Myanmar Baseline AMTR Outlet Survey Report PDF
Myanmar Baseline AMTR Outlet Survey Report PDF
Myanmar Baseline AMTR Outlet Survey Report PDF
Dr. Tin Aung Director, Strategic Information Department, PSI Myanmar, adapted the ACTwatch
Outlet Survey for use in Myanmar, oversaw all aspects of implementation and
management of the study and prepared the report.
Dr. Megan Littrell Senior Research Advisor, PSI Malaria Control & Child Survival Department, provided
technical guidance and supervised interviewers training and data analysis.
Gary Mundy Regional Researcher, reviewed and advised the study design.
Dr Chaw Su Su Win Research officer, PSI/Myanmar, facilitated interviewers training and coordinated
data collection.
Zaw Win Research Manager, PSI/Myanmar, facilitated interviewers trainings, managed field
data collection and data entry, conducted data analysis assisted prepared the
report.
Saw Pa Pa Naing Researcher, PSI Myanmar, assisted data entry and data analysis.
Dr. Hnin Su Su Khin Deputy Director, AMTR, PSI/ Myanmar, provided project detail information and
advised implementation of the study.
Page I
Page II
List of Figures
Figure 1. Availability of antimalarials by outlet type .............................................................................. 3
Figure 2. Relative distribution of outlet types stocking antimalarials .................................................... 4
Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock ............... 4
Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests .... 5
Figure 5. Median price of an AETD antimalarial treatment in the private sector .................................. 5
Figure 6. Market share of AETDs sold/distributed in the past week (7 days) within each outlet type .. 6
Figure 7. Oral artemisinin monotherapy market share within outlet types, by brand .......................... 6
Figure 8. Provider knowledge of recommended first-line treatment and dosing regimens .................. 7
Figure 10. Location of Myanmar .......................................................................................................... 13
Page III
Term Definition
Adult Equivalent An AETD is the number of milligrams (mg) of an antimalarial drug needed
Treatment Dose (AETD) to treat a 60 kg adult.
Antimalarial Any medicine recognized by the WHO for the treatment of malaria.
Medicines used solely for the prevention of malaria were excluded from
analysis in this report.
Antimalarial The simultaneous use of two or more drugs with different modes of
combination therapy action to treat malaria.
Artemisinin An antimalarial medicine that has a single active compound, where this
monotherapy active compound is artemisinin or one of its derivatives.
Artemisinin and its Artemisinin is a plant extract used in the treatment of malaria. The most
derivatives common derivatives of artemisinin used to treat malaria are artemether,
artesunate, and dihydroartemisinin.
Censused cluster A cluster where field teams conducted a full census of all outlets with the
potential to sell antimalarials.
Cluster The primary sampling unit, or cluster, for the outlet survey is an
administrative unit determined by the Myanmar Information
Management Unit that hosts a population size of approximately 1,000 to
13,000 inhabitants. In Myanmar, these units are defined as wards and
village tracts. Wards are in the urban areas and village tracts which
comprise of a group of villages in rural areas.
Combination therapy The use of two or more classes of antimalarial drugs/molecules in the
treatment of malaria that have independent modes of action.
Enumerated Outlets Outlets that were visited by a member of the field teams and for which,
at minimum, basic descriptive information was collected.
Page IV
Nationally registered ACTs registered with a countrys national drug regulatory authority and
ACTs permitted for sale or distribution in-country. Each country determines its
own criteria for placing a drug on its nationally registered listing.
Non-artemisinin An antimalarial treatment that does not contain artemisinin or any of its
therapy derivatives.
Oral artemisinin Artemisinin or one of its derivatives in a dosage form with an oral route
monotherapy of administration. These include tablets, suspensions, and syrups and
exclude suppositories and injections.
Rapid-Diagnostic Test A test used to confirm the presence of malaria parasites in a patients
(RDT) for malaria bloodstream.
Screened An outlet that was administered the screening questions of the outlet
survey questionnaire (see Screening criteria).
Screening criteria The set of requirements that must be satisfied before the full
questionnaire is administered. In this survey an outlet met the screening
criteria if (1) they had antimalarials in stock at the time of the survey visit,
or (2) they report having stocked them in the past three months.
Treatment/dosing The timing and number of doses of an antimalarial used to treat malaria.
regimen This schedule often varies by patient weight.
Page V
Non first-line quality ACTs that are not the governments recommended first-line treatment
assured ACTs (NAACT): for uncomplicated malaria, but which do appear on the WHO list of
approved ACTs or the UNICEF procurement list.
Brands included in this category and audited during data collection are:
Other ACTs ACTs that appear on neither the WHO list of approved ACTs or the
UNICEF procurement list. This includes all audited brands of ACTs not
included in the other two ACT categories:
Arco
Artecospe (Adults)
Duo-Cotecxin
Co-Artesun
D-Artepp
Artemodi (Adults/Children)
Quinsunat
Macsunate FD (kid)
Arflo Quin
Lumiter
Artecom
Page VI
Page VII
Page VIII
Financing for malaria control has increased substantially over the last decade, facilitating significant
progress towards international targets for prevention and treatment. Increased coverage of at-risk
populations with vector control as well as effective case management with artemisinin combination
therapy (ACT) is contributing to substantial reductions in malaria cases and deaths. The spread of
artemisinin resistance in P. falciparum malaria parasites would threaten recent malaria control
progress across endemic countries.
