Madagascar Outlet Endline, ACTwatch 2011

Transcription

Evidence for Malaria Medicines Policy
Outlet Survey
Republic of Madagascar
2011 Survey Report
MINSTERE DE LA SANTE
PUBLIQUE
www.ACTwatch.info
Copyright © 2012 Population Services International (PSI). All rights reserved.
Acknowledgements
ACTwatch is funded by the Bill and Melinda Gates Foundation.
This study was implemented by Population Services International (PSI).
ACTwatch’s Advisory Committee:
Mr. Suprotik Basu
Mr. Rik Bosman
Ms. Renia Coghlan
Dr. Thom Eisele
Mr. Louis Da Gama
Dr. Paul Lalvani
Dr. Ramanan Laxminarayan
Dr. Matthew Lynch
Dr. Bernard Nahlen
Dr. Jayesh M. Pandit
Dr. Melanie Renshaw
Mr. Oliver Sabot
Ms. Rima Shretta
Dr. Rick Steketee
Dr. Warren Stevens
Dr. Gladys Tetteh
Prof. Nick White, OBE
Prof. Prashant Yadav
Dr. Shunmay Yeung
www.ACTwatch.info
Advisor to the United Nations (UN) Secretary General's Special Envoy for
Malaria
Supply Chain Expert, Former Senior Vice President, Unilever
Global Access Associate Director, Medicines for Malaria Venture (MMV)
Associate Professor, Tulane University
Malaria Advocacy & Communications Director, Global Health Advocates
Executive Director, RaPIDPharmacovigilance Program
Senior Fellow, Resources for the Future
Malaria Program Director, VOICES, Johns Hopkins University Centre for
Communication Programs
Deputy Coordinator, President's Malaria Initiative (PMI)
Head, Pharmacovigilance Department, Pharmacy and Poisons Board-Kenya
Chief Technical Advisor, ALMA
Vice-President, Vaccines Clinton Foundation
Senior Program Associate, Strengthening Pharmaceutical Systems
Program, Management Sciences for Health
Science Director, Malaria Control and Evaluation Partnership in Africa
(MACEPA)
Health
Economist
Deputy Director Country Programs, Systems for Improved Access to
Pharmaceuticals and Services, Management Sciences for Health
Professor of Tropical Medicine, Mahidol and Oxford Universities
Professor of Supply Chain Management, MIT-Zaragoza International
Logistics
Program
Paediatrician
& Senior Lecturer, London School of Hygiene and Tropical
Medicine(LSHTM)
The following individuals contributed as follows to the research study in Madagascar:
Iarimalanto Rabary
Director of Research Monitoring and Evaluation, PSI/Madagascar, assisted
with advocacy and survey implementation.
Jacky Raharinjatovo
ACTwatch Country Program Coordinator and Quantitative Research
Coordinator, PSI/Madagascar, was responsible for all aspects of
implementation and management of the survey.
Justin Rahariniaina
ACTwatch Research Supervisor, PSI/Madagascar, assisted the Country
Program Coordinator and was responsible for the coordination of trainings,
data collection, and data cleaning.
Sitraka Ramamonjisoa Quantitative Research Supervisor, PSI/Madagascar, assisted the Country
Program Coordinator and helped with training and data collection.
Andry Rabemantsoa
Senior Research Coordinator, Monitoring and Evaluation, PSI/Madagascar,
helped to manage communication.
Dr. Rova
Ratsimandisa
Malaria Treatment Coordinator, PSI/Madagascar, provided information on
the national malaria context and assisted with the training.
Arsène Ratsimbasoa
Deputy Director of NMCP, Ministry of Health Madagascar, contributed to
report writing and dissemination of findings.
Hellen Gatakaa
Senior Research Associate, ACTwatch Central, provided overall guidance on
the analysis and construction of indicators.
Julius Ngigi
Research Associate, ACTwatch Central, assisted with the field preparations,
and trained field workers.
Stephen Poyer
Research Associate, ACTwatch Central, conducted analysis of the data.
Dr. Kathryn O’Connell
Principal Investigator, ACTwatch Central, provided overall technical
guidance.
Tanya Shewchuk
Project Director, ACTwatch Central, provided overall oversight and
dissemination.
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The ACTwatch Group is comprised of the following individuals:
PSI ACTwatch Central
Tanya Shewchuk, Project Director; Dr. Kathryn O’Connell, Principal
Investigator; Hellen Gatakaa, Senior Research Associate; Stephen Poyer,
Illah Evance, Julius Ngigi, Research Associates; Linda K.Ongwenyi, ACTwatch
Project Assistant.
PSI ACTwatch
Country Program
Coordinators
Cyprien Zinsou, PSI/Benin; Sochea Phok, PSI/Cambodia; Dr. Louis Akulayi,
ASF/DRC; Jacky Raharinjatovo, PSI/Madagascar; Ekundayo Arogundade,
SFH/Nigeria; Peter Buyungo, PACE/Uganda; Felton Mpasela, SFH/Zambia.
LSHTM
Dr. Kara Hanson, Principal Investigator; Edith Patouillard, Dr. Catherine
Goodman, Benjamin Palafox, Sarah Tougher, Immo Kleinschmidt, coinvestigators. LSHTM is responsible for the supply chain research
component of ACTwatch.
The Independent Evaluator for the Affordable Medicines Facility-malaria Phase 1 Evaluation is
comprised of the following individuals:
LSHTM
Dr. Kara Hanson, Principal Investigator, Dr. Catherine Goodman, Sarah
Tougher, Dr. Barbara Wiley, Dr. Andrea Mann, co-investigators.
ICF International
Dr. Fred Arnold, Director, Dr. Yazoume Ye, Dr. Ruilin Ren, co-investigators.
Suggested citation:
ACTwatch Group, PSI/Madagascar and the Independent Evaluation Team. (2012) ACTwatch Outlet
Survey Report 2011 (Round 3). Endline Outlet Survey Report for the Independent Evaluation of Phase 1
of the Affordable Medicines Facility - malaria (AMFm), Madagascar. Antananarivo, Madagascar:
ACTwatch/PSI Madagascar.
ACTwatch Contacts
Madagascar
Mr. Jacky Raharinjatovo
ACTwatch Country Program Coordinator
Population Services International/Madagascar
Immeuble Fiaro Ampefiloha
BP 7748 Antananarivo
Madagascar
Phone: + 261 202262984
Email: [email protected]
ACTwatch Central
Dr. Kathryn O’Connell
ACTwatch Principal Investigator
Malaria & Child Survival Department
Population Services International
Regional Technical Office
P.O. Box 14355-00800 Nairobi, Kenya
Phone: + 254 20 4440125/6/7/8
Email: [email protected]
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Table of Contents
List of Tables .................................................................................................................. vii
List of Figures ................................................................................................................... x
Definitions ....................................................................................................................... xi
Classification of ACTs .................................................................................................... xiv
Classification of treatment for severe malaria ............................................................. xvii
Classification of RDTs .................................................................................................. xviii
List of Abbreviations ..................................................................................................... xix
Executive Summary ...................................................................................................... xxii
Overview of ACTwatch .................................................................................................. xxii
Overview of the independent evaluation process.......................................................... xxii
Endline outlet survey methods ..................................................................................... xxiii
Key findings from the outlet survey .............................................................................. xxiv
Key findings on AMFm implementation: process and key contextual factors .............. xxxiv
1.
Background ......................................................................................................... 36
1.1 Overview of ACTwatch and the AMFm phase 1 ........................................................ 36
1.1.1 ACTwatch Research Project ................................................................................... 36
1.1.2 AMFm phase 1 ...................................................................................................... 37
1.2 Overview of the AMFm Phase 1 Independent Evaluation (IE).................................... 38
1.3 Country background – context ................................................................................. 42
1.3.1 Overview of the country ........................................................................................ 42
1.3.2 Description of health care system .......................................................................... 43
1.3.2 Epidemiology of malaria ....................................................................................... 44
1.3.4 Antimalarial Policies and Regulatory Environment ................................................. 45
1.3.5 Malaria control strategy ....................................................................................... 45
1.3.6 Malaria financing.................................................................................................. 46
2.
Methods ............................................................................................................. 48
2.1 Outlet survey ........................................................................................................... 48
2.1.1 Outlet survey indicators ........................................................................................ 48
2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators ................................. 50
2.1.3 Sampling Approach ............................................................................................... 52
2.1.4 Data collection ...................................................................................................... 55
2.1.5 Data processing .................................................................................................... 57
2.1.6 Data analysis ........................................................................................................ 58
3.
Results- Outlet survey......................................................................................... 61
3.1 Characteristics of the sample ................................................................................... 61
3.2 Availability of antimalarial drugs .............................................................................. 99
3.2.1 Antimalarials in stock ............................................................................................ 99
3.2.2 Antimalarials in stock by type.............................................................................. 100
3.2.3 Stockouts of quality-assured ACTs ....................................................................... 107
3.2.4 Population coverage of outlets with quality-assured ACTs ................................... 108
3.3 Pricing of antimalarials (Affordability) .................................................................... 109
3.3.1 Cost to patients of antimalarials.......................................................................... 109
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3.3.2 Gross percentage markup between purchase price and retail selling price ........... 115
3.3.3 Availability and cost to patients of diagnostic tests (RDT/microscopy) ................. 121
3.4 Quality-assured ACTs market share ........................................................................ 126
3.5 Provider knowledge of first-line antimalarial treatment and ACT regimen .............. 129
3.6 AMFm logo ............................................................................................................ 133
4.
AMFm implementation: process and key contextual factors ........................... 142
4.1 Introduction ........................................................................................................... 142
4.2 Methods ................................................................................................................ 142
4.3 Findings.................................................................................................................. 142
4.3.1 Description of the AMFm implementation process ............................................... 142
4.3.2 Implementation of AMFm supporting interventions ............................................. 143
4.3.3 Key events and context ....................................................................................... 147
4.3.4 Conclusion .......................................................................................................... 147
5.
Summary of findings ......................................................................................... 150
5.1 Quality of data collected ........................................................................................ 150
5.2 Availability of quality-assured ACTs ........................................................................ 150
5.3 Pricing/affordability of quality-assured ACTs .......................................................... 151
5.4 Market share of quality-assured ACTs .................................................................... 151
6.
References ........................................................................................................ 152
7.
Acknowledgements .......................................................................................... 156
8.
Appendices ....................................................................................................... 157
8. 1 Questionnaire ....................................................................................................... 157
8.2 ACTs classified as quality-assured ........................................................................... 175
8.3 Final sample ........................................................................................................... 184
8.4 Survey team ........................................................................................................... 195
8.5 Description of outlet types visited for this survey ................................................... 196
8.6 Sampling weights ................................................................................................... 200
8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs) ................ 201
8.8 Nationally Registered ACTs ..................................................................................... 209
8.9 Child QAACTs ......................................................................................................... 214
8.10 RDT manufacturers submitting to WHO for product testing.................................. 215
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List of Tables
IE Tables
Table 2.1. 1: Primary AMFm indicators ....................................................................................... 48
Table 2.1. 2: Primary ACTwatch indicators .................................................................................. 49
Table 3.1. 1: Outlets enumerated by location, drugs stocked and final interview status Madagascar, 2011
.......................................................................................................................................... 93
Table 3.1. 2: Outlets enumerated* [Madagascar], 2011 .............................................................. 94
Table 3.1. 3: Outlets with antimalarials in stock* [Madagascar], 2011** .................................... 95
Table 3.1. 4: Number of products audited [Madagascar], 2011 ................................................... 96
Table 3.1. 5: Outlets with at least one staff member who completed secondary school or primary school
[Madagascar] 2011............................................................................................................. 97
Table 3.1. 6: Outlets with a staff member with a health-related qualification [Madagascar], 201198
Table 3.2. 1: Outlets with antimalarials in stock in [Madagascar], 2011 ....................................... 99
Table 3.2. 2: Outlets with non-artemisinin therapy in stock [Madagascar], 2011 ....................... 100
Table 3.2.3. a: Outlets with artemisinin monotherapy in stock (all dosage forms) [Madagascar], 2011
........................................................................................................................................ 101
Table 3.2. 3. b: Outlets with oral artemisinin monotherapy in stock [Madagascar], 2011 .......... 102
Table 3.2. 4: Outlets with non-quality-assured ACTs in stock [Madagascar], 2011 ..................... 103
Table 3.2.5. a: Outlets with quality-assured ACTs in stock [Madagascar], 2011 ......................... 104
Table 3.2.5. b: Outlets with quality-assured ACTs with and without the AMFm logo in stock
[Madagascar], 2011.......................................................................................................... 105
Table 3.2. 5. c: Public health facility outlets with quality-assured ACTs among ALL public health facilities
in [Madagascar], 2011 ...................................................................................................... 106
Table 3.2. 6: Outlets with stock-outs of quality-assured ACTs [Madagascar], 2011 .................... 107
Table 3.2. 7: Percentage of the population living in censused “sub-counties” with outlets with qualityassured ACTs in stock at the time of survey [Madagascar], 2011 ...................................... 108
Table 3.3. 1: Cost to patients of non-artemisinin therapy, in US dollars*, [Madagascar], 2011 .. 109
Table 3.3. 2: Cost to patients of artemisinin monotherapy, in US dollars*, [Madagascar], 2011 110
Table 3.3. 3: Cost to patients of non-quality-assured ACTs, in US dollars*, [Madagascar], 2011 111
Table 3.3. 4: Cost to patients of quality-assured ACTs, in US dollars*, [Madagascar], 2011 ....... 112
Table 3.3.5. a : Cost to patients of the most popular antimalarial in terms of national private for-profit
outlet sales volumes (chloroquine) for all dosage types, in US dollars*, [Madagascar], 2011 .... 113
Table 3.3.5. b: Cost to patients of the most popular antimalarial in terms of national private for-profit
outlet sales volumes (chloroquine) for tablets, in US dollars*, [Madagascar], 2011 .......... 113
Table 3.3.5. c: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes
for all outlet types (chloroquine) for all dosage types, in US dollars*, [Madagascar], 2011 114
Table 3.3. 5. d: Cost to patients of the most popular antimalarial in terms of national outlet sales
volumes for all outlet types (chloroquine) for tablets, in US dollars*, [Madagascar], 2011 114
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Table 3.3. 6: Gross percentage markup between purchase price and retail selling price of non-artemisinin
therapy [Madagascar], 2011 ............................................................................................. 115
Table 3.3. 7: Gross percentage markup between purchase price and retail selling price of artemisinin
monotherapy [Madagascar], 2011.................................................................................... 116
Table 3.3. 8: Gross percentage markup between purchase price and retail selling price of non-qualityassured ACTs [Madagascar], 2011 .................................................................................... 117
Table 3.3.9. a: Gross percentage markup between purchase price and retail selling price of qualityassured ACTs [Madagascar], 2011 .................................................................................... 118
Table 3.3. 9. b: Gross percentage markup between purchase price and retail selling price of qualityassured ACTs, by presence of the AMFm logo, [Madagascar], 2011 .......................................... 119
Table 3.3. 10: Median total gross markup between first-line buyer price and retail selling price of qualityassured ACTs bearing the AMFm logo, in US dollars, [Madagascar], 2011 ......................... 120
Table 3.3. 11: Availability of any diagnostic test for malaria, Madagascar, 2011 ........................ 121
Table 3.3. 12:Availability of malaria microscopy, Madagascar, 2011 ......................................... 122
Table 3.3. 13: Cost to patients of malaria microscopy in 2010 US dollars Madagascar, 2011 ..... 123
Table 3.3. 14:Availability of rapid diagnostic tests for malaria, Madagascar, 2011 ..................... 124
Table 3.3. 15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in 2010 US dollars Madagascar,
2011................................................................................................................................. 125
Table 3.4. 1:Percentage breakdown of antimalarial sales volumes by antimalarial type, Madagascar, 2011
........................................................................................................................................ 126
Table 3.4. 2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm
logo and QAACTs without the AMFm logo, [Madagascar], 2011 ....................................... 127
Table 3.4. 3: Percentage breakdown of antimalarial sales volumes by outlet type, [Madagascar], 2011
........................................................................................................................................ 128
Table 3.5. 1: Provider knowledge of first-line antimalarial treatment, [Madagascar], 2011 ....... 129
Table 3.5. 2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult.
[Madagascar], 2011.......................................................................................................... 130
Table 3.5. 3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child,
[Madagascar], 2011.......................................................................................................... 131
Table 3.5. 4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Madagascar],
2011................................................................................................................................. 132
Table 3.6. 1: Provider recognition of AMFm logo, [Madagascar], 2011 ...................................... 133
Table 3.6. 2: Provider knowledge of the AMFm logo [Madagascar], 2011 ................................. 134
Table 3.6. 3: Sources from which providers have seen or heard of the AMFm logo, [Madagascar], 2011
........................................................................................................................................ 135
Table 3.6. 4: Percentage of antimalarials bearing the AMFm logo, [Madagascar], 2011 ............ 136
Table 3.6. 5: Provider knowledge of the AMFm programme, [Madagascar], 2011 ..................... 137
Table 3.6. 6: Sources from which providers have seen or heard of AMFm [Madagascar], 2011 . 138
Table 3.6. 7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials
with the AMFm logo [Madagascar], 2011 ......................................................................... 139
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Table 3.6. 8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials
with the AMFm logo [Madagascar], 2011 ......................................................................... 140
Table 3.6. 9: Providers who have received training on antimalarials with the AMFm logo, [Madagascar],
2011................................................................................................................................. 141
Table 4.3. 1. Summary of key factors likely to have supported or hindered achievement of AMFm goals in
Madagascar ..................................................................................................................... 148
Table 8.2.1: List of Quality-Assured ACTs for availability, price and market share indicators...... 176
Table 8.3. 1: List of clusters/sub-districts sampled and their population, Madagascar, 2011 ..... 184
Table 8.4. 1: List of staff members involved in the survey, [Madagascar], 2011 ......................... 195
Table 8.7.1: AETD Calculation details by antimalarial type ........................................................ 203
ACTwatch Tables
Table A.1: Availability of antimalarials, by outlet type ................................................................. 63
Table A.2: Availability of antimalarials, by public health facility outlet type ................................. 65
Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type
.......................................................................................................................................... 66
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Table A.4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type ..... 68
Table A.5: Price of antimalarials, by outlet type .......................................................................... 69
Table A.6: Affordability of antimalarials, by outlet type .............................................................. 70
Table A.7: Availability of diagnostic tests, by outlet type ............................................................. 71
Table A.8:Price of diagnostic tests, by outlet type ....................................................................... 72
Table A.9: Availability of diagnostic tests, by public health facility outlet type............................. 73
Table A.10: Market share, by outlet type .................................................................................... 74
Table A.11: Provider knowledge, by outlet type .......................................................................... 75
Table A.12:Provider knowledge, by public health facility outlet type .......................................... 76
Table A.13: Provider perceptions, by outlet type ........................................................................ 77
Table A.14: Availability of antimalarials, by urbanicity ................................................................ 78
Table A.15: Availability of antimalarials among outlets stocking at least one antimalarial, by urbanicity
.......................................................................................................................................... 80
Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by urbanicity ..... 82
Table A.17: Price of antimalarials, by urbanicity .......................................................................... 83
Table A.18: Affordability of antimalarials, by urbanicity .............................................................. 84
Table A.19: Availability of diagnostic tests, by urbanicity ............................................................ 85
Table A.20: Price of diagnostic tests, by urbanicity...................................................................... 86
Table A.21: Market share, by urbanicity...................................................................................... 87
Table A.22: Provider knowledge, by urbanicity ........................................................................... 88
Table A.23: Provider perceptions, by urbanicity .......................................................................... 89
Table B.1: Market share by antimalarial category within each outlet type .................................. 90
Table B. 2: Market share by antimalarial category within urban and rural strata ......................... 91
List of Figures
Figure 1. Availability of antimalarials among all outlets, by outlet type ..................................... xxv
Figure 2. Outlet types stocking antimalarials............................................................................ xxvi
Figure 3. Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type
...................................................................................................................................... xxvii
Figure 4. Availability of non-artemisinin therapy, among outlets stocking at least one antimalarial, by
outlet type .................................................................................................................... xxviii
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Figure 5. Availability of treatment for severe malaria, among outlets stocking at least one antimalarial,
by outlet type.................................................................................................................. xxix
Figure 6. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic testsxxx
Figure 7. Median price of antimalarial treatment per AETD in the private sector, by outlet typexxxi
Figure 8. Market share of AETDs sold/distributed in the past week (7 days) within outlet typesxxxii
Figure 9. Market share of AETD sold/distributed in the past week (7 days) across outlet typesxxxiii
Figure 10. Provider knowledge of recommended first-line treatment and dosing regimens ... xxxiv
Figure 11: Timeline of key events related to AMFm implementation process and context in Madagascar
........................................................................................................................................ 149
Figure 1.2. 1. AMFm Phase 1 Results Framework ........................................................................ 39
Figure 1.2. 2: The Independent Evaluation Impact model ........................................................... 40
Figure 1.2. 3: The Independent Evaluation Design ...................................................................... 40
Figure 1.3. 1: Location of Madagascar......................................................................................... 42
Figure 1.3. 2: Geographical distribution of confirmed malaria cases (per 1000 population, Madagascar,
2010) ................................................................................................................................. 45
Figure 3.1. 1: Survey flow diagram, [Madagascar], 2011 ............................................................. 61
Definitions
Term
Definition
Adult Equivalent An AETD is the number of milligrams (mg) of an antimalarial drug needed to treat a
Treatment Dose 60 kg adult.
(AETD)
Antimalarial
Any medicine recognized by the WHO for the treatment of malaria. Medicines used
solely for the prevention of malaria were excluded from analysis of key indicators in
this report.
Artemisinin-based An antimalarial that combines artemisinin or one of its derivatives with an
Combination
antimalarial or antimalarials of a different class. Refer to Combination Therapy
Therapy (ACT)
(below).
Artemisinin
An antimalarial medicine that has a single active compound, where this active
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monotherapy
compound is artemisinin or one of its derivatives.
Artemisinin and its Artemisinin is a plant extract used in the treatment of malaria. The most common
derivatives
derivatives of artemisinin used to treat malaria are artemether, artesunate, and
dihydroartemisinin.
Booster Sample
A booster sample is an extra sample of units (in this case, outlets) of a type not
adequately represented in the main survey, but which are of special interest. In this
survey, all tertiary care, district/provincial level facilities, pharmacies and drug stores
(dépôt de médicament) were included in the administrative district of the sampled
commune. For smaller health facilities, simple random sampling informed the
selection: for each of the 28 rural communes 12 smaller health facilities per rural
district were selected; and in each of the 18 urban communes 16 smaller health
facilities per district were selected.
Cluster
The primary sampling unit, or cluster, for the outlet survey. It is an administrative
unit determined by the Ministry of Health (MOH) that hosts a population size of
approximately 10,000 to 15,000 inhabitants. These units are defined by political
boundaries. In Madagascar, they were defined as communes.
Censused
commune
A commune where field teams conducted a full census of all outlets with the
potential to sell antimalarials.
Child Equivalent
Treatment Dose
(CETD)
Combination
therapy
Dosing/treatment
regimen
Enumerated
Outlets
A CETD is the number of milligrams (mg) of an antimalarial drug needed to treat a 10
kg child.
First-line
treatment
Monotherapy
Nationally
registered ACTs
Non-artemisinin
therapy
Outlet
The use of two or more classes of antimalarial drugs/molecules in the treatment of
malaria that have independent modes of action.
The posology or timing and number of doses of an antimalarial used to treat malaria.
This schedule often varies by patient weight.
Outlets that were visited by a member of one of the field teams, and, at a minimum,
basic descriptive information was collected (sections C1-C9 of the outlet survey
questionnaire).
The government recommended treatment for uncomplicated malaria. Madagascar’s
first-line treatment for malaria is artesunate - amodiaquine, 50/153mg.
An antimalarial medicine that has a single mode of action. This may be a medicine
with a single active compound or a synergistic combination of two compounds with
related mechanisms of action.
ACTs registered with a country’s national drug regulatory authority and permitted for
sale or distribution in-country. Each country determines its own criteria for placing a
drug on its nationally registered listing.
An antimalarial medicine that does not contain artemisinin or any of its derivatives.
Any point of sale or provision of a commodity to an individual. Outlets are not
restricted to stationary points of sale and may include mobile units or individuals.
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Refer to Appendix 8.5 for a description of the outlet types visited for this survey.
Oral artemisinin Artemisinin or one of its derivatives in a dosage form with an oral route of
monotherapy
administration. These include tablets, suspensions, and syrups and exclude
suppositories and injections.
Quality-assured
Artemisinin-Based
Combination
Therapies
(QAACTs)
QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and
Malaria’s Quality Assurance Policy.
For the purpose of the Independent Evaluation, a QAACT is any ACT which appeared
on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality
assurance policy prior to baseline or endline data collection (see
http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General),
or which previously had C-status in an earlier Global Fund quality assurance policy
and was used in a program supplying subsidized ACTs.
At endline, QAACTs were defined as any ACT which appeared on the Global Fund’s
indicative list of antimalarials meeting its quality assurance policy as at September
2011, or which previously had C-status in an earlier Global Fund quality assurance
policy and was used in a program supplying subsidized ACTs.
Rapid Diagnostic Malaria rapid diagnostic tests, sometimes called "dipsticks" or malaria rapid
Test (RDT) for diagnostic devices, assist in the diagnosis of malaria by providing evidence of the
malaria
presence of malaria parasites in human blood. RDTs do not require laboratory
equipment, and can be performed and interpreted by non-clinical staff.
Screened
Screening criteria
Second-line
treatment
Sub-district (SD)
An outlet that was administered the screening questions (S1 to S4) of the outlet
survey questionnaire (see 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.
The government recommended second-line treatment for uncomplicated malaria.
Madagascar’s second-line treatment for malaria is quinine. Second-line treatment
includes all dosage forms.
The primary sampling unit, or cluster, for the outlet survey. It is an administrative
unit determined by the Ministry of Health (MOH) that host a population size of
approximately 10,000 to 15,000 inhabitants. These units frequently are defined by
geographical, health, or political boundaries, and are based around wards.
In Madagascar, they were defined as communes, which comprise a number of
fokantany.
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Classification of ACTs
1
Term
Quality-assured ACTs
[QAACTs]:
Definition
For the purpose of the Independent Evaluation, a QAACT is any ACT which
appeared on the Global Fund's Indicative List of antimalarials meeting the
Global Fund's quality assurance policy as at September 20111, or which
previously had C-status in an earlier Global Fund quality assurance policy
and was used in a programme supplying subsidised ACTs.
In Madagascar, the following quality-assured ACTs were found in outlets:
Artefan 20/120, AL, Ajanta Pharma Limited
Coartem 20/120, AL, Novartis Pharma
Coartem Dispersible 20/120, AL, Novartis Pharma
Lumartem, AL, 20mg/120mg, Cipla Ltd
ACTipal 50mg/153mg, ASAQ, Strides Arcolab Ltd.
ACTipal 25mg/67,5mg, ASAQ, Sanofi-Aventis
ACTipal 50mg/135mg, ASAQ, Sanofi-Aventis
Arsuamoon Adultes, ASAQ, 50mg/150mg, Guilin Pharmaceutical Co. Ltd
Artesunate + Amodiaquine [generic], ASAQ, 50mg/153mg, Ipca Ltd
Larimal (Junior), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
Larimal (Child), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
Larimal (Adult), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
Falcimon kit (Adulte), ASAQ, 50mg/153mg, Cipla Ltd
Falcimon kit (Enfant 7 à 13 ans), ASAQ, 50mg/153mg, Cipla Ltd
Falcimon kit (Enfant de moins de 6 ans), ASAQ, 50mg/153mg, Cipla Ltd
Coarsucam Infant, ASAQ, 25mg/67.5mg, Sanofi-Aventis France
Coarsucam Toddler, ASAQ, 50mg/135mg, Sanofi-Aventis France
Coarsucam Child, ASAQ, 100mg/270mg, Sanofi-Aventis France
Coarsucam Adults, ASAQ, 100mg/270mg, Sanofi-Aventis France
Winthrop Infant, ASAQ, 25mg/67.5mg, Sanofi-Aventis France
Winthrop Toddler, ASAQ, 50mg/135mg, Sanofi-Aventis France
Winthrop Child, ASAQ, 100mg/270mg, Sanofi-Aventis France
Winthrop Adults, ASAQ, 100mg/270mg, Sanofi-Aventis France
First-line, qualityassured ACTs
[FAACTs]:
Government recommended first-line ACTs (any ASAQ regardless of
strength) for uncomplicated malaria meeting the quality-assured
definition. A complete listing of these antimalarials is provided in the
appendices. In Madagascar, the following first-line quality-assured ACTs
were found in outlets:
ACTipal 50mg/153mg, ASAQ, Strides Arcolab Ltd.
ACTipal 25mg/67,5mg, ASAQ, Sanofi-Aventis
ACTipal 50mg/135mg, ASAQ, Sanofi-Aventis
Arsuamoon Adultes, ASAQ, 50mg/150mg, Guilin Pharmaceutical Co. Ltd
Artesunate + Amodiaquine [generic], ASAQ, 50mg/153mg, Ipca Ltd
Larimal (Junior), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
Larimal (Child), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General
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Larimal (Adult), ASAQ, 50mg/153mg, Guilin Pharmaceutical Co., Ltd
Falcimon kit (Adulte), ASAQ, 50mg/153mg, Cipla Ltd
Falcimon kit (Enfant 7 à 13 ans), ASAQ, 50mg/153mg, Cipla Ltd
Falcimon kit (Enfant de moins de 6 ans), ASAQ, 50mg/153mg, Cipla Ltd
Coarsucam Infant, ASAQ, 25mg/67.5mg, Sanofi-Aventis France
Coarsucam Toddler, ASAQ, 50mg/135mg, Sanofi-Aventis France
Coarsucam Child, ASAQ, 100mg/270mg, Sanofi-Aventis France
Coarsucam Adults, ASAQ, 100mg/270mg, Sanofi-Aventis France
Winthrop Infant, ASAQ, 25mg/67.5mg, Sanofi-Aventis France
Winthrop Toddler, ASAQ, 50mg/135mg, Sanofi-Aventis France
Winthrop Child, ASAQ, 100mg/270mg, Sanofi-Aventis France
Winthrop Adults, ASAQ, 100mg/270mg, Sanofi-Aventis France
Non-first-line, qualityassured ACTs [NAACTs]:
ACTs that are not the government’s recommended first-line treatment
for uncomplicated malaria, but which do meet the quality-assured
definition. A complete listing of these antimalarials is provided in the
appendices. In Madagascar, the following non first-line quality-assured
ACTs were found in outlets:
Coartem 20/120, AL, Novartis Pharma
Coartem Dispersible 20/120, AL, Novartis Pharma
Lumartem, AL, 20mg/120mg, Cipla Ltd
Non-quality-assured
ACTs:
ACTs that do not meet with the definition of being quality-assured.
In Madagascar, the following non-quality-assured ACTs were found in
outlets:
Amosunate, ASAQ, Adams Pharmaceuticals
Artecom, DHA-PPQ-Trim, Odypharm Ltd
Artediam, ASAQ
Artemodi, ASAQ, Holleypharm
Artrin, AL, Medreich Plc
ASAQ Denk, ASAQ, Denk Pharma
Asunate Denk Plus, AS-SP, Denk Pharma
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Other ACT Classifications
Child QAACTs
QAACTs in a combination of strength and pack size targeted at children.
A complete listing of these antimalarials is provided in the appendices. In
Madagascar, the following child QAACTs were found in outlets:
Artefan 20/120 5-14kg (Ajanta)
Coartem Dispersible 5-15kg (Novartis)
Lumartem 5kg to <15kg (Cipla)
ACTipal 25mg/67.5mg (Sanofi Aventis)
ACTipal 50mg/135mg (Sanofi Aventis)
ACTipal 50mg/153mg (Strides Arco Labs)
Artesunate + Amodiaquine Child 1-6 years (Ipca Laboratories)
Coarsucam Infant 2-11 months (Sanofi Aventis)
Coarsucam Toddler 1-5 years (Sanofi Aventis)
Falcimon Kit Young Children up to 6 years (Cipla)
Larimal Child 1-6 years (Ipca Laboratories)
Winthrop Infant 2-11 months (Sanofi Aventis)
Winthrop Toddler 1-5 years (Sanofi Aventis)
Nationally registered
ACTs:
ACTs registered with a country’s national drug regulatory authority and
permitted for sale or distribution in-country. Each country determines its
own criteria for placing a drug on its nationally registered listing. A full list
of nationally registered antimalarials can be found in the appendices. In
Madagascar, the following nationally registered drugs were found in
outlets:
ACTipal
Amosunate, ASAQ, Adams Pharmaceuticals
Arsuamoon, ASAQ, Guilin Pharmaceutical
Artecom, DHA-PPQ-Trim, Odypharm Ltd
Artediam, ASAQ
Coarsucam, ASAQ, Sanofi Aventis
Coartem Dispersible, AL, Novartis
Falcimon Kit, ASAQ, Cipla
Winthrop, ASAQ, Sanofi Aventis
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Classification of treatment for severe malaria
Term
Any treatment for
severe malaria
Definition
WHO recommends parenteral artesunate as first-line treatment in the
management of severe falciparum malaria in African children, with
artemether or quinine injections as acceptable alternatives if parenteral
artesunate is not available2.If complete treatment for severe malaria is
not possible, patients with severe malaria should be given pre-referral
treatment and referred immediately to an appropriate facility for further
treatment. The following are options for pre-referral treatment: rectal
artesunate, injectable quinine, injectable artesunate and injectable
artemether.
In Madagascar, the following treatments for severe malaria were in
outlets:
Injectable quinine
Injectable artemether
2
nd
Guidelines for the treatment of malaria, 2 edition – revision 1.WHO. Geneva: 2010.
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Classification of RDTs
Term
RDTs from a
manufacturer that has
submitted a product to
WHO Malaria RDT
Product Testing
Rounds 1-3
Definition
RDTs from a manufacturer that has submitted at least one product for
testing during rounds 1-3 of the WHO Malaria RDT Product Testing cycle
(2008-2011)3. A complete listing of these manufacturers is provided in the
appendices.
In Madagascar, products from the following submitting manufacturers
were found in outlets:
Access Bio, Inc.
Orchid Biomedical Systems
Standard Diagnostics, Inc. (now Alere Healthcare (Pty) Ltd)
Vision Biotech (Pty) Ltd. (now Alere Healthcare (Pty) Ltd)
RDTs from a
manufacturer that has
not submitted a
product to WHO
Malaria RDT Product
Testing Rounds 1-3
RDTs from a manufacturer that has not submitted a product for testing
during rounds 1-3 of the WHO Malaria RDT Product Testing (2008-2011).
In Madagascar, products from the following non-submitting
manufacturers were found in outlets:
Cypress Diagnostics
3
Malaria rapid diagnostic test performance summary results of WHO malaria RDT product testing: rounds 1-3 (2008-2011). WHO. Geneva: 2011.
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List of Abbreviations
English Abbreviations
-***
ACT
ACTipal
AETD
AL
AM
AMT
AMFm
ASAQ
CETD
CHAI
CHW
CI
CIA
CIERPA
CRDH
CQ
DCs
DfID
DHAP
DHS
DNDi
FAACT
FBO
FLB
GDP
GFATM
GPS
ICCM
IE
IEC
IMF
IPT
IQR
IRS
ITN
KAP
KII
LLIN
No data were available
Undefined ratio as a non-zero value is being divided by a value of zero
Artemisinin-based Combination Therapy
Socially marketed ACT, artesunate amodiaquine for children
Adult Equivalent Treatment Dose
Artemether-lumefantrine
Antimalarial
Artemisinin monotherapy
Affordable Medicines Facility – malaria
Amodiaquine and artesunate
Child Equivalent Treatment Dose
Clinton Health Access Initiative
Community Health Worker
Confidence Interval
Central Intelligence Agency
Centre International d'Études et de Recherches sur les Populations
Africaines
Centre de Recherche pour le Développement Humain
Chloroquine
Data Contributors
Department for International Development
Dihydroartemisinin-Piperaquine
Demographic and Health Surveys
Drugs for Neglected Diseases initiative
First-line, Quality-assured Artemisinin Combination Therapy
Faith-based organization
First-line Buyers
Gross domestic product
Global Fund to fight AIDS, Tuberculosis, and Malaria (Global Fund)
Global Positioning System
Integrated Community Case Management
Independent Evaluation/Evaluator
Information, Education and Communication
International Monetary Fund
Intermittent Preventive Treatment
Interquartile Range
Indoor Residual Spraying
Insecticide Treated Net
Knowledge, Attitude, and Practice
Key Informant Interview
Long-lasting Insecticidal Net
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LSHTM
mg
M&E
MICS
MIS
MOH
MOHFPSW
n/a
NAACT
nAT
NGO
NMCP
NMS
nQAACT
OTC
PDA
PMI
POP
PSI
PPS
QAACT
RDT
RFP
SD
SP
SIVs
TA
SOP
TERG
UN
UNDP
UNICEF
USD
WHO/AFRO
WHO
London School of Hygiene and Tropical Medicine
milligram
Monitoring and Evaluation
Multiple Indicator Cluster Survey
Malaria Indicator Survey
Ministry of Health
Ministry of Health, Family Planning and Social Welfare
Not applicable: Indicates ratios cannot be calculated as the numerator is
zero
Non-first-Line, Quality-assured Artemisinin-based Combination Therapy
Non-artemisinin Therapy
Nongovernmental organization
National Malaria Control Program
National Malaria Service
Non-Quality-assured Artemisinin-based Combination Therapy
Over the Counter
Personal Digital Assistant
President’s Malaria Initiative
Part one Pharmacies
Population Services International
Probability proportional to size
Quality-assured Artemisinin-based Combination Therapy
Rapid Diagnostic Test
Request for Proposal
Sub-district
Sulfadoxine-pyrimethamine
Supportive Interventions
Technical Assistance
Standard Operating Procedures
Technical Evaluation Reference Group
United Nations
United Nations Development Program
United Nations Children’s Fund
United States Dollar
World Health Organization/Africa region
World Health Organization
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French and Malagasy Abbreviations
AC
ASOS
CSB
DAM
DGILMT
DSME
EDS
INSTAT
MID
ONG
ONM
PNLP
SALFA
UGP
Agent Communautaire
Action Santé Organisation Secours (ONG)
Centre de Santé de Base
Direction de l’Agence des Médicaments
Direction de la Gestion des Intrants de Santé, du Laboratoire et de la
Médecine Traditionnelle
Direction de la Santé de la Mère et de l'Enfant
Enquête Démographique et de Santé
Institut National de la Statistique
Moustiquaires à Imprégnation Durable
Organisation Non Gouvernementale
Ordre National des Médecins
Programme National de Lutte contre le Paludisme
Sampan’Asa Loterana ho an’ny Fampandrosoana (Département pour le
Développement au sein de l’Eglise Luthérienne)
Unité de Gestion de Projets
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Executive Summary
Overview of ACTwatch
The ACTwatch Outlet Survey involves quantitative research at the outlet level in ACTwatch countries
(Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo (DRC)).
Other elements of ACTwatch research include Household Surveys, led by Population Services
International (PSI), and Supply Chain Research, led by the London School of Hygiene & Tropical Medicine
(LSHTM). This report presents the results of a cross-sectional survey of outlets conducted in Madagascar
between November 2011 and January 2012 and also serves as the endline for the Affordable Medicines
Facility – malaria (AMFm) Phase I Independent Evaluation.
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 are also collected. This report presents
indicators on availability, price, volumes, affordability in outlets and provider knowledge of
antimalarials.
Overview of the independent evaluation process
The independent evaluation is part of a multi-faceted monitoring and evaluation framework developed
for Phase 1 of the Affordable Medicines Facility – malaria (AMFm). It is intended to assess whether, and
to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent evaluation will
be summarized in a report to be considered by the Global Fund Board at the end of Phase 1.The four
main objectives of AMFm are: (i) to increase ACT affordability, (ii) to increase ACT availability, (iii) to
increase ACT use, including among vulnerable groups, and (iv) to “crowd out” other oral antimalarials by
gaining market share.
Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene and
Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently operational
Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and Zanzibar), and
Uganda). In addition, the Global Fund contracted with Data Contributors (DCs) that were responsible for
in-country fieldwork, data analysis and country reports. These institutions are Population Services
International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de Recherche pour le
Développement Humain (CRDH).
The ACTwatch Project (www.actwatch.info), which is part of PSI, was responsible for the work in Kenya,
Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health
Institute) and Zanzibar, through funding from both the Bill and Melinda Gates Foundation and the Global
Fund. This work was carried out as part of their existing portfolio and funding stream provided by the Bill
and Melinda Gates Foundation for work in Nigeria, Madagascar, and Uganda. DNDi subcontracted with
the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, to undertake the work in
Ghana. CRDH subcontracted with the Centre International d'Etudes et de Recherches sur les Populations
Africaines (CIERPA) to undertake the work in Niger.
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The IE is based on a non-experimental design with a pre- and post-test intervention assessment in which
each participating country is treated independently as a case study. In addition to measuring the
changes in key indicators pre- and post-intervention, the evaluation includes an assessment of the
implementation process and a comprehensive documentation of the context, both to inform
assessments about causality and to aid in generalizability to other contexts. The current report is based
on the endline assessment in Madagascar, conducted by PSI/ACTwatch. The results of the baseline
survey can be found in the Madagascar baseline report (ACTwatch, 2009) and for all pilots in the MultiCountry Baseline Report (Independent Evaluation Team, 2011). Analysis of changes between baseline
and endline outlet surveys will be presented in the Multi-Country Endline Report (forthcoming),
together with the data that the IE team has compiled from national household surveys. In addition,
