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UPDATE ON TANZANIA’S PILOT
ACT SUBSIDY PROJECT
Roll Back Malaria 13th Board Meeting
29 November 2007
Addis Ababa
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Today’s presentation
Background and context
Results to date
Implications and areas for further exploration
Next steps and timeline
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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)
Source: Hetzel et al. BMC Public Health
Barriers to treatment access in the
private sector
• High cost of ACTs
• Continuing preference for
previously-used, ineffective antimalarials (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
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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.
2.
3.
4.
5.
Maximize benefits to patients
Ensure rapid initiation and implementation
Work at the behest of and in close collaboration with the government and other partners
Replicate normal supply chain processes and behavior
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
• Lead partners: TFDA and NMCP
• Manage relations with local
government
• Conduct dispenser training
Tanzania Pilot
ACT Subsidy
Project
• Implement in-country social marketing and
repackaging
• Build on lessons learned from ACT
repackaging/subsidy experiences in other countries
• Manage procurement of drugs and
implementation of supporting interventions
• Lead communication to global partners
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Three rural districts were selected as representative of socioeconomic
and malaria conditions in Tanzania and sub-Saharan Africa
Shinyanga Rural:
control
Maswa:
subsidy control
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
Kongwa:
price
intervention
• Absence of Accredited Drug
Dispensing Outlets (ADDOs)
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The project has three key components running simultaneously
Monitoring &
evaluation
Key activities
• Baseline survey of duka la dawa baridi and
public/NGO health facilities
• Ongoing monitoring of metrics including enduser price and anti-malarial volumes sold
Procurement
and
distribution
• 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
Supporting
interventions
• 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
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2
Pilot ACT
subsidy
project
3
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Drugs are distributed through two existing channels to the districts
– via a regional distributor or direct to retailer
ACT
Manufacturer
Clinton Foundation
ACTs
procured at
public sector
price
ACTs sold to
wholesaler at
90% subsidy
Wholesaler
Maswa District
Regional
Stock Point
“Direct”
Kongwa District
Regional
Distributor
“Indirect”
Trucks/bikes deliver
direct to shops
Regional
Distributor
“Indirect”
Regional
Stock Point
“Direct”
Shops pick up
drugs from
distributors
Drug
Shops
Trucks/bikes deliver
direct to shops
Drug
Shops
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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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Today’s presentation
Background and context
Results to date
Implications and areas for further exploration
Next steps and timeline
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Four different data collection methods are being employed to
ensure robust data capture
Metric
Exit
interview
• Types/brands of anti-malarials sold/stocked
(incl. subsidized product)
• Volume of subsidized ACT and other antimalarial 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

Mystery
shopper
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Retail Public/NGO
audit sector audit
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
100% =
Other
Quinine
458
343
5%
17%
4%
Subsidized ACT
1%
26%
4%
15%
Amodiaquine
64%
64%
SP
Nonsubsidized 1%
ACT +
monotherapy
2%
August
November
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… and children
Breakdown of products purchased in August vs. November
% of exit interviews purchasing for a child under 5
100% =
79
87
Other
1%
Quinine 1%
26%
Subsidized ACT
6%
90%
Amodiaquine
SP
57%
8%
August
11%
November
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Price paid for subsidized ACTs is in line with other commonlyavailable anti-malarials, and the SRP appears to be effective
Mean and standard deviation of price paid
% of adult exit interviews buying a full dose
Tanzanian Shillings
3,500
3,000
2,500
2,000
1,500
1,000
500
0
Subsidized ACT
SP
In the price intervention
district, the maximum price
paid did not exceed the
SRP of TSH 1200
AQ
Art. Monotherapy
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The majority of patients are getting a full course of anti-malarials
Share of patients purchasing a full dose
% of 440 exit interviews
Subsidized ACT
Any SP
Any AQ
81%
61%
84%
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The importance of shopkeeper recommendation is reinforced,
particularly for subsidized ACTs
Reasons for buying each drug
% of 443 exit interviews
Shopkeeper recommendation
Subsidized
ACT
Any SP
Any AQ
Prescribed
51
22
28
13
42
40
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Previous
use Most
effective
1
12
16
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Price
8
4
7
9
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There continues to be no consumers from the poorest
socioeconomic quintile purchasing anti-malarials in drugstores
Breakdown of consumers by SES: August vs. November
% of 608 (Aug.) and 443 (Nov.) exit interview customers
August
November
43%
33%
27%
28%
29%
28%
11%
1%
Quintile 2
“Poor”
Quintile 3
“Neither rich
nor poor”
Quintile 4
“Richer”
Quintile 5
“Richest”
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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
Percent of public/NGO health facilities reporting a stock out in last 3
months
% of 104 facilities surveyed
34%
Maswa
Kongwa
Shinyanga Rural
Maswa also has the
highest numbers of
consumers seeking antimalarial treatment in the
private sector
11%
21%
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Today’s presentation
Background and context
Results to date
Implications and areas for further exploration
Next steps and timeline
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The preliminary Month 1 findings from highlight potential areas for
further exploration on private sector treatment-seeking in general…
Area
Implication
Socioeconomic status
• Continuing lack of consumers from lowest SES quintile in
private sector drugstores  how can they be reached?
Access for children U5
• Drug shops seem not to be the preferred access point for
caregivers of children under 5
Drivers of product choice
• The importance of shopkeeper recommendation  how to
ensure appropriate knowledge and incentives?
Treatment-seeking in
public vs. private sectors
• The number of people seeking treatment in the private
sector may be linked to public sector ACT availability
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… and specifically on subsidized ACTs
Area
Implication
Pricing
• SRP adherence appears to be high, although price is lower
in the non-SRP district
Uptake and displacement
• 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
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Today’s presentation
Background and context
Results to date
Implications for global and national ACT subsidy efforts
Next steps and timeline
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The project will run for one full year, with quarterly procurement,
data collection and reporting
2007
June
2008
July
Aug.
Sept.
Oct.
Nov.
Month 1
data
collection
Selection +
contracting of
M&E and social
mkting orgs
Dec.
Jan.
Feb.
Q1 data
collection
Mar.
Apr.
May
Q2 data
collection
June
July
Aug.
Q3 data
collection
Sept.
Q4 data
collection
Selection +
contracting of
wholesaler
partner
Baseline data
collection
Q1 ACT
procurement
+ distribution
Q2 ACT
procurement
+ distribution
Q3 ACT
procurement
+ distribution
Q4 ACT
procurement
+ distribution
Supporting interventions – social marketing, marking of SRP
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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!
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