Factors believed to be contributing to emerging drug resistance include the unregulated sale of
artemisinin monotherapies; limited access to ACTs; co-blistered ACTs that are not co-formulated
(facilitating continued use of artemisinin monotherapy); and ubiquitous counterfeit and substandard
drugs. Serious efforts to contain drug resistance are currently underway along the Cambodia-Thai
border.
The MARC is a comprehensive set of interventions, including prevention programs, increased testing
and treatment through public and non-governmental providers, and replacement of artemisinin
monotherapy in the private sector with ACT. PSI has received funding from UK Department for
International Development (DFID), the Bill and Melinda Gates Foundation (BMGF) and Good Ventures,
for Artemisinin Monotherapy Replacement Malaria Project (AMTR) for 3 years, to contribute to the
goal of the Myanmar Artemisinin Resistant Containment program (MARC). Within the MARC
framework, PSI will work with private sector suppliers and providers throughout Myanmar to rapidly
replace widely available artemisinin monotherapy with highly subsidized, quality assured ACTs. Broad
reaching behavior change communications (BCC) targeting both consumers and providers will support
supply chain activities and together will halt the spread of artemisinin resistance in the region.
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 is also collected.
To conduct this outlet study PSI/Myanmar adapted the ACTwatch Outlet Survey, one of the
components of the ACTwatch project. This report presents the results of a cross-sectional survey of
outlets conducted in Myanmar from March to May 2012.
A nationally representative sample of all private outlets with the potential to sell or provide
antimalarials to a consumer was taken through a census approach in 61 wards in the urban domain
and 65 village tracts in the rural domain, giving a total of 122 wards and 130 village tracts across
Myanmar including both the project intervention and control areas. The cluster was defined as wards
in urban and village tract in rural areas. Sampling was conducted using a two-stage probability
proportion to size (PPS) cluster design, with the measure of size being the relative cluster population.
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 are as follows: 1) private
health facilities, private clinics (may or may not be affiliated with a franchise network) and hospitals;
2) registered pharmacies; 3) itinerant drug vendors (hawkers); 4) general retailers (village stores,
groceries, and general stores); and 5) community health workers providing treatment outside of the
Page 1
Several validation and data checking steps occurred during and after data collection. Double data
entry was conducted using a CSPro database system designed with in-built checks for consistency and
range values. Verification of the first and second entries was done and corrections on mismatched
records done until a final verified data was achieved.
Data analysis was conducted in Stata 11.0 (Stata Corp College Station, TX) and included descriptive
summaries and comparisons between urban and rural, and intervention and controls areas.
Key findings
Data collection ran from the 1st March 2012 to 30th May 2012. A total of 3,746 outlets were
approached for inclusion in the study. 88 outlets were not screened for various reasons, including
temporarily closure of outlet and no appropriate person available for interview, and the remaining
3,658 outlets were screened. Among the 3,658 outlets, 1,359 were found stocking any antimalarials
on the day of interview (1256) or had stocked in the past 3-months (103). However, 85 outlets were
not interviewed for reasons such as no appropriate person available for interview or inconvenient
time for the full interview (53), not open at the time of return visits (10), and refused to participate
(22). A total of 1,274 outlets completed interviews: 92 outlets reported having stocked antimalarials at
any point in the three months period prior to the interview and 1,182 outlet reported stocking
antimalarials at the time of the interview.
Page 2
100
80
60
%
40
20
0
Private health facility Pharmacy Itinerant drug vendor General retailer Health worker
N=273 N=454 N=290 N=2,293 N=348
Private
facility
6%
Health
worker Pharmacy
27% 12%
Itinerant
drug vendor
24%
Retailer
31%
100
80
60
%
40
20
0
Private health Pharmacy Itinerant drug General retailer Health worker Total AM-outlets
facility N=342 vendor N=269 N=218 (1159)
N=194 N=136
Any ACT First-line quality assured ACT (FAACT)
Non artemisinin therapy Oral artemisinin monotherapy
Non-oral artemisinin monotherapy
AVAILABILITY OF DIAGNOSTIC BLOOD TESTING:
Among outlets stocking antimalarials in the past three months, availability of diagnostic blood testing
facilities was low (figure 4) except among health workers (70%) and private health facilities (54%).
Microscopic testing was rare; only 4% of private health facilities reported have microscopic testing
available.
Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests
100
80
60
%
40
20
0
Private health facility Pharmacy Itinerant drug vendor General retailer Health worker
N=213 N=353 N=177 N=308 N=223
PRICE OF ANTIMALARIALS: At the time of data collection health workers [n=219] reported providing
QAACT and chloroquine free of charge. The median price of one course of adult equivalent treatment
dose of QAACT in private health facilities was [n=115] 1,000 Kyats and 2,500 Kyats in general retailers.
Very few pharmacies and itinerant drug vendors stocked ACT and median price was not available from
them.
Figure 5. Median price of an AETD antimalarial treatment in the private sector
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
Privatefacility Pharmacy Itinerant drug General retailer Health worker ALL OUTLETS
(n=115; n=8; n=48) (n=11; n=89; vendor (n=12; n=49; (n=358; n=28; (n=506; n=186;
n=530) (n=10; n=12; n=37) n=279) n=47) n=941)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Private facility Pharmacy Itinerant drug General Retailer Health Worker TOTAL MARKET
vendor
Quality assured ACT (QAACT) Other ACT
Chloroquine Non-artemisinin therapy
Oral artemisinin monotherapy Non-oral artemisinin monotherapy
PROVIDER KNOWLEDGE:
Overall, 22% of providers interviewed were able to correctly state AL as the recommended first-line
treatment for uncomplicated malaria in Myanmar. Providers in private facilities and health workers
reported significantly higher knowledge than the retailers in pharmacies or itinerant drug vendors or
general stores.