country case studies on context/process were conducted by the IE, and these case studies are
summarized in the present report.
Endline outlet survey methods
A cluster sampling approach was used because there were no reliable lists of all outlets stocking
antimalarials. Clusters were sub-districts/communes, with an average of 10,000 to 15,000 inhabitants. In
Madagascar, 46 clusters (urban [18 clusters] and rural [28 clusters], were selected with probability
proportional to size (PPS)—a sampling technique in which the probability that a particular sub-district is
selected is proportional to its population size. The sample size was powered to detect a change of 20%
percentage points in availability of quality-assured ACTs between baseline and endline in rural and
urban areas.
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 were: 1) public health facilities
(government hospitals and health centres); 2) pharmacies (pharmacies licensed by the National Drug
Authority and Pharmacists’ Council) 3) drug stores (dépôt de medicament) (licensed by the National
Drug Authority and Pharmacists’ Council); 4) private health facilities (private clinics, private practices,
NGO health centres and dispensaries); 5) grocery stores (épicerie [small groceries], épi bars [small
groceries with bars] and épi gargotes [small groceries with food stalls]);6) Community health workers
(Agent de Santé à Base Communautaire and Agent de Vente à Base Communautaire); and 7) other
outlets (gargotes [food stalls with sit-down eating areas], bars, and other outlets).Refer to the Appendix
8.5 for definitions and numbers of each type of outlet included in the analysis.
A structured endline questionnaire was developed, which included questions to measure indicators for
the Independent Evaluation. Fieldworkers recorded the outlets’ basic details and then asked a screening
question about the availability of antimalarials to decide whether to proceed with the full interview or
not. The questionnaire was administered to a senior person at the outlet to collect data on outlet
identification, outlet characteristics, provider knowledge, antimalarials and rapid diagnostic tests (RDTs)
stocked and stock outs of quality-assured ACTs. They recorded information on “audit sheets” on all
antimalarials and RDT products stocked in terms of their price and volume sold in the past week. Data
quality control tools used in the field were based on those implemented by ACTwatch for the baseline
survey.
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The questionnaire was programmed into personal digital assistants (PDAs).To ensure a high level of data
quality, the DCs undertook data cleaning using a detailed guideline provided by the IE team and also
followed structured ACTwatch guidelines.
For the analysis, the ACTwatch team used a standardized tabulation plan for all ACTwatch tables
presented in this report and analysis “do files” in STATA, which produced all the required ACTwatch
indicators. In addition, the IE team provided a tabulation plan for all IE tables presented in this report,
and analysis “do-files” in STATA, which produced all the required indicators and automatically generated
the IE tables. All analysis was run using STATA version 11, recording results in a log file.
Key findings from the outlet survey
Data were collected between the 7th of November 2011 and the 7th of January 2012. A total of 10,723
outlets were approached. Of these, 682 outlets were not screened for various reasons: 13 providers
refused to be interviewed; 283 outlets were closed down permanently; 236 outlets were not open at the
time of the survey visit; in 139 outlets, providers were not available for interview at the time of the
survey visit; 11 providers were unable to be interviewed for other reasons. Overall, 10,041 outlets
agreed to participate in the ACTwatch outlet survey and were screened. Of these, 2,854 outlets met our
screening criteria; however, interviews could not be conducted for 48 outlets. Of the 2,806 interviews
conducted, 435 reported having stocked antimalarials at any point in the three months prior to the
interview and 2,371 outlets stocked antimalarials at the time of the interview.
AVAILABILITY OF ANY ANTIMALARIAL: Stocking rates of any antimalarial varied by outlet type. In the public/notfor-profit sector, 97% of public health facilities and 82% of private not-for-profit facilities had at least one
antimalarial in stock on the day of interview. Of community health workers, who according to government policy
may treat using antimalarials, 12% stocked an antimalarial. There was substantial variation in the private sector.
More than 71% of private-for-profit facilities, 93% of pharmacies and 96% of drugs stores, stocked antimalarials.
This is in contrast to 21% of general retailers (Figure 1).
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Figure 1. Availability of antimalarials among all outlets, by outlet type
100
80
60
%
40
20
0
N=642
N=802
N=38
N=1,482
N=84
Public health Community Private not TOTAL Public Private for
facility
health worker for profit HF
/ Not for
profit HF
profit
Public / Not for Profit Sector
N=77
N=393
N=8,005
Pharmacy
Drug store
General
retailer
Private Sector
N=8,559
N=10,041
TOTAL Private TOTAL All
outlets
TOTAL All
outlets
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OUTLET TYPES STOCKING ANTIMALARIALS: Figure 2 shows the relative distribution of all outlets that had
at least one antimalarial in stock. General retailers were the most common type of outlet stocking
antimalarials (grocery stores, bars, grocery bar, gargote and grocery-gargote), followed by community
health workers, public health facilities and then drug stores (dépôt de médicament).
Figure 2. Outlet types stocking antimalarials
Gargote , 0.14
Grocery-Gargote , 1.7
Grocery-Bar, 5.3
Bar, 0.27
PHF, 10.62
CHW (MOH), 6.49
CHW
(NGO), 4.83
Private not
for
profit, 1
Private Health
Facility, 1.83
Grocery Store , 60.26
Pharmacy, 1.35
Rural Pharmacy/Drug
Shop, 6.17
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AVAILABILITY OF DIFFERENT CLASSES OF ANTIMALARIALS: Among facilities that stocked antimalarials at any time
in the three months preceding the survey, overall QAACT availability in 2011 was 28%, and this was lower in the
private for-profit sector (9%) than in the public not for-profit sector (92%). However, there was considerable
variation within the private for-profit sector. QAACT availability was much higher in pharmacies (99%) than in
drug stores (56%) or private for-profit facilities (36%). In public health facilities that stocked antimalarials at any
time in the three months preceding the survey, QAACT availability was 94%. QAACT availability was also high
among community health workers (CHWs) (92%).
In public facilities and private for-profit health facilities and pharmacies, availability of QAACTs with and without
the AMFm logo was very similar, but in drug stores, availability of QAACTs with the logo was 51% compared with
only 12% for QAACTs without the logo.
Availability of ACTipal (artesunate-amodiaquine) is also presented in this report. ACTipal is an ACT subsidy
program that PSI has been operating in Madagascar since 2008 with distribution through CHWs and in the private
sector, pharmacies and depots (drug stores). ACTipal was available via 76% of community health workers stocking
antimalarials at any time in the three months preceding the survey. It was rarely available in other outlet types
(<16%), including pharmacies (0%) or drug stores (4%).
Figure 3. Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type
100
Quality Assured ACT (QAACT)
80
QAACT with AMFm logo
ACTipal
60
%
40
20
0
N=612
N=80
N=30
N=722
Public health Community Private not TOTAL Public
facility
/ Not for
profit
N=43
N=72
N=375
N=1,413
N=1,633
N=2,355
Private for
profit HF
Pharmacy
Drug store
General
retailer
TOTAL Private
TOTAL All
outlets
Private Sector
TOTAL All
outlets
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AVAILABILITY OF DIFFERENT CLASSES OF ANTIMALARIALS (continued) Among facilities that stocked
antimalarials at any time in the three months preceding the survey, overall non-artemisinin therapy availability in
2011 was 88%. There was variation in the availability of chloroquine and SP by outlet type, though stocking rates
of chloroquine were generally high in pharmacies, drug shops and retailers. Availability of treatment for severe
malaria is also shown in Figure 5.
Figure 4. Availability of non-artemisinin therapy, among outlets stocking at least one antimalarial, by outlet type
100
Any nAT
SP
CQ
80
60
%
40
20
0
N=612
N=80
N=30
N=722
N=43
Public health Community Private not TOTAL Public Private for
facility
/ Not for
profit HF
profit
N=72
N=375
N=1,413
N=1,633
N=2,355
Pharmacy
Drug store
General
retailer
TOTAL Private
TOTAL All
outlets
Private Sector
TOTAL All
outlets
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Figure 5. Availability of treatment for severe malaria, among outlets stocking at least one antimalarial, by outlet
type
100
Any severe malaria
treatment
Injectable quinine
80
60
%
40
20
0
N=612
N=80
N=30
N=722
Public health Community Private not TOTAL Public
facility
/ Not for
profit
N=43
N=72
N=375
N=1,413
N=1,633
N=2,355
Private for
profit HF
Pharmacy
Drug store
General
retailer
TOTAL Private
TOTAL All
outlets
Private Sector
TOTAL All
outlets
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AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: Of outlets stocking antimalarials in the last three months, 92% of
public health facilities reported offering any rapid diagnostic testing (RDT) services, and 73% of private-not-forprofit facilities offered RDTs. Availability of RDT services was less than 10% across all outlet types in the private
sector. Few facilities provide microscopic testing.
Figure 6. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests
100
Any diagnostic test
Rapid diagnostic tests
80
Microscopic blood tests
60
%
40
20
0
N=639
N=101
N=31
N=771
Public health Community
Private not TOTAL Public
facility
/ Not for
profit
N=49
N=73
N=387
N=1,526
N=2,035
N=2,806
Private for
profit HF
Pharmacy
Drug store
General
retailer
TOTAL Private
TOTAL All
outlets
Private Sector
TOTAL All
outlets
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PRICE OF ANTIMALARIALS: In the public and private not-for-profit sectors, the median QAACT price was USD 0.00,
reflecting the policy of free ACT provision. Pooling all sectors, the median price also remained at zero.
While data are not shown in this report for the 2010 findings of the outlet survey, it is important to note that the
median price of QAACTs in the private for-profit sector increased significantly between 2010 and 2011, from USD
0.14 to USD 0.67 per AETD. The 2010 price reflects the pediatric ACT subsidy program for ACTipal (artesunateamodiaquine) that PSI had been operating in Madagascar since 2008, with distribution through CHWs and in the
private sector, pharmacies and dépôts (drug stores).
The median price of non-quality-assured ACTs in the private for-profit sector was much higher than for QAACTs
(USD 9.36 versus USD 0.67).
The median price for a QAACT with the AMFm logo in private for-profit outlets (USD 0.51) was 1.6 times the median
price of the most popular non-QAACT (chloroquine, USD 0.32) in private for-profit outlets, whether this was
measured in tablet form or among all dosage types.
Figure 7. Median price of antimalarial treatment per AETD in the private sector, by outlet type
$10.00
Quality Assured ACT (QAACT)
QAACT with AMFm logo
$8.00
Chloroquine
$6.00
$4.00
$2.00
$0.00
Private for profit HF
Pharmacy
Drug store
General retailer
TOTAL Private
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VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: Overall market share of QAACTs was 21% in2011,
with nATS accounting for 79% of the overall market share. In the private for-profit sector, market
share of QAACTs was 22%. In public health facilities, QAACT market share was low (13%). Overall
market share of oral AMTs was zero. QAACTs with the AMFm logo accounted for 86% of all QAACTS
dispensed overall and 95% of all QAACTs dispensed in the private for-profit sector.
Figure 8. Market share of AETDs sold/distributed in the past week (7 days) within outlet types
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
PHF
CHW
Private
not for
profit
HF
PHF/NFP
Total
Public/Not for Profit sector
QAACT with logo
SP
Oral artemisinin monotherapy
Private Pharmacy Drug Shop
for profit
HF
General
Retailer
Private for profit
QAACT without logo
Chloroquine
Non-Oral artemisinin monotherapy
Private
Total
Total
Total
Other ACT
Other non-artemisinin therapy
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VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED :( continued) The private for-profit sector was
responsible for 70% of all antimalarials sold or distributed in 2011. Drug stores and retailers accounted for
over 50 % of the total volumes sold or distributed over the previous week.
Figure 9. Market share of AETD sold/distributed in the past week (7 days) across outlet types
100
80
60
40
20
0
Public/Not for Profit
Sector
Total Private
Private for profit
facility
Pharmacy
Drug store
General retailer
QAACTs
QAACTs with logo
non-QAACTs
SP in public sector
Non-artemisinin therapy
Non-oral artemisinin monotherapy
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PROVIDER KNOWLEDGE: Overall, 31% of providers were able to correctly state ASAQ as the recommended
first-line treatment for uncomplicated malaria in Madagascar. Knowledge was higher among providers at
public/not-for-profit outlets, compared to the private sector (77% vs. 18.5 respectively). Providers were more
likely to be able to correctly state the dosing regimen of ASAQ for a child versus an adult.
Figure 10. Provider knowledge of recommended first-line treatment and dosing regimens
100
80
60
%
40
20
0
N=639
N=101
N=31
N=771
N=49
Public health Community Private not for TOTAL Public / Private for
facility
health worker profit HF
Not for profit
profit HF
N=73
N=387
N=1,526
N=2,035
Pharmacy
Drug store
General
retailer
TOTAL Private
Private Sector
N=2,806
TOTAL All
outlets
Key findings on AMFm implementation: process and key contextual factors
AMFm implementation: Eight private sector FLBs were registered in Madagascar, all of whom placed
orders with manufacturers. The FLB for the public sector was the public sector procurement agency,
Unité de Gestion de Project (UGP). The first orders for copaid QAACTs were placed in September 2010
by a private for-profit FLB, with small quantities being delivered in October and December 2010 and
larger quantities in February 2011. A total of 14 months elapsed between the date the first drugs arrived
in Madagascar and the midpoint of fieldwork for the endline outlet survey. Supporting interventions
(SIs) started in January 2011, including a radio and TV campaign which began in April 2011, but
terminated in May 2011 because it was deemed to contravene the law prohibiting advertising of
prescription drugs to the general population. Training activities focused on doctors, paramedics, lab
technicians and CHWs, and an intervention involving medical detailer representatives. There was no
recommended retail price, only an agreement between the Global Fund and FLBs regarding a
‘reasonable margin’ of 150 ariary (or USD0.07) per dose to be added on average across the different
products. By the end of December 2011, a total of 1.2 million treatment doses had been received by
private sector FLBs and 489,000 by the public sector, amounting to only 0.08 treatments per capita,
about one treatment for every 12 people.
Context: ACTs did not have over-the-counter status in Madagascar, and their sale was not permitted in
general stores, however special dispensation was granted for distribution via trained CHWs. PSI had
been distributing subsidized pediatric ACTs via private retailers, and with a network of NGOs in
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Madagascar via trained CHWs, since 2008. IRS and mass distribution of LLINs were taking place.
Continued effects from the 2009 coup d’état led to political and economic deterioration
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1. Background
1.1 Overview of ACTwatch and the AMFm phase 1
1.1.1 ACTwatch Research Project
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 the
evolution of national and international antimalarial drug policy. The research is designed to detect
changes in the availability, price and use of antimalarials over time and between sectors, and to
monitor the effects of policy or intervention developments at country level.
ACTwatch addresses both the supply and demand side of the market. The supply side is evaluated by
collecting level and trend data on antimalarials and rapid diagnostic tests (RDTs) in public and private
sector outlets and wholesalers of antimalarial drugs. To evaluate demand, data are collected at the
household level on consumer treatment-seeking behaviour and knowledge. In combination, the
research components thread together the antimalarial market and consumer behaviour. Findings
can help determine where and to what extent interventions may positively impact access to and use
of quality-assured ACTs and RDTs as well as resistance containment efforts.
The project is being conducted in seven malaria-endemic countries: Benin, Cambodia, DRC,
Madagascar, Nigeria, Uganda and Zambia between 2008 and 2012. Countries were selected with the
aim of studying a diverse range of markets from which comparisons and contrasts could be made.
The research in Nigeria is planned as follows: three outlet surveys (2008, 2009 and 2011); supply
chain research (2009); and two household surveys (2009 and 2012).
This report presents the results of a cross-sectional survey of outlets conducted in Madagascar
between the 7th of November 2011 and the 7th of January 2012. Indicators to address the research
questions were developed in consultation with partners and the ACTwatch Advisory Committee.
Indicators were selected to provide relevant information for policy makers in relation to price,
availability, volumes, mark-ups and treatment seeking behaviour, including type of treatment and
source. While baseline data were collected prior to the Affordable Medicines Facility – malaria
AMFm Phase 1 Independent Evaluation, data were retrospectively analysed to produce indicators to
inform the evaluation. For the endline evaluation, the ACTwatch questionnaire was adapted to
include specific AMFm indicators. The Independent Evaluator provided technical oversight on the
analysis presented in this report, to ensure that results are aligned as far as possible with the AMFm
indicators. The 2011Madagascar Outlet Survey is being employed as part of the baseline for the
Independent Evaluation of the AMFm Phase 1, and also represents the endline survey (Round 3)
results as part of the ACTwatch Project.
www.ACTwatch.info
1.1.2 AMFm phase 1
The success of malaria control efforts depends on a high level of coverage and use of effective
antimalarials such as artemisinin-based combination therapies (ACTs). Although these antimalarials
have been procured in large amounts by countries, evidence suggests that ACT use still remains far
below target levels. Reasons suggested for the low uptake of ACTs include interruptions in public
sector supply; limited availability outside major urban centers; the high prices of the drugs,
particularly in the private sector; lack of provider adherence to new recommendations; and patient
self-treatment with other more common and cheaper antimalarials (Sabot, Mwita et al. 2009).
Lowering the cost of ACTs to the end user through a subsidy mechanism could be an effective way to
increase their uptake (Arrow 2004).
In response to this issue, the Affordable Medicines Facility – malaria (AMFm) hosted by The Global
Fund to Fight AIDS, Tuberculosis and Malaria (GFATM, or the Global Fund) was set up. As described
by Adeyi and Atun (Adeyi and Atun 2010), AMFm is a financing mechanism designed to incorporate
three elements: (1) price reductions through negotiations with ACT manufacturers ; (2) a buyer
subsidy, via a co-payment at the top of the global supply chain by AMFm on behalf of eligible buyers
from the public, private for-profit and private not-for-profit sectors; and (3) support for
interventions to promote appropriate use of ACTs. Examples of these “supporting interventions”
include training providers and outreach to communities to promote ACT utilization. AMFm is being
tested in a first phase that includes 9 pilots in 8 countries: Cambodia, Ghana, Kenya, Madagascar,
Niger, Nigeria, Tanzania (mainland and Zanzibar) and Uganda.
It is expected that in the last quarter of 2012, the Global Fund Board will make a decision regarding
the future of the AMFm on the basis of evidence gathered during Phase 1 regarding progress toward
achieving its four stated objectives: (i) increased ACT affordability, (ii) increased ACT availability, (iii)
increased ACT use, including among vulnerable groups, and (iv) “crowding out” oral artemisinin
monotherapies, chloroquine and sulfadoxine-pyrimethamine by gaining market share. The AMFm
Phase 1 Independent Evaluation has been commissioned to address the need for evidence to base
the Global Fund Board decision.
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1.2 Overview of the AMFm Phase 1 Independent Evaluation (IE)
Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene
and Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently
operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and
Zanzibar), and Uganda)4. In addition, the Global Fund contracted Data Contributors (DCs) to be
responsible for in-country fieldwork, data analysis and country reports. These institutions are
Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de
Recherche pour le Développement Humain (CRDH). PSI was responsible for the work in Kenya,
Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health
Institute) and Zanzibar. PSI's ACTwatch Project (www.actwatch.info) has contributed evidence for
the baseline work in Nigeria and Madagascar, which was conducted prior to the IE surveys. DNDi
subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi,
to undertake the work in Ghana. CRDH subcontracted with the Centre International d'Etudes et de
Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.
The purpose of the IE is to assess how AMFm has evolved in each pilot, and estimate changes
between the baseline and endline surveys in the values of key measures (availability, price, market
share and use of quality-assured ACTs) to inform decisions regarding the future of AMFm beyond
Phase 1. The IE is based on the AMFm (Phase 1) Monitoring and Evaluation (M&E) Results
Framework, with a focus on Outputs and Outcomes (Figure 1.2.1).
4
In March 2011 the AMFm Ad Hoc Committee decided to removeCambodia from the evaluation due to the lack of an eligible ACT for
subsidy.
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Figure 1.2. 1. AMFm Phase 1 Results Framework
ACTs: Artemisinin-based combination therapies; IEC: Information Education and Communication; GF: Global Fund, AMTs:
Antimalarial Treatment; SP: Sulfadoxine-pyrimethamine, CQ: Chloroquine; TA: Technical Assistance, SIVs: Supporting
Interventions
Source: Global Fund, AMFm Phase 1 Monitoring and Evaluation Framework, 2009
The IE is therefore designed to answer four questions related to the availability, affordability, market
share and use of ACTs. These questions are formulated as follows:
1. Has the AMFm mechanism helped increase the availability of quality-assured ACTs to
patients across public, private for-profit and not-for-profit sectors, in rural/urban areas?
2. Has the AMFm mechanism helped to reduce the cost of quality-assured ACTs to patients at
public, private for-profit and not-for-profit outlets in rural/urban areas to a price comparable
to the price of most popular antimalarials?
3. Has the AMFm mechanism helped increase use of quality-assured ACTs, including among
vulnerable groups, such as poor people, rural residents and children?
4. Has the AMFm mechanism helped increase the market share of quality-assured ACTs
relative to all antimalarial treatments in the public, private for-profit and not-for-profit
sectors in rural/urban areas?
To answer these questions, building on the AMFm results framework, the IE impact model (Figure
1.2.2) foresees that subsidizing ACTs, accompanied by effective supporting interventions, will lead to
a decrease in the ACT price. It is therefore anticipated in the model that if ACT price decreases, more
outlets will be willing to stock the product and thereby increase availability. The increase in
availability and the substantial decrease in price will potentially lead to an increase in use.
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Figure 1.2. 2: The Independent Evaluation Impact model
Price reductions
through
negotiations
with
manufacturers,
a subsidy in the
form of a buyer
co-payment,
and supporting
interventions
ACT Price
Decreased
Inputs, Process
ACT
Availability
Increased
Outputs
ACT
Access and
Use
Increased
Malaria
Burden
Decreased
Outcomes
Impact
While an evaluation based on a quasi-experimental design would have provided stronger evidence
to attribute any change in primary outcomes to the intervention, it is challenging to execute such a
study design for an evaluation of a complex public health program such as the AMFm, which is
implemented on a national scale with multiple players. The IE therefore uses a pre- and posttest/intervention design (Figure 1.2.3) in which each participating country is treated independently
as a case study. As the literature suggests for the evaluation of such a complex intervention(Habicht,
Victora et al. 1999; Craig, Dieppe et al. 2008; World Health Organization 2009; Adeyi and Atun 2010),
in addition to measuring the changes in key indicators pre- and post-intervention, the evaluation
includes an assessment of the implementation process to determine whether any lack of impact
reflects implementation failure or genuine ineffectiveness. It also includes comprehensive
documentation of context both to inform assessments about causality and to aid in generalizability
to other contexts.
Figure 1.2. 3: The Independent Evaluation Design
Baseline
Assessment
ACT
availability, price,
market share and use
Intervention
(Financing platform in place and
functional)
Endpoint
Assessment
ACT
availability, price,
market share and use
The evaluation, therefore, includes two major components: (1) a pre- and post-intervention study of
key outcomes through outlet surveys and use of secondary household survey data, and (2)
documentation of key features of the context at baseline and endpoint, and the implementation
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process in each pilot. The descriptions of context and implementation process provide the
information needed to interpret the changes in outcomes over the implementation period, and to
judge whether any observed changes are likely due to AMFm.
The evaluation is based on primary data collected from outlet surveys conducted at baseline and
endline (for questions related to availability, affordability and market share of ACTs); secondary data
from national household surveys (for question related to use of ACT), such as Demographic and
Health Surveys (DHS), Malaria Indicators Surveys (MIS), Multiple Indicator Cluster Surveys (MICS)
and ACTwatch household surveys; in-depth interviews with key stakeholders involved in the drug
supply chain in the country; and review of documents such as reports from AMFm operations
research, malaria treatment guidelines, pharmacy regulations, country-level reports from MOH and
donor partners, including national malaria control strategy documents, results from national
surveys, and any other documents relevant to the context data described above.
For each country, relevant indicators will be computed for the baseline and endpoint from the outlet
surveys. For secondary data from existing national household surveys, appropriate indicators will be
extracted from existing reports. To assess change, the IE will calculate the percentage point change
or the percent change (whichever is relevant for each indicator) between the baseline and the
endpoint. Contextual information will then be processed to help in the interpretation of these
results.
Pilot-specific case studies will be produced, making use of the qualitative and quantitative
approaches described above, to document and describe how the AMFm has evolved in each country.
The evaluation will distinguish two parts: (i) the upstream part, with emphasis on the business model
of the AMFm as a financing platform; and (ii) the downstream part, with emphasis on service
delivery to increase access to and use of ACTs, including by poor people. In the case studies, findings
from nationally representative outlet surveys will be compared before and after the introduction of
the AMFm, taking into account relevant contextual information and results from operational
research that become available to help learn how and why the new model unfolds in a variety of
contexts, while drawing lessons that can help future operations.
While this section gives an overview of the IE to provide the reader with the relevant context, this
report presents the country process, context and results of the endline outlet survey for
Madagascar. This is Step 3of a four-step process.Step 1included the baseline outlet survey and the
ACTwatch Madagascar country-specific baseline report. Step 2 integrated these results into a “Multicountry Baseline Report,” produced by the Independent Evaluation Team. Findings from this endline
outlet survey will be used to inform Step 4, the development of the full AMFm Phase 1 Independent
Evaluation report, which will include results from all operational phase 1 pilots, to be submitted to
the Global Fund.
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1.3 Country background – context
1.3.1 Overview of the country
Madagascar is the world’s fourth largest island and is located in Southern Africa, in the Indian Ocean,
east of Mozambique (Central Intelligence Agency 2011). In 2010, the population of Madagascar was
approximately 20.7 million (United Nations Population Division, 2010). Results from the 2005 DHS
show that approximately 25% of the population resides in urban areas and 75% in rural areas
(Institut National de la Statistique and ICF Macro, 2005), and the average density of the population is
21 per km2.
Generally, the climate of Madagascar is subtropical, with a hot and rainy season between November
and April, and a cooler dry season from May to October. The climate of Madagascar is tropical along
the coast, temperate inland and arid in the south. The east coast receives the most rain and is also
prone to cyclones between February and March. Temperatures are much cooler in the highlands and
can be as low as 4 degrees Celsius. Average temperature ranges in Antananarivo are from 9 to 20
degrees Celsius in July to 16 to 27 degrees Celsius in December.
There are three official languages in Madagascar: Malagasy, French and English. There are a variety
of dialects within the nation, but Malagasy is the common spoken language. Malaria is known locally
as “tazo” or “tazomoka”.
Figure 1.3. 1: Location of Madagascar
Source : http ://www.hoveraid.co.uk/news2.html
From the 1970s until the mid-1990s, Gross Domestic Product (GDP) growth in Madagascar averaged
only 0.5 percent while the population grew at about 2.8 percent per annum. Per capita income
declined from US$473 in 1970 to US$410 in 2008, placing Madagascar among the world’s poorest
countries (World Bank, 2010). According to the 2005 DHS, more than two-thirds of the population
(69%) lives below the poverty line (INSTAT and ICF Macro, 2005). The poverty rate in rural areas is
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significantly higher than in urban areas. The 2009 Human Development Index ranked Madagascar
145th out of 182 countries (United Nations Development Program2010).
Since February 2009, Madagascar has been in the throes of a political crisis which has led to a
further decline in economic growth and job losses. A large fraction of official aid, representing 40
percent of Madagascar’s budget and 75 percent of the investments, remains on hold (International
Monetary Fund, 2010). Economic growth in Madagascar collapsed to just 0.6 percent in 2009, from 7
percent in 2008. This led to a decline in the delivery of social services, including health care and
significant cuts in the public investment program.
Administratively, Madagascar is divided into 6 provinces. In turn, each province is subdivided into
regions, and each region into districts. In addition to these administrative units, each district is
subdivided into communes. Communes are further divided into fokontany, the smallest
administrative unit. A commune is a combination of 6 to 20 fokontany.
1.3.2 Description of health care system
The government is in the process of decentralizing to give more decision-making power to
communes and fokontany. The health system has four distinct functional levels: central, regional,
district and community. The public sector is considered a major source of health care in Madagascar,
especially in rural areas, where it accounts for more than 70% of primary contacts. In urban areas, it
is estimated that fewer than 40% of primary contacts occur in the public health facility (President’s
Malaria Initiative, 2011). Health facilities in the public sector are composed of138 hospitals; 1,335
level 2 health centers (Centre de Santé de Base 2), which are staffed by doctors; 1,059 level 1 health
centers (Centre de Santé de Base 1), which do not have any doctors on staff; and 14,989 community
health workers (CHWs). Community-based delivery through CHWs has historically been an important
distribution channel for antimalarials in Madagascar. For example, from 2005 and 2008, CHWs
distributed an estimated 600,000 treatment doses annually. ACTs have been made widely available
via public health facilities since 2007.
Madagascar also has a significant private sector, which forms an integral part of the health system.
There are 44 hospitals, 724 private or religiously affiliated health centers and more than 1,500
doctors. There is also a private pharmaceutical sector with a network of 22 pharmaceutical
wholesalers, 200 pharmacies and more than 1,000 rural drug stores (depot de Médicament). The
private sector also includes providers that have little or no qualifications (and are not authorized to
dispense medicines) such as grocery stores, for which data suggest that 30% stock antimalarials
(ACTwatch, 2009).
In the public sector, the central medical store, Centrale d’Achats de Médicaments Essentiels et
Générique, called SALAMA, is the only wholesaler importing and distributing drugs and medical
equipment. Public health facilities are either provided with drugs directly through SALAMA, or
through district public sector pharmacies (which receive medicines directly from SALAMA). Public
health facilities are supplied twice in a year, with the exception of facilities that are not accessible
during the rainy season.
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Antimalarials are a notable exception to this system of procurement, as only quinine is available
through SALAMA. ACTs do not go through SALAMA and are instead procured and managed by the
Principal Recipient of the Global Fund and then make their way to health facilities via the National
Malaria Service (NMS).
The private, not-for-profit health facilities working with community health workers utilize the same
system as the public sector, under a program developed by the MOH which aims to make ACTs
continuously available. In the private, for-profit sector, distribution channels for ACTs are different
but complementary.
In September 2008, a socially-marketed co-blister pack of artesunate+amodiaquine (AS+AQ) for
children under five was launched under the name ACTipal. ACTipal is subsidized nationwide and
open to all national-level wholesaler buyers (registered or not) in the country. At the time of the
survey, there were two ACTipal products on the market: Infants from 2 to 11 months, and Child from
1 to 5 years. The original recommended retail price for both ACTipal products, which was printed on
the packing, was 100 Ariary (about $0.05 USD). ACTipal is not classified as an over-the-counter drug
and may not be sold through unregistered outlets. Distribution channels include CHWs, pharmacies
and drug stores (Dépôt de Médicament). In November 2010, after the field work for this study was
completed, ACTipal was rebranded, through distinct packaging, as ACTipal artesunate amodiaquine
Winthrop for pharmacies and medical stores and has a recommended retail price at 200 Ariary. The
recommended retail price for the community level remained at 100 Ariary. Sales in 2009 totaled
519,808 doses and in 2010, 396,470 doses.
Private health facilities are supplied by 33 wholesalers. Most are concentrated in the capital (22
wholesalers). These wholesalers import pharmaceutical products (including generic and branded
products). The source of supply to grocery stores is unknown.
1.3.3 Epidemiology of malaria
Malaria epidemiology varies across the country. Transmission is stable and perennial on the west
and east coasts; seasonal and moderately unstable with occasional epidemics in the central
highlands; and seasonal and very unstable in the south. Malaria transmission occurs all year round in
the north of the country. Three quarters of the population lives in low-transmission areas which are
prone to epidemics and 25% live in areas of high risk (World Health Organization 2010a).
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Figure 1.3. 2: Geographical distribution of confirmed malaria cases (per 1000 population, Madagascar, 2010)
Source: World Malaria Report, 2010
1.3.4 Antimalarial Policies and Regulatory Environment
In 2006, the National Malaria Control Program (NMCP) adopted artesunate amodiaquine
combination therapy (ASAQ) as the first-line treatment for uncomplicated malaria to be made
available free of charge in public health facilities. The second-line treatment is artemetherlumefantrine (AL) with oral quinine as the alternative. Quinine is recommended for the treatment of
severe malaria.
At the community level, antimalarials require medical prescription and do not have over-the-counter
(OTC) status. In addition to the public sector and community health workers, antimalarials can also
be stocked by pharmacies and drug stores (Dépôt de Médicament) that are legally registered with
government authorities as per the 1980 Malagasy public health code. These outlets are obliged to
prominently display their registration certificates and numbers.
Despite the policy change in 2006 from chloroquine to ASAQ as the national first-line treatment, as
of late 2010 the government had still not signed into law a mandate to ban chloroquine from the
market.
1.3.5 Malaria control strategy
The National Malaria Control Strategy tailors prevention and treatment interventions to regions of
the country according to epidemiological risk. Interventions include indoor residual spraying; long
lasting insecticidal net (LLIN) distribution through antenatal clinics, immunization visits, large-scale
campaigns, and social marketing; intermittent preventive treatment for pregnant women; and case
management using parasitological diagnosis in health facilities and clinical diagnosis and RDTs at
community-level.
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The reported number of outpatient malaria cases decreased from an average of 1.6 million in the
period 2000–2004 to 299,094 in 2009, a reduction of 81%. Inpatient malaria cases decreased by 69%
and deaths by 75% in the same period (WHO, 2010a). Some of the decline in reported cases and
deaths may be due to incompleteness of reporting in 2009: a WHO-sponsored rapid impact
assessment in 2010 in district hospitals found a decrease of 34% for inpatient malaria cases and 66%
for inpatient malaria deaths in 2009 compared to the 2001–2004 period (figures cited in WHO,
2010a). It may also be due to the introduction of policy to implement parasitological diagnosis in
public health facilities.
The national programme distributed nearly 6.2 million LLINs during 2007–2009, covering almost 57%
of the population at risk, and applied IRS protecting 6.9 million people at risk (35%) in 2009
(Ministère de la Santé Publique 2009). The 2008 DHS estimated that 59% of households had an ITN
(INSTAT and ICF Macro 2009).
According to national policy, consultation and treatment of uncomplicated malaria in children is to
be provided in public health facilities free of charge. Since mid-2009, the first-line treatment (ASAQ)
has been available in a co-blistered form to public health facilities and CHWs. In 2009, the national
programme delivered 398,413 treatment courses of ACTs but there have been some reports of
challenges in managing stocks to ensure continuous availability at the health facility level.
In May 2010, Madagascar signed a grant agreement with the Global Fund on the Affordable
Medicines Facility – malaria (AMFm). Orders for 556,000 treatments were placed by the end of 2010
with the first ACTs delivered in October 2010, after the field work was completed for this survey in
June 2010. In June 2010, a training of trainers on AMFm was organised and from July onwards,
private practitioners were trained on malaria case management as part of AMFm supporting
interventions.
Parasitological diagnosis of fever is of increasing importance in Madagascar in the context of scaled
prevention efforts. Training by the NMCP on use of rapid diagnostic tests (RDTs) began in 2005, and
microscopy capabilities have been strengthened through increased human resources and training in
the public and private sectors. At the CHW level, presumptive treatment is generally employed in
endemic areas but it is anticipated that RDT use will expand to this level. This follows the launch of
RDT pilots at the end of 2009, and a subsequent directive from the MOH in 2010 permitting RDTs at
the community level. In 2010, efforts were being made to better coordinate the approach at the
community level as there were conflicting messages as to whether CHWs may use RDTs.
1.3.6 Malaria financing
Malaria control financing in Madagascar is almost entirely from external sources (WHO, 2010a).
Funding for malaria control has increased every year, from around US$25 million in 2008 to over
US$104 million in 2010, mainly from the Global Fund, the PMI, United Nations agencies, and other
bilateral agencies.
The National Malaria Control Program has received Round 4 funding from the Global Fund at the
level of $13 million (2009), $7 million (2010), $12 million (2011), $37 million (2012, expected).Round
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7 grants total $12 million (2009), $13 million (2010), $22 million (2011) and $9 million (2012,
expected). In May 2010, Madagascar signed a Global Fund grant for AMFm for 2 years: providing an
additional$1.4 million in 2010 and $760,000 in 2011.
As one of 15 PMI countries, Madagascar received $16.7 million in 2009; $33.9 million in 2010, and a
further $28.8 million was allocated for fiscal year 2011. Although direct support to the government
of Madagascar was suspended following the coup in 2009, PMI has continued to support malaria
control through its international and local partners. PMI funds prevention interventions including
LLIN distribution and promotion of LLIN use, indoor residual spraying and promoting malaria in
pregnancy interventions through awareness-raising and education at the community level. As part of
integrated community case management (iCCM) of children under 5, PMI funds RDTs and ACTs for
community health workers.
Between 2007 and 2009, UNITAID donated more than $5 million to fund ACT procurement.
Madagascar is a World Bank Booster Programme country with funding of $100,000 in 2010 and
2011. World Bank and UNITAID funds were put on hold during the political crisis.
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2. Methods
2.1 Outlet survey
2.1.1 Outlet survey indicators
The following table shows the AMFm Phase 1primary indicators to be measured through the outlet
survey, and presented in this report. Results are presented by urban and rural locations and
nationally. They will also be presented by outlet type (though there may not be sufficient power to
detect statistical differences between outlet types).
Table 2.1. 1: Primary AMFm indicators
Availability indicators
1.1
Proportion of censused outlets that have any antimalarials in stock at the time of survey visit in rural and urban areas
1.2
Proportion of outlets that have non-artemisinin monotherapy or non-artemisinin combination therapy in stock among
outlets with any antimalarials in stock at the time of survey visit in rural and urban areas
1.3
Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in stock at the time
of survey visit in rural and urban areas
1.4 Proportion of outlets that have non-quality-assured ACTs in stock among outlets with any antimalarials in stock at the time of
survey visit in rural and urban areas
1.5 Proportion of outlets that have quality-assured ACTs in stock at the time of survey visit among outlets with any antimalarials
in stock at the time of survey visit in rural and urban areas
1.6 Proportion of outlets with antimalarials in stock at the time of survey visit that have been out of stock of quality-assured ACTs
for at least 1 day in the last 7 days in rural and urban areas
1.7 Proportion of the population living in a “sub-district” where there is at least one outlet that had a quality-assured ACT in stock
at the time of the survey visit in rural and urban areas
Pricing indicators
2.1
Median cost to patients of one adult equivalent treatment dose (AETD) of quality-assured ACTs in rural and urban areas
2.2
Median cost to patients of one AETD of non-quality-assured ACTs in rural and urban areas
2.3
Median cost to patients of one AETD of artemisinin monotherapy in rural and urban areas
2.4
Median cost to patients of one AETD of non-artemisinin monotherapy or non-artemisinin combination therapy in rural and
urban areas
2.5
Median percentage markup between retail purchase and selling price of quality-assured ACTs in rural and urban areas
2.6
Median total markup from first-line buyer purchase price to retail selling price for quality-assured ACTs
Market share indicators
3.0
Total volume of quality-assured ACTs sold or distributed in the last week, as a proportion of the total volume of all
antimalarials sold or distributed in the last week in rural and urban areas
The following table shows the primary ACTwatch indicators measured through the outlet survey,
and presented in this report. Results are presented nationally and by endemicity. They will also be
presented by outlet type (though there may not be sufficient power to detect statistical differences
between outlet types).
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Table 2.1. 2: Primary ACTwatch indicators
Availability indicators
Proportion of censused outlets that have any antimalarials in stock at the time of survey visit.
Proportion of outlets that have any ACTs in stock among outlets with any antimalarials in stock at the time of survey, including:
 Quality-assured ACTs
o
First-line quality-assured ACTs
o
Non-first-line quality-assured ACTs
 Non-quality-assured ACTs
 Nationally registered ACTs
Proportion of outlets that have any non-artemisinin therapy in stock at the time of survey visit, including:
 Chloroquine
 Sulfadoxine-pyrimethamine
 Quinine
Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in stock at the time of
survey visit, including
 Oral artemisinin monotherapy
 Non-oral artemisinin monotherapy
Stock outs
Proportion of outlets that report no disruption in stock of any antimalarial, among outlets with any antimalarial in stock or
reported stock outs in the last three months.
Proportion of outlets that report no disruption in the first-line quality-assured ACT, among outlets with any antimalarials in stock
or reported stock outs in the last three months.
Pricing indicators
Median cost to patients of one adult equivalent treatment dose (AETD) of ACTs, including:
 Quality-assured ACTs
o
First-line quality-assured ACTs
o
Non-first-line quality-assured ACTs
 Non-quality-assured ACTs
 Nationally registered ACTs
Median cost to patients of one AETD of any non-artemisinin therapy, including:
 Chloroquine
 Sulfadoxine-pyrimethamine
 Quinine
Median cost to patients of one AETD of artemisinin monotherapy , including
 Oral artemisinin monotherapy
 Non-oral artemisinin monotherapy
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Affordability
Median cost to patients of one adult equivalent treatment dose (AETD) of first-line quality-assured ACTs relative to the most
popular antimalarial treatment.
Median cost to patients of one AETD of first-line quality-assured ACTs relative to the minimum legal daily wage.
Median cost to patients of one AETD of first-line quality-assured ACTs relative to the international reference price.
Market share indicators
Total volume of ACTs sold or distributed in the last week, as a proportion of the total volume of all anti-malarials sold or
distributed in the last week.
Provider knowledge
Proportion of providers that can correctly state the recommended first-line treatment for uncomplicated malaria, among outlets
with any antimalarials in stock or reported stock outs in the last three months.
Proportion of providers that can state the dosing regimen of the first-line treatment for an adult among outlets with any
antimalarials in stock or reported stock outs in the last three months.
Proportion of providers that can state the dosing regimen of the first-line treatment for a two year old, among outlets with any
antimalarials in stock or reported stock outs in the last three months.
2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators
While there are many similarities between the AMFm Phase 1 and ACTwatch indicators there are
notable differences, particularly in terms of the types of antimalarial classifications, denominators
for some provider indicators, prices (notably the use of different exchange rates and presentation of
median prices for tablet vs. other formulations) and the presentation of indicators in the report. The
following subsection helps to explain these differences by providing background on: 1) antimalarial
classifications 2) ACTwatch primary indicators and 3) AMFm Phase 1 primary indicators.
Classification of antimalarials
Antimalarials are presented within three broad policy-relevant categories:



