Transcript Zambia Access To ACT Initiative Results of Public Pilot

Improving Patient Access
to Malaria Drugs in Zambia
Results of a Pilot Project
Partnership
DFID
The World
Bank
USAID
MOH
Crown Agents
John Snow
Inc.
Introduction
Why was the pilot designed?
Zambia has been successful in expanding access to preventive services
for malaria but treatment is lagging behind prevention efforts
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
% of children <5yrs
slept under ITN last
night
% househols
sprayed previous 12
months
% mothers who took
2+ doses of IPT
0
MIS 2006
MIS 2008
% children took
antimalarial within 24h
% children took Coartem
within 24h
MIS 2006
MIS 2008
Problem: Drugs are often times
unavailable in health facilities
• The baseline survey conducted in Dec/Jan 08/09 shows that
drugs were not available at the time of the visit:
– Pediatric ACT was unavailable in 40% of the facilities
– SP was unavailable in 55% of the facilities
– Amoxicillin was not available in 72% of the facilities
• Stock-outs on district level are less common indicating that
distribution from districts to health facilities is the main
bottleneck in the system
Unavailability of lifesaving drugs before the pilot
Dec 2008-Jan 2009
Quinine Tabs
0%
Quinine Injection
0%
8%
34%
33%
OralconF
41%
17%
CTX
45%
33%
Benzyl Penicillin
23%
DHO
50%
Amoxicillin Suspension
HF
72%
AL 4x6
0%
AL 3x6
0%
AL 2x6
0%
AL 1x6
0%
34%
34%
38%
42%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Improving access to essential drugs in
Zambia
Objective
Identify the most cost-effective way to improve the availability of
drugs through strengthening of the supply chain from district
to health facility
Approach
Pilot project that compares the effectiveness of two different
supply chain interventions to select one (or a
combination/variation) that can be rolled-out nationally
Design
Improving the overall supply chain
• The project was initially focused on malaria
drugs only
• To avoid a fragmented supply chain and
increase the impact of the pilot on health
outcomes the focus shifted from malaria
drugs only to all essential drugs
Distribution Structure before the pilot
72
district
stores
Approx.
1450
health
centers
2 Interventions Tested
Common design features for A & B systems:
• Commodity Planner (CP) dedicated to logistics based in District Health Office
(DHO)
System A:
• Health Facilities (HFs) place orders to DHO who places orders to MSL
• Kits are disaggregated into individual drugs at the central level and distributed
to the district store
• Districts are responsible for assembling orders for the health facilities and
transportation from district to health facility
System B:
• HFs place orders directly to MSL
• Kits are disaggregated at the central level and packed in sealed packages to
each individual facility
• Districts only responsible for transportation from district to health facility
System A
Commodity Planners
Commodity planner
Commodity planner
Commodity planner
Commodity planner
System B
Commodity Planner + Sealed Packages
Commodity planner
Commodity planner
Commodity planner
Pilot Evaluation Design
• Districts randomly selected from 54 peri-urban and rural
districts in Zambia
• Total of 24 districts: 8 districts for system A, 8 districts for
system B and 8 control districts
• Pilot implementation for a one-year period
• Baseline data collected in Dec-Jan 2008 and follow-up data
during the same period in 2009
District Selection
Results
Reduced Stockouts
in A System
SP
46%
Quinine Tabs
7%
Quinine Injection
16%
OralconF*
16%
Metronidazole
44%
Male Condoms
13%
Malaria RDTs
19%
DepoProvera*
A baseline
17%
CTX*
A endline
37%
Benzyl Penicillin Inj.
4%
Amoxicillin Suspension
31%
AL 4x6
41%
AL 3x6
22%
AL 2x6*
25%
AL 1x6*
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
*the reduction in stockout rate is statistically significant with respect to any observed change in control districts
Dramatically Reduced Stockouts in
B System
SP*
16%
Quinine Tabs*
12%
Quinine Injection*
3%
OralconF
7%
Metronidazole
42%
Male Condoms*
6%
Malaria RDTs
DepoProvera*
18%
B baseline
0%
CTX*
B endline
33%
Benzyl Penicillin
4%
Amoxicillin Suspension*
16%
AL 4x6*
12%
AL 3x6*
6%
AL 2x6*
7%
AL 1x6*
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
*the reduction in stockout rate is statistically significant with respect to any observed change in control districts
• Average decrease in stockout probability from
control to option B for pediatric ACT is 38
percentage points
Days of Stockouts for Malaria Drugs
reduced (Q4 2009=90 days)
40
35
30
25
Control
A
20
B
15
10
5
0
AL 1x6
AL 2x6
AL 3x6
AL 4x6
Malaria RDTs
SP
Far more people get their lifesaving
drugs in B districts
Share of population demand for lifesaving drugs
not met due to unavailability in Q4
Quinine Tabs
Quinine Injection
OralconF
CTX
Benzyl Penicillin
Amoxicillin Suspension
AL 4x6
AL 3x6
B
AL 2x6
A
AL 1x6
Control
0%
10%
20%
30%
40%
50%
60%
Average Reporting Rates
to MSL
100%
95%
90%
85%
Version A
80%
Version B
75%
70%
65%
60%
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Improved Storage Conditions in
intervention districts
Facility maximized storage potential
Adequate storage conditions
Appropriate fire safety equipment
Storage secured by lock and key
B Districts
A Districts
Control Districts
Medicines separated from insecticides and chemicals
Separated damaged or expired medicines
Commodities stored according to FEFO
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Impact on under five deaths
• Preliminary estimations show that currently
there are 200,000 children U5 per year with
malaria who visit a public health facility and
cannot be treated because the drugs are not
available
• With a nationwide scale up of model A this
number would be reduced to 100,000
• With a nationwide scale up of model B it
would be reduced to 40,000
Impact on under five deaths
• Preliminary calculations suggest that as a
result of the increase in access to one
drug(pediatric ACT) out of all essential drugs
– About 5600 under five deaths/year (18% of
malaria deaths) could be averted if the B system
was to be scaled up nationwide
• The benefits are much higher if stock improvements
of all drugs are taken into account
Costs of Improving the Supply Chain
• Cost-effectiveness analysis is currently being conducted
• A and B districts share the same cost structure for CPs
Operational Running Costs for
CPs/ district (gross)
Set-up costs (training of CPs,
laptop etc)
Total monthly running costs (CP
salary)
Total yearly running costs
ZMK
USD
13,250,000
2,650
6,900,000
1,380
82,800,000
16,560
• Additional Costs to B at the central level: 13 pickers and packers, 2 data clerks
taking orders from HF, 22 additional trips/month(because sealed packages take
more space), packing material and stationary for sealed boxes
Summary of Results
• System B performs significantly better than system A and control
districts
• There is a significant and large decrease in number of days of
stockouts in B districts compared to control
• Unmet demand is significantly lower in B districts compared to A
and control
• Reporting rates from district health officers to MSL have increased
during the pilot period for both A and B districts to nearly 100%
• Both A and B districts have significantly better storage conditions
than control districts after the pilot period
• Preliminary estimations for one drug show that the scale up of
system B has the potential to avert a large number of under-five
deaths
Next Steps
• Press Release of Results: April 20
• Cost-effectiveness analysis
• Technical Discussions on scenarios for scale-up
April 19-23
For more information, contact:
Monique Vledder
Senior Health Specialist
202-478-2518
[email protected]