100
80
%60
40
20
0
Private Facility Pharmacy Itinerant drug vendor General retailer Health Worker
N=213 N=353 N=177 N=308 N=223
PROVIDER PRACTICE:
The practice of cutting the strip and selling partial pack or individual tablets is more common at
pharmacies and general stores. Over 90% of the private health facilities and 80% of health workers
reported that they did not cut out blisters or sell partial doses.
Figure 9. Providers practice of not cutting blisters or selling partial packs in last month
100
90
80
70
60
50
40
30
20
10
0
Private health facility Pharmacy Itinerant drug General retailer Health worker
N=205 N=354 vendor N=299 N=239
N=169
Background
Overview of the Research Project
Artemisinin resistance
Financing for malaria control has increased substantially over the last decade, facilitating significant
progress towards international targets for prevention and treatment. Increased coverage of at-risk
populations with vector control as well as effective case management with artemisinin combination
therapy (ACT) is contributing to substantial reductions in malaria cases and deaths. The spread of
artemisinin resistance in P. falciparum malaria parasites would threaten recent malaria control
progress across endemic countries. Alternative antimalarial medicines with equivalent levels of
efficacy are not expected to become available for at least seven to eight years.
P. falciparum resistance to artemisinin derivatives has already begun to emerge; the first case was
confirmed in Cambodia, near the Thai border (Pailin province) in 2009. There is now evidence of
artemisinin-resistant P. falciparum parasites in southern Myanmar and along the Chinese-Myanmar
border. This pattern is alarming as it follows previous patterns of global diaspora of antimalarial drug
resistance (e.g. chloroquine resistance).
Factors believed to be contributing to emerging drug resistance include the unregulated sale of
artemisinin monotherapies; limited access to ACTs; co-blistered ACTs that are not co-formulated
(facilitating continued use of artemisinin monotherapy); and ubiquitous counterfeit and substandard
drugs. Serious efforts to contain drug resistance are currently underway along the Cambodia-Thai
border. However, unless artemisinin resistant malaria is also contained in Myanmar, there is a real
threat that resistant strains will develop and spread to sub-Saharan African. This represents an
imminent threat to Roll Back Malaria and Millennium Development Goal targets, potentially
undermining years of progress in malaria control and placing millions of lives at risk.
The early and correct treatment of malaria in Myanmar is constrained by limited access to high
quality, affordable health care, diagnostics and drugs. The private sector is well-placed to address the
Page 9
The private market for malaria treatment in Myanmar is highly centralized. A rapid supply chain
assessment conducted by PSI found that one company, AA Pharmaceuticals, dominates the market
and accounts for at least 70% of national sales. AA Pharmaceuticals provides AA Artesunate, a
monotherapy that was found to be the most common drug found at all levels of the supply chain.
The geographical area of eastern Myanmar with the highest burden of disease includes areas of the
country that are hard to reach and often politically sensitive. These combined factors cause constant
changes in accessibility. Based on key informant interviews and implementing partners who are
working in the areas, about 51 townships where around 38% of population is residing is inaccessible
due to security reason, and those areas will be excluded from the study.
Page 10
Intervention description
PSI has engaged the major private sector supplier of artemisinin monotherapy, AA Pharmaceuticals, in
an agreement to purchase highly subsidized, pre-packaged, quality-assured ACTs from PSI. This is
expected to rapidly replace artemisinin monotherapy in at least 70% of all private sector malaria
treatment providers in Myanmar. Approximately 9 million courses of ACT will be sold through AA
Pharmaceuticals over three years. PSI will complement this with a BCC campaign targeting providers
and consumers in high-risk eastern border areas. Communications will focus on the importance of
testing and the need to complete a full course of ACT.
As ACTs become widely promoted and accessible, ACT treatment for fever is expected to increase
among people living in project areas. The proportion of malaria cases treated with artemisinin
monotherapy in target areas is expected to decline to less than 10% in year 2 of the project. As a
result, parasite clearance rates at sentinel sites will hold steady or improve, indicating no spread of
resistance.
In 2008, Population Services International (PSI) in partnership with the London School of Hygiene and
Tropical Medicine (LSHTM) launched a five-year multi-country research project called ACTwatch. The
project is designed to provide a comprehensive picture of the antimalarial market to inform national
and international antimalarial drug policy evolution.
The methods used to measure availability, market share and price of ACTs and monotherapies for the
ACTwatch program, were then used for the independent evaluation of the AMFm project and will
continue to be used for the second phase of the ACTwatch program. These methods are being
employed here to monitor expected changes in the availability of ACTs among private sector outlets in
Myanmar as a result of the AMTR project. The survey will be repeated in July/August 2013, with
findings reported by January 2014.
This report presents the results of a cross-sectional survey of outlets conducted in eastern Myanmar
between March and May 2012.
Page 12
Myanmar, the largest country in mainland South-East Asia with a total land area of 676,578 square
kilometers, stretches 2200 kilometers from north to south and 925 kilometers from east-west at its
widest point. It is approximately the size of France and England combined. It is bounded on the north
and north-east by the People's Republic of China, on the east and south-east by the Lao People's
Democratic Republic and the Kingdom of Thailand, on the west and south by the Bay of Bengal and
Andaman Sea, on the west by the People's Republic of Bangladesh and the Republic of India.