Non-artemisinin Therapy (nAT)
Artemisinin Monotherapy (AMT)
Artemisinin-based Combination Therapy (ACT).
ACTs are further sub-divided as:


Quality-assured ACTs (QAACTs), which include:
o First-line, Quality-assured ACTs (FAACTs),
o Non-first-line Quality-assured ACTs (NAACTs)
Non-quality-assured ACTs
For further details on this classification see section 2.1.6.3 Classification of antimalarials.
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ACTwatch versus AMFm classifications
Given the objectives of the AMFm Phase 1, indicators focus on the following antimalarial
classifications: 1) non-artemisinin therapy, 2) artemisinin monotherapy, 3) QAACTs and 4) Nonquality-assured ACTs.
In addition to these classifications, ACTwatch also presents data on FAACTs, NAACTs, and nationally
registered antimalarials, which are relevant for national policy. Artemisnin monotherapy is also
further classified as oral and non-oral artemisinin monotherapy as per WHO recommendations that
intravenous artesunate should be used as first-line treatment in the management of severe P.
falciparum malaria in African children and adults (WHO, 2010b). ACTwatch further classifies nonartemisinin therapy into chloroquine, sulfadoxine-pyrimethamine and quinine.
ACTwatch versus AMFm denominators
 Provider knowledge
The ACTwatch indicator on provider knowledge of the first-line antimalarial treatment includes
outlets that had an antimalarial at the time of survey or in the previous three months. For the AMFm
Evaluation Indicator, only outlets that had an antimalarial in stock at the time of survey are included
in the denominator. Therefore, there are slight differences in the results for these knowledge
indicators.
 Rapid diagnostic tests and malaria microscopy
The ACTwatch indicator on availability of RDTs and malaria microscopy includes outlets that had an
antimalarial at the time of survey or in the previous three months. For the AMFm Evaluation
Indicator, only outlets that had an antimalarial in stock at the time of survey are included in the
denominator. Therefore there are slight differences in the results for these diagnosis indicators.
ACTwatch versus AMFm evaluation exchange rates
 Price
Price data were collected in local currencies and converted to their US$ equivalent. The US$
conversion used in this report (for ACTwatch indicators) is equivalent to the average interbank rate
for the period of data collection. This approach is used to facilitate comparisons over time between
other rounds of ACTwatch data collection, and between other ACTwatch countries. This differs from
the AMFm approach, which uses the average 2010 exchange rate over the whole year in which data
collection took place. Given these differences, separate tables for price indicators were provided to
the Independent Evaluator for AMFm, using the 2010 exchange rate. The prices presented in this
report are therefore slightly different from those presented in the “Multicounty Baseline Report”
produced by the Independent Evaluation Team, which synthesizes results from all pilot AMFm
countries.
In addition, a notable difference between the price measures for the AMFm indicators and the
ACTwatch indicators is the presentation of price for tablets and other formulations. Price measures
for ACTwatch only include tablet formulations. The price of non-tablet formulations, such as
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powders for reconstitution, suspensions, suppositories and syrups, are excluded. In contrast to this,
the AMFm indicators present information for both tablet and non-tablet formulations.
2.1.3 Sampling Approach
The sampling approach was based on that used in ACTwatch outlet surveys conducted in previous
survey rounds (including outlets in the public, private for-profit, and not-for-profit
sectors)(Shewchuk, O’Connell et al. 2011).
The target sampling units were all types of outlets that have the potential to sell or provide
antimalarials in Madagascar. The outlets were classified into two main categories and sampling
procedures employed to select outlets within each category:
Category 1: public health facilities (this included national university hospitals, regional and district
hospitals, public health centers [levels 1 and 2]), pharmacies and drug stores (Dépôt de
Médicament).
Category 2: other antimalarial drug sellers, including private clinics and practices, grocery stores,
bars (with and without grocery stores attached), gargotes5, NGO clinics and community health
workers (NGO and public health facility based).
Sampling procedures were employed to select outlets within each category, as described below.
Sample size determination
The outlet survey is designed to measure differences in indicators over time. The sample size that
was needed depended on the type of indicator to be measured (proportion, mean or median) and
the level of precision required. The following paragraphs summarise the methodology for
determining the overall sample size needed to detect statistically significant changes over time in
proportions (increases).
The sample size calculations were based on Indicator 1.5 – Availability of QAACTS (the proportion of
outlets that sell QAACTs as a share of the number of outlets that had stocks of any kind of
antimalarials at the time of the survey). This indicator has been chosen because of concerns that
QAACTs were too rare at baseline to provide a feasible sample size for the price/affordability
indicators.
The required sample size for the endline survey is calculated in 3 steps:
1. The required number of outlets with antimalarials in stock on the day of the survey
2. The number of outlets that must be enumerated to arrive at this number of antimalarialselling outlets (“gross sample size”)
3. The number of communes that must be visited to arrive at this number of outlets
(“operational sample size”).
The same sample size for the endline survey is a function of the reference indicator value measured
5
Small informal bar/restaurant
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and the sample size achieved in the baseline survey. The required sample size for a single domain
for the endline survey is calculated using the following formula:
n

Deff  Z1 P(1  P)(1  1 /  )  Z1 P1 (1  P1 ) /   P2 (1  P2 )

2
( P1  P2 ) 2
where:
n = desired sample size for the endline survey for a specific domain (urban or rural)
P1 = the indicator value measured at the baseline survey
P2 = the expected value of the indicator at the endpoint survey
P = (P1+P2)/2
λ=the ratio of the baseline survey sample size over the endline survey sample size which can
only be solved in a recursive calculation
Z1-α = the standard normal 1-α quintile corresponding to an α (type I) error with a one-sided
test; replace α by α/2 if a two-sided test is desired
Z1-β = the standard normal 1-β quintile corresponding to the power of the test
Deff = the design effect for cluster sampling
The required sample size has been calculated on the basis of the following assumed values of the key
parameters:
P1 = the value of the key outcome indicator measured at baseline survey: 19.8% (for the urban
domain and 24.2% for the rural domain, respectively).
P2 = the expected value of the indicator at the endline survey; a 20 percentage point difference
will be desired (assuming that a 20% point increase is the minimum necessary to justify the
importance in public health policy terms)
P = (P1+P2)/2
P2 – P1 = the change in availability from baseline to endline is 20 percentage points (the minimum
level of change felt to be needed to justify continuing the intervention on public health grounds)
Z1-α = 1.64 corresponding to an α (type I) error of 5% with a one-sided test
Z1-β = 0.84 corresponding to a power of test at 80% (or a type II error of 20%)
Deff = estimated design effect from the baseline survey data, which is 21 for the urban domain
and 18 for the rural domain.
This gives1540 and 900 outlets in the denominator of the indicator, for the urban and rural domains,
respectively, which are the number of outlets having any kind of antimalarial stocks at the time of
the survey.

The estimated gross sample size (number of outlets enumerated) needed for the QAACT
availability indicator is determined by the following formula:
N  n1 / Pam
Where Pam is the proportion of outlets having antimalarial stocks at the time of the survey among all
outlets enumerated. In this equation, the assumptions are as follows: N = desired sample size of all
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outlets for monitoring availability indicators, n1= the number of outlets with antimalarial stocks at
the time of the survey, which is 1540 and 900 for the urban and rural domains, respectively.
The value ofPam (the proportion of outlets having antimalarials in stock at the time of the survey
among all outlets enumerated) was estimated based on the baseline survey data. These data
indicated that 33% of the outlets in urban areas and 35% of the outlets in rural areas, on average,
had antimalarials in stock at the time of the survey. By applying these percentages to the above
formula, a total number of 4680 outlets in the urban domain and 2571 outlets in the rural domain
must be interviewed in order to detect a 20 percentage point increase in QAACT availability, for
urban and rural domains separately.
 Number of communes
To convert the gross sample size into the number of communes, we apply the estimated average
number of outlets per commune (noutlet). The number of outlets needed to reach the required
number of outlets with antimalarials in stock may be different for urban and rural areas depending
on the average number of outlets per commune (noutlet) and the percentage of outlets with
antimalarials (Pam) in urban and rural areas separately.
The baseline survey results show that there are, on average, 262 outlets interviewed per urban
commune and 94 outlets interviewed per rural commune. By applying these estimated parameters,
the optimal number of communes required to reach the estimated number of outlets would be 18 in
the urban domain and 28 in the rural domain, giving a total of 46 communes required in a country.
Selection procedure of the sub-districts
The last census in Madagascar was conducted in 1993 and was used as the sample frame for the
2010 outlet survey. The desired cluster size for the outlet survey was approximately 10,000 to
15,000 inhabitants, which corresponded most closely to a commune in Madagascar. The list of
communes from the 1993 census included population size, and communes were classified as either
urban or rural (Institut National de la Statistique 1999). In addition, a facility listing was used to
confirm the location of public health facilities (Ministére de la Santé Publique, 2007), pharmacies
and drug stores (Ordre National des Pharmaciens, 2009).
The sample was selected using a stratified cluster design, with urban and rural areas constituting the
two strata. A total of 46 communes (18 urban and 28 rural) were selected with probability
proportional to size from the 1993 census. Areas which were non-endemic, such as the capital city
of Antananarivo, were excluded from the sampling frame.
In each selected commune, a census of all Category 1 and Category 2 outlets was conducted. All
outlets that stocked antimalarials at the time of the survey or in the past 3 months were eligible for
interview.
The sample was supplemented by a booster sample of Category 1 outlets (including drug stores
(Dépôt de Médicament) operating in the district of the sampled commune. Oversampling ensured
adequate representation of relatively rare but important antimalarial outlet types. All public sector
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tertiary care, district/provincial level facilities, and pharmacies and drug stores (Dépôt de
Médicament) located in the corresponding district of the sampled commune were included. For
lower-level public health facilities, in each of the 19 rural communes, 12 lower-level health facilities
per rural district were selected; and in each of the 19 urban communes 16 lower level health
facilities per district were selected. If districts had fewer than 40 public health facilities combined,
then all of the facilities were censused. All Category 1 booster outlets that stocked antimalarials at
the time of the survey or in the past 3 months were eligible for interview.
If more than one commune was selected from one district, all the selected communes shared the
same booster sample. The booster sample comprised all the public health facilities and registered
pharmacies listed in the district, but not in any of the selected communes.
2.1.4 Data collection
Preparatory phase
The study initially received ethical clearance from Madagascar’s ethical approval committee at the
Ministry of Health on the 3rd of November 2011.
The questionnaire mirrored the ACTwatch questionnaire employed in Madagascar in
2008(Shewchuk, O’Connell et al. 2011). However, the IE team made several adaptations to the
questionnaire at endline in Madagascar to ensure that the IE indicators were included and other
requests from key stakeholders were met (e.g., the addition of questions on stockouts of qualityassured ACTs, training courses attended, and knowledge of proper dosing of quality-assured ACTs).
Four modules were used in the outlet survey: 1) a screening module identified outlets that were
eligible for the audit and provider interview; 2) a provider module collected information on outlet
demographics (e.g., health qualifications of staff, number of staff that prescribe or dispense
medicines), provider knowledge of the first-line treatment, and provider perceptions; and 3) an
antimalarial audit module collected data for each antimalarial stocked, including information on
brand name, generic name and strengths, package type and size, recall of volumes sold over the
week before the survey, recall of last purchase price and selling price and 4) an RDT audit which
determine brand name, price and manufacturer of RDTs. The questionnaire was translated into
Malagasy.
Questionnaires were programmed into Personal Digital Assistants (PDAs). PDA programming used
Visual Basic running on the Windows Mobile 5.0 operating system. The PDA programming was
pretested prior to the main data collection.
Sixty (60) candidates participated in an eight-day outlet survey training between the 17th and 28th of
October 2011 in Antananarivo. Standardised training materials developed by ACTwatch were
adapted to the national setting, and administered by PSI/Madagascar research staff. Training
sessions covered completing the questionnaire, informed consent, conducting the census, and
identifying outlet types. Interviewers were trained to identify antimalarial medicines, including the
differences between ACTs and non-ACTs, trade names and generics, packaged and loose tablets, and
the various formulations. PDAs were introduced to the field staff after the main body of the training
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had been completed. A field practice session was undertaken to mimic actual data collection. Of the
60 candidates, 27were selected as interviewers, 9 as supervisors and 9 as quality controllers.
Supervisors and quality controllers received additional training to clarify roles and responsibilities in
the field. This training also included a review of logistical procedures to be followed during data
collection, trouble-shooting PDAs and backing up data.
Standard Operating Procedures (SOPs) developed by ACTwatch were used to help ensure high
quality data. The SOPs outline each element of data collection and management, e.g., questionnaire
translation, questionnaire pretesting, fieldworker training, and double data entry.
Fieldwork
Nine teams carried out data collection, each consisting of one team supervisor, one quality
controller and three interviewers. Two coordinators were responsible for managing the supervisors
and ensuring that standardized methods were implemented. Fieldwork commenced on the 7th of
November 2011 and was completed on the 7th of January 2012.
During fieldwork, specific outlets were identified in sampled communes using a number of
approaches. Official lists of outlets operating in selected communes were obtained from the Ministry
of Health prior to fieldwork, and were then used to help verify outlets within each commune. In
addition, supervisors identified key informants (such as health officials and other local government
officials) and, through discussion with these key informants, obtained a list of potential medicine
outlets in their area and worked with them to draw up a rough sketch map of their locations. To
estimate the boundaries of each commune, supervisors liaised with commune chiefs and with local
guides. The teams were also provided with district and commune maps to further identify
boundaries. Road maps were also used where available. Finally, during data collection a snowball
technique was used whereby outlets included in the survey were asked to identify other outlets
stocking, or with the potential to stock, medicine in the commune.
For each outlet that was identified during the census, the outlet type and location were noted, along
with its longitude and latitude coordinates (obtained via hand-held GPS units). The fieldworker then
identified the most senior staff member currently present at the outlet, and screening questions
were administered. For outlets that were eligible, the interviewer then read the information sheet to
the senior staff person and obtained witnessed oral consent to proceed with the full interview. The
questionnaire is included in the Appendix.
At the end of each day, all collected data were synchronized from the PDAs to computers and
submitted to a database residing in a directory acting as a central server.
Teams were visited by supervisors and quality controllers in the field during the survey period. Spot
checks were conducted on at least 10% of all outlets by quality controllers. Supervisors observed
10% of interviews, verifying adherence to study procedures. Supervisory and quality control
measures also included a review of teams’ PDA records, using a tool in Excel to facilitate data checks.
Data were checked for any inconsistencies, irregular skip patterns or large amounts of missing data.
PSI coordinators also uploaded data from interviewers’ PDAs for review, and also documented
reasons why certain outlets could not be accessed.
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2.1.5 Data processing
Data recorded on PDAs. The final raw dataset was sent to ACTWatch Central, based in Nairobi,
where cleaning was conducted. Any clarifications or errors were documented and sent back to
PSI/Madagascar for verification.
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2.1.6 Data analysis
Data analysis process
Detailed data cleaning guidelines giving step-by-step instructions on how to clean each section of the
data using range and consistency checks were utilized during the analysis process. Commands
executed for data cleaning were documented using a “syntax file”, and the results of running these
commands using a “log file”.
A standardized tabulation plan was used for all tables presented in this report, which were produced
using standard analysis “do-files” in STATA. Analysis was run using STATA version 11, recording
results in a “log file”.
Accounting for the survey design in data analysis
We accounted for three aspects of the sampling design during the analysis:
 Sampling weights: Sample weights were calculated for the outlet survey data to allow for 1)
difference in sampling probabilities due to variation in the size of strata, 2) the oversampling for
the booster sample, and 3) the sampling strategy, which involves a census of outlets in
communes of varying size, selected using probability proportional to size (PPS) sampling.
Weights were based on sampling probabilities and were calculated by the IE after data cleaning
was complete. Appendix 8.6 provides a detailed description of the calculations performed and
weights used.
 Clustering: As the sample was clustered at the level of the district for the booster sample and the
sub-district for other outlets, the calculation of the standard errors takes the clustering into
account because outlets in a given cluster are likely to be more similar to each other than to
outlets in other clusters. (The standard errors did not take into account clustering of products
within outlets because a complete list of all relevant products in each outlet was obtained and
no sampling was performed).
 Stratification: As communes were sampled separately in each stratum, it was necessary to adjust
for this in the calculation of standard errors.
To account for these design features in the tabulations, we used the STATA commands for analyzing
complex survey data (“svy” commands) to weight the data and calculate confidence intervals which
account for clustering and stratification. We declared the primary sampling unit (district), the weight
variable (wt), the strata and the finite population correction (fpc) equaling the sampling fraction for
each stratum (the number of sampled communes in a stratum divided by the total number of
communes in the stratum, or 0.5 if the sampling fraction was greater than 50 percent).6 This was
specified as:
svyset district [pweight=wt], strata (strata) fpc (fpc)
We calculated a proportion and its 95 percent confidence interval (CI) as:
6
For simplicity we used the district as the primary sampling unit for both booster sample and main sample outlets, as it is rare for there to
be more than one main sample communes from the same stratum in a district. In Madagascar, there was/were more than one main
sample communesin 3 district/s in the urban stratum, and 0 district/sin the rural stratum. However, we defined fpcon the basis of the
number of communes in the stratum to present a true picture of the proportion of clusters selected.
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svy: proportion VariableName
Classification of antimalarials
For the purpose of the analysis, antimalarials were split into three broad policy relevant categories:
non-artemisinin therapy (nAT), artemisinin monotherapy (AMT) and artemisinin-based combination
therapy (ACT).
-
-
-
-
-
ACTs were further sub-divided into quality-assured ACTs (QAACTs) and non-quality-assured
ACTs. QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and
Malaria’s Quality Assurance Policy. For the purpose of the Independent Evaluation, a QAACT
is any ACT which appeared on the Global Fund's indicative list of antimalarials meeting the
Global Fund's quality assurance policy prior to baseline or endline data collection (see
http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General),
or
which previously had C-status in an earlier Global Fund quality assurance policy and was
used in a program supplying subsidized ACTs. At endline, QAACTs were defined as any ACT
which appeared on the Global Fund’s indicative list of antimalarials meeting its quality
assurance policy as at September 2011, or which previously had C-status in an earlier Global
Fund quality assurance policy and was used in a program supplying subsidized ACTs. A list of
all ACTs qualifying as QAACTs at the time of the endline survey is included in Appendix 8.2.
ACTs were further sub-divided into First-line Quality-assured ACTs (FAACTs) and Non-firstline Quality-assured ACTs (NAACTs), and nationally registered antimalarials, which are
relevant for national policy (WHO, 2010b). FAACTs are government recommended first-line
ACTs (i.e., ASAQ in Madagascar) for uncomplicated malaria meeting the quality-assured
definition. NAACTs are ACTs that are not the government’s recommended first-line
treatment for uncomplicated malaria (i.e., AL in Madagascar), but which do meet the
quality-assured definition. FAACTs and NAACTs are only presented for the ACTwatch
indicators.
ACTs were also classified as nationally registered ACTs. Nationally registered ACTs are ACTs
registered with a country’s national drug regulatory authority and permitted for sale or
distribution in-country. Each country determines its own criteria for placing a drug on its
nationally registered listing. A list of nationally registered ACTs at the time of data collection
is given in appendix 8.8.Nationally registered ACTs are only presented for the ACTwatch
indicators.
AMT were further classified into oral and non-oral AMT, to distinguish between non-oral
AMT, which are recommended for treatment of severe malaria, versus oral AMT, which are
targeted for removal from the market as a key policy goal.
nATs were further classified into chloroquine, sulfadoxine-pyrimethamine, quinine,
amodiaquine or other nATs that may be found in the dataset (e.g., Halofantrine). These
categories are only presented for the ACTwatch indicators.
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Calculation of antimalarial volumes, prices and markups
Antimalarial volume and price data are reported in terms of adult equivalent treatment doses
(AETDs) using an AETD calculator developed by ACTwatch with some modifications (Shewchuk,
O'Connell et al. 2011). An AETD is defined as the number of milligrams (mg) of an antimalarial drug
needed to treat a 60 kg adult (refer to Appendix 8.7 for details). The number of mg/kg used to
calculate one AETD was defined as what was recommended for a particular drug in the treatment
guidelines for uncomplicated malaria in areas of low drug resistance issued by WHO (as of 5 April
2011). Where WHO treatment guidelines did not exist, such as for Halofantrine (Halfan), or
Dihydroartemisinin, AETDs were based on the product manufacturer’s treatment guidelines. In the
case of ACTs, which have two or more active antimalarial ingredients packaged together (either coformulated or co-blistered), the strength of the artemisinin-based component was used as the basis
for the AETD calculations. Information collected on the medicine strength and unit size, as listed on
the product packaging, was then used to calculate the number of AETDs contained in each unit.
Market share was calculated by dividing the number of AETDs of a particular antimalarial category
sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked
antimalarials, but some or all sales volumes were missing, we did not impute for missing values.
Price data are reported using median and inter-quartile range, which are appropriate for describing
distributions likely to be skewed. There are some differences in the exchange rate that was used for
ACTwatch and the IE.

