75737 DIME BRIEF Zambia: reducing inefficiencies in the antimalarial supply chain The Development Background Impact Evaluation Zambia holds a mixed record in malaria control. On the one hand, the country has made Initiative is a broad- great strides in providing universal access to preventive services. By way of illustration, based World Bank between 2006 and 2008 the fraction of households owning at least one bed net rose program to generate from 48% to 72%. knowledge on the effectiveness of Despite progress in improving access to prevention, case management remains weak. A government programs. 2008 survey established that a meager 11% of children under-five living in urban areas It supports government and 5% of those in rural areas took Artemisinin-based combination therapy (ACT), the agencies adopt a state-of-the-art antimalarial, within the same/next day of fever onset. culture of real time evidence-based The government of Zambia thus acknowledged the need to urgently improve access to policy-making on the and guarantee the availability of antimalarial drugs and diagnostic tools, leading to the basis of rigorous creation of the Zambia Access-to-ACT Initiative (ZAAI). impact evaluation. By testing how to make Impact evaluation policies work, it Earlier analyses showed that underperformance in case management could principally contributes to be attributed to inefficiencies in public drug supply: while distribution proceeded fairly improving policy efficiently from the central medical store to the districts, bottlenecks appeared in performance. deliveries from district stores to individual public health facilities (HF). This, in turn, DIME works with 300 results in frequent stock-outs of ACTs and rapid diagnostic tests (RDTs). agencies in 72 countries across 15 The principal objectives of ZAAI were therefore to identify the most cost-effective thematic programs to method of enhancing public sector supply chains, determine to what extent the private generate knowledge, sector could be harnessed to increase access to ACTs and RDTs, and quantify the improve quality of combined impact of interventions in both public and private sectors on household operations and decision-making and treatment-seeking behavior. strengthen country capacity for evidence- In the public sector, two primary channels for revamping public supply chains were based policy- making. identified. First, efficiency increases could be achieved through a reconfiguration of resources in the existing distribution system at the district level, i.e. through This impact evaluation introducing a Community Planner (CP) responsible for effective stock management and is part of the Malaria coordinating timely and accurate information from HFs (System A). Stock-outs could Impact Evaluation also be averted through changes in the structure of the distribution network itself, on Program. top of the changes in System A. District stores could serve as ‘cross-docking points’, i.e. as a pass through for consignments already packed and labeled for individual HFs, eliminating the need to hold stocks at the district level (System B). The public sector intervention was implemented in peri-urban and rural districts, since malaria prevalence in urban areas is relatively low and the health system performs comparatively well. 16 out of a total of 58 peri-urban and rural districts received one of the two interventions, with 8 assigned to System A (district stores + CP), and 8 to System B (cross-docking + CP). An additional 8 districts were selected to serve as controls (existing system). Photo: Benoist Carpentier As roughly 42% individuals who seek care for fever do so in private facilities, ZAAI DIME Brief on Zambia 1 Impact evaluation results chart of the public sector study show that System B Results (cross-docking + CP) results in dramatic increases in ACT availability at public HFs. If implemented on a nationwide scale this new supply model has the potential of reducing both child and adult malaria-related mortality by 21% and 25% respectively. Furthermore, System B is four times as cost-effective as System A (only CP) – while the latter reduces stock-out day of one tracer drug at a cost of $14.50 per day in additional operating costs, the former achieves the same reduction at a cost of just $4.20 per day. Preliminary results of the private sector intervention show that both diagnostic capacity and ACT use have increased includes a private sector component which evaluates in the intervention areas. Exit interviews show that as the effects of an ACT and RDT price subsidy as well as many as 80% of febrile patients were offered an RDT in several accompanying interventions – such as accredited stores. These gains were matched by a repackaging, suggested retail price, public awareness significant increase in the use of ACTs, and a reduction in campaigns and incentives to wholesalers – on the the use of ineffective antimalarials. Almost 83% of clients stocking, dispensing and household demand for purchasing antimalarials in these facilities chose an ACT, ACTs. versus a mere 17.2% in non-accredited outlets. A rapid analysis of retail and wholesale outlets in six The results suggest an overall improvement in the districts preceded the intervention. The highest availability and use of effective treatment . A greater volume product was Sulfadoxine-Pyrimethamine proportion of fever cases are seeking care, being diagnosed (SP) at 61%. Only 25% of private sector outlets had with RDTs, and receiving ACTs. Most gains are attributable ACT stocks, which sold for almost 15 times the price to improvements in service from public facilities. However, of SP. High prices, together with a perception of low the contribution of increased availability in the private demand and overwhelming SP market penetration sector is also apparent. act as principal barriers to a more widespread use of ACTs. Policy recommendations Acknowledging the impressive impact of the new public To mitigate these adverse conditions, a system of supply method, Zambia decided to scale up the direct- subsidies was introduced. ACT prices were set at the order system nationwide, which is expected to result in lowest possible level for end-patients, making them 16,000 fewer malaria-related deaths in children under five competitive with the price of SP. The level of co- by 2015. Private sector results demonstrate that there is a payment for RDTs was set in such way that the cost vital role to be played by private providers in reducing the of diagnosis to the end-patient was minimal/zero, in malaria burden. However, the widespread implementation order to induce demand for diagnosis prior to taking of such an approach necessitates further regulatory reform. ACTs. Although the study focuses on ACTs, the underlying Due to the high cots of ACT and RDT subsidization, objective is to provide an example for the supply of all the private sector intervention was limited to four essential drugs. Extending the innovative supply schemes districts. These were selected to ensure that to cover drugs outside the category of antimalarials would communities with high malaria burden and limited probably yield even greater gains for the health care access to ACTs and RDTs would benefit from system as a whole. inclusion in the scheme. All private outlets meeting certain eligibility criteria could qualify to sell the Source: subsidized ACTs and RDTs. Friedman, Jed; Vledder, Monique; Sjoblom, Miria; Yadav, Prashant. (unpublished). “Zambia: Improving Access to ACTs.” For more info on DIME, contact Arianna Legovini (alegovini@worldbank.org) or see www.worldbank.org/dime To contact the author email: Jed Friedman (jfriedman@worldbank.org) DIME Brief on Zambia 2