Malaria remains a leading cause of morbidity and mortality in Myanmar. Considerable progress has
been made over the past 20 years in reducing the burden. However, the disease is still a priority public
health problem in the country. It is a re-emerging public health problem due to climatic and ecological
changes, population migration, development of multi-drug resistant P.falciparum parasite,
development of insecticide resistant vectors and changes in behavior of malaria vectors. Drug
resistant malaria has been detected along the international border areas particularly Myanmar Thai
border and in some pocket areas in other parts of the country. Emerging of resistance of Plasmodium
falciparum to artemisinin in Mon State, Tanintharyi and Bago Regions is seriously threatening the
progress in malaria control.
Myanmar Health Care System1
Myanmar health care system evolves with changing political and administrative system and relative
roles played by the key providers are also changing although the Ministry of Health remains the major
provider of comprehensive health care. It has a pluralistic mix of public and private system both in the
financing and provision. Health care is organized and provided by public and private providers.
In implementing the social objective laid down by the State, and the National Health Policy, the
Ministry of Health is taking the responsibility of providing promotive, preventive, curative and
rehabilitative services to raise the health status of the population. Department of Health one of 7
departments under the Ministry of Health plays a major role in providing comprehensive health care
throughout the country including remote and hard to reach border areas. Some ministries are also
providing health care for their employees and their families. They include Ministries of Defense,
Railways, Mines, Industry, Energy, Home and Transport. Ministry of Labour has set up three general
hospitals, two in Yangon and the other in Mandalay to render services to those entitled under the
social security scheme. Ministry of Industry is running a Myanmar Pharmaceutical Factory and
producing medicines and therapeutic agents to meet the domestic needs. The private, for profit,
sector is mainly providing ambulatory care though some providing institutional care has developed in
Yangon, Mandalay and some large cities in recent years. Funding and provision of care is fragmented.
1
Health in Myanmar 2012, Report of the Department of Health of the Republic of the Union of Myanmar
Page 14
Prevention and control of malaria by providing information, education and communication up to the
grass root level
Prevention and control of malaria by promoting personal protective measures and/or by introducing
environmental measures as principle methods and application of chemical and biological methods in
selected areas depending on local epidemiological condition and available resources
Prevention, early detection and containment of epidemics
Provision of early diagnosis and appropriate treatment
To promote capacity building and program management of malaria control program (human,
financial and technical)
To strengthen the partnership by means of intrasectoral and intersectoral cooperation and
collaboration with public sector, private sector, local and international non-governmental
organizations, UN agencies and neighboring countries
To intensify community participation, involvement and empowerment
To promote basic and applied field research
Page 15
Private Health facility (including private hospital, poly clinic, general practitioners clinic);
Health Workers providing treatment outside the public health facilities (Retired or currently
employed nurses, midwives, other community health workers and Sun Primary Health
workers are included);
Pharmacy;
Itinerant drug vendor (Informal health providers and travelling or mobile drug suppliers); and
General retailer (General store, villages stores and groceries)
A cluster sampling approach was adopted. All outlets found in a selected cluster were included in the
sample. Clusters were geographical areas such as wards and village tracts.
For subsequent surveys tracking changes from the baseline, all indicators will be reported separately
for intervention and control areas. Each of these areas will be further sub-divided into urban and rural
sites2, giving four domains in total: i) rural intervention areas; ii) rural control areas; iii) urban
intervention areas; iv) urban control areas. Sample size calculations were powered to detect changes
in indicators between baseline and follow up surveys, in each of these four domains.
Sampling frames of all townships included in the project areas (intervention) and non-project areas
(control) were developed3. Thirteen townships in each area were selected using PPS. In each selected
township, a sampling frame of wards and village tracts were then developed. Five wards and five
village tracts were then selected again using PPS4. If the selected township has only 4 wards then all 4
wards were selected. All the townships selected have at least 4 wards and 5 village tracts. A census of
all outlets in the private sector with the potential to sell or provide antimalarials to individuals was
conducted.
The sample size calculations were based on the need to estimate the proportion of outlets that sell
QAACTs, with the denominator being outlets that have stocks of any kind of antimalarials at the time
of the survey. Sample size calculations are based on the need to detect a future 15 percentage point
increase in QAACT availability, assuming a baseline estimate of 17%.
2
The program was designed in a way that BCC activities targeting the providers emphasizing the importance of RDT testing and completing
full course using medical detailing methodology will be focused at project areas, i.e., 92 townships in eastern part of Myanmar where
artemisinin drug resistance is highly suspected while distribution of subsidized quality assured ACTs are nationwide. Therefore, the impact of
the BCC activities (the changes in providers knowledge and attitude between intervention (92 townships) and control (i.e., other townships
outside of 92) will be measured in this study.
3
51 inaccessible townships were excluded from the sampling frame.
4
Data collection for the outlet survey occurs in the same clusters as those selected for the malaria household survey.