For ACTwatch, price data were collected in local currencies and converted to their US$
equivalent using the average interbank rate for the period of data collection (US$ = 2161.14
Ariary, source: www.oanda.com).

For the IE, price data were collected in local currencies and adjusted to 2010 prices in order
to facilitate comparisons to baseline estimates which were adjusted to 2010 prices for all
pilots. Prices were adjusted using the ratio of the average national consumer price index for
2011 to the national average consumer price index for 2010 (IMF, International Financial
Statistics). These 2010 prices were then converted to their USD equivalent using the average
interbank rate for 2010 (USD = LCU 2138.56, source www.oanda.com).
Retail gross percentage mark-ups were calculated for each product as the difference between selling
price and purchase price, divided by purchase price. In cases where an outlet received an
antimalarial for free from its supplier and distributes the product for free, the retail markup was set
to 0%. In cases where an outlet received an antimalarial for free from its supplier, but does not
distribute the product for free, the retail markup was set to missing. The tables that present markup
data indicate the number of observations set to missing for this reason.
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3. Results- Outlet survey
3.1 Characteristics of the sample
Throughout the document, reference will be made to the letters in this flow diagram (A to E) as a
reminder of which subset of outlets a given table is referring to.
Figure 3.1. 1: Survey flow diagram, [Madagascar], 2011
A
Outlets enumerated*
[10,723]
Outlets not
screened
[682]
B
Outlets screened
[10,041]
Eligible respondent not available / Time not
convenient for interview
[139]
Outlet not open at the time
[236]
[]
Outlet closed permanently
[283]
[]
Other
[]
[11]
Refused
[13]
[]
Interview interrupted
[7]
Eligible respondent not available / Time not
convenient for interview
[6]
[]
[0]
[]
Other
[2]
[]
Refused
[33]
[]
Outlets which did not
meet screening criteria
[7,187]
C
Outlets which met
screening criteria
1=[2,409] or 2=[445]
Outlets not
interviewed
[48]
D
Outlets interviewed**
[2,806]
E
Outlets with
antimalarials in stock
on day of visit
[2,371]
Outlets with no
antimalarials in stock
on day of visit***
[435]
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.
*Enumerated means were visited and filled in at a minimum basic descriptive information (sections C1-C9 of
questionnaire)
**Interviewed means that final interview status was ‘completed’ or ‘partially completed ‘but had stock in previous 3
months
***Outlets with no antimalarials in stock on day of visit but had stock in previous 3 months
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Table A.1: Availability of antimalarials, by outlet type
Table A.1: Availability of antimalarials, by outlet type
Public
Health
Facility
%
(95% CI)
Proportion of
outlets that had:7
Antimalarials in
stock at the time
of survey visit
%
(95% CI)
Private
not-for-profit
HF
%
(95% CI)
TOTAL
Public/Not-forprofit
%
(95% CI)
Private
For-profit
HF
%
(95% CI)
N=802
N=38
N=1,482
Community
Health Worker
N=642
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
N=84
N=77
N=393
N=8,005
N=8,559
N=10,041
96.9
(93.0, 98.6)
11.5
(6.1, 20.8)
81.9
(59.8, 93.2)
20.8
(13.8, 30.2)
70.8
(53.3, 83.7)
93.3
(74.9, 98.5)
96.1
(93.2, 97.8)
20.6
(17.7, 23.9)
22.7
(19.7, 26.0)
22.2
(19.3, 25.5)
90.8
(87.2, 93.5)
10.5
(5.3, 19.8)
58.8
(36.4, 78.1)
18.9
(12.3, 27.9)
25.4
(10.8, 48.8)
92.4
(74.8, 98.0)
54.0
(44.4, 63.4)
0.5
(0.3, 0.9)
2.0
(1.5, 2.7)
6.1
(4.6, 8.2)
90.7
(87.0, 93.4)
10.5
(5.3, 19.8)
58.8
(36.4, 78.1)
18.8
(12.2, 27.9)
25.1
(10.6, 48.6)
92.4
(74.8, 98.0)
54.0
(44.4, 63.4)
0.5
(0.3, 0.9)
2.0
(1.5, 2.7)
6.1
(4.6, 8.2)
90.7
(87.0, 93.4)
10.5
(5.3, 19.8)
55.4
(32.9, 75.8)
18.8
(12.2, 27.8)
23.6
(9.4, 47.7)
87.2
(74.3, 94.2)
47.5
(38.0, 57.2)
0.4
(0.2, 0.8)
1.8
(1.3, 2.4)
5.9
(4.4, 8.0)
0.8
(0.3, 2.0)
0.0
--
5.7
(2.1, 14.8)
0.1
(0.1, 0.3)
4.0
(1.5, 10.4)
78.8
(63.3, 88.9)
18.8
(13.9, 25.1)
0.1
(<0.1, 0.6)
0.8
(0.5, 1.2)
0.6
(0.4, 0.9)
Any child
QAACT
QAACT
with the
AMFm
logo
Other
subsidised
QAACT
Non-qualityassured ACT
85.9
(82.0, 89.0)
10.5
(5.3, 19.8)
38.1
(21.6, 57.9)
18.1
(11.7, 27.1)
23.5
(9.4, 47.7)
86.3
(73.2, 93.6)
43.6
(34.6, 53.0)
0.4
(0.2, 0.8)
1.7
(1.2, 2.4)
5.7
(4.2, 7.7)
70.0
(62.2, 76.8)
1.2
(0.3, 4.8)
30.1
(16.0, 49.4)
8.2
(5.2, 12.7)
11.8
(5.1, 25.0)
89.4
(76.5, 95.6)
49.2
(39.4, 59.0)
0.2
(0.1, 0.6)
1.6
(1.2, 2.1)
3.2
(2.4, 4.2)
2.1
(1.2, 3.8)
8.7
(4.0, 17.7)
0.0
--
8.0
(3.8, 15.9)
10.8
(1.5, 49.4)
0.0
--
3.7
(2.0, 6.8)
0.3
(0.1, 0.6)
0.4
(0.2, 0.8)
2.2
(1.2, 4.3)
3.6
(2.2, 5.8)
0.2
(<0.1, 0.9)
2.0
(0.6, 7.0)
0.5
(0.3, 1.1)
1.4
(0.4, 4.7)
35.6
(19.0, 56.5)
1.8
(0.8, 3.9)
0.0
--
0.2
(0.1, 0.4)
0.3
(0.2, 0.5)
Nationally
Registered ACT
89.5
(85.4, 92.6)
8.4
(5.0, 13.8)
58.8
(36.4, 78.1)
16.8
(11.7, 23.6)
14.0
(6.9, 26.6)
87.2
(74.3, 94.2)
48.9
(39.4, 58.4)
0.1
(<0.1, 0.4)
1.5
(1.1, 2.0)
5.2
(4.1, 6.6)
Any ACT
Qualityassured ACT
(QAACT)
First-line
(FAACT)
Non-firstline (NAACT)
continued on next page
7
The denominator for this table is all screened outlets [n=10,041]. Of the 2,409 outlets that reporting stocking antimalarials on the day of interview, 38 did not proceed to the full interview and 53 audits were incomplete. These 91 cases are
thus missing information on the classification of all antimalarials stocked and are omitted from the availability figures by classification. The smallest sample size for each outlet type is: public health facility, n=598; community health
worker, n=801; private not-for-profit health facility, n=37; private for-profit health facility, n=79; pharmacy, n=74; drug store, n=390; general retailer, n=7,961; total, n=9,940.
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Public
Private
TOTAL
Private
Community
Drug
General
TOTAL
TOTAL
Health
not-for-profit
Public/NotFor-profit
Pharmacy
Health Worker
Store
retailer
Private
Outlets
Facility
HF
for-profit
HF
%
%
%
%
%
%
%
%
%
%
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
(95% CI)
84.2
1.1
50.0
9.7
68.8
93.2
94.6
20.1
22.1
19.1
Any non-artemisinin
therapy
(78.4, 88.6)
(0.5, 2.5)
(28.3, 71.7)
(6.4, 14.2)
(51.0, 82.3)
(74.5, 98.5)
(91.1, 96.8)
(17.0, 23.4)
(19.1, 25.5)
(16.2, 22.3)
63.7
0.1
24.1
6.5
32.1
85.4
65.2
0.6
2.4
3.4
Sulfadoxinepyrimethamine (SP)
(56.2, 70.6)
(<0.1, 1.1)
(9.5, 49.0)
(4.3, 9.7)
(15.8, 54.3)
(68.1, 94.1)
(59.2, 70.7)
(0.3, 1.1)
(1.8, 3.2)
(2.7, 4.3)
2.1
0.7
11.9
1.0
13.8
61.1
78.4
20.0
21.2
16.3
Chloroquine
(1.3, 3.5)
(0.3, 2.1)
(2.5, 41.8)
(0.5, 2.1)
(3.3, 43.5)
(45.4, 74.8)
(71.1, 84.2)
(17.0, 23.4)
(18.2, 24.5)
(13.7, 19.3)
20.5
0.0
20.9
2.2
3.0
15.7
7.1
<0.1
0.2
0.7
Oral Quinine
(16.2, 25.6)
-(8.0, 44.6)
(1.4, 3.4)
(0.6, 12.7)
(8.6, 26.9)
(4.1, 12.0)
(<0.1, <0.1)
(0.1, 0.4)
(0.5, 0.9)
53.9
0.2
27.6
5.6
67.5
88.1
75.8
<0.1
2.3
3.1
Quinine Injection
(IM/IV)**§
(45.9, 61.6)
(<0.1, 1.3)
(11.1, 53.7)
(3.7, 8.5)
(49.7, 81.4)
(71.8, 95.6)
(68.8, 81.6)
(<0.1, <0.1)
(1.8, 2.9)
(2.5, 3.9)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Amodiaquine
----------0.0
0.0
2.7
<0.1
0.4
34.5
0.5
0.0
0.2
0.1
Other [Halofantrine,
Mefloquine]
--(0.5, 13.1)
(<0.1, 0.2)
(0.1, 1.9)
(27.5, 42.2)
(0.2, 1.4)
-(0.1, 0.3)
(0.1, 0.2)
0.3
0.0
0.0
<0.1
0.4
6.5
0.0
0.0
<0.1
<0.1
Any artemisinin
monotherapy
(<0.1, 1.9)
--(<0.1, 0.2)
(0.1, 1.9)
(2.0, 19.1)
--(<0.1, 0.2)
(<0.1, 0.1)
0.0
0.0
0.0
0.0
0.4
0.0
0.0
0.0
<0.1
<0.1
Oral artemisinin
monotherapy
----(0.1, 1.9)
---(<0.1, 0.0)
(<0.1, <0.1)
0.3
0.0
0.0
<0.1
0.4
6.5
0.0
0.0
<0.1
<0.1
Non oral artemisinin
monotherapy
(<0.1, 1.9)
--(<0.1, 0.2)
(0.1, 1.9)
(2.0, 19.1)
--(<0.1, 0.2)
(<0.1, 0.1)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
ArtesunateIV/IM*§
----------0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Rectal
Artesunate*§
----------0.3
0.0
0.0
<0.1
0.4
6.5
0.0
0.0
<0.1
<0.1
Artemether
**§
IV/IM
(<0.1, 1.9)
--(<0.1, 0.2)
(0.1, 1.9)
(2.0, 19.1)
--(<0.1, 0.2)
(<0.1, 0.1)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
**§
Artemotil IV/IM
----------54.0
0.2
27.6
5.6
67.5
88.1
75.8
<0.1
2.3
3.1
Any treatment for severe
malaria
(46.0, 61.8)
(<0.1, 1.3)
(11.1, 53.7)
(3.7, 8.5)
(49.7, 81.4)
(71.8, 95.6)
(68.8, 81.6)
(<0.1, <0.1)
(1.8, 2.9)
(2.5, 3.9)
*
WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children [Guidelines for the treatment of malaria, 2nd edition – revisions 1].
**
Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available [Guidelines for the treatment of malaria, 2nd edition – revisions 1].
§
If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The
following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.
Source: ACTwatch Outlet Survey, Madagascar, 2011
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Table A.2: Availability of antimalarials, by public health facility outlet type
Any
hospital
Health Centre
with doctor
Health Centre without
doctor
Total Public
Health Facilities
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
N=43
N=392
N=207
N=642
8
Proportion of outlets that had:
Antimalarials in stock at the time of
survey visit
Any ACT
Quality-assured ACT (QAACT)
First-line (FAACT)
Non-first-line (NAACT)
Any child QAACT
QAACT with the AMFm logo
Other subsidised QAACT
Non-quality-assured ACT
Nationally Registered ACT
Any non-artemisinin therapy
Sulfadoxine-pyrimethamine (SP)
Chloroquine
Oral Quinine
Quinine Injection (IM/IV)
Amodiaquine
Other[Halofantrine, Mefloquine]
Any artemisinin monotherapy
Non oral artemisinin monotherapy
Artesunate IV/IM
Rectal Artesunate
Artemether IV/IM
Artemotil IV/IM
Any treatment for severe malaria
100.0
-74.6
(54.0, 88.1)
74.6
(54.0, 88.1)
74.6
(54.0, 88.1)
8.4
(2.6, 23.9)
66.1
(46.0, 81.7)
55.1
(36.6, 72.3)
0.0
-7.6
(2.0, 24.9)
72.8
(52.6, 86.6)
93.6
(84.2, 97.6)
36.0
(20.8, 54.6)
1.9
(0.4, 7.6)
36.4
(22.2, 53.4)
85.7
(71.8, 93.4)
0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
--
97.4
(92.2, 99.2)
93.0
(88.6, 95.7)
92.7
(88.1, 95.6)
92.7
(88.1, 95.6)
0.2
(<0.1, 1.5)
88.1
(83.9, 91.3)
73.7
(64.9, 81.0)
2.6
(1.3, 5.1)
4.0
(2.2, 7.2)
92.0
(87.2, 95.1)
83.6
(77.4, 88.4)
64.2
(56.2, 71.5)
1.9
(1.0, 3.6)
22.2
(16.6, 29.1)
55.3
(46.5, 63.8)
0.0
-0.0
-0.4
(0.1, 3.1)
0.0
-0.4
(0.1, 3.1)
0.0
-0.0
-0.4
(0.1, 3.1)
0.0
--
95.3
(90.1, 97.8)
90.0
(84.1, 93.9)
90.0
(84.1, 93.9)
90.0
(84.1, 93.9)
0.4
(0.1, 2.7)
85.7
(78.6, 90.8)
66.3
(55.7, 75.4)
1.6
(0.6, 4.3)
2.1
(0.6, 6.9)
88.2
(80.8, 93.0)
83.4
(74.6, 89.6)
68.0
(58.1, 76.5)
2.6
(0.9, 6.8)
14.6
(8.2, 24.7)
45.4
(34.6, 56.6)
0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
--
96.9
(93.0, 98.6)
90.8
(87.2, 93.5)
90.7
(87.0, 93.4)
90.7
(87.0, 93.4)
0.8
(0.3, 2.0)
85.9
(82.0, 89.0)
70.0
(62.2, 76.8)
2.1
(1.2, 3.8)
3.6
(2.2, 5.8)
89.5
(85.4, 92.6)
84.2
(78.4, 88.6)
63.7
(56.2, 70.6)
2.1
(1.3, 3.5)
20.5
(16.2, 25.6)
53.9
(45.9, 61.6)
0.0
-0.0
-0.3
(<0.1, 1.9)
0.0
-0.3
(<0.1, 1.9)
0.0
-0.0
-0.3
(<0.1, 1.9)
0.0
--
85.7
(71.8, 93.4)
55.5
(46.7, 64.0)
45.4
(34.6, 56.6)
54.0
(46.0, 61.8)
8
The denominator for this table is all screened public health facilities [n=642]. Of the 620 outlets that reporting stocking antimalarials on the day of
interview, 2 did not proceed to the full interview and 42 audits were incomplete. These 44 cases are thus missing information on the classification of all
antimalarials stocked and are omitted from the availability figures by classification. The smallest sample size for each outlet type is: any hospital, n=42;
health centre with doctor, n=363; health centre without doctor, n=193; total, n=598.
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Among outlets with an
antimalarial in stock, proportion
of outlets that had:
Public
Health
Facility
Community
Health
Worker
Private
not-forprofit HF
%
(95% CI)
%
(95% CI)
%
(95% CI)
TOTAL
Public /
Not-forprofit
%
(95% CI)
N=612
N=80
N=30
N=722
Private
For-profit
HF
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
N=43
N=72
N=375
N=1,413
N=1,633
N=2,355
93.9
(91.1, 95.8)
92.0
(79.0, 97.2)
71.9
(41.4, 90.3)
92.0
(86.3, 95.4)
36.1
(16.1, 62.5)
99.1
(95.1, 99.9)
56.2
(46.1, 65.9)
2.4
(1.3, 4.3)
9.2
(6.9, 12.0)
28.1
(21.5, 35.7)
93.7
(90.8, 95.7)
92.0
(79.0, 97.2)
71.9
(41.4, 90.3)
91.9
(86.1, 95.4)
35.7
(15.7, 62.2)
99.1
(95.1, 99.9)
56.2
(46.1, 65.9)
2.4
(1.3, 4.3)
9.2
(6.9, 12.0)
28.1
(21.5, 35.7)
93.7
(90.8, 95.7)
92.0
(79.0, 97.2)
67.7
(38.1, 87.8)
91.7
(85.9, 95.2)
33.5
(14.1, 60.7)
93.6
(87.3, 96.9)
49.4
(39.5, 59.5)
2.0
(1.0, 3.8)
8.1
(6.1, 10.8)
27.2
(20.6, 35.0)
0.8
(<0.1, 2.1)
0.0
--
6.9
(2.5, 18.1)
0.7
(<0.1, 1.4)
5.7
(1.9, 16.0)
84.5
(72.4, 92.0)
19.6
(14.4, 26.1)
0.4
(<0.1, 2.8)
3.6
(2.4, 5.2)
2.9
(2.0, 4.2)
Any child QAACT
88.8
(85.3, 91.5)
92.0
(79.0, 97.2)
46.6
(20.6, 74.7)
88.5
(82.2, 92.8)
33.4
(14.0, 60.7)
92.6
(86.0, 96.3)
45.3
(36.0, 55.0)
1.7
(0.8, 3.6)
7.6
(5.5, 10.3)
26.1
(19.7, 33.6)
QAACT with the AMFm
logo
72.4
(64.5, 79.1)
10.8
(2.7, 34.5)
36.9
(15.4, 65.2)
40.0
(27.5, 54.0)
16.7
(7.5, 33.3)
95.9
(91.2, 98.2)
51.2
(41.0, 61.2)
1.1
(<0.1, 2.8)
7.1
(5.3, 9.5)
14.6
(11.3, 18.6)
2.2
(1.2, 3.9)
76.1
(50.7, 90.8)
0.0
--
39.4
(22.9, 58.7)
15.4
(2.1, 60.5)
0.0
--
3.9
(2.0, 7.2)
1.3
(0.5, 3.1)
1.8
(1.0, 3.4)
10.3
(5.4, 18.7)
3.7
(2.2, 6.1)
1.8
(<0.1, 7.5)
2.4
(0.7, 8.5)
2.7
(1.4, 4.9)
1.9
(0.5, 7.0)
38.2
(21.9, 57.7)
1.8
(0.8, 4.0)
0.0
--
0.9
(<0.1, 2.0)
1.3
(0.8, 2.1)
92.5
(89.0, 95.0)
73.3
(47.7, 89.2)
71.9
(41.4, 90.3)
82.1
(66.2, 91.5)
20.0
(10.0, 35.8)
93.6
(87.3, 96.9)
50.9
(40.9, 60.7)
0.7
(<0.1, 2.1)
6.8
(5.0, 9.1)
24.0
(19.0, 29.7)
87.0
(81.8, 90.9)
9.3
(3.5, 22.4)
61.1
(27.8, 86.6)
47.2
(32.6, 62.3)
97.7
(92.8, 99.3)
100.0
--
98.5
(96.7, 99.3)
99.5
(98.5, 99.8)
99.4
(98.6, 99.7)
87.5
(79.3, 92.7)
65.9
(59.0, 72.2)
1.3
(<0.1, 8.9)
29.5
(11.8, 56.7)
31.9
(22.0, 43.7)
45.6
(24.2, 68.8)
91.6
(79.1, 96.9)
67.8
(62.1, 73.1)
3.0
(1.5, 5.8)
10.8
(8.0, 14.4)
15.6
(12.3, 19.5)
Chloroquine
2.2
(1.3, 3.6)
6.5
(2.1, 18.6)
14.6
(3.1, 47.8)
4.9
(2.3, 10.1)
19.7
(5.0, 53.3)
65.6
(53.3, 76.1)
81.6
(75.1, 86.6)
99.1
(98.0, 99.6)
95.2
(93.6, 96.5)
74.9
(67.5, 81.0)
Oral Quinine
21.2
(16.8, 26.4)
0.0
--
25.5
(7.9, 57.9)
10.7
(7.3, 15.4)
4.2
(0.9, 17.8)
16.9
(9.8, 27.6)
7.4
(4.3, 12.5)
<0.1
(<0.1, <0.1)
1.0
(0.6, 1.6)
3.2
(2.5, 4.1)
Any ACT
First-line (FAACT)
Sulfadoxine-pyrimethamine
(SP)
66 | P a g e
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Amodiaquine
Private
For-profit
HF
Pharmacy
Drug
Store
General
retailer
%
(95% CI)
33.7
(13.8, 61.7)
0.0
--
TOTAL
Public /
Not-forprofit
%
(95% CI)
27.6
(18.8, 38.5)
0.0
--
%
(95% CI)
95.9
(90.1, 98.4)
0.0
--
%
(95% CI)
94.5
(85.6, 98.1)
0.0
--
%
(95% CI)
78.9
(72.0, 84.4)
0.0
--
%
(95% CI)
<0.1
(<0.1, <0.1)
0.0
--
0.5
(<0.1, 1.5)
Public
Health
Facility
Community
Health
Worker
Private
not-forprofit HF
%
(95% CI)
55.7
(47.2, 63.9)
0.0
--
%
(95% CI)
1.5
(<0.1, 11.3)
0.0
--
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
10.3
(7.9, 13.3)
0.0
--
%
(95% CI)
14.2
(11.5, 17.4)
0.0
--
0.0
--
0.7
(<0.1, 1.4)
0.6
(<0.1, 1.1)
0.0
--
0.0
--
0.1
(<0.1, 0.7)
0.1
(<0.1, 0.5)
0.0
--
0.0
--
3.2
(0.6, 16.1)
0.2
(<0.1, 0.8)
0.5
(<0.1, 2.8)
0.3
(<0.1, 1.9)
0.0
--
0.0
--
0.1
(<0.1, 0.9)
0.5
(<0.1, 2.8)
37.0
(27.9,
47.1)
7.0
(2.3, 19.6)
0.0
--
0.0
--
0.0
--
0.0
--
0.5
(<0.1, 2.8)
0.0
--
0.0
--
0.0
--
<0.1
(<0.1, <0.1)
<0.1
(<0.1, <0.1)
0.3
(<0.1, 1.9)
0.0
--
0.0
--
0.1
(<0.1, 0.9)
0.5
(<0.1, 2.8)
7.0
(2.3, 19.6)
0.0
--
0.0
--
0.1
(<0.1, 0.7)
0.1
(<0.1, 0.5)
Artesunate IV/IM
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
Rectal Artesunate
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
Artemether IV/IM
0.3
(<0.1, 1.9)
0.0
--
0.0
--
0.1
(<0.1, 0.9)
0.5
(<0.1, 2.8)
7.0
(2.3, 19.6)
0.0
--
0.0
--
0.1
(<0.1, 0.7)
0.1
(<0.1, 0.5)
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
0.0
--
1.5
(<0.1,
11.3)
33.7
(13.8,
61.7)
27.6
(18.8,
38.6)
95.9
(90.1,
98.4)
94.5
(85.6,
98.1)
78.9
(72.0,
84.4)
0.0
(<0.1,
<0.1)
10.3
(7.9, 13.3)
14.2
(11.5, 17.4)
Other[Halofantrine,
Mefloquine]
Oral artemisinin
monotherapy
Non oral artemisinin
monotherapy
Artemotil IV/IM
55.8
(47.4,
64.0)
67 | P a g e
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Table A.4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type
Private
For-profit
HF
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
N=31
39.5
(17.0, 67.5)
N=25
TOTAL
Public /
Not-forprofit
%
(95% CI)
N=771
50.4
(43.3, 57.4)
N=715
%
(95% CI)
N=49
36.9
(18.9, 59.6)
N=27
%
(95% CI)
N=73
21.7
(14.7, 30.9)
N=72
%
(95% CI)
N=387
32.0
(25.7, 39.0)
N=244
%
(95% CI)
N=1,526
43.9
(35.6, 52.6)
N=18
%
(95% CI)
N=2,035
42.7
(35.5, 50.2)
N=361
%
(95% CI)
N=2,806
44.3
(37.9, 50.9)
N=1,076
56.1
(43.7, 67.8)
32.6
(12.3, 62.5)
59.0
(50.7, 66.9)
50.3
(22.3, 78.1)
50.0
(42.4, 57.6)
45.3
(37.2, 53.8)
75.6
(49.9, 90.6)
53.7
(44.7, 62.5)
57.7
(51.1, 63.9)
N=91
N=23
N=712
N=20
N=69
N=221
N=17
N=327
N=1,039
64.9
(58.8, 70.5)
56.5
(43.9, 68.4)
28.6
(10.4, 57.9)
59.2
(50.8, 67.2)
56.1
(24.6, 83.3)
62.9
(53.7, 71.2)
47.5
(39.0, 56.2)
71.6
(46.4, 88.0)
56.6
(48.9, 64.1)
58.6
(51.9, 65.0)
N=612
33.7
Expired stock of any antimalarial
(26.6, 41.6)
N=558
28.9
10
Expired stock of QAACT
(22.0, 36.9)
N=558
28.9
Expired stock of FAACT
(22.0, 36.9)
N=639
97.3
Acceptable storage conditions for
medicines11
(95.2, 98.4)
N=80
29.4
(12.2, 55.5)
N=75
31.5
(13.5, 57.5)
N=75
31.5
(13.5, 57.5)
N=101
88.5
(59.8, 97.5)
N=30
49.1
(21.2, 77.6)
N=24
61.0
(29.9, 85.2)
N=22
64.8
(33.6, 87.0)
N=31
100.0
--
N=722
32.3
(22.1, 44.6)
N=657
31.3
(20.3, 45.0)
N=655
31.4
(20.3, 45.0)
N=771
92.9
(76.4, 98.1)
N=43
24.5
(7.3, 57.1)
N=19
44.7
(8.7, 87.3)
N=15
46.9
(9.2, 88.5)
N=49
88.8
(70.0, 96.4)
N=72
33.9
(23.1, 46.7)
N=71
6.8
(4.1, 10.9)
N=68
7.0
(4.2, 11.3)
N=73
87.9
(75.3, 94.5)
N=375
13.2
(9.2, 18.5)
N=208
7.0
(4.1, 11.7)
N=180
7.5
(4.2, 13.0)
N=387
97.1
(91.5, 99.1)
N=1,143
5.0
(3.1, 7.9)
N=13
54.8
(22.7, 83.4)
N=12
66.5
(30.7, 89.9)
N=1,526
89.5
(84.8, 92.8)
N=1,633
6.9
(4.8, 9.7)
N=311
21.3
(13.2, 32.5)
N=275
23.8
(14.3, 37.0)
N=2,035
89.9
(85.5, 93.1)
N=2,355
13.4
(9.4, 18.9)
N=968
28.7
(19.8, 39.5)
N=930
29.6
(20.5, 40.5)
N=2,806
90.6
(86.5, 93.5)
No disruption in stock in the past 3
months
No disruption in stock of qualityassured ACT (QAACT) in the past 3
months, among outlets stocking
QAACT in the past 3 months
Public
Health
Facility
Community
Health
Worker
Private
not-forprofit HF
%
(95% CI)
N=639
47.7
(41.0, 54.4)
N=598
%
(95% CI)
N=101
53.1
(41.2, 64.7)
N=92
64.9
(58.8, 70.5)
N=598
No disruption in stock of first-line
quality-assured ACT (FAACT) in the
past 3 months, among outlets
stocking FAACT in the past 3
months
9
9
Information on expired stock was missing for 17% of cases [n=1,958]. Missing values were particularly common for general retailers (23%, n=875) and drug stores (17%, n=311).
Information on expired QAACT stock was missing for 4% of cases [n=934]; Information on expired FAACT stock was missing for 4% of cases [n=897].
11
Information on acceptable storage conditions was unavailable or missing for 7% of cases [n=2,621].
10
68 | P a g e
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Table A.5: Price of antimalarials, by outlet type
Public
Health
Facility
Community
Health
Worker
Private
not-for-profit
HF
TOTAL
Public / Notfor-profit
Private
for-profit
HF
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
%
%
%
%
%
%
%
%
%
98.5
1.3
100
83.2
1.7
0.0
0.0
0.0
0.3
25.4
Proportion of first-line quality-assured ACT
(FAACT) distributed free of cost
(by volumes of AETDs)
Median price of a tablet AETD:12
First-line (FAACT)
Chloroquine
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
Median [IQR]
(N of Antimalarials)
$0.00
(1,981)
[0.00-0.00]
$0.00
(1,976)
[0.00-0.00]
$0.00
(973)
[0.00-0.00]
$0.00
(20)
[0.00-0.00]
$0.00
(22)
[0.00-0.00]
$0.19
(126)
[0.19-0.38]
$0.19
(126)
[0.19-0.38]
$0.19
(27)
[0.00-0.38]
$0.19
(73)
[0.19-0.38]
$0.00
(2)
[0.00-0.38]
$0.00
(82)
[0.00-0.00]
$0.00
(74)
[0.00-0.00]
$0.00
(50)
[0.00-0.00]
$
(0)
[-]
$0.00
(2)
[0.00-0.00]
$0.00
(2,189)
[0.00-0.19]
$0.00
(2,176)
[0.00-0.19]
$0.00
(1,050)
[0.00-0.00]
$0.19
(93)
[0.19-0.38]
$0.00
(26)
[0.00-0.00]
$0.48
(45)
[0.38-0.95]
$0.48
(37)
[0.38-0.95]
$0.95
(29)
[0.48-1.91]
$0.38
(1)
[n/a]
$3.82
(1)
[n/a]
$0.86
(435)
[0.45-8.83]
$0.76
(279)
[0.38-1.91]
$0.51
(303)
[0.38-0.95]
$
(0)
[-]
$10.02
(40)
[8.31-10.88]
$0.72
(564)
[0.45-1.53]
$0.67
(449)
[0.38-1.53]
$0.67
(516)
[0.45-1.15]
$0.38
(18)
[0.19-0.38]
$1.91
(7)
[0.95-11.46]
$0.57
(13)
[0.38-0.95]
$0.57
(12)
[0.38-0.67]
$0.67
(6)
[0.38-1.15]
$0.57
(7)
[0.57-0.57]
$
(0)
[-]
$0.67
(1,057)
[0.38-1.53]
$0.57
(777)
[0.38-1.15]
$0.57
(854)
[0.38-1.15]
$0.57
(26)
[0.38-0.57]
$9.36
(48)
[7.78-10.88]
$0.00
(3,246)
[0.00-0.38]
$0.00
(2,953)
[0.00-0.38]
$0.00
(1,904)
[0.00-0.57]
$0.19
(119)
[0.19-0.38]
$7.64
(74)
[0.00-10.50]
$0.00
(385)
[0.00-0.00]
$0.21
(19)
[0.00-0.36]
$0.48
(1)
[n/a]
$0.36
(5)
[0.36-0.43]
$0.29
(14)
[0.14-0.43]
$1.07
(2)
[1.07-1.07]
$0.00
(400)
[0.00-0.00]
$0.36
(26)
[0.36-0.43]
$0.43
(16)
[0.38-0.48]
$0.36
(7)
[0.21-0.36]
$0.48
(144)
[0.33-2.34]
$1.00
(50)
[0.72-1.07]
$0.38
(284)
[0.29-0.48]
$0.36
(338)
[0.21-0.36]
$0.48
(22)
[0.43-0.48]
$0.36
(1,152)
[0.36-0.36]
$0.43
(466)
[0.33-0.48]
$0.36
(1,547)
[0.36-0.36]
$0.33
(866)
[0.00-0.48]
$0.36
(1,573)
[0.36-0.36]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$0.00
(503)
[0.00-0.00]
$0.5
(72)
[0.05-0.05]
$0.00
(21)
[0.00-0.00]
$0.00
(596)
[0.00-0.05]
$0.10
(11)
[0.10-0.24]
$0.21
(101)
[0.14-1.00]
$0.24
(129)
[0.19-0.29]
$0.14
(8)
[0.14-0.14]
$0.21
(249)
[0.14-0.29]
$0.05
(845)
[0.00-0.10]
$4.45
(335)
[4.44-5.22]
$
(0)
[-]
$4.45
(333)
[4.44-5.22]
$10.10
(1)
[n/a]
$
(0)
[-]
$10.10
(1)
[n/a]
$9.09
(14)
[6.06-21.21]
$
(0)
[-]
$9.09
(14)
[6.06-21.21]
$4.45
(350)
[4.44-5.22]
$
(0)
[-]
$4.45
(348)
[4.44-5.22]
$12.12
$11.28
(37)
(143)
[10.10-15.15]
[8.08-20.31]
$
$
(0)
(0)
[-]
[-]
$12.12
$10.36
(37)
(141)
[10.10-15.15]
[8.08-20.31]
$8.08
(451)
[6.36-10.60]
$
(0)
[-]
$8.08
(451)
[6.36-10.60]
$6.06
(1)
[n/a]
$
(0)
[-]
$6.06
(1)
[n/a]
$9.09
(632)
[7.07-14.14]
$
(0)
[-]
$9.09
(630)
[7.07-12.53]
$8.08
(982)
[5.05-11.28]
$
(0)
[-]
$8.08
(978)
[5.05-11.11]
Median price of a package:
Paediatric QAACT (pack for a 10kg child)
Median price of an AETD:
Artesunate IV/IM
Quinine Injection IV/IM
12
A total of 7,165 antimalarials were found in 2,355 outlets. Of these, 5,956 antimalarials are included in the pricing analysis; price indicators are based on tablet-formulation AETDs. Free antimalarials were found in 26.1% of outlets with
antimalarials, and 2482 of the 7,054 antimalarials for which price information was recorded were available for free.
69 | P a g e
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Table A.6: Affordability of antimalarials, by outlet type
Public
Health
Facility
Community
Health
Worker
Private
not-forprofit HF
TOTAL
Public / Notfor-profit
Private
For-profit
HF
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
0.5
n/a
n/a
1.3
0.9
2.0
1.6
1.9
n/a
n/a
0.5
n/a
n/a
2.6
0.5
1.9
1.9
1.6
n/a
n/a
0.5
n/a
n/a
1.3
0.8
1.9
1.6
1.6
n/a
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
0.2
n/a
n/a
0.4
0.8
0.7
0.5
0.6
n/a
n/a
0.2
n/a
n/a
0.9
0.5
0.6
0.6
0.5
n/a
First-line quality-assured ACT
(FAACT)
n/a
0.2
n/a
n/a
0.4
0.7
0.6
0.5
0.5
n/a
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
0.2
n/a
n/a
0.5
0.7
0.6
0.5
0.5
n/a
%
%
%
%
%
%
%
%
%
%
N=31
N=31
N=49
N=73
N=387
N=1,526
N=2,035
N=2,066
34.2
(29.6, 39.1)
34.1
(29.7, 38.8)
34.0
(29.6, 38.8)
Median price of a tablet AETD relative to
chloroquine, the most
popular13antimalarial treatment in
Madagascar:
First-line quality-assured ACT
(FAACT)
the minimum legal daily wage
($1.10)14:
Median price of a first-line qualityassured tablet AETD relative to the
international reference price ($1.06)15
Proportion of outlets that:
23.6
(7.5, 54.0)
Offer credit to consumers for
antimalarials16
23.6
(7.5, 54.0)
39.3
(18.5, 64.9)
13.9
(9.2, 20.3)
36.4
(31.9, 41.2)
13
Chloroquine was the most popular antimalarial (non-ACT) by volumes sold/distributed in the past week.
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
15
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. $1.06 is the median listed supplier
price for 12+12 tablets of ASAQ 50mg/153mg. This figure is based on data from four suppliers. Co-formulated supplier prices are also available but only from one supplier.
16
This question was not asked in Public Health Facilities and figures for CHWs are not shown due to large amounts of missing data.
14
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Table A.7: Availability of diagnostic tests, by outlet type
Proportion of outlets that had:17
Any diagnostic test
Rapid diagnostic tests (RDTs)
RDTs from a manufacturer that
has submitted a product to WHO
Malaria RDT Product Testing
Rounds 1-3
has not submitted a product to
WHO Malaria RDT Product
Testing Rounds 1-3
Proportion of outlets that provided
diagnostic tests for free, among outlets
providing diagnostic tests
Public
Health
Facility
%
(95% CI)
N=639
92.3
(88.9, 94.7)
5.0
(3.8, 6.5)
91.8
(88.6, 94.2)
N=629
Community
Health
Worker
%
(95% CI)
N=101
54.1
(39.9, 67.6)
4.3
(0.8, 19.7)
54.1
(39.9, 67.6)
N=100
Private
not-forprofit HF
%
(95% CI)
N=31
72.7
(41.7, 90.9)
14.0
(6.5, 27.5)
71.5
(40.4, 90.3)
N=29
TOTAL
Public/Notfor-profit
%
(95% CI)
N=771
70.5
(59.2, 79.7)
5.0
(2.3, 10.4)
70.3
(59.1, 79.5)
N=758
Private
For-profit
HF
%
(95% CI)
N=49
9.2
(4.1, 19.4)
3.5
(1.5, 8.3)
8.5
(3.8, 17.8)
N=49
93.0
(89.3, 95.4)
54.6
(40.4, 68.0)
71.5
(40.4, 90.3)
71.0
(59.5, 80.2)
0.0
--
0.0
--
0.0
--
0.0
--
N=591
100.0
-N=33
44.7
(26.7, 64.3)
N=588
100.0
-Source: ACTwatch Outlet Survey, Madagascar, 2011
Any diagnostic test
17
18
N=65
93.2
(74.6, 98.4)
N=1
100.0
-N=65
93.2
(74.6, 98.4)
N=26
100.0
-N=11
82.2
(34.2, 97.6)
N=24
100.0
--
N=682
97.3
(89.0, 99.4)
N=45
79.2
(44.4, 94.8)
N=677
97.3
(89.0, 99.4)
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
N=73
6.6
(3.3, 12.8)
0.0
-6.5
(3.2, 12.7)
N=73
%
(95% CI)
N=387
1.5
(0.6, 3.4)
0.0
-1.5
(0.6, 3.4)
N=387
%
(95% CI)
N=1,526
0.0
-0.0
-0.0
-N=1,510
%
(95% CI)
N=2,035
0.4
(<0.1, 0.7)
0.1
(<0.1, <0.1)
0.4
(<0.1, 0.7)
N=2,019
%
(95% CI)
N=2,806
15.5
(11.8, 20.2)
1.1
(0.5, 2.7)
15.4
(11.7, 20.1)
N=2,777
7.4
(3.3, 15.8)
6.5
(3.2, 12.7)
1.5
(0.6, 3.4)
0.0
--
0.4
(<0.1, 0.6)
15.4
(11.6, 20.2)
1.1
(<0.1, 3.9)
0.0
--
0.0
--
0.0
--
0.0
(<0.1, <0.1)
0.0
(<0.1, <0.1)
N=16
84.2
(52.8, 96.2)
N=6
0.0
-N=14
84.2
(52.8, 96.2)
N=4
N=6
0.0
--
N=0
N=0
60.6
(19.7, 90.6)
N=0
N=0
--
--
--
N=4
N=6
N=0
0.0
--
60.6
(19.7, 90.6)
--
--
N=26
55.7
(32.9, 76.3)
N=6
0.0
-N=24
55.7
(32.9, 76.3)
N=708
96.5
(89.8, 98.9)
N=51
75.0
(39.3, 93.3)
N=701
96.5
(89.8, 98.9)
Information on proportion of outlets that had diagnostic tests was missing for less than 1% of cases [n=2,789].
Excluding outlets with RDTs where the manufacturer could not be identified.
71 | P a g e
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Table A.8:Price of diagnostic tests, by outlet type
Public
Health
Facility
Median US$
[IQR] (N)
Community
Health
Worker
Median US$
[IQR] (N)
Private
not-forprofit HF
Median US$
[IQR] (N)
TOTAL
Median US$
[IQR] (N)
Private
For-profit
HF
Median US$
[IQR] (N)
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
$0.14
(27)
[0.00, 0.48]
$0.00
(1)
[n/a]
$0.00
(5)
[0.00, 1.05]
$0.00
(33)
[0.00, 0.00]
$1.67
(5)
[0.95, 1.67]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$1.67
(5)
[0.95, 1.67]
$0.00
(38)
[0.00, 0.24]
$0.00
(597)
[0.00, 0.00]
$0.00
(67)
[0.00, 0.00]
$0.00
(24)
[0.00, 0.00]
$0.00
(688)
[0.00, 0.00]
$0.00
(13)
[0.00, 0.00]
$3.48
(4)
[0.24, 3.58]
$0.00
(6)
[0.00, 0.14]
$
(0)
[-]
$0.00
(23)
[0.00, 0.95]
$0.00
(711)
[0.00, 0.00]
$0.00
(67)
[0.00, 0.00]
$0.00
(24)
[0.00, 0.00]
$0.00
(688)
[0.00, 0.00]
$0.00
(12)
[0.00, 0.00]
$3.48
(4)
[0.24, 3.58]
$0.00
(6)
[0.00, 0.14]
$
(0)
[-]
$0.00
(22)
[0.00, 0.95]
$0.00
(710)
[0.00, 0.00]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$2.39
(1)
[n/a]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$2.39
(1)
[n/a]
$2.39
(1)
[n/a]
Median price of:
RDTs from a manufacturer
that has submitted a product
$0.00
(597)
[0.00, 0.00]
to WHO Malaria RDT Product
Testing Rounds 1-3
RDTs from a manufacturer
that has not submitted a
$
(0)
[-]
product to WHO Malaria RDT
Product Testing Rounds 1-3
72 | P a g e
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Table A.9: Availability of diagnostic tests, by public health facility outlet type
Health Centre
with doctor
Health Centre
without doctor
%
(95% CI)
N=43
%
(95% CI)
N=391
%
(95% CI)
N=205
Any diagnostic test
94.1
(84.6, 97.9)
93.3
(89.0, 96.0)
90.1
(85.4, 93.3)
92.3
(88.9, 94.7)
59.6
(40.7, 76.0)
1.0
(<0.1, 2.5)
2.3
(0.7, 7.7)
5.0
(3.8, 6.5)
87.3
(74.9, 94.1)
93.3
(89.0, 96.0)
90.1
(85.4, 93.3)
91.8
(88.6, 94.2)
N=385
N=201
N=629
94.2
(89.7, 96.8)
91.9
(86.7, 95.2)
93.0
(89.3, 95.4)
0.0
--
0.0
--
0.0
--
19
N=43
87.3
has submitted a product to
(74.9, 94.1)
Testing Rounds 1-3
0.0
-Testing Rounds 1-3
19
Total
Public Health
Facilities
%
(95% CI)
N=639
Any
hospital
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Table A.10: Market share, by outlet type
Public
Health
Facility
%
3.7
Each antimalarial category as a proportion of
the total volume of all antimalarials (AETDs)
sold or distributed in the past week:20
Any ACT
First-line (FAACT)
Community
Health
Worker
%
0.9
Private
not-forprofit HF
%
1.1
TOTAL
%
5.7
Private
For-profit
HF
%
2.1
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
6.2
%
7.1
%
0.1
%
15.4
%
21.1
3.5
0.8
1.1
5.4
2.1
6.1
7.1
0.1
15.3
20.7
3.5
0.8
0.9
5.2
2.0
4.3
5.6
0.1
12.1
17.3
<0.1
0.2
<0.1
0.2
1.8
1.5
0
0
3.2
3.4
2.8
<0.1
0.4
3.2
2.0
5.6
7.0
0.1
14.6
17.8
0
0.8
0.1
0.9
0
0
0.1
0
0.1
0.9
0.3
0.1
0
0.3
0
0.1
<0.1
0
0.1
0.4
3.7
0.8
1.0
5.5
2.0
5.1
6.1
0.1
13.3
18.8
23.7
0.4
0.6
24.6
1.8
3.1
23.7
25.8
54.3
78.9
SP
23.0
0
0.5
23.5
0.7
2.3
7.3
1.3
11.6
35.0
Chloroquine
<0.1
0.4
0
0.4
0.8
0.5
15.8
24.5
41.6
42.0
Oral Quinine
0.3
0
0.1
0.4
<0.1
<0.1
<0.1
<0.1
0.1
0.4
0.4
0
<0.1
0.4
0.3
0.2
0.5
<0.1
1.0
1.4
Amodiaquine
0
0
0
0
0
0
0
0
0
0
Other [Halofantrine, Mefloquine]
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ArtesunateIV/IM
0
0
0
0
0
0
0
0
0
0
Rectal Artesunate
0
0
0
0
0
0
0
0
0
0
Artemether IV/IM
0
0
0
0
0
0
0
0
0
0
Artemotil IV/IM
0
0
0
0
0
0
0
0
0
0
0.4
0
<0.1
0.4
0.3
0.2
0.5
0
1.0
1.4
20
There were a total of 8085 AETDs (unweighted) sold or distributed in the past week. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-quality-assured ACT; QAACT decompose fully into FAACT
and NAACT. Row and column totals exhibit minor rounding errors.
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Table A.11: Provider knowledge, by outlet type
Public
Health
Facility
%
(95% CI)
N=639
Proportion of providers that can:
86.3
(80.4, 90.6)
Correctly state the recommended first-line
treatment for uncomplicated malaria21
Community
Health
Worker
%
(95% CI)
N=101
69.6
(55.9, 80.5)
N=101
State at least one health danger sign in a child
that requires referral to a public health
22
facility :
Private
not-forprofit HF
%
(95% CI)
N=31
75.5
(45.7, 91.8)
N=31
TOTAL
%
(95% CI)
N=771
76.7
(67.8, 83.8)
N=132
Private
For-profit
HF
%
(95% CI)
N=49
74.9
(42.7, 92.3)
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
N=73
%
(95% CI)
N=387
%
(95% CI)
N=1,526
%
(95% CI)
N=2,035
%
(95% CI)
N=2,806
75.3
(65.5, 83.1)
54.2
(47.4, 60.9)
13.6
(9.6, 19.0)
18.5
(14.4, 23.3)
30.9
(25.2, 37.2)
N=1,526
N=2,035
N=2,167
N=49
N=73
N=387
74.8
(55.8, 87.4)
92.9
(81.6, 97.5)
75.9
(57.4, 88.0)
88.4
(65.6, 96.8)
68.0
(55.1, 78.6)
74.9
(68.3, 80.6)
59.3
(50.9, 67.2)
61.1
(53.4, 68.2)
63.1
(56.1, 69.6)

