PROGRAM BRIEF: PSI/MYANMAR Improving Malaria Case Management in the Private Sector: Artemisinin Monotherapy Replacement (AMTR) Project psi.org
1 Artemisinin Monotherapy Replacement Project 2012-2015 AMTR PROJECT available in 70% of private sector outlets. In 2012, oral artemisinin monotherapy was Continued use of oral artemisinin-based monotherapy (AMT) is widely considered to be one of the main contributing factors to the development and spread of resistance to artemisinin and its derivatives. In 2012, alarmingly high rates of oral AMT availability and use were detected in the private sector where the majority of people seek care across Myanmar. In response to this situation, the international Non-Profit Organization (NGO) of Population Services International (PSI) implemented the Artemisinin Monotherapy Replacement Malaria (AMTR) project. The projects aims to rapidly displace oral AMT with subsidized, quality assured Artemisinin-based Combination Therapy (ACT) in the private sector. This quality assured ACT is distributed through AA Pharmacy and Polygold key suppliers in the country who previously distributed most of the oral AMT found in Eastern Myanmar. Distribution of oral AMT was replaced with the sale of quality assured ACT branded as SupaArte. An additional brand, Artel Plus, was introduced in 2013 to facilitate market competition. Both SupaArte and Artel Plus are branded with a quality seal. Complementing the private sector distribution of subsidized ACT are a variety of demand creation activities targeting antimalarial providers and patients. Underserved outlets (pharmacies, general retailers and itinerant drug vendors) are also targeted by product promoters in project intervention areas. These types of outlets are referred to as priority outlets. Private facilities and community health workers ( non-priority outlets) who have access to the public sector or other INGO/NGO did not receive this product promoter outreach intervention. To monitor the project, a census of all private sector outlets was completed, and yearly outlet surveys have been conducted in both intervention (where product promoters operate) and comparison areas. These surveys screened the availability, market share and price of antimalarials. What types of outlets have antimalarials? In 2012, one in five priority outlets stocked an antimalarial medicine. In 2015, less than one in ten priority outlets stocked an antimalarial medicine, reflecting a gradual decline in availability over the years among these outlet types. This overall decrease is an expected response to the falling number of malaria cases in the country. How available is oral artemisinin monotherapy? In 2012, oral AMT was available in 70 percent of priority outlets. By 2015, only one in three outlets was found to stock this medicine in the intervention area. However, a 15 percent increase in availability of oral AMT was observed between 2014 and 2015 in the intervention area. Oral AMT availability was higher in the comparison area than the intervention area with one in three outlets stocking this class of medicine in 2015. What brands of oral artemisinin monotherapy are being sold and for what price? Most of the packages found in Eastern Myanmar in 2015 were Artesunate manufactured by Mediplantex in Vietnam. Providers recalled that customers typically ask for these medicines by name and rather than selling a full course, will provide a patient with two or three tablets for around 500 Myanmar kyat. Most of the oral AMT in stock at the time of the survey was not expired. How available is quality assured ACT?
Artemisinin Monotherapy Replacement Project 2012-2015 2 Priority outlets: pharmacies, general retailers and itinerant drug vendors are targeted by product promoters in the AMTR Project s intervention area. Availability of Oral Artemisinin Monotherapy among Priority Outlets in the Intervention Area (2012-2015) 100% Availability of oral artemisinin monotherapy decreases over time among priority outlets in the intervention area. Slight increases are observed between 2014 and 2015. 70% 50% 50% 30% 10% 2012 2013 2014 2015
3 Artemisinin Monotherapy Replacement Project 2012-2015 Antimalarial market share among priority outlet types in intervention and comparison areas (2012-2015) Quality-assured ACT market share increases over time among priority outlets in the intervention area from < 5% in 2012 to over 50% in 2015. Increases in quality assured ACT are found between 2012 & 2015 among priority outlets in the intervention area. In 2015, 62% of priotiy outlets stock a quality assured ACT. 4% 2012 62% 2013 79% 2014 62% 2015 In 2012 availability of any quality assured ACT was less than 10 percent among priority outlets in both the comparison and intervention area. By 2015, quality assured ACT was available in 60 percent of priority outlets in the intervention area. Though increases were also found among outlets in the comparison area, availability only increased to 20 percent in 2015. Is the quality assured ACT affordable? The recommended retail selling price of the branded ACT is 500 Myanmar Kyat. In 2015, 90% of the priority outlets that stock the medicine reportedly sell the ACT for this price. share in 2015. PSI is conducting further study to better understand what may account for this suprising increase. To what extent are rapid diagnostic tests available? Availability of malaria rapid diagnostic tests (RDTs) among antimalarial-stocking outlets has increased slightly over time in the intervention area, but still remains low among priority outlets in 2015. Market Share Market share of quality assured ACT has increased from 2012 to 2015. The majority of quality assured ACT packages sold in 2015 were those with the quality seal. Since 2013, the market share of quality assured ACT has consistently been higher in the intervention area than the comparison area. Oral AMT stubbornly remains in the market. Slight increases of oral AMT were observed between 2014 and 2015 in the intervention area, with oral AMT comprising 25 percent of the market
Artemisinin Monotherapy Replacement Project 2012-2015 4 15% Availability of RDT among priority outlets in 2015 Conclusion Considerable progress has been made to increase access to high quality, affordable ACT in Eastern Myanmar. Supportive interventions have been effective in helping to maximize the benefit of subsidized quality assured ACT distribution. Availability and sale of oral AMT persists and appears to have increased over the last two years. This points to the need to enforce the current policy banning the importation of non-licensed oral AMT products and prohibiting any new licenses as a means of creating a supportive environment for on-going interventions in Eastern Myanmar and throughout the country. Malaria elimination strategies must ensure improved case management in the private sector, where most febrile patients seek treatment. This can be done through improved availability of both ACT and RDT. Future strategies will therefore learn from the ACT experience to increase the availability of RDTs in the private sector, and expand all project activities into Western Myanmar. For further information contact: Dr Hnin Su Su Khin, PSI/Myanmar Malaria Director hsskhin@psimyanmar.org