Transcript Poster presentation

Investigating Competition & Regulation in the
Retail Market for Malaria Treatment
in Rural Tanzania
Goodman C1, Kachur SP2,3, Abdulla S2, Bloland P3, Mills A1
1London
School of Hygiene & Tropical Medicine
2Ifakara Health Research & Development Centre, Tanzania
3US Centers for Disease Control & Prevention
Tanzanian Antimalarial Drug Policy
• 1st line drug changed from Chloroquine to SP in 2001
• Plan to introduce Antimalarial Combination Therapy (ACT) as
1st line in health facilities in 2006
• ACT has high efficacy & provides rapid relief, but will increase
factory gate price of 1st line 10-20 fold
High Use of Retail Sector
Of those with fever, 29% visited a facility,
61% visited a shop
Objectives
Use an economic framework to assess:
• The operation of the retail market, & its impact on
accessibility, price & quality of fever/malaria treatment
• The capacity for regulation to counteract market
failures
• Potential points for policy intervention
• Implications for the implementation of ACT
Data Collection Methods
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•
•
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Census of all drug retailers
Semi-structured interviews
Structured survey
Antimalarial retail audits
IMPACT Study Sites
T A N ZA N IA
Morogoro
Morogoro
District
District
Rufiji
Rufiji
District
District
Kilombero
Kilombero
District
District
0
100
Ulanga
Ulanga
District
District
200
Kilometers
TANZANIA: Location of DSS Survey Sites in the
IHRDC / TEHIP / AMMP Collaborative Program
Typical Drug Retailers
Part II Drug Store
General shops &
stalls
Does the retail market ensure
high treatment accessibility?
Population ratios demonstrate relative accessibility of
retailers, especially general stores:
1 facility / 5416 people
1 drug store / 4570 people
1 general retailer selling drugs / 273 people
Important antimalarial source
Antimalarial Volumes by Source
(equivalent doses)
•Retailers accounted for 39% of
antimalarial volumes
•But % general stores stocking
antimalarials fell from 29% of
those stocking drugs in mid2000 to 14% in late-2001, as
chloroquine was withdrawn
Drug Shops,
34%
Private
Facilities, 20%
General Stores,
5%
Government
Facilities, 41%
Does the retail market ensure
low drug prices?
Ratio of Median Retail Price to International Reference Prices
(Nov/Dec 2001)
•Persistence of high &
variable retail markups
12
•1st
10.9
2nd
&
line unaffordable
to many
10
8
6.2
6.0
5.9
6
3.7
4
2.7
1.8
2
0.4
0
CQ
QN
AQ
Loose Tablets
SP
CQ
QN
AQ
SP
Packaged Tablets
Source for IRP: International Drug Price Indicator Guide, 2001, Median supplier price
Does the retail market ensure
high treatment quality?
Quantitative & qualitative evidence indicate that:
General stores compete on convenience:
•On average open 98 hours/week (cf 40 in Gov facilities)
•62% of population within 15 mins (cf 26% for Gov facilities)
Drug stores compete on drug availability:
•Stocked effective AMs when Gov facilities only had chloroquine
•Fewer stockouts of shorter duration than Gov facilities
Important quality problems persist:
•Over 30% SP samples of poor quality
•78% of tablets from retailers sold loose (not packaged)
•94% drug stores stocked prescription-only antimalarials
•SP child’s dose incorrectly specified by 58% drug store staff &
all staff in general stores stocking SP
Why are Markets Failing?
Weak price competition due to:
•
•
•
High concentration
Strong geographical market segmentation
Implicit collusion to avoid antagonising fellow traders?
Competition won’t ensure high quality if:
•
Quality is imperfectly observable
–
–
•
Drug quality
Staff expertise
Quality doesn’t reflect patient preferences
–
•
Demand for inappropriate prescription-only medicines
Consumers lack ability to pay
–
–
Demand for sub-therapeutic doses
Demand for antipyretics/painkillers only
Why is Regulation Failing?
General shops
• Minimal drug-related inspection
• Confusion over whether AMs are permitted
Drug Stores
• Regular inspections consume scarce resources but
have little impact on stocking of prohibited products or
staff qualifications
• Divergence between official regulations & locally
legitimised practice
• Lack of positive strategies to increase knowledge or
access to essential drugs
Widespread
Retail Sector
Malaria
Treatment
?
Introducing
Artemisinin-based
Combination
Therapy (ACT)
Implications for ACT
If only subsidised through facilities:
• Retail sector will still be widely used
• Majority of customers will use monotherapy or no
antimalarial
• Powerful incentive for leakage of ACT from the public
sector
If subsidised through the retail sector:
• Potential to double coverage?
• Cost would dramatically increase
• Cannot rely on retail competition to keep prices low,
nor ensure good drug quality & appropriate advice
A Potential ACT Retail
Sector Intervention
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•
•
•
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Pre-packaged ACT for OTC sale with clear labelling &
locally tested instructions
Single overbranded product, or limited number of qualitymarked brands
Subsidised at national or global level
Retail price maintenance by price labelling & consumer
campaign
For sale in drug shops, & general stores in remote areas
Mass media communication campaign
Positive role for regulators in improving knowledge &
encouraging regular stocking
Research Priorities
Drug policies are changing
now!
Ensure systematic evaluation of
• Impact of ACT in facilities on operation of the
retail market
• Impact of retail sector strategies on retailer &
consumer behaviour
• Comprehensive costing of retail sector
interventions
The Retail Sector
Important drug source
High risk for quality
Carefully consider the implications of
ALL drug policy decisions for retail
sector outcomes