Convulsions
47.8
(37.6, 58.1)
56.2
(25.2, 83.1)
48.3
(38.2, 58.5)
55.6
(31.4, 77.4)
24.6
(14.7, 38.3)
40.4
(33.6, 47.6)
25.2
(18.3, 33.6)
26.8
(20.5, 34.3)
29.8
(23.5, 36.9)

Vomiting
36.2
(23.9, 50.7)
53.5
(25.3, 79.7)
37.3
(25.4, 51.0)
38.8
(18.7, 63.6)
51.4
(44.1, 58.7)
42.0
(35.2, 49.1)
25.5
(20.7, 30.9)
27.2
(22.8, 32.2)
28.6
(24.3, 33.3)

Unable to drink/breastfeed
27.9
(15.6, 44.6)
61.8
(34.1, 83.5)
30.0
(17.1, 47.2)
9.1
(3.9, 20.0)
11.0
(6.7, 17.4)
22.7
(19.0, 26.8)
14.7
(11.5, 18.7)
15.1
(12.1, 18.6)
17.1
(13.6, 21.3)

Excessive sleep/difficult to wake up
0.0
--
1.4
(<0.1, 7.7)
0.1
(<0.1, <0.1)
0.0
--
6.2
(1.2, 26.0)
2.8
(1.4, 5.7)
2.9
(1.8, 4.5)
2.9
(1.9, 4.3)
2.5
(1.6, 3.8)

