in 2011 was 28%, and this was lower in the private for-profit sector (9%) than in the public not for-profit sector (92%). However, there was considerable variation within the private for-profit sector. QA ACT availability was much higher in pharmacies (99%) than in drug stores (56%) or private for-profit facilities (36%). In public health facilities that stocked antimalarials at any time in the three months preceding the survey, QA ACT availability was 94%. QA ACT availability was also high among community health workers (CHWs) (92%). In public facilities and private for-profit health facilities and pharmacies, availability of QA ACTs with and without the AMFm logo was very similar, but in drug stores, availability of QA ACTs with the logo was 51% compared with only 12% for QA ACTs without the logo.

Availability of ACTipal (artesunate-amodiaquine) is also presented in this report. ACTipal is an ACT subsidy program that PSI has been operating in Madagascar since 2008 with distribution through CHWs and in the private sector, pharmacies and depots (drug stores). ACTipal was available via 76% of community health workers stocking antimalarials at any time in the three months preceding the survey. It was rarely available in other outlet types (<16%), including pharmacies (0%) or drug stores (4%). Among facilities that stocked antimalarials at any time in the three months preceding the survey, overall non-artemisinin therapy availability in 2011 was 88%. There was variation in the availability of chloroquine and SP by outlet type, though stocking rates of chloroquine were generally high in pharmacies, drug shops and retailers.

Availability of diagnostic blood testing

Of outlets stocking antimalarials in the last three months, 92% of public health facilities reported offering any rapid diagnostic testing (RDT) services, and 73% of private not for-profit facilities offered RDTs. Availability of RDT services was less than 10% across all outlet types in the private sector. Few facilities provide microscopic testing.

Price of antimalarials

In the public and private not-for-profit sectors, the median QA ACT price was USD 0.00, reflecting the policy of free ACT provision. Pooling all sectors, the median price also remained at zero. While data are not shown in this report for the 2010 findings of the outlet survey, it is important to note that the median price of QA ACTs in the private for-profit sector increased significantly between 2010 and 2011, from USD 0.14 to USD 0.67 per AETD. The 2010 price reflects the pediatric ACT subsidy program for ACTipal (artesunate-amodiaquine) that PSI had been operating in Madagascar since 2008, with distribution through CHWs and in the private sector, pharmacies and dépôts (drug stores). The median price of non-quality-assured ACTs in the private for-profit sector was much higher than for QA ACTs (USD 9.36 versus USD 0.67). The median price for a QA ACT with the AMFm logo in private for-profit outlets (USD 0.51) was 1.6 times the median price of the most popular non-QA ACT (chloroquine, USD 0.32) in private for-profit outlets, whether this was measured in tablet form or among all dosage types.

Volumes of antimalarials sold/distributed

Overall market share of QA ACTs was 21% in 2011, with nATS accounting for 79% of the overall market share. In the private for-profit sector, market share of QAACTs was 22%. In public health facilities, QA ACT market share was low (13%). Overall market share of oral AMTs was zero. QA ACTs with the AMFm logo accounted for 86% of all QAACTS dispensed overall and 95% of all QA ACTs dispensed in the private for-profit sector. The private for-profit sector was responsible for 70% of all antimalarials sold or distributed in 2011. Drug stores and retailers accounted for over 50 % of the total volumes sold or distributed over the previous week.

Provider knowledge

Overall, 31% 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 (77% vs. 18.5 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 (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 Madagascar between November 2011 and January 2012 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 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 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 Madagascar, conducted by PSI/ACTwatch. The results of the baseline survey can be found in the Madagascar baseline report (ACTwatch, 2009) 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 (forthcoming), 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-districts/communes, with an average of 10,000 to 15,000 inhabitants. In Madagascar, 46 clusters (urban [18 clusters] and rural [28 clusters], were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular sub-district 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 and health centres); 2) pharmacies (pharmacies licensed by the National Drug Authority and Pharmacists’ Council) 3) drug stores (dépôt 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], épi bars [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).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.

The questionnaire was programmed into personal digital assistants (PDAs).To ensure a high level of data quality, the DCs undertook data cleaning using a detailed guideline provided by the IE team and also followed structured ACTwatch guidelines. 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 “do-files” 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.

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