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UPDATE ON TANZANIA’S PILOT ACT SUBSIDY PROJECT

Roll Back Malaria 13th Board Meeting29 November 2007

Addis Ababa

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Background and context

Results to date

Implications and areas for further exploration

Next steps and timeline

Today’s presentation

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Malaria is one of Tanzania’s greatest health problems, taking a heavy toll on its people and burdening its health system

• 85% of population at risk of stable, endemic malaria • 14 – 18 million malaria cases every year

• More than 100,000 people killed, most young children

• Estimated 3.4% reduction in annual GDP due to absenteeism and death

• Estimated 40% of all hospital admissions due to malaria

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Over 50% of Tanzanians seek treatment in the private sector, but there are many barriers to effective, affordable treatment

Treatment-seeking behavior

• Over 40% of Tanzanians seek anti-malarial treatment through the private sector: drug stores, general stores and private health facilities

–Tanzania is scaling up the Accredited Drug Dispensing Outlet (ADDO) program from 4 regions to nationwide, but this is expected to take until 2010 and in the meantime many patients will continue to seek treatment at drug stores (duka la dawa baridi)

Barriers to treatment access in the private sector

• High cost of ACTs

• Continuing preference for previously-used, ineffective anti-malarials (e.g., Chloroquine, SP)

• Dearth of drugstores in most rural, remote areas

• Continuing classification of ACTs as a prescription-only medicine

• Limited training of drug store dispensers

• Poor packaging of drugs

Source: Hetzel et al. BMC Public Health

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The pilot ACT subsidy project aims to both provide data for policymaking as well as to increase access in the target areas

Objectives:

1. Inform policymaking at both the national and global levels, particularly related to the introduction of an ACT subsidy, by providing evidence on the impacts of a top-level subsidy of medicines through the private sector

2. Substantially increase access to affordable, effective, high-quality malaria treatment in the targeted intervention areas

Key questions:

1. What is the final price paid by patients for subsidized drugs?

2. What is the effect of a package of accompanying interventions (e.g., SRP, repackaging, social marketing) on end-user price and uptake?

3. What is the impact of the subsidy on the purchase and use of ACTs compared to other anti-malarials?

Principles:

1. Maximize benefits to patients

2. Ensure rapid initiation and implementation

3. Work at the behest of and in close collaboration with the government and other partners

4. Replicate normal supply chain processes and behavior

5. Minimize leakage

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The pilot project is being led by the Ministry of Health and Social Welfare and implemented by PSI – Tanzania and the Clinton

Foundation

• Manage procurement of drugs and implementation of supporting interventions

• Lead communication to global partners

• Lead partners: TFDA and NMCP• Manage relations with local

government• Conduct dispenser training

• Implement in-country social marketing and repackaging

• Build on lessons learned from ACT repackaging/subsidy experiences in other countries

Tanzania Pilot ACT Subsidy

Project

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Three rural districts were selected as representative of socioeconomic and malaria conditions in Tanzania and sub-Saharan Africa

District selection criteria:

• High burden of stable, endemic malaria

• Malaria-related DHS indicators in line with national averages

• Significant number of local drug shops (duka la dawa baridi)

• Socioeconomic indicators indicative of rural, poor population

• Low opportunity for leakage across borders or to large cities

• Absence of Accredited Drug Dispensing Outlets (ADDOs)

Kongwa:

price intervention

Maswa:

subsidy control

Shinyanga Rural:

control

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The project has three key components running simultaneously

Pilot ACT subsidy project

Procurement and distribution

Monitoring & evaluation

Supporting interventions

Key activities

• Baseline survey of duka la dawa baridi and public/NGO health facilities

• Ongoing monitoring of metrics including end-user price and anti-malarial volumes sold

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3 • Social marketing/behavior change communication activities focused solely in target districts

• Placement of suggested retail price• Repackaging of drugs into Tanzania-specific,

user-friendly Kiswahili package• Training of drugstore dispensers on proper

administration of Coartem and improving malaria knowledge

• Quantification of quarterly uptake of ACTs through duka la dawa baridi in target districts

• Procurement of ACTs and resale to national wholesaler at a subsidized price

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Wholesaler

Regional Distributor“Indirect”

Regional Distributor“Indirect”

Clinton Foundation

Drug Shops

DrugShops

ACTs procured at public sector

price

ACTs sold to wholesaler at 90% subsidy

ACT Manufacturer

Kongwa DistrictMaswa District

Regional Stock Point

“Direct”

Regional Stock Point

“Direct”Shops pick up

drugs from distributors

Trucks/bikes deliver direct to shops

Trucks/bikes deliver direct to shops

Drugs are distributed through two existing channels to the districts – via a regional distributor or direct to retailer

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The packaging was designed specifically for Tanzania to encourage effective and responsible ACT distribution

• Cover photos and color schemes differentiate doses• Compelling, high-quality presentation attracts demand• National brand is prominent; manufacturer brand included

• Simple, clear instructions in Kiswahili and pictorially• Timing of doses clearly indicated, and reflects other specific elements of National Malaria Treatment Guidelines

• Prepackaged drug from manufacturer slides into package; ensures quality and removes risk of contamination during repackaging•Expiration date on original packaging visible