Unconscious/coma
34.5
(23.7, 47.2)
35.4
(14.1, 64.6)
34.5
(24.8, 45.7)
24.3
(8.0, 54.4)
8.3
(4.9, 13.7)
18.1
(12.8, 24.9)
11.4
(6.0, 20.7)
12.1
(7.0, 20.2)
15.2
(10.2, 22.1)
21
Information on proportion of providers that correctly state the recommended first-line treatment for uncomplicated malaria was missing for less than 1% of cases [n=2,798]. The indicators proportion of providers that can correctly state
the dosing regimen of the first-line treatment for an adult/a two-year old child can not be presented due to the manner in which this data was collected.
22
This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for less than 1% of cases [n=2,164]. Providers could state multiple responses
and totals may sum to more than 100%.
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Table A.12:Provider knowledge, by public health facility outlet type
Any
hospital
Health Centre
with doctor
Health Centre
without doctor
Total
Public Health Facilities
%
(95% CI)
N=43
%
(95% CI)
N=391
%
(95% CI)
N=205
%
(95% CI)
N=639
65.4
(45.9, 80.8)
Correctly state the recommended first-line
treatment for uncomplicated malaria
88.1
(82.2, 92.2)
87.1
(79.2, 92.3)
86.3
(80.4, 90.6)
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Table A.13: Provider perceptions, by outlet type
Proportion of providers that:
Agree with the statement,
“Customers often request an
antimalarial by name.”23
“I generally decide which
antimalarial medicine customers
receive.”
Report that an ACT is the most
effective antimalarial medicine for
an adult24
Report that an ACT is the most
effective antimalarial medicine for a
child
Public
Health
Facility
%
(95% CI)
N=639
Community
Health
Worker
%
(95% CI)
N=101
Private
not-for-profit
HF
%
(95% CI)
N=31
TOTAL
%
(95% CI)
N=771
Private
For-profit
HF
%
(95% CI)
N=49
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
%
(95% CI)
N=73
%
(95% CI)
N=387
%
(95% CI)
N=1,526
%
(95% CI)
N=2,035
%
(95% CI)
N=2,806
4.5
(2.9, 6.8)
4.5
(1.3, 14.3)
3.1
(0.8, 11.0)
4.4
(2.0, 9.3)
14.2
(4.4, 37.4)
25.5
(18.8, 33.6)
41.0
(35.5, 46.7)
83.5
(80.8, 85.8)
78.4
(76.0, 80.6)
62.6
(56.8, 68.1)
88.7
(84.7, 91.8)
96.1
(88.0, 98.8)
89.7
(77.1, 95.7)
92.8
(88.9, 95.5)
97.9
(94.5, 99.2)
57.0
(35.0, 76.5)
59.5
(52.0, 66.6)
39.1
(32.7, 45.9)
41.9
(36.3, 47.8)
52.8
(47.0, 58.6)
84.2
(79.1, 88.2)
15.9
(6.7, 33.3)
69.0
(40.4, 87.9)
46.0
(33.8, 58.8)
24.9
(13.6, 41.2)
68.7
(58.5, 77.4)
36.7
(29.2, 44.8)
4.6
(2.1, 10.0)
8.0
(5.2, 12.3)
16.2
(12.2, 21.1)
88.3
(84.8, 91.2)
90.6
(80.9, 95.7)
78.2
(50.5, 92.7)
89.2
(83.8, 92.9)
52.0
(31.0, 72.4)
85.9
(79.1, 90.8)
53.4
(47.2, 59.4)
5.9
(3.4, 10.2)
11.2
(8.3, 14.8)
27.8
(21.5, 35.2)
23
24
Information on this pair of indicators was missing for less than 1% of cases [n=2,804, and n=2,803].
Information on this pair of indicators was missing for less than 1% of cases [n=2,805, and n=2,804].
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Table A.14: Availability of antimalarials, by urbanicity
Urban
Public / Not-forprofit
%
(95% CI)
N=331
Antimalarials in stock at the time of survey
visit
Any ACT
First-line (FAACT)
Any child QAACT
Chloroquine
Oral Quinine
34.2
(24.9, 44.8)
30.7
(21.6, 41.5)
30.7
(21.6, 41.5)
29.9
(20.8, 41.0)
2.4
(1.1, 4.9)
30.2
(21.2, 40.9)
22.1
(15.2, 31.0)
1.7
(0.7, 4.1)
0.5
(0.2, 1.5)
30.4
(21.4, 41.2)
23.7
(17.0, 32.1)
16.5
(11.2, 23.6)
0.8
(0.2, 2.7)
10.8
(6.5, 17.5)
Rural
Private
Total
%
(95% CI)
N=6,188
%
(95% CI)
N=6,519
15.1
(12.6, 18.1)
2.7
(2.0, 3.8)
2.7
(2.0, 3.7)
2.6
(1.9, 3.5)
1.8
(1.2, 2.7)
2.5
(1.8, 3.5)
2.6
(1.9, 3.5)
<0.1
(<0.1, 0.1)
0.8
(0.4, 1.6)
2.6
(1.9, 3.6)
14.7
(12.1, 17.7)
2.5
(1.8, 3.5)
13.6
(11.0, 16.6)
0.5
(0.3, 0.8)
16.4
(13.7, 19.4)
4.5
(3.5, 5.8)
4.5
(3.5, 5.8)
4.3
(3.3, 5.6)
1.9
(1.3, 2.7)
4.3
(3.3, 5.5)
3.8
(2.9, 5.1)
0.1
(0.1, 0.3)
0.8
(0.4, 1.6)
4.4
(3.4, 5.7)
15.2
(12.6, 18.3)
3.4
(2.5, 4.6)
12.8
(10.4, 15.5)
1.1
(0.7, 1.7)
%
(95% CI)
N=1,151
20.1
(13.0, 29.9)
18.3
(11.5, 27.7)
18.2
(11.5, 27.7)
18.2
(11.5, 27.7)
<0.1
(<0.1, 0.1)
17.5
(10.9, 26.9)
7.5
(4.5, 12.0)
8.3
(3.9, 16.7)
0.5
(0.3, 1.1)
16.1
(11.0, 23.1)
8.9
(5.8, 13.5)
6.0
(3.9, 9.2)
1.0
(0.5, 2.2)
1.7
(1.0, 2.9)
Private
Total
TOTAL
Outlets
%
(95% CI)
N=2,371
%
(95% CI)
N=3,522
%
(95% CI)
N=10,041
24.9
(21.2, 29.1)
1.8
(1.3, 2.7)
1.8
(1.3, 2.7)
1.6
(1.1, 2.3)
0.5
(0.3, 0.8)
1.5
(0.9, 2.3)
1.3
(0.9, 1.9)
0.5
(0.3, 1.0)
<0.1
(<0.1, 0.1)
1.2
(0.8, 1.7)
24.3
(20.5, 28.6)
2.4
(1.7, 3.3)
23.5
(19.7, 27.7)
0.2
(0.1, 0.3)
23.6
(19.9, 27.6)
6.5
(4.6, 9.1)
6.5
(4.6, 9.1)
6.3
(4.4, 8.9)
0.4
(0.2, 0.6)
6.0
(4.2, 8.6)
3.0
(2.2, 4.2)
2.7
(1.4, 5.3)
0.2
(0.1, 0.3)
5.4
(4.1, 7.2)
20.0
(16.5, 23.9)
3.4
(2.6, 4.4)
17.1
(14.0, 20.8)
0.6
(0.4, 0.8)
22.2
(19.3, 25.5)
6.1
(4.6, 8.2)
6.1
(4.6, 8.2)
5.9
(4.4, 8.0)
0.6
(0.4, 0.9)
5.7
(4.2, 7.7)
3.2
(2.4, 4.2)
2.2
(1.2, 4.3)
0.3
(0.2, 0.5)
5.2
(4.1, 6.6)
19.1
(16.2, 22.3)
3.4
(2.7, 4.3)
16.3
(13.7, 19.3)
0.7
(0.5, 0.9)
Continued on next page
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Table A.14: Availability of antimalarials, by urbanicity
Urban
%
(95% CI)
N=331
Rural
Private
Total
%
(95% CI)
N=6,188
%
(95% CI)
N=6,519
%
(95% CI)
N=1,151
Private
Total
TOTAL
Outlets
%
(95% CI)
N=2,371
%
(95% CI)
N=3,522
%
(95% CI)
N=10,041
13.8
2.8
3.5
5.2
2.2
3.0
3.1
(8.6, 21.5)
(2.0, 3.8)
(2.6, 4.6)
(3.3, 8.1)
(1.6, 2.9)
(2.3, 3.9)
(2.5, 3.9)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Amodiaquine
-------0.6
0.6
0.6
0.0
<0.1
<0.1
0.1
(0.1, 2.9)
(0.4, 1.1)
(0.4, 1.1)
-(<0.1, <0.1)
(<0.1, <0.1)
(0.1, 0.2)
0.0
0.1
0.1
<0.1
0.0
<0.1
<0.1
-(<0.1, 0.5)
(<0.1, 0.5)
(<0.1, 0.2)
-(<0.1, 0.1)
(<0.1, 0.1)
0.0
<0.1
<0.1
0.0
0.0
0.0
<0.1
-(<0.1, 0.1)
(<0.1, 0.1)
---(<0.1, <0.1)
0.0
0.1
0.1
<0.1
0.0
<0.1
<0.1
-(<0.1, 0.5)
(<0.1, 0.5)
(<0.1, 0.2)
-(<0.1, 0.1)
(<0.1, 0.1)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
ArtesunateIV/IM*§
-------0.0
0.0
0.0
0.0
0.0
0.0
0.0
Rectal Artesunate*§
-------0.0
0.1
0.1
<0.1
0.0
<0.1
<0.1
**§
Artemether IV/IM
-(<0.1, 0.5)
(<0.1, 0.5)
(<0.1, 0.2)
-(<0.1, 0.1)
(<0.1, 0.1)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
**§
Artemotil IV/IM
-------13.8
2.8
3.5
5.2
2.2
3.0
3.1
(8.6, 21.5)
(2.0, 3.8)
(2.6, 4.6)
(3.3, 8.1)
(1.6, 2.9)
(2.3, 3.9)
(2.5, 3.9)
*
WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children [Guidelines for the treatment of malaria, 2nd edition –
revisions 1].
**
Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available [Guidelines for the treatment of malaria, 2nd edition –
revisions 1].
§
If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further
treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.
Source: ACTwatch Outlet Survey, Madagascar, 2011.
Quinine Injection (IM/IV)**§
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Urban
Among outlets with an antimalarial in
stock, proportion of outlets that had:
Any ACT
First-line (FAACT)
Any child QAACT
Chloroquine
Oral Quinine
Quinine Injection (IM/IV)**§
Amodiaquine
Rural
Private
Total
TOTAL
Outlets
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
N=974
N=618
N=763
N=1,381
N=2,355
%
(95% CI)
Private
Total
%
(95% CI)
N=104
N=870
92.1
(87.3, 95.2)
92.1
(87.3, 95.2)
89.8
(82.9, 94.1)
7.2
(3.8, 13.2)
90.7
(85.3, 94.2)
67.4
(56.4, 76.9)
5.1
(2.0, 12.5)
1.7
(0.7, 3.9)
91.5
(86.6, 94.6)
71.8
(59.9, 81.3)
49.9
(36.9, 63.0)
2.4
(0.7, 8.4)
33.0
(23.2, 44.6)
42.2
(29.0, 56.6)
0.0
-1.9
(0.4, 9.0)
18.6
(14.3, 23.9)
18.5
(14.2, 23.8)
17.4
(13.2, 22.6)
12.3
(8.2, 18.1)
16.9
(12.5, 22.4)
17.4
(13.2, 22.7)
0.2
(<0.1, 0.9)
5.3
(2.7, 10.3)
17.7
(13.5, 22.8)
99.3
(98.6, 99.7)
16.9
(12.8, 22.0)
92.0
(88.3, 94.5)
3.1
(1.8, 5.2)
18.8
(14.5, 24.0)
0.0
-4.4
(2.5, 7.4)
28.4
(23.3, 34.2)
28.4
(23.3, 34.1)
27.1
(22.1, 32.7)
11.7
(7.9, 16.9)
26.7
(21.5, 32.7)
24.0
(18.9, 29.9)
0.8
(0.4, 1.9)
4.8
(2.4, 9.3)
27.5
(22.5, 33.2)
95.7
(93.3, 97.3)
21.3
(16.7, 26.8)
80.2
(75.8, 84.0)
7.0
(4.9, 9.8)
21.8
(17.4, 27.1)
0.0
-4.0
(2.4, 6.8)
91.9
(85.6, 95.6)
91.9
(85.5, 95.6)
91.9
(85.5, 95.6)
0.1
(<0.1, 0.5)
88.3
(81.4, 92.9)
37.7
(24.9, 52.5)
42.3
(24.8, 62.0)
2.8
(1.4, 5.2)
81.3
(64.3, 91.3)
45.1
(30.0, 61.0)
30.4
(20.2, 42.9)
5.1
(2.4, 10.9)
8.8
(5.7, 13.5)
26.3
(17.2, 38.0)
0.0
-0.0
--
7.5
(5.3, 10.5)
7.5
(5.3, 10.5)
6.5
(4.5, 9.2)
2.0
(1.2, 3.3)
5.9
(3.9, 8.9)
5.3
(3.7, 7.5)
2.1
(1.1, 3.9)
0.1
(<0.1, 0.2)
4.8
(3.3, 6.9)
99.4
(98.5, 99.7)
9.7
(6.7, 13.7)
95.8
(94.0, 97.1)
0.6
(0.3, 1.3)
8.8
(6.5, 11.8)
0.0
-0.1
(<0.1, 0.2)
28.0
(20.6, 36.9)
28.0
(20.6, 36.9)
27.2
(19.8, 36.2)
1.5
(0.9, 2.5)
26.0
(18.7, 34.8)
13.1
(9.7, 17.5)
11.8
(6.1, 21.4)
0.7
(0.4, 1.2)
23.4
(17.9, 30.0)
86.2
(76.6, 92.2)
14.7
(11.2, 19.0)
74.0
(65.4, 81.1)
2.6
(1.9, 3.6)
13.0
(10.2, 16.5)
0.0
-<0.1
(<0.1, 0.1)
28.1
(21.5, 35.7)
28.1
(21.5, 35.7)
27.2
(20.6, 35.0)
2.9
(2.0, 4.2)
26.1
(19.7, 33.6)
14.6
(11.3, 18.6)
10.3
(5.4, 18.7)
1.3
(0.8, 2.1)
24.0
(19.0, 29.7)
87.5
(79.3, 92.7)
15.6
(12.3, 19.5)
74.9
(67.5, 81.0)
3.2
(2.5, 4.1)
14.2
(11.5, 17.4)
0.0
-0.6
(<0.1, 1.1)
Continued on next page
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Urban
Among outlets with an antimalarial in
stock, proportion of outlets that had:
Private
Total
TOTAL
Outlets
%
(95% CI)
%
(95% CI)
%
(95% CI)
%
(95% CI)
N=974
N=618
N=763
N=1,381
N=2,355
0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-0.0
-8.8
(6.5, 11.8)
<0.1
(<0.1, 0.2)
0.0
-<0.1
(<0.1, 0.2)
0.0
-0.0
-<0.1
(<0.1, 0.2)
0.0
-13.0
(10.2, 16.5)
Private
Total
%
(95% CI)
N=104
N=870
0.0
-0.0
-0.0
-0.0
§
ArtesunateIV/IM*
-0.0
§
Rectal Artesunate*
-0.0
§
Artemether IV/IM **
-0.0
§
Artemotil IV/IM **
-42.2
(29.0, 56.6)
Rural
%
(95% CI)
%
(95% CI)
0.9
(0.2, 3.6)
0.1
(<0.1, 0.3)
0.9
(0.2, 3.6)
0.0
-0.0
-0.9
(0.2, 3.6)
0.0
-18.8
(14.5, 24.0)
0.8
(0.2, 3.2)
0.1
(<0.1, 0.3)
0.8
(0.2, 3.2)
0.0
-0.0
-0.8
(0.2, 3.2)
0.0
-21.8
(17.4, 27.1)
0.1
(<0.1, 0.9)
0.0
-0.1
(<0.1, 0.9)
0.0
-0.0
-0.1
(<0.1, 0.9)
0.0
-26.4
(17.3, 38.0)
0.1
(<0.1, 0.5)
<0.1
(<0.1, <0.1)
0.1
(<0.1, 0.5)
0.0
-0.0
-0.1
(<0.1, 0.5)
0.0
-14.2
(11.5, 17.4)
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Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by urbanicity
Urban
%
(95% CI)
N=108
62.9
(51.8, 72.8)
No disruption in stock in the past 3
months
N=96
No disruption in stock of quality-assured
ACT (QAACT) in the past 3 months,
among outlets stocking QAACT in the
past 3 months
76.4
(66.6, 84.0)
N=94
No disruption in stock of first-line
quality-assured ACT (FAACT) in the past
3 months, among outlets stocking FAACT
in the past 3 months
75.8
(65.8, 83.6)
N=104
Expired stock of any antimalarial
20.3
(13.2, 29.8)
N=92
Expired stock of QAACT
Expired stock of FAACT
15.4
(8.2, 27.1)
Private
Total
%
(95% CI)
N=1,143
%
(95% CI)
N=1,251
43.7
(38.7, 48.9)
45.8
(41.4, 50.2)
N=124
49.4
(40.5, 58.3)
N=114
57.2
(47.6, 66.2)
N=220
60.7
(52.9, 68.0)
N=208
65.2
(57.1, 72.4)
N=870
N=974
8.2
(5.6, 11.9)
10.2
(7.4, 13.8)
N=115
N=207
6.4
(4.3, 9.5)
10.3
(6.8, 15.3)
N=90
N=107
N=197
15.8
(8.4, 27.8)
6.7
(4.4, 10.0)
10.7
(7.0, 15.9)
N=108
Acceptable storage conditions for
medicines
Rural
96.4
(92.0, 98.4)
N=1,143
N=1,251
91.9
(88.6, 94.3)
92.4
(89.3, 94.7)
%
(95% CI)
N=663
49.5
(41.9, 57.0)
N=619
57.8
(48.9, 66.1)
N=618
58.0
(49.1, 66.5)
N=618
33.4
(22.5, 46.5)
N=565
32.7
(21.0, 47.1)
N=565
32.7
(21.0, 47.1)
N=663
92.6
(74.6, 98.1)
Private
Total
TOTAL
Outlets
%
(95% CI)
N=892
%
(95% CI)
N=1,555
%
(95% CI)
N=2,806
42.5
(34.1, 51.3)
44.1
(36.7, 51.7)
N=237
55.3
(43.6, 66.5)
N=213
56.4
(46.2, 66.1)
N=763
N=856
57.2
(49.9, 64.3)
N=831
57.7
(50.3, 64.8)
N=1,381
6.6
(4.4, 10.0)
13.9
(9.3, 20.3)
N=196
N=761
27.9
(17.2, 41.9)
N=168
32.1
(19.0, 48.8)
N=892
89.6
(84.3, 93.2)
31.7
(21.9, 43.5)
N=733
32.6
(22.6, 44.5)
N=1,555
90.3
(85.6, 93.5)
44.3
(37.9, 50.9)
N=1,076
57.7
(51.1, 63.9)
N=1,039
58.6
(51.9, 65.0)
N=2,355
13.4
(9.4, 18.9)
N=968
28.7
(19.8, 39.5)
N=930
29.6
(20.5, 40.5)
N=2,806
90.6
(86.5, 93.5)
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Table A.17: Price of antimalarials, by urbanicity
Urban
%
Proportion of first-line quality-assured
ACT distributed free of cost
(by volumes of AETDs)
Median price of a tablet AETD:
87.2
Median [IQR]
Rural
Private
Total
%
%
%
0.9
83.2
82.9
Median [IQR]
Median [IQR]
Median [IQR]
Private
Total
TOTAL
Outlets
%
%
%
0.0
0.3
25.4
Median [IQR]
Median [IQR]
Median [IQR]
$0.00
(301)
[0.00-0.00]
$0.00
(290)
[0.00-0.00]
$0.00
(155)
[0.00-0.00]
$0.38
(8)
[0.19-0.38]
$0.00
(3)
[0.00-0.00]
$0.76
(560)
[0.43-6.68]
$0.76
(380)
[0.38-1.91]
$0.57
(399)
[0.38-0.95]
$0.57
(1)
[n/a]
$10.02
(45)
[8.31-10.88]
$0.48
(861)
[0.00-1.15]
$0.38
(670)
[0.00-0.95]
$0.45
(554)
[0.24-0.76]
$0.38
(9)
[0.19-0.38]
$9.36
(48)
[7.78-10.88]
$0.00
(1,888)
[0.00-0.19]
$0.00
(1,886)
[0.00-0.19]
$0.00
(895)
[0.00-0.00]
$0.19
(85)
[0.19-0.38]
$0.00
(23)
[0.00-0.00]
$0.57
(497)
[0.38-1.15]
$0.57
(397)
[0.38-0.95]
$0.67
(455)
[0.48-1.15]
$0.38
(25)
[0.38-0.57]
$0.95
(3)
[0.38-11.46]
$0.00
(2,385)
[0.00-0.38]
$0.00
(2,283)
[0.00-0.29]
$0.00
(1,350)
[0.00-0.48]
$0.19
(110)
[0.19-0.38]
$0.00
(26)
[0.00-0.00]
$0.00
(3,246)
[0.00-0.38]
$0.00
(2,953)
[0.00-0.38]
$0.00
(1,904)
[0.00-0.57]
$0.19
(119)
[0.19-0.38]
$7.64
(74)
[0.00-10.50]
$0.00
(48)
[0.00-0.10]
$0.36
(3)
[0.36-0.86]
$0.43
(193)
[0.33-1.67]
$0.36
(829)
[0.36-0.36]
$0.43
(241)
[0.29-1.62]
$0.36
(832)
[0.36-0.36]
$0.00
(352)
[0.00-0.00]
$0.36
(23)
[0.36-0.43]
$0.38
(273)
[0.33-0.48]
$0.36
(718)
[0.36-0.36]
$0.24
(625)
[0.00-0.43]
$0.36
(741)
[0.36-0.36]
$0.33
(866)
[0.00-0.48]
$0.36
(1,573)
[0.36-0.36]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
$
(0)
[-]
Median price of a package:
Paediatric QAACT (pack for a 10kg
child)
Median price of an AETD:
$0.00
(83)
[0.00-0.00]
$0.24
(127)
[0.14-0.57]
$0.14
(210)
[0.00-0.24]
$0.00
(513)
[0.00-0.15]
$0.09
(122)
[0.14-0.24]
$0.05
(635)
[0.00-0.05]
$0.05
(845)
[0.00-0.10]
$5.05
(42)
[4.44-6.06]
$10.10
(225)
[7.57-15.15]
$10.02
(267)
[7.07-15.04]
$4.45
(308)
[4.44-5.22]
$9.09
(407)
[7.07-12.12]
$7.07
(715)
[5.05-10.10]
$8.08
(982)
[5.05-11.28]
$
(0)
[-]
$5.05
(42)
[4.44-6.06]
$
(0)
[-]
$10.10
(223)
[7.57-15.15]
$
(0)
[-]
$9.09
(265)
[7.07-15.04]
$
(0)
[-]
$4.45
(306)
[4.44-5.22]
$
(0)
[-]
$9.09
(407)
[7.07-12.12]
$
(0)
[-]
$7.07
(713)
[5.05-10.10]
$
(0)
[-]
$8.08
(978)
[5.05-11.11]
First-line (FAACT)
Chloroquine
Artesunate IV/IM
Quinine Injection IV/IM
83 | P a g e
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Table A.18: Affordability of antimalarials, by urbanicity
Urban
Rural
Total
Private
Total
TOTAL
Outlets
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
2.1
1.3
n/a
1.6
n/a
n/a
n/a
1.6
1.3
n/a
1.9
n/a
n/a
First-line quality-assured ACT (FAACT)
n/a
2.1
1.1
n/a
1.6
n/a
n/a
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
0.7
0.4
n/a
0.5
n/a
n/a
n/a
0.5
0.4
n/a
0.6
n/a
n/a
First-line quality-assured ACT (FAACT)
n/a
0.7
0.3
n/a
0.5
n/a
n/a
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
Ratio
n/a
0.7
0.4
n/a
0.5
n/a
n/a
%
%
%
%
%
%
%
N=26
N=1,143
N=1,169
N=5
N=892
N=897
N=2,066
15.3
(6.0, 33.8)
17.2
(13.0, 22.4)
17.2
(13.0, 22.2)
Private
Ratio
chloroquine, the most popular
antimalarial treatment in Madagascar:
the minimum legal daily wage
($1.10):
Median price of a first-line qualityassured tablet AETD relative to the
international reference price ($1.06)
Proportion of outlets that:
Offer credit to consumers for
antimalarials25
29.0
(5.5, 74.0)
37.2
(32.3, 42.4)
37.2
(32.2, 42.5)
34.0
(29.6, 38.8)
25
This question was not asked in Public Health Facilities and figures for CHWs are not shown due to large amounts of missing data.
84 | P a g e
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Table A.19: Availability of diagnostic tests, by urbanicity
Urban
%
(95% CI)
N=108
Rural
Private
Total
%
(95% CI)
N=1,143
%
(95% CI)
N=1,251
%
(95% CI)
N=663
Private
Total
TOTAL
Outlets
%
(95% CI)
N=892
%
(95% CI)
N=1,555
%
(95% CI)
N=2,806
95.6
(89.1, 98.3)
1.9
(1.2, 3.0)
12.2
(10.2, 14.5)
68.6
(57.0, 78.3)
0.1
(0.1, 0.3)
16.1
(11.7, 21.6)
15.5
(11.8, 20.2)
21.9
(16.8, 27.9)
0.5
(0.3, 0.9)
2.8
(2.2, 3.6)
3.7
(1.2, 11.2)
0.0
--
0.9
(0.2, 3.2)
1.1
(0.5, 2.7)
93.7
(87.8, 96.8)
1.8
(1.1, 2.9)
11.8
(9.8, 14.1)
68.5
(56.9, 78.2)
0.1
(0.1, 0.3)
16.0
(11.7, 21.6)
15.4
(11.7, 20.1)
Any diagnostic test
has submitted a product to WHO
Rounds 1-3
Testing Rounds 1-3
Proportion of outlets that provided
diagnostic tests for free, among outlets
providing diagnostic tests
N=106
N=1,241
N=652
N=884
N=1,536
N=2,777
93.7
(87.8, 96.8)
1.7
(1.0, 2.7)
11.7
(9.7, 14.0)
69.3
(57.4, 79.0)
0.1
(0.1, 0.3)
16.0
(11.6, 21.7)
15.4
(11.6, 20.2)
0.0
--
0.2
(0.1, 0.4)
0.1
(0.1, 0.4)
0.0
--
0.0
--
0.0
--
0.0
(<0.1, <0.1)
N=20
N=122
N=580
N=6
N=586
N=708
54.0
(28.8, 77.3)
93.8
(83.6, 97.8)
97.1
(88.0, 99.3)
60.6
(20.1, 90.4)
96.8
(88.4, 99.2)
96.5
(89.8, 98.9)
N=6
N=34
N=17
N=0
N=17
N=51
93.6
(67.4, 99.1)
93.6
(67.5, 99.1)
93.6
(67.5, 99.1)
75.0
(39.3, 93.3)
N=18
N=116
N=579
N=6
N=585
N=701
54.0
(28.8, 77.3)
93.8
(83.6, 97.8)
97.1
(88.0, 99.3)
60.6
(20.1, 90.4)
96.8
(88.4, 99.2)
96.5
(89.8, 98.9)
N=102
100.0
--
Any diagnostic test
N=28
N=1,135
32.6
(15.3, 56.3)
N=98
100.0
--
0.0
--
--
26
85 | P a g e
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Table A.20: Price of diagnostic tests, by urbanicity
Urban
Rural
Private
Total
TOTAL
Outlets
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
Median US$
[IQR] (N)
$1.67
[0.95, 1.67] (5)
$0.48
[0.00, 1.19] (24)
$0.00
[0.00, 0.00] (14)
$
[-] (0)
$0.00
[0.00, 0.00] (14)
$0.00
[0.00, 0.24] (38)
$0.00
[0.00, 0.00] (99)
$0.00
[0.00, 3.48] (17)
$0.00
[0.00, 0.00] (116)
$0.00
[0.00, 0.00] (589)
$0.00
[0.00, 0.19] (6)
$0.00
[0.00, 0.00] (595)
$0.00
[0.00, 0.00] (711)
RDTs from a manufacturer that has
submitted a product to WHO
Rounds 1-3
$0.00
(99)
[0.00, 0.00]
$0.00
(16)
[0.00, 3.48]
$0.00
(115)
[0.00, 0.00]
$0.00
(589)
[0.00, 0.00]
$0.00
(6)
[0.00, 0.19]
$0.00
(595)
[0.00, 0.00]
$0.00
(710)
[0.00, 0.00]
RDTs from a manufacturer that has
not submitted a product to WHO
Rounds 1-3
$
[-] (0)
$2.39
[n/a] (1)
$2.39
[n/a] (1)
$
[-] (0)
$
[-] (0)
$
[-] (0)
$2.39
[n/a] (1)
Median US$
[IQR] (N)
Private
Total
Median US$
[IQR] (N)
$0.48
[0.00, 1.05] (19)
Median price of:
86 | P a g e
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Table A.21: Market share, by urbanicity
Urban
Private
%
%
27
sold or distributed in the past week:
Any ACT
Rural
Total
Private
Total
TOTAL
Outlets
%
%
%
%
%
0.6
5.7
6.4
5.1
9.6
14.7
21.1
0.6
5.7
6.3
4.8
9.6
14.4
20.7
First-line (FAACT)
0.5
3.7
4.2
4.8
8.3
13.1
17.3
0.2
1.9
2.1
0
1.3
1.3
3.4
0.4
5.2
5.5
2.8
9.5
12.3
17.8
<0.1
0
<0.1
0.8
0.1
0.9
0.9
0
0.1
0.1
0.3
0
0.3
0.4
0.6
4.6
5.2
4.9
8.6
13.6
18.8
3.4
10.5
13.8
21.2
43.8
65.1
78.9
3.0
3.9
6.9
20.5
7.6
28.1
35.0
SP
Chloroquine
<0.1
6.1
6.2
0.4
35.5
35.8
42.0
Oral Quinine
0.2
<0.1
0.3
0.1
<0.1
0.2
0.4
0.1
0.3
0.5
0.3
0.7
1.0
1.4
Amodiaquine
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ArtesunateIV/IM
0
0
0
0
0
0
0
Rectal Artesunate
0
0
0
0
0
0
0
Artemether IV/IM
0
0
0
0
0
0
0
Artemotil IV/IM
0
0
0
0
0
0
0
0.1
0.3
0.5
0.3
0.7
1.0
1.4
27
There were a total of 8,085 AETDs (unweighted) sold or distributed in the past week. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-qualit-aAssured ACT; QAACT decompose fully into
FAACT and NAACT. Row and column totals exhibit minor rounding errors.
87 | P a g e
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Table A.22: Provider knowledge, by urbanicity
Urban
Correctly state the recommended firstline treatment for uncomplicated malaria
State at least one health danger sign in a
child that requires referral to a public
health facility28:
Rural
Private
Total
TOTAL
Outlets
%
(95% CI)
N=1,251
%
(95% CI)
N=663
%
(95% CI)
N=892
%
(95% CI)
N=1,555
%
(95% CI)
N=2,806
23.8
(19.4, 28.8)
31.1
(26.2, 36.6)
75.7
(66.2, 83.2)
17.5
(13.0, 23.2)
30.9
(24.4, 38.2)
N=43
N=1,143
N=1,186
N=89
N=892
N=981
78.7
(60.5, 89.9)
52.9
(46.3, 59.4)
54.0
(47.2, 60.7)
75.8
(56.4, 88.3)
62.5
(53.6, 70.7)
64.6
(56.4, 71.9)
63.1
(56.1, 69.6)
%
(95% CI)
N=108
Private
Total
%
(95% CI)
N=1,143
90.6
(84.8, 94.3)
30.9
(25.2, 37.2)
N=2,167

Convulsions
54.4
(37.9, 70.0)
21.4
(16.0, 28.1)
22.8
(17.0, 29.9)
48.0
(37.6, 58.7)
27.8
(20.4, 36.6)
30.9
(23.7, 39.2)
29.8
(23.5, 36.9)

Vomiting
42.9
(32.0, 54.5)
30.0
(26.2, 34.1)
30.6
(26.7, 34.8)
37.1
(24.8, 51.4)
26.7
(21.6, 32.5)
28.3
(23.4, 33.7)
28.6
(24.3, 33.3)

Unable to drink/breastfeed
36.7
(21.2, 55.5)
13.9
(11.1, 17.4)
14.9
(11.5, 19.1)
29.7
(16.4, 47.7)
15.3
(11.8, 19.5)
17.5
(13.5, 22.4)
17.1
(13.6, 21.3)

Excessive sleep/difficult to wake
up
2.0
(0.3, 10.8)
2.1
(1.2, 3.9)
2.1
(1.2, 3.8)
0.0
--
3.0
(1.9, 4.7)
2.5
(1.5, 4.1)
2.5
(1.6, 3.8)