Page 16
3. Assuming the same sample size for the baseline survey, the required sample size for a single
domain was calculated using the following formula:
n=
(
Deff Z 1 2P(1 P) + Z 1 P1 (1 P1 ) + P2 (1 P2 ) )
2
( P1 P2 ) 2
where:
n = desired sample size for the baseline survey
P1 = the hypothesized value of the indicator at year 1 (time 1 or baseline survey) (17%)
P2 = the expected value of the indicator at year 2 (32%)
P = (P1+P2)/2 = 24.5
Z1- = the standard normal 1- quintile corresponding to an (type I) error with a one-sided test;
replace by /2 if a two-sided test is desired (1.64)
Z1- = the standard normal 1- quintile corresponding to the power of the test (0.84)
Deff = the design effect for cluster sampling (estimated at 2.5)
It was estimated that a sample of 277 outlets stocking any kind of antimalarial at the time of the
survey would be needed in each of the four domains, giving a total sample of 1108 outlets. Using the
assumption that 28% of outlets will stock any kind of antimalarials, a total of 3957 outlets were
screened.
Questionnaire
The outlet survey questionnaire comprised 3 modules: a screening module for all outlets; an audit
module (the antimalarial audit sheets and RDT audit sheets) for outlets with antimalarials in stock on
the day of interview; and a provider module for all eligible outlets, including those with no
antimalarials in stock on the day of interview but who had stocked antimalarials in the past three
months. Audit sheets were based on the Health Action International questionnaire for essential
medicines, developed with the World Health Organization.
The screening module was used to record the type and location of all outlets and to identify outlets
that were eligible for the audit and provider modules. The audit module was used to collect data
relating to each antimalarial product an eligible outlet had in stock on the day of interview. This
information came from the antimalarial packaging: brand name, generic name and strengths, package
type and size; and from provider recall: amount sold or distributed in the last 7 days, retail selling
Page 17
Paper questionnaires were administered during data collection. The questionnaire was finalised in
English and translated into local Myanmar language versions. During data collection, questionnaires
were administered in a local Myanmar language, with numbers recorded in their Arabic form (i.e. 1, 2,
3, etc). Prior to finalisation and training, the questionnaire was pilot-tested to assess the
appropriateness of question wording as well as to verify the skip patterns and interviewer instructions.
Page 18
Screening questions were used to ascertain inclusion of the outlet into the study; 1) Do you have any
antimalarial medicines in stock today? 2) Are there any antimalarial medicines that are out of stock
today, but that you stocked in the past 3 months? Outlets that did not have antimalarials on the day of
survey and/or have not had them in the three months preceding the survey do not meet the inclusion
criteria. For ineligible outlets information related to the outlet type and location was noted and the
interviewer continued to the next potential outlet.
For outlets that met the inclusion criteria, the field worker gave information on the study and asked to
the outlet owner (or the person at the outlet with most authority) to interview the main provider or
pharmacist, given this person is most likely to be able to provide reliable information related to
volumes and stock-outs. After obtaining agreement from the outlet owner, the interview took place
with the person recommended by the outlet owner as the most senior or main provider. If there were
multiple providers working in a single outlet, the main provider was asked to complete the interview
provided that he/she was 18 years and above. If he/she was unavailable, the next most senior
provider was invited for interview. Prior to administering the questionnaire, the provider5 was asked
to give informed verbal consent. Once consent had been given, the provider and audit modules were
administered. In case an outlet was closed or the provider was too busy, the interviewer arranged to
come back at another time. Up to one call back was made. Show cards were used to help identify the
interviewers and the providers the type of antimalarials.
Below are the inclusion and exclusion criteria for the study.
Research team
Five teams of field workers with permanent and part-time staff of PSI/Myanmar were formed to
collect data. Each team consisted of 2-4 members. Team leaders and assistant team leaders were
responsible for checking recorded information and ensuring that it was valid and correct during the
data collection, in addition to ensuring a full census of all outlets with a potential to sell antimalarials
was conducted. Supervision of the field work was provided by a project manager who oversaw quality
control.
5
Based on Rapid Assessment Supply Chain Study conducted in 2010 and 2011, it is anticipated that main providers/pharmacists are 18 years
old and above.
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Pilot study
A pilot study was conducted in clusters different from those selected for the study. The objectives
were to estimate the time taken to do the survey in an outlet, test the questionnaire and explore team
management and organization. The pilot would also identify and address any unanticipated challenges
for the full study. Verbal informed consent was obtained from all participants participating in pilot
test. The same procedure of administering verbal consent form was applied as the main study. The
pilot study was taken place after the training for a period of two days.
Data processing
Data were double entered into a CSPro database system designed with in-built checks for consistency
and range values. Verification of the first and second entries was performed, and corrections on
records that did not match done until a final consistent dataset was achieved.
Data analysis
Analysis Plan
Data analysis was conducted in Stata 11.0 (Stata Corp College Station, TX) and included descriptive
summaries and comparisons between urban and rural, and intervention and controls areas. Indicators
were also calculated by outlet type, as presented in this report. Survey settings and sampling weights
were used to account for the clustered design and to allow estimation of national estimates.
Indicators were calculated according to an analysis plan that defined numerators and denominators;
key indicators included availability of antimalarials, price of antimalarials, volumes of antimalarials
sold/distributed in the last one week, and knowledge and provider perceptions on antimalarial
treatment.
Stock-out information was collected through both the drug audit and provider interviews. For each
drug found in stock, providers were asked if the drug, specific to the brand, and dose, had been out of
stock at any point over the past three months. Providers were also asked to list all drugs that were not
currently in stock, but had been in stock during the previous 3 months. These two measures were
combined to calculate the proportion of outlets with a reported stock-out of at least one drug,
amongst those that had recently stocked such drugs (defined as stocking today or in the last 3
months). This information measures the ability of outlets to maintain supply rather than provide a
particular treatment at a given point in time.