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Background and context

Results to date

Implications and areas for further exploration

Next steps and timeline

Today’s presentation

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Four different data collection methods are being employed to ensure robust data capture

Mystery shopper

Public/NGO sector audit

Exit interview

Retail auditMetric

• Types/brands of anti-malarials sold/stocked (incl. subsidized product)

• Volume of subsidized ACT and other anti-malarial sales

• Sale price per dose• Package conditions – loose, original, etc. • Availability and stocks of Coartem in nearby

public/NGO sector health facilities

• Intended recipient of drugs • Age and gender of patient• Socioeconomic status of purchaser’s

household • Reason for purchase

• Location (peri-urban vs. rural) and clustering/competition

GPS

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The subsidized ACTs have quickly gained market share, appearing to displace AQ for adults…

Breakdown of products purchased in August vs. November

% of adult exit interviews

Non-subsidized ACT + monotherapy

SP

Amodiaquine

QuinineOther

1% 2%

64%64%

26%

4%

5%

15%4%

1%

458100% = 343

August November

17% Subsidized ACT

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… and children

Breakdown of products purchased in August vs. November

% of exit interviews purchasing for a child under 5

SP

Amodiaquine

QuinineOther

8%

57%

90%

1%1%

6%

79100% = 87

August November

26% Subsidized ACT

11%

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Price paid for subsidized ACTs is in line with other commonly-available anti-malarials, and the SRP appears to be effective

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Subsidized ACT SP AQ Art. Monotherapy

In the price intervention district, the maximum

price paid did not exceed the SRP of TSH 1200

Mean and standard deviation of price paid

% of adult exit interviews buying a full dose

Tan

zani

an S

hilli

ngs

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The majority of patients are getting a full course of anti-malarials

81%

61%

84%

Share of patients purchasing a full dose

% of 440 exit interviews

Subsidized ACT

Any SP

Any AQ

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42 12 25

40

1

8

16

12

9

7

451

22

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The importance of shopkeeper recommendation is reinforced, particularly for subsidized ACTs

Subsidized ACT

Reasons for buying each drug

% of 443 exit interviews

Any SP

Any AQ

Shopkeeper recommendation Prescribed

Previous use

Most effective

Price

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11%

28%

1%

43%

28%

33%29%

27%

There continues to be no consumers from the poorest socioeconomic quintile purchasing anti-malarials in drugstores

Quintile 2

“Poor”

Quintile 3

“Neither rich nor poor”

Quintile 4

“Richer”

Breakdown of consumers by SES: August vs. November

% of 608 (Aug.) and 443 (Nov.) exit interview customers

Quintile 5

“Richest”

August

November

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The occurrence and duration of stock outs in public/NGO health facilities varies significantly by district, perhaps acting as a driver for private sector treatment-seeking behavior

34%

11%

21%

Percent of public/NGO health facilities reporting a stock out in last 3 months

% of 104 facilities surveyed

Maswa

Kongwa

Shinyanga Rural

Maswa also has the highest numbers of

consumers seeking anti-malarial treatment in the

private sector

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Background and context

Results to date

Implications and areas for further exploration

Next steps and timeline

Today’s presentation

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The preliminary Month 1 findings from highlight potential areas for further exploration on private sector treatment-seeking in general…

• Continuing lack of consumers from lowest SES quintile in private sector drugstores how can they be reached?

• Drug shops seem not to be the preferred access point for caregivers of children under 5

• The importance of shopkeeper recommendation how to ensure appropriate knowledge and incentives?

Socioeconomic status

Area Implication

Access for children U5

Drivers of product choice

• The number of people seeking treatment in the private sector may be linked to public sector ACT availability

Treatment-seeking in public vs. private sectors

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… and specifically on subsidized ACTs

• SRP adherence appears to be high, although price is lower in the non-SRP district

Area Implication

Pricing

• Stocking of subsidized ACTs by store owners has occurred rapidly, although it will take time to penetrate all stores

• It appears that the subsidized ACT is most displacing AQ, as SP and other anti-malarials’ sales are staying relatively constant

Uptake and displacement

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Background and context

Results to date

Implications for global and national ACT subsidy efforts

Next steps and timeline

Today’s presentation

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The project will run for one full year, with quarterly procurement, data collection and reporting

June

2007

July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug.

2008

Baseline data

collection

Supporting interventions – social marketing, marking of SRP

Month 1

data

collection

Q2 data

collection

Q3 data

collection

Q4 data

collection

Q1 ACT

procurement

+ distribution

Q2 ACT

procurement

+ distribution

Q3 ACT

procurement

+ distribution

Q4 ACT

procurement

+ distribution

Selection +

contracting of

M&E and social

mkting orgs

Selection +

contracting of

wholesaler

partner

Q1 data

collection

Sept.

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The lessons learned from the pilot will directly inform the planned nationwide scale-up, funded by Global Fund Round 7

• Tanzania’s Global Fund Round 7 grant provides for a nationwide subsidy of ACTs for Under-5s in private sector drug shops – both duka la dawa baridi and ADDO

• Key elements will include:

– Repackaging

– Dispenser training

– Social marketing

• The Ministry of Health and Social Welfare, with the support of partners, will be moving towards rapid implementation

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ASANTENI SANA!