Unconscious/coma
38.7
(27.6, 51.1)
9.1
(5.9, 14.0)
10.4
(7.0, 15.2)
34.3
(24.3, 46.0)
12.6
(6.8, 22.3)
16.0
(10.3, 24.0)
15.2
(10.2, 22.1)
28
This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for less than 1% of cases [n=2,164]. Providers could state multiple responses
and totals may sum to more than 100%.
88 | P a g e
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Table A.23: Provider perceptions, by urbanicity
Urban
%
(95% CI)
N=108
Rural
%
(95% CI)
N=663
Private
Total
TOTAL
Outlets
%
(95% CI)
N=892
%
(95% CI)
N=1,555
%
(95% CI)
N=2,806
Private
Total
%
(95% CI)
N=1,143
%
(95% CI)
N=1,251
2.6
(1.0, 6.5)
79.6
(75.5, 83.2)
71.1
(65.8, 75.9)
4.5
(2.0, 9.9)
78.2
(75.4, 80.7)
61.3
(54.5, 67.7)
62.6
(56.8, 68.1)
“I generally decide which antimalarial
medicine customers receive.”
83.2
(75.6, 88.8)
34.9
(30.1, 40.1)
40.2
(35.2, 45.4)
93.6
(89.3, 96.2)
43.2
(36.7, 50.0)
54.8
(48.0, 61.4)
52.8
(47.0, 58.6)
Report that an ACT is the most effective
antimalarial medicine for an adult
67.1
(57.0, 75.8)
14.6
(12.1, 17.5)
20.4
(17.6, 23.5)
44.5
(31.8, 57.9)
6.9
(3.8, 12.0)
15.5
(11.1, 21.2)
16.2
(12.2, 21.1)
Report that an ACT is the most effective
antimalarial medicine for a child
84.3
(79.5, 88.1)
18.1
(15.0, 21.6)
25.3
(21.3, 29.9)
89.6
(83.8, 93.5)
9.9
(6.8, 14.2)
28.2
(20.9, 36.8)
27.8
(21.5, 35.2)
Proportion of providers that:
Agree with the statement, “Customers
often request an antimalarial by name.”
89 | P a g e
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Additional Tables
Table B.1: Market share by antimalarial category within each outlet type
Public
Health
Facility
Community
Health
Worker
Private
not-forprofit HF
TOTAL
Private
For-profit
HF
Pharmacy
Drug
Store
General
retailer
TOTAL
Private
TOTAL
Outlets
N=1868
N=25
N=258
N=2,152
N=229
N=2,286
N=1,733
N=1,684
N=5,933
N=8,085
%
%
%
%
%
%
%
%
%
%
13.6
72.4
66.3
18.9
53.9
66.6
23.0
0.2
22.1
21.1
First-line (FAACT)
12.7
12.6
65.2
65.2
66.3
56.7
17.8
17.2
53.9
53.4
65.9
46.8
23.0
18.3
0.2
0.2
22.0
17.3
20.7
17.3
<0.1
10.1
12.4
1.1
1.0
25.8
0.6
10.5
46.5
51.7
15.7
60.6
0
22.7
0
0.2
4.6
21.0
3.4
17.8
0
0.9
13.3
64.1
7.2
65.1
3.4
0
63.1
2.9
1.1
18.2
0
0
52.1
0
0.7
55.5
0.2
<0.1
19.8
0
0
0.2
0.1
0.1
19.1
0.9
0.4
18.8
86.4
27.6
33.7
81.1
46.1
33.4
77.0
99.8
77.9
78.9
83.9
0.1
0
27.6
27.8
0
77.3
1.2
18.4
20.3
24.8
5.9
23.8
51.3
4.9
94.9
16.6
59.7
35.0
42.0
1.1
1.3
0
0
0
0
0
0
3.3
2.7
0
0
1.2
1.4
0
0
0.3
7.2
0
0
0.2
2.5
0
0
0.1
1.7
0
0
<0.1
0
0
0
0.1
1.5
0
0
0.4
1.4
0
0
0
0
0
0
0
0
0
0
0
0
ArtesunateIV/IM
Rectal Artesunate
Artemether IV/IM
Artemotil IV/IM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1.3
0
2.7
1.4
7.2
2.5
1.7
0
1.5
1.4
Each antimalarial category as a
proportion of the total volume of all
antimalarials (AETDs) sold or
distributed within a given outlet type
in the past week:
Any ACT
SP
Chloroquine
Oral Quinine
Amodiaquine
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Table B.2: Market share by antimalarial category within urban and rural strata
Urban
sold or distributed within a given stratum and
sector in the past week:
Any ACT
First-line (FAACT)
Rural
TOTAL
Outlets
Public/Not-for-profit
Private
Total
Public/Not-for-profit
Private
Total
N=1,332
N=4,241
N=5,573
N=820
N=1,692
N=2,512
N=8,085
%
%
%
%
%
%
%
15.8
35.4
31.5
19.4
18.0
18.5
21.1
15.8
35.0
31.2
18.1
18.0
18.0
20.7
11.6
23.1
20.8
18.1
15.6
16.4
17.3
4.2
11.9
10.4
0
2.5
1.7
3.4
9.6
31.9
27.5
10.7
17.7
15.4
17.8
0.1
0
<0.1
3.1
0.2
1.2
0.9
0
0.4
0.3
1.3
0
0.4
0.4
14.5
28.6
25.8
18.8
16.2
17.0
18.8
84.2
64.6
68.5
80.6
82.0
81.5
78.9
SP
74.6
24.4
34.3
77.8
14.3
35.2
35.0
Chloroquine
0.4
38.0
30.5
1.3
66.3
44.9
42.0
Oral Quinine
6.1
0.2
1.4
0.4
0.1
0.2
0.4
3.0
2.1
2.3
1.1
1.3
1.2
1.4
Amodiaquine
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ArtesunateIV/IM
0
0
0
0
0
0
0
Rectal Artesunate
0
0
0
0
0
0
0
Artemether IV/IM
0
0
0
0
0
0
0
Artemotil IV/IM
0
0
0
0
0
0
0
3.0
2.1
2.3
1.1
1.3
1.2
1.4
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AMFm Endline Phase 1 Indicators
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Table 3.1. 1: Outlets enumerated by location, drugs stocked and final interview status Madagascar, 2011
Final interview status
Number of outlets enumerated (Flow Diagram Reference A)
Number of outlets stocking drugs at the time of the survey visit
Number of outlets meeting the screening criteria* (Flow Diagram Reference C)
Number of outlets stocking antimalarials at the time of the survey visit (Flow Diagram
Reference E)
Number of outlets without antimalarials in stock at the time of the survey visit, but who
had antimalarials in stock at some time in the 3 months previous to the survey
Urban
n
Rural
n
Total
n
6894
1840
1282
3829
1742
1572
10723
3582
2854
982
1389
2371
269
166
435
Final interview status
Outlet Not Screened
375
307
682
Eligible respondent not available
49
90
139
109
127
236
Outlet closed permanently
201
82
283
Refused
8
5
13
Other
8
3
11
Outlet did not meet screening criteria
5237
1950
7187
Outlet met screening criteria, but not interviewed (total)
31
17
48
6
1
7
3
3
6
0
0
0
Refused
22
11
33
Other
0
2
2
Completed interview
1238
1510
2748
Partially completed interview
13
45
58
3
3
6
2
37
39
0
0
0
Refused
2
1
3
Other
6
4
10
Response rate (%)
%
%
%
Proportion of outlets enumerated that were screened
94.6
92.0
93.6
Proportion of outlets meeting screening criteria that were interviewed**
97.6
98.9
98.3
* The number of outlets meeting the screening criteria is defined as the sum of the number of outlets stocking
antimalarials at the time of the survey and the number of outlets without antimalarials in stock at the time of the survey,
but who had antimalarials in stock at some time in the 3 months previous to the survey.
** Response rate was calculated as outlets where final interview status was “Completed interview” or “Partially completed
interview” as a percentage of all outlets meeting the screening criteria (i.e. flow diagram reference D divided by C).
Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)
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Table 3.1. 2: Outlets enumerated* [Madagascar], 2011
Number of outlets enumerated, by location and type of outlet
Urban
Rural
Censused sub- Booster
Censused sub- Booster
Type of outlet
counties
Total
counties
sample
sample
Public health facility
41
31
72
61
Private not-for-profit
health facility
34
0
34
100
0
46
30
6342
6518
33
2
0
35
235
0
Total
Total
Censused subcounties
Booster
sample
Total
605
666
102
636
738
6
0
6
40
0
40
100
15
0
15
115
0
115
79
32
6342
6553
4
39
2142
2200
0
363
0
363
4
402
2142
2563
50
69
8484
8718
33
365
0
398
83
434
8484
9116
235
594
0
594
829
0
829
Private for-profit outlet
Private for-profit health
facility
Pharmacy
Drug Store
General retailer
Itinerant drug vendor
Total
Community health
worker**
Total
6828
66
6894
2861
968
3829
9689
1034
* Flow diagram reference A
** The Community health worker category includes 105 NGO-supported CHWs and 724 government-supported CHWs.
10723
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Table 3.1. 3: Outlets with antimalarials in stock* [Madagascar], 2011**
Number of outlets with antimalarials in stock at the time of the survey where an interview was conducted, by location and
type of outlet
Urban
Rural
Total
Censused
Booster
Censused
Booster
Censused
Booster
Type of outlet
sub-counties
sample Total sub-counties
sample Total sub-counties
sample Total
Public health
facility
39
26
65
49
504
553
88
530
618
Private not-forprofit health
facility
26
0
26
5
0
5
31
0
31
34
0
34
11
0
11
45
0
45
42
26
743
29
2
0
71
28
743
1
34
406
0
313
0
1
347
406
43
60
1149
29
315
0
72
375
1149
-
-
-
-
-
-
-
-
-
845
31
876
452
313
765
1297
344
1641
15
0
15
66
0
66
81
0
81
Private for-profit
outlet
Private forprofit health
facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
Total
Community health
worker
Total
925
57
982
572
817
1389
1497
874
2371
* Flow diagram reference E. An interview was conducted if final interview status for an outlet was “Completed interview” or
“Partially completed”.
** These numbers form the denominator for all subsequent tables, unless specified otherwise. Any variation in the stated
denominator in subsequent tables is due to missing data on specific variables.
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Table 3.1. 4: Number of products audited [Madagascar], 2011
Number of products audited by outlet type, product type, and location
Urban
Rural
Number of
Number of
products audited
products audited
201
1789
Private not-for-profit health
78
7
facility
569
506
Community health worker
26
101
Total
874
2403
facility
Total
Artemisinin monotherapy
facility
Total
Non-Artemisinin therapy
Private
not-for-profit
health
facility
Total
All antimalarials
facility
Total
Total
Number of
products audited
1990
85
1075
127
3277
1
22
23
2
0
2
59
0
62
3
2
27
62
2
89
0
2
2
0
0
0
6
0
6
0
0
2
6
0
8
96
776
872
36
6
42
1403
0
1535
1467
7
2256
2870
7
3791
298
2589
2887
116
13
129
2037
26
2477
1976
110
4688
4013
136
7165
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Table 3.1. 5: Outlets with at least one staff member who completed secondary school or primary school [Madagascar]
2011
Outlets with at least one staff member who completed secondary school or primary school* (n) as a percentage of all outlets with any
antimalarials in stock at the time of the survey visit (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
At least one staff member completed primary school
100.0
65
99.9 (99.4, 100.0)
553
99.9 (99.4, 100.0)
618
100.0
26
100.0
5
100.0
31
100.0
100.0
100.0
95.1 (92.6, 96.8)
100.0
100.0
98.9 (96.2, 99.7)
85.0 (78.3, 89.9)
86.5 (80.3, 90.9)
11
1
347
403
0
762
100.0
100.0
99.0 (96.7, 99.7)
86.4 (80.6, 90.6)
96.1 (94.0, 97.5)
34
71
28
743
0
876
87.9 (82.6, 91.8)
45
72
375
1146
0
1638
100.0
15
90.5 (72.9, 97.1)
66
90.8 (73.9, 97.2)
81
Total
96.6 (94.8, 97.8)
982
88.6 (83.0, 92.5)
1386
89.7 (84.9, 93.1)
2368
At least one staff member completed secondary school
98.5 (96.1, 99.5)
65
84.9 (74.5, 91.5)
551
86.4 (77.0, 92.3)
616
Private not-for-profit health facility
Private for-profit health facility
Pharmacy
Drug Store
General retailer
Total
100.0
26
100.0
5
100.0
31
92.7 (75.8, 98.1)
99.1 (94.7, 99.9)
74.5 (53.2, 88.3)
42.1 (30.9, 54.1)
90.1 (49.1, 98.8)
100.0
56.0 (48.4, 63.4)
26.4 (18.3, 36.5)
30.3 (22.6, 39.4)
11
1
347
405
0
764
90.6 (61.0, 98.4)
99.1 (95.1, 99.8)
58.0 (50.8, 64.8)
28.6 (21.2, 37.3)
52.2 (40.4, 63.7)
34
71
28
736
0
869
33.7 (26.5, 41.7)
45
72
375
1141
0
1633
26.3 (11.9, 48.4)
15
10.1 (3.5, 25.8)
66
10.5 (3.9, 25.4)
81
Total
57.1 (46.4, 67.1)
975
34.2 (26.9, 42.4)
1386
37.3 (30.5, 44.6)
2361
Pharmacy
Drug Store
General retailer
Total
* The two groups are not mutually exclusive. Providers noted as having completed primary school include those who have completed
secondary school and those who have not completed secondary school but who have completed primary school.
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Table 3.1. 6: Outlets with a staff member with a health-related qualification [Madagascar], 2011
Outlets with at least one staff member with a health-related qualification* (n) as a percentage of all outlets with any antimalarials in
stock at the time of the survey visit (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
Pharmacy
Drug Store
General retailer
Total
94.1 (86.8, 97.5)
65
87.3 (76.8, 93.5)
553
88.1 (78.8, 93.6)
618
100.0
26
100.0
5
100.0
31
92.7 (75.8, 98.1)
97.5 (90.4, 99.4)
30.1 (17.9, 46.0)
2.2 (1.3, 3.6)
100.0
100.0
15.3 (8.4, 26.3)
0.8 (0.3, 2.2)
4.2 (2.6, 6.8)
11
1
335
403
0
750
98.4 (94.1, 99.6)
97.6 (91.0, 99.4)
16.9 (10.4, 26.4)
1.0 (0.5, 2.1)
17.7 (13.3, 23.3)
34
70
28
740
0
872
6.3 (4.5, 8.8)
45
71
363
1143
0
1622
0.0
15
0.0
66
0.0
81
Total
26.4 (21.4, 32.2)
978
13.6 (10.9, 16.8)
1374
15.3 (12.6, 18.5)
2352
* A health-related qualification was defined as pharmacy, nurse or medical doctor related training. Pharmacy related training includes
pharmacy studied to a certificate or diploma level; Nurse related training includes studying nursing to a certificate level (nurse aid) and
diploma level; Medical doctor training includes clinical officers who studied medicine to a diploma level and fully qualified physicians.
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3.2 Availability of antimalarial drugs
3.2.1 Antimalarials in stock
Table 3.2. 1: Outlets with antimalarials in stock in [Madagascar], 2011
Indicator 1.1: Outlets that had any antimalarials in stock at the time of the survey visit* (n) as a percentage of all outlets where
screening questions were completed** (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
Pharmacy
Drug Store
General retailer
Total
Total
100.0
66
96.5 (92.1, 98.5)
576
96.8 (93.0, 98.6)
642
80.9 (65.3, 90.5)
32
82.5 (42.7, 96.8)
6
81.9 (59.8, 93.2)
38
49.2 (34.0, 64.5)
94.0 (72.5, 99.0)
94.7 (80.1, 98.7)
12.5 (10.2, 15.4)
81.5 (55.3, 94.0)
54.7 (6.5, 95.5)
96.3 (93.0, 98.1)
23.0 (19.3, 27.1)
24.9 (21.1, 29.2)
14
2
363
1992
0
2371
70.8 (53.3, 83.7)
93.3 (74.9, 98.5)
96.1 (93.2, 97.8)
20.6 (17.6, 23.9)
15.1 (12.4, 18.2)
70
75
30
6013
0
6188
22.7 (19.7, 26.0)
84
77
393
8005
0
8559
7.2 (2.7, 17.5)
233
11.7 (6.0, 21.5)
569
11.5 (6.1, 20.8)
802
16.3 (13.6, 19.5)
6519
23.6 (19.9, 27.7)
3522
22.2 (19.2, 25.5)
10041
* Flow diagram reference E
** Flow diagram reference B. Screening questions asked whether outlets had any medicines in stock that day, or any antimalarials in
stock that day, and if not whether they had had any medicines, or any antimalarials, in stock in the previous 3 months.
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3.2.2 Antimalarials in stock by type
Table 3.2. 2: Outlets with non-artemisinin therapy in stock [Madagascar], 2011
Indicator 1.2: Outlets that had non-artemisinin monotherapy or non-artemisinin combination therapy in stock (n) as a percentage
of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
N
Percentage
N
Percentage
N
Type of outlet
(95% CI)
(95% CI)
(95% CI)
92.5 (83.1, 96.9)
63
86.3 (80.3, 90.7)
536
87.0 (81.8, 90.9)
599
62.5 (54.6, 69.7)
25
60.3 (13.4, 93.7)
5
61.1 (27.8, 86.6)
30
89.3 (72.9, 96.3)
100.0
100.0
99.6 (98.7, 99.9)
100.0
100.0
98.3 (96.3, 99.2)
99.4 (98.3, 99.8)
99.4 (98.4, 99.7)
11
1
347
404
0
763
97.7 (92.8, 99.3)
100.0
98.5 (96.7, 99.3)
99.5 (98.5, 99.8)
99.3 (98.6, 99.7)
32
71
28
739
0
870
99.4 (98.6, 99.7)
43
72
375
1143
0
1633
0.0
15
9.5 (3.5, 23.3)
65
9.3 (3.5, 22.4)
80
86.2 (76.5, 92.3)
1369
87.5 (79.3, 92.7)
2342
Pharmacy
Drug Store
General retailer
Total
Total
95.7 (93.2, 97.3)
973
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Table 3.2.3. a: Outlets with artemisinin monotherapy in stock (all dosage forms) [Madagascar], 2011
Indicator 1.3: Outlets that had artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock
at the time of the survey visit* (N), by location and type of outlet.
Type of outlet
Urban
Percentage
(95% CI)
N
Rural
Percentage
(95% CI)
N
Total
Percentage
(95% CI)
N
0.0
62
0.3 (0.0, 2.2)
514
0.3 (0.0, 1.9)
576
0.0
25
0.0
5
0.0
30
2.5 (0.6, 10.2)
7.1 (2.2, 20.5)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
11
1
347
404
0
763
0.5 (0.1, 2.8)
7.0 (2.3, 19.6)
0.0
0.0
0.9 (0.2, 3.8)
31
71
28
739
0
869
0.1 (0.0, 0.7)
42
72
375
1143
0
1632
0.0
15
0.0
65
0.0
80
0.8 (0.2, 3.3)
971
<0.1 (<0.1, 0.2)
1347
0.1 (0.0, 0.5)
2318
Private for-profit outlets
Pharmacy
Drug Store
General retailer
Total
Total
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Table 3.2. 3. b: Outlets with oral artemisinin monotherapy in stock [Madagascar], 2011
Indicator 1.3: Outlets that had oral artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock at
the time of the survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
0.0
62
0
514
0.0
576
0.0
25
0
5
0.0
30
2.5 (0.6, 10.2)
0.0
0.0
0.0
0
0
0
0
0
11
1
347
404
0
763
0.5 (0.1, 2.8)
0.0
0.0
0.0
0.1 (<0.1, 0.4)
31
71
28
739
0
869
<0.1 (<0.1, <0.1)
42
72
375
1143
0
1632
0.0
15
0
65
0.0
80
0.1 (<0.1, 0.3)
971
0
1347
<0.1 (<0.1, <0.1)
2318
Pharmacy
Drug Store
General retailer
Total
Total
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Table 3.2. 4: Outlets with non-quality-assured ACTs in stock [Madagascar], 2011
Indicator 1.4: Outlets that had non-quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the
time of the survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
0.4 (0.1, 2.3)
62
4.1 (2.4, 6.8)
515
3.7 (2.2, 6.1)
577
6.3 (1.9, 19.3)
25
0.0
5
2.4 (0.7, 8.5)
30
9.1 (3.1, 23.7)
38.6 (21.6, 58.9)
10.6 (4.3, 23.9)
0.0
0.0
0.0
0.8 (0.3, 2.4)
0.0
0.1 (0.0, 0.2)
11
1
347
404
0
763
1.9 (0.5, 7.0)
38.2 (21.9, 57.7)
1.8 (0.8, 4.0)
0.0
5.3 (2.6, 10.6)
31
71
28
739
0
869
0.9 (0.4, 2.0)
42
72
375
1143
0
1632
0.0
15
1.8 (0.4, 7.8)
65
1.8 (0.4, 7.5)
80
4.8 (2.4, 9.6)
971
0.7 (0.4, 1.2)
1348
1.3 (0.8, 2.1)
2319
Pharmacy
Drug Store
General retailer
Total
Total
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Table 3.2.5. a: Outlets with quality-assured ACTs in stock [Madagascar], 2011
Indicator 1.5: Outlets that had quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the time of
the survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
91.1 (84.2, 95.2)
64
94.0 (90.7, 96.2)
536
93.7 (90.8, 95.7)
600
89.6 (75.9, 95.9)
25
60.8 (18.5, 91.4)
5
71.9 (41.4, 90.3)
30
58.5 (38.1, 76.4)
99.1 (94.7, 99.9)
87.9 (66.7, 96.4)
0.4 (0.1, 1.2)
29.5 (8.2, 66.1)
100.0
52.5 (41.8, 62.9)
2.7 (1.4, 5.0)
7.5 (5.3, 10.5)
11
1
347
404
0
763
35.7 (15.7, 62.2)
99.1 (95.1, 99.8)
56.2 (46.1, 65.9)
2.4 (1.3, 4.3)
18.5 (14.0, 24.0)
31
71
28
739
0
869
9.2 (6.9, 12.0)
42
72
375
1143
0
1632
100.0
15
91.8 (78.2, 97.2)
65
92.0 (79.0, 97.2)
80
28.4 (23.1, 34.3)
973
28.0 (20.5, 37.0)
1369
28.1 (21.5, 35.7)
2342
Pharmacy
Drug Store
General retailer
Total
Total
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Table 3.2.5. b: Outlets with quality-assured ACTs with and without the AMFm logo in stock [Madagascar], 2011
Indicator 1.5: Outlets that had quality-assured ACTs with and without the AMFm in stock (n) as a percentage of outlets with any antimalarials
in stock at the time of the survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
Stocked QAACTs with the AMFm logo
70.7 (53.2, 83.6)
62
72.6 (63.8, 79.9)
528
72.4 (64.5, 79.1)
590
61.9 (45.5, 76.0)
25
21.1 (2.5, 73.6)
5
36.9 (15.4, 65.2)
30
41.8 (20.9, 66.1)
95.9 (90.9, 98.2)
87.9 (66.7, 96.4)
0.2 (0.1, 0.7)
9.9 (1.9, 38.5)
100.0
46.8 (36.2, 57.7)
1.2 (0.4, 3.3)
5.3 (3.7, 7.5)
11
1
347
404
0
763
16.7 (7.5, 33.3)
95.9 (91.2, 98.1)
51.2 (41.0, 61.2)
1.1 (0.4, 2.8)
17.4 (13.0, 22.9)
31
71
28
739
0
869
7.1 (5.3, 9.5)
42
72
375
1143
0
1632
62.3 (36.6, 82.6)
15
9.5 (1.9, 36.0)
65
10.8 (2.7, 34.5)
80
Total
24.0 (18.7, 30.2)
971
13.1 (9.7, 17.6)
Stocked QAACTs without the AMFm logo
1361
14.6 (11.3, 18.6)
2332
63.6 (44.1, 79.4)
64
72.3 (65.1, 78.5)
531
71.3 (64.8, 77.1)
595
69.9 (47.7, 85.6)
25
60.8 (18.5, 91.4)
5
64.3 (34.8, 85.9)
30
26.0 (13.3, 44.6)
82.3 (67.3, 91.3)
30.7 (14.7, 53.3)
0.2 (0.0, 1.3)
19.6 (2.5, 69.8)
100.0
9.7 (6.3, 14.7)
1.5 (0.6, 3.6)
2.6 (1.5, 4.3)
11
1
347
404
0
763
20.9 (4.7, 58.6)
82.5 (68.5, 91.1)
11.9 (8.4, 16.7)
1.3 (0.5, 3.1)
12.2 (8.2, 17.6)
31
71
28
739
0
869
4.0 (2.8, 5.8)
42
72
375
1143
0
1632
79.2 (51.8, 93.1)
15
82.9 (59.3, 94.2)
65
82.8 (60.3, 93.9)
80
Total
19.5 (15.4, 24.4)
973
20.8 (13.9, 29.8)
1364
20.6 (14.6, 28.2)
2337
Pharmacy
Drug Store
General retailer
Total
Pharmacy
Drug Store
General retailer
Total
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Table 3.2. 5. c: Public health facility outlets with quality-assured ACTs among ALL public health facilities in
[Madagascar], 2011
Public health facilities that had quality-assured ACT in stock (n) as a percentage of ALL public health facilities screened (N),
by location.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
91.1 (84.2, 95.2)
64
90.6 (86.4, 93.6)
558
90.7 (87.0, 93.4)
622
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3.2.3 Stockouts of quality-assured ACTs
Table 3.2. 6: Outlets with stock-outs of quality-assured ACTs [Madagascar], 2011
Indicator 1.6: Outlets that were out of stock of all quality-assured ACTs for at least 1 day in the last 7 days (n) as a
percentage of outlets with any quality-assured ACTs in stock at the time of the survey visit or in the 4 weeks preceding the
survey visit (N), by location and type of outlet*
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
facility
Private for- profit health
facility
Pharmacy
Drug Store
General retailer
Total
1.3 (0.2, 7.0)
54
1.1 (0.4, 3.3)
515
1.1 (0.4, 2.9)
569
0.0
22
0.0
2
0.0
24
0.0
19
0.0
1
0.0
20
4.8 (1.4, 14.8)
0.0
0.0
0.0
4.2 (1.7, 10.1)
0.0
3.3 (1.2, 8.4)
1
198
5
0
205
4.8 (1.5, 14.1)
3.5 (1.4, 8.6)
0.0
2.9 (0.7, 11.1)
67
24
3
0
113
3.1 (1.4, 6.7)
68
222
8
0
318
0.0
16
1.5 (0.2, 10.1)
64
1.4 (0.2, 9.6)
80
Total
2.0 (0.6, 6.5)
205
1.6 (0.7, 3.8)
786
1.7 (0.8, 3.5)
991
*This indicator measures stock-outs of quality-assured ACTs among outlets that have recently stocked these products. The
denominator may include outlets which had no antimalarials in stock on the day of the survey but which had stocked them
in the previous 3 months. A stock-out is defined as being out of stock of all quality-assured ACTs for at least 1 day in the
last seven days. Outlets that have recently stocked QAACTs are defined as outlets with any QAACTs in stock at the time of
the survey visit or in the 4 weeks preceding the survey visit.
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3.2.4 Population coverage of outlets with quality-assured ACTs
Table 3.2. 7: Percentage of the population living in censused “sub-counties” with outlets with quality-assured ACTs in
stock at the time of survey [Madagascar], 2011
Indicator 1.7: Population living in a censused “sub-district” where there was at least one of a given type of outlet with a quality-assured
ACT in stock at the time of the survey visit (n) as a percentage of the total population living in all the censused “sub-districts” (N), by
location.
Urban
Rural
Total
Percentage
Percentage
Percentage
(95% CI)
N
(95% CI)
N
(95% CI)
N
At least one public health facility
stocking quality-assured ACTs
At least one private not-for-profit
health facility stocking quality-assured
ACTs
At least one private for-profit outlet
At least one community health worker
94.4 (76.0, 98.9)
638229
89.3 (70.3, 96.7)
509449
89.8 (73.2, 96.6)
77.8 (59.0, 89.5)
7.1 (1.7, 25.8)
14.1 (7.2, 25.7)
94.4 (71.5, 99.1)
64.3 (44.4, 80.2)
67.3 (49.2, 81.3)
27.8 (11.7, 52.6)
57.1 (37.8, 74.5)
54.3 (37.2, 70.4)
100.0
100.0
At least one outlet of any type
100.0
Source of the Population data: Madagascar National Census Frame, 2002
1147678
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3.3 Pricing of antimalarials (Affordability)
3.3.1 Cost to patients of antimalarials
Table 3.3. 1: Cost to patients of non-artemisinin therapy, in US dollars*, [Madagascar], 2011
Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)** of non-artemisinin monotherapy or nonartemisinin combination therapy, by location, type of outlet and dosage form.
Urban
Rural
Total
Number
Number
Number
Median cost
of
Median cost
of
Median cost
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
All dosage forms
2.78 [0.00, 3.98]
94
1.44 [0.00, 3.98]
759
1.85 [0.00, 3.98]
853
5.42 [0.38, 7.23]
32
2.69 [0.96, 3.62]
6
2.69 [0.73, 6.33]
38
facility
0.32 [0.32, 6.67]
1372
0.32 [0.32, 0.34]
1451
0.32 [0.32, 0.43]
2823
Community health workers
0
0.38 [0.32, 0.38]
7
0.38 [0.32, 0.38]
7
Total
0.34 [0.32, 6.33]
1498
0.32 [0.32, 0.43]
2223
0.32 [0.32, 0.64]
3721
Tablets
0.00 [0.00, 2.78]
63
0.00 [0.00, 0.00]
456
0.00 [0.00, 0.03]
519
0.38 [0.32, 1.92]
18
0.96 [0.13, 2.69]
4
0.96 [0.30, 2.69]
22
facility
0.32 [0.32, 0.38]
1076
0.32 [0.32, 0.32]
1013
0.32 [0.32, 0.32]
2089
0
0.38 [0.32, 0.38]
6
0.38 [0.32, 0.38]
6
Total
0.32 [0.32, 0.43]
1157
0.32 [0.32, 0.32]
1479
0.32 [0.32, 0.32]
2636
Oral liquids
5.13 [5.13, 5.13]
1
0
5.13 [5.13, 5.13]
1
5.98 [5.98, 5.98]
1
0
5.98 [5.98, 5.98]
1
facility
6.41 [5.98, 6.75]
35
6.84 [5.13, 8.55]
22
6.41 [5.81, 7.26]
57
0
0
0
Total
6.41 [5.98, 6.75]
37
6.84 [5.13, 8.55]
22
6.41 [5.81, 6.84]
59
Injectables
3.99 [3.98, 4.52]
30
3.99 [3.98, 4.67]
303
3.99 [3.98, 4.67]
333
8.13 [5.42,
7.18 [5.42, 9.04]
13
18.98 [3.62, 18.98]
2
15
facility
18.98]
8.33 [7.23,
8.13 [6.33,
261
8.13 [6.33, 10.85]
416
677
13.46]
11.22]
0
9.04 [9.04, 9.04]
1
9.04 [9.04, 9.04]
1
8.13 [6.33,
304
6.33 [4.52, 9.04]
722
7.23 [4.52, 9.27]
1026
Total
11.22]
Other
0
0
0
0
0
0
facility
0
0
0
0
0
0
Total
0
0
0
* 1 USD = 2138.56 Ariary, after converting 2011 to 2010 prices;
** An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every
audited antimalarial.
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Table 3.3. 2: Cost to patients of artemisinin monotherapy, in US dollars*, [Madagascar], 2011
Indicator 2.3: Median cost to patients of one adult equivalent treatment dose (AETD)** of artemisinin monotherapy, by location, type of
outlet and dosage form.
Urban
Rural
Total
Number
Number
Number
Median cost
of
Median cost
of
Median cost
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
All dosage forms
0.00 [0.00,
0
2
0.00 [0.00, 0.00]
2
0.00]
0
0
0
facility
36.83 [31.62,
2
0
36.83 [31.62, 42.04]
2
42.04]
0
0
0
36.83 [31.62,
0.00 [0.00,
2
2
31.62 [0.00, 42.04]
4
Total
42.04]
0.00]
All oral dosage forms
0
0
0
0
0
0
facility
0
0
0
0
0
0
Total
0
0
0
Tablets
0
0
0
0
0
0
facility
0
0
0
0
0
0
Total
0
0
0
Oral liquids
0
0
0
0
0
0
facility
0
0
0
0
0
0
Total
0
0
0
Injectables
0.00 [0.00,
0
2
0.00 [0.00, 0.00]
2
0.00]
0
0
0
facility
36.83 [31.62,
2
0
36.83 [31.62, 42.04]
2
42.04]
0
0
0
36.83 [31.62,
0.00 [0.00,
2
2
31.62 [0.00, 42.04]
4
Total
42.04]
0.00]
Other
0
0
0
0
0
0
facility
0
0
0
0
0
0
Total
0
0
0
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Table 3.3. 3: Cost to patients of non-quality-assured ACTs, in US dollars*, [Madagascar], 2011
Indicator 2.2: Median cost to patients of one adult equivalent treatment dose (AETD)** of non-quality-assured ACTs by location, type of
outlet and dosage form.
Urban
Rural
Total
Number
Number
Number
Median cost
of
Median cost
of
Median cost
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
All dosage forms
Public health
4.70 [4.70, 4.70]
1
0.00 [0.00, 0.00]
21
0.00 [0.00, 0.00]
22
facility
Private not-for0.00 [0.00, 0.00]
2
0
0.00 [0.00, 0.00]
2
profit health facility
Private for-profit
9.14 [7.48, 10.25]
54
0.85 [0.34, 10.25]
3
9.14 [7.48, 10.25]
57
outlet
Community health
0
0.00 [0.00, 0.34]
2
0.00 [0.00, 0.34]
2
workers
Total
9.14 [7.48, 10.25]
57
0.00 [0.00, 0.00]
26
7.90 [0.00, 9.74]
83
Tablets
Public health
4.70 [4.70, 4.70]
1
0.00 [0.00, 0.00]
21
0.00 [0.00, 0.00]
22
facility
Private not-for0.00 [0.00, 0.00]
2
0
0.00 [0.00, 0.00]
2
Private for-profit
8.97 [7.43, 9.74]
45
0.85 [0.34, 10.25]
3
8.37 [6.96, 9.74]
48
outlet
Community health
0
0.00 [0.00, 0.34]
2
0.00 [0.00, 0.34]
2
workers
Total
8.37 [6.96, 9.74]
48
0.00 [0.00, 0.00]
26
6.84 [0.00, 9.40]
74
Oral liquids
Public health
0
0
0
facility
Private not-for0
0
0
Private for-profit
10.25 [8.66, 27.52]
9
0
10.25 [8.66, 27.52]
9
outlet
Community health
0
0
0
workers
Total
10.25 [8.66, 27.52]
9
0
10.25 [8.66, 27.52]
9
Injectables
Public health
0
0
0
facility
Private not-for0
0
0
Private for-profit
0
0
0
outlet
Community health
0
0
0
workers
Total
0
0
0
Other
Public health
0
0
0
facility
Private not-for0
0
0
Private for-profit
0
0
0
outlet
Community health
0
0
0
workers
Total
0
0
0
** An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited
antimalarial.
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Table 3.3. 4: Cost to patients of quality-assured ACTs, in US dollars*, [Madagascar], 2011
Indicator 2.1: Median cost to patients of one adult equivalent treatment dose (AETD)** of quality-assured ACTs, by presence of the
AMFm logo, location and type of outlet
Urban
Rural
Total
Number
Number
Number
Median cost
of
Median cost
of
Median cost
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
Adult equivalent treatment dose (AETD)*
facility
Total
0.00 [0.00, 0.00]
All QAACTs
201
0.00 [0.00, 0.00]
0.00 [0.00, 0.00]
75
0.68 [0.38, 5.98]
0.34 [0.17, 0.68]
0.43 [0.00, 1.03]
560
25
861
facility
Total
0.00 [0.00, 0.00]
facility
Total
0.00 [0.00, 0.00]
1780
0.00 [0.00, 0.00]
1981
0.00 [0.00, 0.00]
7
0.00 [0.00, 0.00]
82
0.51 [0.34, 1.03]
0.17 [0.17, 0.34]
0.00 [0.00, 0.34]
497
101
2385
0.60 [0.34, 1.37]
0.17 [0.17, 0.34]
0.00 [0.00, 0.34]
1057
126
3246
QAACTs with the AMFm logo
100
0.00 [0.00, 0.00]
873
0.00 [0.00, 0.00]
973
4
0.00 [0.00, 0.00]
50
455
18
1350
0.51 [0.34, 1.03]
0.17 [0.00, 0.34]
0.00 [0.00, 0.51]
854
27
1904
907
0.00 [0.00, 0.00]
1008
46
0.00 [0.00, 0.00]
0.51 [0.34, 0.85]
0.34 [0.10, 0.68]
0.40 [0.21, 0.68]
399
0.60 [0.43, 1.03]
9
0.00 [0.00, 0.17]
554
0.00 [0.00, 0.43]
QAACTs without the AMFm logo
0.00 [0.00, 0.00]
101
0.00 [0.00, 0.00]
0.00 [0.00, 0.00]
29
0.00 [0.00, 0.00]
3
0.00 [0.00, 0.00]
32
9.10 [7.69, 14.36]
0.26 [0.17, 0.68]
3.59 [0.00, 9.36]
161
16
307
0.51 [0.34, 0.68]
0.17 [0.17, 0.34]
0.09 [0.00, 0.17]
42
83
1035
7.90 [0.51, 10.25]
0.17 [0.17, 0.34]
0.17 [0.00, 0.34]
203
99
1342
453
0.00 [0.00, 0.00]
503
1
0.00 [0.00, 0.00]
21
122
59
635
0.19 [0.13, 0.26]
0.04 [0.04, 0.04]