Page 20
Classification of antimalarials
For the purpose of analysis, antimalarials were split into three policy-relevant categories: non-
artemisinin therapy, artemisinin monotherapy, and artemisinin combination therapy (ACT). ACTs were
further sub-divided as follows:
Page 21
A
Outlets enumerated*
[3,746] Eligible respondent not available, time
not convenient for interview, outlet not
Outlets not screened open at the time, outlet permanently
closed, or refused
[88]
B
Outlets screened
[3,658]
Outlets which did not
meet Screening criteria
[2,299]
C Outlets which met
screening criteria:
1=[1256] or 2= [103] Eligible respondent not available/Time [46]
not convenient for interview :
Outlets not interviewed
Outlet not open at the time : [10]
[85]
Other : [7]
D
Outlets interviewed** Refused : [22]
[1,274]
Outlets with no
antimalarials in stock
on day of visit
E Outlets with [92]
antimalarials
in stock on day of visit
[1,182]
1: Antimalarials in stock on day of visit ; 2: No antimalarials in stock on day of visit, but antimalarials in stock in previous 3 months
*Enumerated means were visited and filled in at a minimum basic descriptive information
** Interviewed means that final interview status was completed
Screening Criteria:
1: Antimalarials in stock on day of visit; 2: No antimalarials in stock on day of visit, but antimalarials in stock in previous 3 months
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% % % % % %
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Proportion of outlets that had: N=273 N=454 N=290 N=2,293 N=348 N=3,658
Antimalarials in stock at the time of 82.2 78.8 55.0 14.7 72.7 31.9
survey visit (71.7, 89.4) (64.5, 88.4) (46.1, 63.6) (9.8, 21.5) (63.3, 80.4) (27.7, 36.4)
Among outlets with an antimalarial in
N=194 N=342 N=136 N=269 N=218 N=1159
stock, proportion of outlets that had:
66.8 16.7 7.9 3.1 76.6 29.4
Any ACT
(55.2, 76.7) (9.3, 28.3) (3.2, 18.0) (1.2, 7.9) (68.7, 83.0) (23.2, 36.5)
54.6 7.0 7.7 2.8 76.1 27.2
Quality Assured ACT (QAACT)
(40.3, 68.2) (2.2, 20.1) (3.2, 17.8) (1.0, 7.9) (68.2, 82.5) (20.9, 34.5)
54.6 5.2 7.7 2.2 76.1 26.7
First-line (FAACT) (40.3, 68.2) (1.9, 13.4) (3.2, 17.8) (0.5, 8.3) (68.2, 82.5) (20.4, 34.1)
(6.3, 26.3) (6.1, 16.1) (0.0, 1.0) (0.1, 0.7) (0.7, 3.9) (1.8, 4.2)
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% % % % % %
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
Proportion of outlets that had: N=204 N=353 N=166 N=285 N=239 N=1247
No disruption in stock in the past 3 82.0 54.3 51.8 74.2 71.5 66.2
months among outlets that stock (75.6, 87.0) (46.2, 62.2) (40.6, 62.8) (66.0, 81.0) (62.6, 79.0) (60.9, 71.1)
any AM at the time of survey visit or
in the past 3 months
N=97 N=12 N=14 N=10 N=175 N=308
No disruption in stock of first-line
quality assured ACT (FAACT) in the
89.5 73.8 78.3 69.4 83.4 83.1
past 3 months, among outlets that
(81.3, 94.3) (31.6, 94.5) (39.7, 95.2) (16.2, 96.4) (75.0, 89.3) (75.5, 88.6)
have stocked FAACT in the past 3
months
N=156 N=281 N=63 N=167 N=150 N=817
6 20.5 26.2 22.2 17.4 39.6 25.9
Expired stock of any antimalarial
(8.0, 43.5) (14.3, 43.1) (10.5, 40.8) (9.5, 29.8) (26.6, 54.1) (19.2, 34.0)
N=91 N=10 N=10 N=9 N=152 N=272
Expired stock of first-line quality 13.4 47.5 37.2 34.8 31.3 29.7
assured ACT (FAACT) (3.2, 42.3) (18.5, 78.2) (8.4, 79.2) (10.0, 71.9) (20.7, 44.4) (20.3, 41.3)
N=199 N=354 N=150 N=289 N=216 N=1,208
Acceptable storage conditions for 93.5 87.1 91.6 87.1 91.1 89.6
7
medicines (82.7, 97.8) (80.8, 91.5) (861, 95.1) (78.9, 92.5) (85.0, 94.8) (85.4, 92.6)
6
Information on expired drug was missing for 30% of cases (n=342 missing cases). Missing values were particularly common for itinerant
drug vendors (54%; n=73 missing cases), then general retailers (38%; n=102 missing cases) and health workers (32%; n=68 missing cases)
7
Information on acceptable storage conditions was missing for 5% of cases (n=66 missing cases)
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Sulfadoxine-pyrimethamine 500 60 30 75 0 60
(SP) [500-500] (2) [51-60] (14) [0-150] (8) [60-150] (13) [0-500] (2) [30-150] (39)
8
A total of 3,206 antimalarials were found in 1,159 outlets. Of these, 1,930 antimalarials are included in the pricing analysis; price indicators
are based on tablet-formulation AETDs. Free antimalarials were found in 16% of outlets with antimalarials, and 510 of the 2,493
antimalarials for which price information was recorded were available for free.
