75738 In 2006 DIME BRIEF Zambia – Can the private sector play a stronger role in malaria diagnosis and treatment? The Development Impact The poor in many countries lack access to essential malaria diagnosis and Evaluation Initiative at the treatment methods. One of the reasons is that many patients access malaria World Bank supports treatment through the private and informal sectors, where the availability of government agencies to diagnostic tests and drugs can be limited and where prices for the recognized adopt a culture of real front line drugs (Artemisinin-based Combination Therapies or ACTs), are time, evidence-based policy-making. The generally high. Strengthening the private sector role offers great potential in objective of the initiative is the fight against malaria. to help programs learn how to improve their A number of countries including Tanzania, Kenya and Cambodia are piloting performance over time by the provision of subsidized ACTs through the private sector1. Early findings both measuring results, and indicate that subsidies can improve uptake, but the pilots are not conclusive comparing policy and more analysis is needed to understand how to maximize uptake. In alternatives side by side to parallel there is research into strengthening the provision by private drug determine which stores of rapid diagnostic tests (RDTs). alternatives are more effective on the basis of This policy brief summarizes the evaluation findings of a program in Zambia rigorous impact evaluation. which sought to enable the private sector to play a stronger role in malaria DIME works with 300 diagnosis and treatment. The main conclusion of the evaluation was that a agencies in 72 countries to well managed intervention can strengthen access to ACTs through the private improve knowledge, quality sector whilst also reducing the use of ineffective antimalarials. of operations and country capacity for evidence- based policy-making. Case Study Background The Zambia Access to ACT Initiative (ZAAI) was ACT, the adopted first line treatment for malaria, launched in 2009 and included parallel public within the same/next day of onset of fever. sector and private sector components. The public sector component focused on strengthening the In Zambia it can be common to seek care through availability of essential drugs in public clinics, the private sector. A 2004 study in Zambia found often in remote areas. The private sector that roughly 42 percent of the population seeks component was concerned with assessing the treatment for fever through non public sector effectiveness of a combined ACT and RDT subsidy. sources (treatment at home, private sector clinics, The evaluation of this component gauged whether drug stores, pharmacies, etc). But ACTs and RDTs the program increased the affordability and access are not readily available through private sector to ACTs; decreased the use of ineffective anti- drug stores. In part this is because of constraining malarials, and increased diagnostic capacity of the legislation in Zambia. ACTs are classified as a private sector. prescription only medication and so are only legally available in registered pharmacies. Added In 2008 only 29 percent of Zambian children to this, the Zambian Pharmaceutical Act does not under the age of five took an anti-malarial within allow for local (second tier) pharmacies. In rural 24 hours of onset of symptom. And only 11 areas there are virtually no registered pharmacies, percent of children under-five living in urban therefore availability of ACTs/RDTs is more areas and 5 percent of those in rural areas took limited. DIME Brief: Zambia – Can the private sector play a stronger role in malaria diagnosis and treatment? The ZAAI private sector program was the government’s first proactive attempt to regulate private sector sellers in more remote areas DID YOU KNOW? through accreditation. The program had three main components: (1) A subsidy for ACTs and RDTs A THIRD OF THE WORLD’S POPULATION, INCLUDING ACTs and RDTs were procured from the ALMOST HALF OF THE manufacturers at the public sector price, and POPULATION OF AFRICA LACK then sold at a subsidized price to existing REGULAR ACCESS TO ESSENTIAL pharmaceutical wholesalers. The products DRUGS. (WHO 2004) were delivered through normal distribution channels to accredited drug outlets in the pilot districts. a. Community Sensitization and Training (2) Accreditation program based on Tanzania’s ADDO model There were a series of measures to increase community awareness, including: This included a training curriculum which public awareness campaigns (radio), covered dispensing practices, ethical issues, drama shows, signs on the shops, such as inventory control, supply chain management the health shop logo shown in the photo, and an entrepreneurship module. There was a health messages on packages of ACTs, basic set of enforceable infrastructure, banners, posters, etc. covering personnel, records, and product standard. Finally there was increased The program covered up to 63 accredited stores. oversight from the Pharmaceutical Regulatory 28,170 ACT courses and 41,900 RDTs were Authority (PRA), although this was relatively shipped during the program, and store levels light touch. For example, no outlet was visited suggest more than 20,000 people underwent more than twice. diagnosis. The evaluation used a quasi experimental design and was rolled out in four rural/peri-urban districts with 3 control districts. Data collection methods for the evaluation included; a dedicated private shop and wholesaler survey at baselines; audits, including the use of ACT tracer packages; exit interviews with customers; mystery shopping; and population-representative household surveys. DIME Brief: Zambia – Can the private sector play a stronger role in malaria diagnosis and treatment? Overall Findings (4) Levels of diagnosis have increased. More people over five are using the private sector for diagnostic tests, while under (1) The program showed clear improvements fives had more diagnostic tests in the in access to malaria diagnosis and public sector. treatment. There is a 20 Looking at the impact on the overall percent population, the evaluation showed a high increase in the level of awareness of the program in the level of treated areas, and people’s behavior diagnosis, and significantly shifted towards diagnosis and for under fives treatment in formal outlets and away from the increase is self-treatment. 