9
Chloroquine was the most popular non-artemisinin therapy by volume sold/distributed in the past week. The market share for oral
artesunate was very similar to that for chloroquine and thus both are shown here as they could be considered equally popular.
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10
Minimum daily wage information taken from United States Department of State, 2010. Country Reports on Human Rights Practices.
Available at: http://www.state.gov/g/drl/rls/hrrpt/2010/index.htm.
Conversion to kyats at a rate of $1 = 870 kyats.
11
International reference price taken from Management Sciences for Health, 2010. International drug price indicator guide. Available at:
http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2010_en.pdf. $1.42 is the median listed supplier price for 24 tablets of AL
20mg/120mg.
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12
Information on proportion of providers that correctly state the recommended first-line treatment for uncomplicated malaria was missing
for 4 cases [n=1,270].
13
Information on proportion of providers that correctly state at least one health danger sign was missing for 2 of cases [n=1, 272].
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14
Information on indicator was missing for 14 cases [private health facility 2, pharmacy 2, and general retailer 10].
15
Information on indicator was missing for 35 cases [pharmacy 18, and general retailer 17].
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16
Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACTs and Non-quality Assured ACT; QAACTs decompose
fully into FAACTs and NAACTs; nationally registered ACTs are either QAACTs or non-QAACTs. Row and column totals exhibit minor rounding
errors.
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Artesunate Powder Injection 60mg Guilin Pharmaceutical Co., Ltd China Artesun /
60mg
Artesunate Powder Injection 60mg Guilin Pharmaceutical Co., Ltd China Artesunate for
Injection
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17
In total, 3,746 outlets were enumerated during data collection. 3,658 outlets were successfully screened, however the outlet classification was
missing for 6 cases and they are excluded from the breakdown presented here.
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today, but that you stocked in the past 3 months? study and gain consent.
Record start time in C10
No 0 and go to Q13a.
0,99 Go to C10 and
Dont know 99 complete Result of Visit,
then record details in
Ending the Interview.
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Time started
(use 24hr clock)
95:95 = NA [___|___]:[___|___] [___|___]:[___|___]
Time completed
(use 24hr clock)
95:95 = NA [___|___]:[___|___] [___|___]:[___|___]
Result
[___]
[___]
1 = Completed (Provider interview conducted) Go to E1
2 = Outlet does not meet screening criteria Go to E1
3 = Interview interrupted Go to C12 and note time convenient for call back
4 = Eligible respondent not available Go to C12 and note time convenient for call back
5 = Outlet not open at the time Go to C12 and note time convenient for call back
6 = Outlet closed permanently Go to E1
7 = Refused Go to C11
8 = Other (specify): [_________________]
Refusal / Appointments
C11. If the provider refused, why? Circle one answer.
1 = Client load Ask for a time provider would prefer to be interviewed, note in C12 and return at this time.
2 = Thinks its an inspection / nervous about license Go to E1
3 = Not interested Go to E1
4 = Refuses to give reason Go to E1
5 = Other (specify): Go to E1
C12. Interviewer: use this space to record any appointment that has been made for a call back to complete the interview
[___|___|___|___|___|___|___|___|___|___]
9999999995 = Not applicable/no respondent/no telephone 9999999997 = Refused
E3. Do you have any questions or comments for us? Record any questions or comments from provider.
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A1. Can you please show me the full range of antimalarials that you currently have in stock.
Do you currently have any of the following antimalarials in stock?
Prompt entire list using antimalarial prompt card. No response to be recorded.
The second pile should contain all the antimalarials in any form other than tablets, suppositories or
granules. Use the Non-Tablet Drug Audit Sheet to record these.
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Product 1. Generic name 2. Strength 3. Dosage form 4. Brand name 5. Manufacturer 5a. Country 6. Is this 6a.Does this
Number [___|___] of antimalari product have an
[___|___|___].[___]mg 1 = Tablet manufacture al expired? Padonma logo
[___|___] r (quality seal)?
[___|___] [___|___|___].[___]mg 2 = Suppository Do not write 1 = Yes 1 = Yes
[___|___] here 0 = No
0 = No
[___|___|__].[___]mg 3 = Granule 99 = Dont
know 6b. Does this
product have an
AMFm logo?
1 = Yes
[___|___] [___|___|___] 0 = No
7. Package size 8. Quantity in 9. Amount sold/distributed in the last 7 days 10a. Has this 10b. Within 11. Retail selling price 12. Wholesale purchase 12a. Comments
(Fill in number) stock (Record # of tins or packages described in Q7 OR record AM been the past 3 price
There are a total of (Record total # of the total # of tablets / suppositories / granule packs sold) stocked out in months, was [___|___|___] tablets, For the outlets most recent
packages or tins 9a. In total [___|___|___] packages or tins (or) the past 3 this drug out suppositories or granule wholesale purchase
[___|___|___|___] tablets described in Q7) [___|___|___] tablets, suppositories or months? of stock for packs cost an individual
/ suppositories / granule granule packs more than one customer [___|___|___|___] tablets,
packs in each (circle There are a total of week? suppositories or granule
type): [___|___|___|___] 9b. To individual consumers 1 = Yes Go to [___|___|___|___|___]Kyats packs cost
1 = Package packages / tins / [___|___|___] packages or tins (or) 1 = Yes Free = 00000;
10b
granule packs of [___|___|___] tablets, suppositories or granule packs Refused = 997/99997; [___|___|___|___|___]Kyats
2 = Pot/tin 0 = No
this antimalarial in 0 = No Go to Dont know = 998/99998
stock 99= Dont Free = 00000;
11
at this outlet. 9c. To small scale sellers know Refused = 9997/ 99997;
Refused = 9997; [___|___|___] packages or tins (or) 99 = Dont Dont know = 9998 / 99998
Dont know = [___|___|___] tablets, suppositories or granule packs know
9998 N/A = 995; Refused = 997; Dont know = 998 (Go to
11)
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Product 1. Generic name 2. Strength 3. Dosage 4. Brand name 5. 5a. Country 6. Is this
Number form Manufacturer of antimalarial
[___|___] [___|___|___|___].[___] mg manufacture expired?
[___|___] /[___|___|___].[___] mL 4= Syrup ere 1 = Yes
[___|___] 5 = Suspension 0 = No
[___|___|___|___].[___] mg 6 = Liquid 99 = Dont
[___|___] /[___|___|___].[___] mL Injection know
7 = Powder
[___|___|___|___].[___] mg injection
/[___|___|___].[___] mL 8 = Other
(specify)
[___|___] [______] [___|___|___]
6a.Does this 7. Package size 8. Quantity in 9. Amount sold / 10a. Has this 10b. 11. Retail selling price 12. Wholesale purchase price 12a. Comments
product have (Fill in number) stock distributed in the last 7 AM been Within the For the outlets most recent
an Padonma There are a total of (Record total # of days stocked out inpast 3 [___|___]bottles, wholesale purchase
logo (quality bottles or 9a. In total the past 3 months, ampoules or vials cost [___|___|___|___] bottles,
seal)? [___|___|___|___].[___]mL ampoules [___|___|___] bottles, months? was this an individual customer ampoules or vials cost
(or mg for powder injections) described in Q7) ampoules or vials drug out of [___|___|___|___|___] [___|___|___|___|___] Kyats
1 = Yes in each (circle type): stock for Kyats Free = 00000;
1 = Bottle There are a total of 9b. To individual 1 = Yes Go to more than Free = 00000; Refused = 9997/ 99997;
0 = No
[___|___|___|___] consumers one week? Refused = 97 / 99997; Dont know = 9998 / 99998
2 = Ampoule / Vial 10b
bottles / [___|___|___] bottles, Dont know = 98 /
ampoules of this ampoules or vials 0 = No Go to 1 = Yes 99998
6b. Does this Refused = 9997;
antimalarial in
product have Dont know = 9998 11 0 = No
stock at this
an AMFm
outlet. 9c. To small scale sellers 99 = Dont 99= Dont
logo?
[___|___|___] bottles, know (Go to know
1 = Yes 0 = No
Refused = 9997; ampoules or vials 11)
Dont know =
9998 N/A = 995
Refused = 997;
Dont know = 998
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Product Number 1. Brand name 2. Manufacturer 3. Country of 4. Amount sold / distributed / used in the last 7 days to
Manufacture individual consumers
(Record the total number of tests)
[___|___]
This outlet sold / distributed / used
[___|___|___|___] tests in the last 7 days
Refused = 9997; Dont know = 9998
[___|___|___] [___|___|___] [___|___|___]
Do not write here Do not write here Do not write here
5. Has this test been out 6. Retail selling price 7. Wholesale purchase price For the outlets most recent 8. Comments
of stock at any time over For 1 test, you charge wholesale purchase
the past 3 months?
[___|___|___|___] Kyats [___|___|___|___] tests cost
1 = Yes
Free = 0000; [___|___|___|___|___|___] Kyats
0 = No
Refused = 9997;
99 = Dont know Dont know=9998 Free = 000000; Refused = 999997; Dont know=999998
Product Number 1. Brand name 2. Manufacturer 3. Country of 4. Amount sold / distributed / used in the last 7 days to
Manufacture individual consumers
(Record the total number of tests)
[___|___]
This outlet sold / distributed / used
[___|___|___|___] tests in the last 7 days
Refused = 9997; Dont know = 9998
[___|___|___] [___|___|___] [___|___|___]
Do not write here Do not write here Do not write here
5. Has this test been out 6. Retail selling price 7. Wholesale purchase price For the outlets most recent 8. Comments
of stock at any time over For 1 test, you charge wholesale purchase
the past 3 months?
1 = Yes [___|___|___|___] Kyats [___|___|___|___] tests cost
0 = No
Free = 0000; [___|___|___|___|___|___] Kyats
99 = Dont know Refused = 9997;
Dont know=9998 Free = 000000; Refused = 999997; Dont know=999998
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Dont know 99
P18 (if above is 3 or 4, ask: Why do you
think it is not important to provide a test
[_______________________________]
for a person with fever before giving
malaria treatment?
P19 How confident are you that the results Very confident / RDTs always accurate 1
of rapid diagnostic tests for malaria are Somewhat confident / RDTs are 2
accurate give the correct diagnosis? sometimes accurate
Somewhat unconfident / RDTs are rarely 3
accurate
Very unconfident / RDTs are never 4
accurate 99
Dont know
P20 Are some antimalarial drugs are banned Yes 1
in Myanmar?
No 0 0,99
One response only. P22
Dont know 99
P21 Which antimalarial drugs are banned in
Myanmar?
[_________________________]
Looking for either Generic name or
Brand name. If Dont know, enter
[_________________________]
99 on the first line.
[_________________________]
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