30 percent. For the latter this increase is almost entirely (2) Fewer people were treating themselves through public sector facilities. For over (especially for under fives). fives there is a 6 percent increase in the use of the private sector for diagnosis (which is The overall numbers not seeking any formal statistically significant). A similar pattern care reduced by 15 percent, which is with regard to the age groups is seen looking statistically significant. The reductions were at diagnosis received through RDTs. The rise particularly apparent for under fives with a in private sector diagnosis by RDT is of lower 17 percent reduction. magnitude than the rate of any private sector diagnosis (1.8 percentage point versus 5.5 (3) Those seeking formal care have accessed percentage point) which indicates that both the public and private sector facilities. implementing effective RDT diagnosis in the private sector is challenging. For the under fives, this occurs mainly (5) The program has shown a 14 percent rise in public sector in the number of people receiving malaria facilities. For the medication and a decrease in the use of over five other drugs. population, the increase is divided There was a 28 percent increase in the between the public proportion of fever cases who were receiving and private sector ACTs. These ACTs were being supplied by and the rise in both the public and private sectors with a 20 private sector care Access is often blocked by percent and a 5 percent increase poor roads and is substantial given respectively. Overall there was a significant inadequate means of the very low (5 percent) decrease in patients receiving transportation. baseline. Overall other malaria drugs in the treatment areas. there was a 15 percent increase in the population seeking care in the public sector (6) The substantial increase in use of public and a 26 percent increase for the under five sector facilities for under fives is population. For over fives, there is a more surprising and requires further analysis. even spread between public and private facilities. The rate at which over fives sought Part of program activities involved care at private facilities increased by 6 encouragement to formal care seeking and percent. This represents a substantial change ACT usage through direct communication from the baseline level of 1-2 percent. and media such as street plays. It is possible that parents were influenced by this and feel DIME Brief: Zambia – Can the private sector play a stronger role in malaria diagnosis and treatment? comfortable visiting the private sector for for more than 10 months it is likely that their own fever care but prefer to take their greater increases would have resulted. young children to formal health clinics. Added to this the evaluation found anecdotal evidence of a high degree of cooperation Broad Conclusions between health clinics and nearby health (1) This evaluation demonstrated that a well shops, with the latter often serving as stock managed intervention can strengthen access back-ups if the public clinics were out of to ACTs through the private sector whilst RDTs or ACTs. As such it is also possible that also reducing the use of ineffective increased drug availability in the overall antimalarials. system induces more parents to present sick children to clinic. (2) The findings interestingly show significant increases in the use of both private and (7) Knowledge of the Health Shops increased public sector facilities. This may be because substantially in treatment areas close to the program helped to raise awareness of the shop clusters. general need for diagnosis and treatment and it may also be due to co-operation between This is expected given that accessibility is the public and private sectors. Further strongly related to distance. Apparently the analysis is required to explore this. most effective means of raising awareness of the health shop program comes from street (3) The program demonstrates that is also plays and other media. This is important to possible to increase the diagnostic capacity note since, while the street plays and other in the private sector, although ensuring full program media introduced the health shop adherence to diagnostic and dispensing program, they also conveyed broader protocols is challenging. The improvements messages on the importance of prompt seen in this case are also notable given that diagnosis for fever and the curative the pilot was only operational for 10 months properties of ACTs. before the evaluation. Overall the extent of improvement might be (4) As a further direct result of the program, the characterized as moderate. For example Pharmaceutical Regulatory Authority (PRA) there is only a 6 percent increase in over has recognized the limitations of the current fives care seeking in private sector shops. But regulatory framework, and will introduce an if the subsidy program had been operational amendment to the Pharmaceutical Act to register and accredit local drug stores. Source: Friedman, J., et al (unpublished) “Zambia Improving Access to ACTs” This document was prepared by Sonal Bhatt and is based on the results of the World Bank-supported Essential Drug Public Pilot Program in Zambia, which was funded by the World Bank, U.S. Government and DFID. www.worldbank.org/dime For further information contact Jed Friedman jfriedman@worldbank.org DIME Brief: Zambia – Can the private sector play a stronger role in malaria diagnosis and treatment?