0.04 [0.00, 0.09]
249
72
845
222
0.00 [0.00, 0.00]
248
1
0.00 [0.00, 0.00]
11
99
10
332
0.21 [0.17, 0.26]
0.00 [0.00, 0.04]
0.00 [0.00, 0.17]
194
11
464
Pediatric formulation -Pack for a two-year old child (10kg)***
facility
Total
0.00 [0.00, 0.00]
50
All QAACTs
0.00 [0.00, 0.00]
0.00 [0.00, 0.00]
20
0.00 [0.00, 0.00]
facility
Total
0.00 [0.00, 0.00]
0.21 [0.13, 0.51]
0.04 [0.02, 0.09]
0.13 [0.00, 0.21]
0.00 [0.00, 0.00]
0.17 [0.13, 0.21]
0.00 [0.00, 0.00]
0.13 [0.00, 0.21]
127
0.17 [0.13, 0.21]
13
0.04 [0.04, 0.04]
210
0.04 [0.00, 0.04]
QAACTs with the AMFm logo
26
0.00 [0.00, 0.00]
10
0.00 [0.00, 0.00]
95
0.21 [0.21, 0.26]
1
0.04 [0.00, 0.04]
132
0.00 [0.00, 0.13]
QAACTs without the AMFm logo
0.00 [0.00, 0.00]
24
0.00 [0.00, 0.00]
231
0.00 [0.00, 0.00]
255
0.00 [0.00, 0.00]
10
0
0.00 [0.00, 0.00]
10
facility
3.43 [0.90, 4.46]
32
0.13 [0.09, 0.13]
23
0.13 [0.09, 0.90]
55
0.04 [0.04, 0.09]
12
0.04 [0.04, 0.04]
49
0.04 [0.04, 0.04]
61
Total
0.09 [0.00, 3.43]
78
0.04 [0.00, 0.04]
303
0.04 [0.00, 0.04]
381
***Pediatric formulations (PFs) are packages intended for children. In the calculation of median cost we include only packages whose
age (weight) range includes a 2 year old (10kg) child.
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Table 3.3.5. a : Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales
volumes (chloroquine) for all dosage types, in US dollars*, [Madagascar], 2011
Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)** of the most popular antimalarial in terms of
national private for-profit sales volumes in [Madagascar] that is not a quality-assured ACT, for all dosage types (chloroquine), by
location and type of outlet
Total
Urban
Rural
Number
Number
Number
Type of
Median cost
of
Median cost
of
of
Median cost
outlet
[IQR]
products
[IQR]
products
products
[IQR]
Private for
profit outlet
0.32 [0.32, 0.32]
864
0.32 [0.32, 0.32]
740
0.32 [0.32, 0.32]
1,604
Table 3.3.5. b: Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales
volumes (chloroquine) for tablets, in US dollars*, [Madagascar], 2011
national private for-profit sales volumes in [Madagascar] that is not a quality-assured ACT, for tablets (chloroquine), by location and
type of outlet
Urban
Rural
Total
Number
Number
Number
Type of
of
Median
cost
of
Median
cost
of
Median cost
outlet
products
[IQR]
products
[IQR]
products
[IQR]
Private forprofit outlet
0.32 [0.32, 0.32]
829
0.32 [0.32, 0.32]
718
0.32 [0.32, 0.32]
1,547
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Table 3.3.5. c: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all
outlet types (chloroquine) for all dosage types, in US dollars*, [Madagascar], 2011
national sales volumes for all outlet types in [Madagascar] that is not a quality-assured ACT, for all dosage types (chloroquine), by
Rural
Total
Urban
Number
Number
Number
Type of
Median cost
of
of
of
Median cost
Median cost
outlet
[IQR]
products
products
products
[IQR]
[IQR]
0.32 [0.32, 0.32]
869
0.32 [0.32, 0.32]
763
0.32 [0.32, 0.32]
1,632
All outlets
Table 3.3. 5. d: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all
outlet types (chloroquine) for tablets, in US dollars*, [Madagascar], 2011
national sales volumes for all outlet types in [Madagascar] that is not a quality-assured ACT, for tablets (chloroquine), by location
and type of outlet
Urban
Rural
Total
Number
Number
Number
Type of
Median cost
of
Median cost
of
Median cost
of
outlet
[IQR]
products
[IQR]
products
[IQR]
products
All outlets 0.32 [0.32, 0.32]
832
0.32 [0.32, 0.32]
741
0.32 [0.32, 0.32]
1,573
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3.3.2 Gross percentage markup between purchase price and retail selling
price
Table 3.3. 6: Gross percentage markup between purchase price and retail selling price of non-artemisinin therapy
[Madagascar], 2011
Median percentage markup between purchase price and retail selling price of non-artemisinin monotherapy or non-artemisinin
combination therapy by location and type of outlet
Urban
Rural
Total
Number
Number
Number
Median markup
of
Median markup
of
Median markup
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
15.1 [0.0, 30.9]
77
0.0 [0.0, 15.2]
675
0.0 [0.0, 15.2]
752
Private not-forprofit health facility
20.0 [9.1, 60.0]
14
15.4 [14.3, 448.6]
5
20.0 [9.1, 448.6]
19
60.0 [25.0, 85.2]
34
66.7 [33.3, 100.0]
16
66.7 [33.3, 100.0]
50
38.9 [35.0, 53.8]
42.9 [30.0, 60.0]
66.7 [66.7, 100.0]
172
105
645
47.0 [40.0, 52.9]
50.0 [33.3, 78.6]
66.7 [60.0, 100.0]
7
733
376
38.9 [35.0, 52.9]
50.0 [33.3, 75.0]
66.7 [60.0, 100.0]
179
838
1021
Private for-profit
outlet
Private for-profit
health facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
Total
0
66.7 [38.8, 66.7]
Community health
worker
Total
66.7 [35.0, 66.7]
0
0
956
66.7 [42.9, 100.0]
1132
66.7 [42.9, 100.0]
2088
0
100.0 [25.0, 100.0]
7
100.0 [25.0, 100.0]
7
1047
66.7 [25.0, 100.0]
1819
66.7 [25.6, 100.0]
2866
Note: 10 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. Refer to section 0
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Table 3.3. 7: Gross percentage markup between purchase price and retail selling price of artemisinin monotherapy
[Madagascar], 2011
Indicator 2.5: Median percentage markup between purchase price and retail selling price of artemisinin monotherapy
by location and type of outlet
Urban
Rural
Total
Number
of
products
0
Private not-forprofit health facility
0
0
0
Private for-profit
outlet
Private for-profit
health facility
0
0
0
0
0
0
0
0
0
0
0
0
Type of outlet
Median markup
[IQR]
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
-
Total
Median markup
[IQR]
Number
of
products
0.0 [0.0, 0.0]
2
0.0 [0.0, 0.0]
2
-
-
0
Total
Community health
worker
Median markup
[IQR]
Number
of
products
-
-
-
-
0
0
0
-
0
-
0
0
0.0 [0.0, 0.0]
2
0.0 [0.0, 0.0]
2
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Table 3.3. 8: Gross percentage markup between purchase price and retail selling price of non-quality-assured ACTs
[Madagascar], 2011
Median percentage markup between purchase price and retail selling price of non-quality-assured ACTs by location and type of outlet
Urban
Rural
Total
Number
Number
Number
Median markup
of
Median markup
of
Median markup
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
11.1 [11.1, 11.1]
1
health facility
0.0 [0.0, 0.0]
11.1 [11.1, 11.1]
38.0 [38.0, 38.1]
Private for-profit
outlet:
Private for-profit
health facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
66.7 [23.0, 135.3]
Total
38.0 [38.0, 38.2]
21
0.0 [0.0, 0.0]
2
0
0.0 [0.0, 0.0]
3
13
0
0
11.1 [11.1, 11.1]
38.0 [38.0, 38.1]
1
0
66.7 [23.0, 100.0]
4
0
0.0 [0.0, 0.0]
100.0 [100.0,
100.0]
0
Community health
worker
22
2
13
5
0
0
0
20
100.0 [100.0,
100.0]
1
38.0 [38.0, 41.0]
0
0.0 [0.0, 100.0]
2
0.0 [0.0, 100.0]
24
11.1 [0.0, 38.0]
Total
38.0 [37.3, 38.1]
23
0.0 [0.0, 0.0]
3
21
2
47
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Table 3.3.9. a: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs [Madagascar],
2011
Indicator 2.5: Median percentage markup between purchase price and retail selling price of quality-assured ACTs by location and type of outlet
Urban
Rural
Total
Number
Number
Number
Median markup
of
Median markup
of
Median markup
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
0.0 [0.0, 0.0]
198
0.0 [0.0, 0.0]
1756
0.0 [0.0, 0.0]
1954
health facility
0.0 [0.0, 0.0]
68
0.0 [0.0, 0.0]
7
0.0 [0.0, 0.0]
75
42.9 [0.0, 71.4]
33
42.9 [42.9, 100.0]
4
42.9 [42.9, 100.0]
37
39.5 [33.3, 57.9]
50.0 [32.3, 66.7]
50.0 [50.0, 50.0]
173
72
2
41.2 [40.0, 42.1]
50.0 [25.0, 71.4]
50.0 [40.0, 66.7]
5
324
6
39.5 [33.3, 57.9]
50.0 [27.7, 66.7]
50.0 [40.0, 66.7]
178
396
8
Private for-profit
outlet
Private for-profit
health facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
Total
Community health
worker
0
0
0
40.6 [29.9, 66.7]
280
50.0 [33.3, 66.7]
339
43.5 [33.3, 66.7]
619
100.0 [0.0, 100.0]
17
100.0 [0.0, 100.0]
52
100.0 [0.0, 100.0]
69
Total
11.1 [0.0, 42.9]
563
0.0 [0.0, 42.1]
2154
0.0 [0.0, 42.9]
2717
Note: 59 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. 50 of these were among
CHWs. Refer to section 0
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Table 3.3. 9. b: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs, by presence of
the AMFm logo, [Madagascar], 2011
Indicator 2.5: Median percentage markup between purchase price and retail selling price of quality-assured ACTs by presence of the AMFm logo by
Urban
Rural
Total
Number
Number
Number
Median markup
of
Median markup
of
Median markup
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
QAACTs with the AMFm logo*
0.0 [0.0, 0.0]
97
0.0 [0.0, 0.0]
861
0.0 [0.0, 0.0]
958
health facility
Private for-profit
outlet
Private for-profit
health facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
Total
0.0 [0.0, 0.0]
42
0.0 [0.0, 0.0]
4
0.0 [0.0, 0.0]
46
66.7 [60.0, 100.0]
20
42.9 [42.9, 42.9]
3
42.9 [42.9, 66.7]
23
42.9 [35.1, 66.7]
60.0 [40.0, 100.0]
66.7 [66.7, 66.7]
120
59
1
41.6 [40.6, 42.8]
50.0 [25.0, 66.7]
36.7 [33.3, 40.0]
4
307
2
42.9 [35.1, 61.3]
50.0 [32.4, 71.4]
40.0 [33.3, 40.0]
124
366
3
0
0
0
50.0 [36.4, 73.9]
200
42.9 [33.3, 66.7]
316
42.9 [33.3, 66.7]
516
Community health
worker
0.0 [0.0, 100.0]
5
0.0 [0.0, 0.0]
9
0.0 [0.0, 0.0]
14
Total
30.0 [0.0, 57.9]
1190
0.0 [0.0, 32.4]
1534
895
0.0 [0.0, 0.0]
996
0.0 [0.0, 0.0]
344
0.0 [0.0, 0.0]
QAACTs without the AMFm logo**
101
0.0 [0.0, 0.0]
health facility
0.0 [0.0, 0.0]
26
0.0 [0.0, 0.0]
3
0.0 [0.0, 0.0]
29
0.0 [0.0, 0.0]
13
100.0 [100.0, 100.0]
1
100.0 [0.0, 100.0]
14
38.0 [33.3, 41.0]
28.2 [27.1, 32.3]
50.0 [50.0, 50.0]
40.0 [40.0, 40.0]
66.7 [25.0, 100.0]
50.0 [50.0, 66.7]
66.7 [50.0, 100.0]
1
17
4
0
23
38.1 [33.3, 40.0]
32.3 [27.1, 57.9]
50.0 [50.0, 66.7]
33.3 [24.2, 38.6]
53
13
1
0
80
44.2 [28.2, 66.7]
54
30
5
0
103
100.0 [25.0, 100.0]
12
100.0 [100.0, 100.0]
43
100.0 [100.0, 100.0]
55
0.0 [0.0, 30.1]
219
0.0 [0.0, 100.0]
964
0.0 [0.0, 100.0]
1183
Private for-profit
outlet
facility
Pharmacy
Drug Store
General retailer
Total
Community health
worker
Total
Note: *14 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. Refer to section 0(QAACTs
with logo)
**45 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. Refer to section 0 (QAACTs
without logo)
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Table 3.3. 10: Median total gross markup between first-line buyer price and retail selling price of quality-assured ACTs bearing
the AMFm logo, in US dollars, [Madagascar], 2011
Indicator 2.6: Median total gross markup* between first-line buyer price** and retail selling price per adult equivalent treatment dose
(AETD)*** of quality-assured ACTs bearing the AMFm logo, by location and type of outlet
Urban
Rural
Total
Number
Number
Number
Median markup
of
Median markup
of
Median markup
of
Type of outlet
[IQR]
products
[IQR]
products
[IQR]
products
-0.06 [-0.07, -0.04]
100
-0.07 [-0.07, -0.06]
873
-0.06 [-0.07, -0.04]
973
health facility
Private for-profit
outlet
Private for-profit
health facility
Pharmacy
Drug Store
General retailer
Itinerant drug
vendor
Total
Community health
worker
-0.06 [-0.07, -0.04]
46
-0.06 [-0.07, -0.05]
4
-0.06 [-0.07, -0.04]
50
0.62 [0.36, 1.64]
26
0.82 [0.36, 1.64]
3
0.82 [0.36, 1.64]
29
0.36 [0.25, 0.77]
0.36 [0.28, 0.82]
0.95 [0.95, 2.53]
299
72
2
0.32 [0.18, 0.59]
0.53 [0.29, 0.99]
0.53 [0.28, 0.84]
4
444
4
0.36 [0.24, 0.77]
0.48 [0.28, 0.99]
0.53 [0.28, 0.84]
303
516
6
0
0
0
0.36 [0.28, 0.82]
399
0.53 [0.28, 0.95]
455
0.45 [0.28, 0.84]
854
0.27 [0.03, 0.61]
9
-0.04 [-0.04, 0.13]
18
0.11 [-0.04, 0.27]
27
Total
0.28 [0.14, 0.65]
554
-0.04 [-0.07, 0.28]
1350
-0.04 [-0.07, 0.36]
1904
*Median total gross markup is the median of the difference between the retail selling price and the mean first-line buyer price for each
QAACT.
**First-Line Buyer (FLB) price data were provided by The Global Fund.
*** An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited
antimalarial
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3.3.3 Availability and cost to patients of diagnostic tests (RDT/microscopy)
Any diagnostic test
Table 3.3. 11: Availability of any diagnostic test for malaria, Madagascar, 2011
Outlets where any diagnostic tests (microscopy or RDT) were available* (n) as a percentage of outlets with any antimalarials in stock at
the time of the survey visit** (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
98.5 (93.4, 99.7)
65
94.0 (91.4, 95.9)
552
94.5 (92.2, 96.2)
617
91.6 (65.7, 98.4)
25
60.8 (18.5, 91.4)
5
72.7 (41.7, 90.9)
30
47.3 (37.2, 57.7)
7.1 (3.6, 13.4)
0.0
0.0
0.0
0.0
1.7 (0.7, 4.0)
0.0
0.1 (0.1, 0.3)
11
1
347
399
0
758
10.6 (4.6, 22.5)
7.0 (3.7, 12.9)
1.5 (0.6, 3.5)
0.0
2.5 (1.5, 4.2)
34
70
28
739
0
871
0.5 (0.3, 0.9)
45
71
375
1138
0
1629
88.5 (72.0, 95.8)
15
64.6 (44.8, 80.4)
66
65.2 (45.8, 80.6)
81
Total
15.1 (12.6, 18.0)
976
19.5 (14.8, 25.4)
1381
18.9 (14.8, 23.8)
2357
Pharmacy
Drug Store
General retailer
Total
* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the day
of the survey visit
** Flow diagram reference E
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Malaria microscopy
Table 3.3. 12: Availability of malaria microscopy, Madagascar, 2011
Outlets where malaria microscopic tests were available* (n) as a percentage of outlets with any antimalarials in stock at the time of the
survey visit** (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
22.9 (15.8, 31.9)
63
3.1 (1.9, 4.9)
553
5.2 (3.9, 6.8)
616
36.2 (22.8, 52.1)
25
0.0
5
14.0 (6.5, 27.5)
30
18.1 (11.4, 27.6)
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
11
1
347
403
0
762
4.1 (1.7, 9.6)
0.0
0.0
0.0
0.6 (0.3, 1.3)
34
70
28
739
0
871
0.1 (<0.1, 0.2)
45
71
375
1142
0
1633
0.0
15
5.7 (1.2, 22.8)
66
5.6 (1.2, 22.2)
81
3.5 (2.7, 4.6)
974
1.1 (0.3, 4.0)
1386
1.4 (0.6, 3.3)
2360
Pharmacy
Drug Store
General retailer
Total
Total
* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the
day of the survey visit
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Table 3.3. 13: Cost to patients of malaria microscopy in 2010 US dollars Madagascar, 2011
Median cost* to patients of one malaria diagnostic test with microscopy, by outlet type and patient age
Urban
Rural
Number of
Number of
outlets
outlets
reporting
reporting
price of
price of
Median cost
malaria
Median cost
malaria
Type of outlet
[IQR]
microscopy
[IQR]
microscopy
Adults
Median cost
[IQR]
Number of
outlets
reporting
price of
malaria
microscopy
13
0.13 [0.00, 0.43]
27
0.43 [0.00, 1.07]
14
health facility
0.00 [0.00, 0.94]
5
0
0.00 [0.00, 0.94]
5
1.50 [0.85, 1.50]
5
0
1.50 [0.85, 1.50]
5
1.50 [0.85, 1.50]
0
0
0
0
5
0
0
0
0
0
1.50 [0.85, 1.50]
0
0
0
0
5
facility
Pharmacy
Drug Store
General retailer
Total
0.00 [0.00, 0.13]
Total
0
0.00 [0.00, 0.00]
1
0.00 [0.00, 0.00]
1
Total
0.43 [0.00, 1.07]
24
0.00 [0.00, 0.00]
Children
14
0.00 [0.00, 0.21]
38
0.43 [0.00, 1.07]
14
0.00 [0.00, 0.13]
13
0.13 [0.00, 0.43]
27
Private-not-for-profit
health facility
0.00 [0.00, 0.94]
5
0
0.00 [0.00, 0.94]
5
5
0
1.50 [0.85, 1.50]
5
0
0
0
0
5
0
0
0
0
0
1.50 [0.85, 1.50]
0
0
0
0
5
Private for- profit
outlet
Private for-profit
1.50 [0.85, 1.50]
health facility
Pharmacy
Drug Store
General retailer
Total
1.50 [0.85, 1.50]
Community health
worker
Total
0.43 [0.00, 1.07]
0
0.00 [0.00, 0.00]
1
0.00 [0.00, 0.00]
1
24
0.00 [0.00, 0.00]
14
0.00 [0.00, 0.21]
38
*1 USD = 2138.56 Ariary, after converting 2011 to 2010 prices.
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Diagnostic test with rapid diagnostic tests
Table 3.3. 14: Availability of rapid diagnostic tests for malaria, Madagascar, 2011
Outlets where rapid diagnostic tests were available (n) as a percentage of outlets with any antimalarials in stock at the time of the
survey visit* (N), by location and type of outlet.
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
96.1 (89.7, 98.6)
65
93.8 (91.3, 95.6)
552
94.1 (91.8, 95.7)
617
89.2 (66.6, 97.2)
24
60.8 (18.5, 91.4)
5
71.5 (40.4, 90.3)
29
43.7 (33.8, 54.0)
7.0 (3.6, 13.3)
0.0
0.0
0.0
0.0
1.7 (0.7, 4.0)
0.0
0.1 (0.1, 0.3)
11
1
347
400
0
759
9.8 (4.3, 20.7)
6.9 (3.6, 12.9)
1.5 (0.6, 3.5)
0.0
2.3 (1.4, 4.0)
34
71
28
739
0
872
0.5 (0.3, 0.9)
45
72
375
1139
0
1631
88.5 (72.0, 95.8)
15
64.6 (44.8, 80.4)
66
65.2 (45.8, 80.6)
81
Total
14.6 (12.1, 17.5)
976
19.4 (14.7, 25.3)
1382
18.8 (14.7, 23.7)
2358
Pharmacy
Drug Store
General retailer
Total
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Table 3.3. 15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in 2010 US dollars Madagascar, 2011
Median cost* to patients of one rapid diagnostic test for malaria, by location, outlet type and patient age
Urban
Rural
Number of
Number
Median cost
RDT
Median cost
of RDT
Type of outlet
[IQR]
products
[IQR]
products
Adults
Total
Median cost
[IQR]
Number
of RDT
products
0.00 [0.00, 0.00]
61
0.00 [0.00, 0.00]
530
0.00 [0.00, 0.00]
591
facility
0.00 [0.00, 0.00]
22
0.00 [0.00, 0.00]
2
0.00 [0.00, 0.00]
24
0
0.00 [0.00, 0.00]
13
3.12 [0.21, 3.20]
0.00 [0.00, 0.17]
0.00 [0.00, 0.17]
0
6
0
0
6
0.00 [0.00, 0.85]
4
6
0
0
23
Private for- profit health
0.00 [0.00, 0.00]
facility
Pharmacy
3.12 [0.21, 3.20]
Drug Store
General retailer
Total
0.00 [0.00, 3.12]
13
4
0
0
0
17
0.00 [0.00, 0.17]
0.00 [0.00, 0.00]
11
0.00 [0.00, 0.00]
46
0.00 [0.00, 0.00]
57
Total
0.00 [0.00, 0.00]
111
0.00 [0.00, 0.00]
Children
584
0.00 [0.00, 0.00]
695
0.00 [0.00, 0.00]
61
0.00 [0.00, 0.00]
531
0.00 [0.00, 0.00]
592
facility
0.00 [0.00, 0.00]
22
0.00 [0.00, 0.00]
2
0.00 [0.00, 0.00]
24
0.00 [0.00, 0.00]
13
0
0.00 [0.00, 0.00]
13
3.12 [0.21, 3.20]
0.00 [0.00, 0.13]
0
6
0
0
6
3.12 [0.21, 3.20]
0.00 [0.00, 0.13]
0.00 [0.00, 3.12]
4
0
0
0
17
0.00 [0.00, 0.85]
4
6
0
0
23
0.00 [0.00, 0.00]
14
0.00 [0.00, 0.00]
49
0.00 [0.00, 0.00]
63
Total
0.00 [0.00, 0.00]
114
0.00 [0.00, 0.00]
*1 USD = 2138.56 Ariary, after converting 2011 to 2010 prices.
588
0.00 [0.00, 0.00]
702
facility
Pharmacy
Drug Store
General retailer
Total
0.00 [0.00, 0.13]
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3.4 Quality-assured ACTs market share
Table 3.4. 1: Percentage breakdown of antimalarial sales volumes by antimalarial type, Madagascar, 2011
Indicator 4.1: Total number of AETDs of each antimalarial type sold or distributed in the week preceding the survey visit (n), as a
percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any antimalarials in stock at
the time of the survey visit (N), by location and type of outlet
Urban
Rural
Total
Percentage
N
Percentage
N
Percentage
N
10.2
13.0
12.7
0.0
1.0
0.9
0.0
0.0
0.0
0.0
0.0
0.0
89.8
86.0
86.4
Total
100.0 1094.0
100.0
774.1
100.0
1868.0
Total
41.3
0.0
0.0
0.0
58.7
100.0
Total
35.0
0.4
0.0
0.0
64.6
100.0
Total
100.0
0.0
0.0
0.0
0.0
100.0
All outlets
Total
31.2
0.3
0.0
0.0
68.5
100.0
236.6
85.1
0.0
0.0
0.0
14.9
100.0
4240.8
18.0
0.0
0.0
0.0
82.0
100.0
1.4
65.0
7.2
0.0
0.0
27.7
100.0
5572.8
18.0
0.4
0.0
0.0
81.5
100.0
21.5
66.3
0.0
0.0
0.0
33.7
100.0
258.2
1692.4
22.0
0.1
0.0
0.0
77.9
100.0
5933.2
24.0
65.2
7.2
0.0
0.0
27.6
100.0
25.3
2511.9
20.7
0.4
0.0
0.0
78.9
100.0
8084.7
Note: The most popular antimalarial in Madagascar was SP in urban areas, chloroquine in rural areas, and chloroquine overall. The most
popular drug is defined as the highest number AETDs sold in the week preceding the survey.
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Table 3.4. 2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm logo
and QAACTs without the AMFm logo, [Madagascar], 2011
Indicator 4.1: Total number of AETDs of QAACTs sold or distributed in the week preceding the survey visit (n), as a
percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any
antimalarials in stock at the time of the survey visit (N), for all QAACTs, QAACTs with the AMFm logo and QAACTs without
the AMFm logo, by location and type of outlet
Urban
Rural
Total
Percentage
N
Percentage
N
Percentage
N
All QAACTs
10.2
13.0
12.7
QAACTs with logo
7.3
10.4
10.1
2.9
2.6
2.6
QAACTs without logo
Total number of AETDs
1094.0
774.1
1868.0
sold
Private not- for-profit
health facility
All QAACTs
QAACTs with logo
QAACTs without logo
sold
All QAACTs
QAACTs with logo
QAACTs without logo
sold
All QAACTs
QAACTs with logo
QAACTs without logo
sold
All outlets
All QAACTs
QAACTs with logo
QAACTs without logo
sold
41.3
20.0
21.3
85.1
30.2
54.9
236.6
35.0
31.9
3.1
66.3
25.8
40.5
21.5
18.0
17.7
0.3
4240.8
100.0
71.7
28.3
22.0
21.0
1.0
1692.4
65.0
0.8
64.3
1.4
31.2
27.5
3.7
258.2
5933.2
65.2
1.1
64.1
24.0
18.0
15.4
2.7
5572.8
25.3
20.7
17.8
2.9
2511.9
8084.7
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Table 3.4. 3: Percentage breakdown of antimalarial sales volumes by outlet type, [Madagascar], 2011
Indicator 4.1: Total number of AETDs sold or distributed in the week preceding the survey visit by each outlet type (n), as a
percentage of all antimalarial AETDs sold or distributed in the week preceding the survey visit by all outlets with any antimalarials
in stock at the time of the survey visit (N), by location and antimalarial type
Urban
Rural
Total
Percentage
N
Percentage
N
Percentage
N
Public health facilities
5.3
21.8
16.8
Private not-for-profit health facilities
4.6
5.6
5.3
90.0
66.9
73.9
0.1
5.7
4.0
Total
100.0
1724.4
100.0
425.2
100.0
2149.6
Total
0.0
0.0
100.0
0.0
100.0
Oral artemisinin therapies
Total
-
Non-oral artemisinin therapies
Total
-
Non-artemisinin therapies
Total
21.3
3.0
75.7
0.0
100.0
26.6
73.3
0.0
0.0
26.7
100.0
0.0
-
0.0
-
3821.8
31.9
0.2
67.4
0.5
100.0
All antimalarials
16.2
3.5
80.2
<0.1
Total
100.0
5572.8
30.2
1.2
67.0
1.6
100.0
8.2
61.2
0.0
16.5
22.3
100.0
34.8
0.0
-
0.0
0.0
-
0.0
2078.6
30.0
0.7
68.8
0.4
100.0
5900.3
2511.9
27.4
1.6
69.7
1.3
100.0
8084.7
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3.5 Provider knowledge of first-line antimalarial treatment and ACT
regimen
Table 3.5. 1: Provider knowledge of first-line antimalarial treatment, [Madagascar], 2011
Providers able to correctly identify the antimalarial for first-line treatment* (n) as a percentage of outlets with
antimalarials in stock at the time of the survey visit** (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
90.9 (81.1, 95.9)
65
85.6 (78.8, 90.5)
553
86.2 (80.2, 90.6)
618
facility
82.4 (67.0, 91.5)
26
71.0 (25.5, 94.6)
5
75.5 (45.7, 91.8)
31
88.4 (75.6, 95.0)
34
66.1 (26.7, 91.3)
11
71.1 (37.8, 90.9)
45
73.4 (64.5, 80.8)
84.4 (76.1, 90.2)
13.1 (9.4, 18.1)
100.0
51.0 (43.7, 58.3)
13.7 (9.4, 19.7)
18.1 (13.9, 23.1)
1
346
403
0
761
73.7 (65.2, 80.8)
54.5 (47.5, 61.4)
13.7 (9.8, 18.7)
26.7 (22.4, 31.4)
71
28
740
0
873
19.4 (15.7, 23.6)
72
374
1143
0
1634
100.0
15
70.5 (55.7, 82.0)
65
71.3 (57.0, 82.2)
80
facility
Pharmacy
Drug Store
General retailer
Total
Total
35.3 (30.5, 40.5)
979
32.7 (26.6, 39.4)
1384
33.0 (27.7, 38.8)
* 52 providers responded "AFMm"; these cases have been treated as correctly identifying the first-line treatment.
2363
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Table 3.5. 2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult. [Madagascar],
2011
Providers able to describe correctly the dosing regimen for quality-assured ACTs for an adult (n) as a percentage of the number of
outlets with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
85.7 (74.1, 92.7)
53
84.5 (80.0, 88.1)
488
84.6 (80.5, 87.9)
541
74.3 (55.1, 87.2)
22
100.0
2
87.6 (69.2, 95.7)
24
45.6 (31.2, 60.7)
76.8 (69.9, 82.6)
73.9 (63.8, 82.0)
0.0
56.5 (38.2, 73.1)
0
1
174
4
0
180
28.0 (10.8, 55.5)
77.1 (70.5, 82.6)
66.1 (54.9, 75.7)
32.7 (6.1, 78.4)
72.0 (66.7, 76.8)
17
70
25
2
0
114
62.3 (50.0, 73.2)
18
71
199
6
0
294
0.0
12
0.0
56
0.0
68
Pharmacy
Drug Store
General retailer
Itinerant Health Worker
Total
100.0
64.4 (50.7, 76.1)
33.7 (6.0, 80.2)
Total
71.6 (63.8, 78.4)
201
45.2 (33.6, 57.5)
726
49.2 (38.5, 60.0)
927
* “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number
of times the medicine should be taken per day and the duration of the dose in number of days for a 60kg adult for a specific product
which they selected from the QAACTs that they stocked.
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Table 3.5. 3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child, [Madagascar], 2011
Providers able to describe correctly the dosing regimen for quality-assured ACT for a child (n) as a percentage of the number of outlets
with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
73.6 (55.8, 86.1)
51
65.0 (57.1, 72.1)
483
65.9 (58.8, 72.3)
534
Private not- for-profit health facility
76.5 (55.6, 89.4)
21
34.7 (3.0, 90.3)
2
54.6 (18.3, 86.6)
23
73.5 (52.4, 87.5)
47.7 (36.9, 58.7)
39.7 (20.0, 63.4)
0.0
100.0
100.0
42.9 (35.8, 50.3)
0.0
37.7 (30.4, 45.7)
1
1
173
4
0
179
83.7 (61.0, 94.4)
48.3 (37.9, 58.9)
42.4 (35.5, 49.6)
0.0
48.0 (38.0, 58.2)
17
70
23
2
0
112
41.6 (35.6, 47.7)
18
71
196
6
0
291
75.5 (59.2, 86.7)
11
63.7 (55.7, 71.1)
53
64.0 (56.3, 71.1)
64
Pharmacy
Drug Store
General retailer
Total
Total
59.2 (51.0, 66.8)
195
59.2 (53.6, 64.7)
717
59.2 (54.3, 63.9)
912
* “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number
of times the medicine should be taken per day and the duration of the dose in number of days for child under 2 years (10kg) for a
specific product which they selected from the QAACTs that they stocked.
Note: A significant number of incorrect responses for this indicator occur among respondents who selected a QAACT specific to 2-11
month children, but who went on to state the correct dosing regimen for the 2-11 month group.
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Table 3.5. 4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Madagascar], 2011
Private for-profit providers stating a specific reason for why they were not stocking QAACTs (n) as a percentage of all private for-profit
outlets* not stocking QAACTs at the time of the survey visit** (N), by location
Urban
Rural
Total
Percentage
Percentage
Percentage
Reason
(95% CI)
N
(95% CI)
N
(95% CI)
N
Too expensive
3.3 (2.3, 4.8)
1029
4.1 (2.0, 8.1)
697
4.0 (2.2, 7.3)
Not profitable
0.7 (0.3, 1.6)
0.6 (0.2, 1.4)
0.6 (0.3, 1.2)
The outlet is not allowed to sell them
14.3 (11.4, 17.8)
6.6 (4.3, 10.1)
7.7 (5.6, 10.6)
They have too many side effects
0.3 (0.1, 0.7)
0.2 (0.0, 1.5)
0.2 (0.0, 1.1)
They do not work well
0.2 (0.1, 0.4)
0.2 (0.0, 1.4)
0.2 (0.0, 1.1)
They are not available/my suppliers do not
31.4 (26.8, 36.4)
37.8 (30.4, 45.8)
36.9 (30.5, 43.7)
have it in stock
My customers do not ask for them
25.5 (20.1, 31.7)
18.1 (14.0, 23.1)
19.2 (15.6, 23.4)
I don’t know about these drugs
33.3 (28.6, 38.3)
35.9 (29.2, 43.2)
35.5 (29.7, 41.8)
I am temporarily out of stock
3.5 (1.4, 8.5)
2.4 (1.3, 4.2)
2.5 (1.5, 4.1)
Other
1.9 (0.9, 3.9)
3.7 (1.9, 6.9)
3.4 (1.9, 6.1)
* This indicator excludes responses from public-health facilities and CHW.
** Note that a provider could give more than one response to this question. Percentage may add to more than 100
1726
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3.6 AMFm logo
Table 3.6. 1: Provider recognition of AMFm logo, [Madagascar], 2011
Providers able to recognize the AMFm logo* (n) as a percentage of the number of outlets with antimalarials in stock at the time of the
survey visit** (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
89.5 (78.8, 95.1)
65
76.1 (70.3, 81.1)
553
77.6 (72.4, 82.0)
618
83.8 (44.8, 97.0)
26
71.0 (25.5, 94.6)
5
76.0 (44.2, 92.7)
31
91.1 (77.4, 96.8)
98.1 (91.5, 99.6)
96.8 (88.9, 99.2)
30.1 (23.8, 37.2)
50.0 (23.5, 76.5)
100.0
70.5 (62.0, 77.9)
23.6 (18.3, 30.0)
28.2 (23.3, 33.6)
11
1
347
405
0
764
59.2 (35.2, 79.5)
98.1 (92.1, 99.6)
73.3 (65.4, 80.0)
24.5 (19.9, 29.9)
43.7 (38.2, 49.4)
34
71
28
743
0
876
30.5 (26.2, 35.2)
45
72
375
1148
0
1640
92.4 (65.0, 98.8)
15
33.2 (20.1, 49.6)
66
34.6 (21.4, 50.7)
81
Pharmacy
Drug Store
General retailer
Total
Total
49.8 (43.8, 55.7)
982
34.4 (29.4, 39.8)
1388
36.5 (32.0, 41.3)
2370
* All respondents were shown a visual aid depicting the AMFm logo. And were asked whether they have seen the symbol before. A
provider is “able to recognize the AMFm logo” if they answer that they have seen the symbol before.
** Flow diagram reference E.
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Table 3.6. 2: Provider knowledge of the AMFm logo [Madagascar], 2011
Providers stating a specific meaning of the AMFm logo (n) as a percentage of outlets that recognized the AMFm logo (N), by
location*
Urban
Rural
Total
Percentage
Percentage
Percentage
Meaning of AMFm logo
(95% CI)
N
(95% CI)
N
(95% CI)
Effective/quality
antimalarial
Affordable antimalarial
An antimalarial in high
demand
Effective/quality
medicine
Affordable medicine
A medicine in high
demand
It means nothing
I don’t know what it
means
Other meaning:
Antimalarial
Other meaning:
Medicine from plant
Other meaning:
Antimalarial/ACT from
plant
Other meaning: Malaria
Other meaning: "Green"
/ "Plant" / "Health" /
"Environment"
Other meaning: other
36.9 (27.9, 47.0)
418
33.0 (23.7, 43.7)
785
33.7 (25.9, 42.4)
13.5 (9.4, 19.0)
6.1 (3.6, 10.1)
7.4 (5.1, 10.8)
2.8 (1.4, 5.3)
2.0 (1.1, 3.3)
2.1 (1.4, 3.2)
4.9 (3.1, 7.9)
7.0 (3.6, 13.5)
6.7 (3.7, 11.7)
2.8 (1.3, 6.2)
0.7 (0.4, 1.5)
1.1 (0.6, 2.0)
0.1 (<0.1, 0.6)
0
<0.1 (<0.1, <0.1)
5.8 (3.2, 10.4)
3.9 (1.9, 7.9)
4.3 (2.4, 7.3)
18.5 (12.9, 25.9)
21.6 (15.9, 28.7)
21.0 (16.2, 26.8)
7.5 (3.6, 15.0)
11.0 (6.6, 17.9)
10.4 (6.6, 15.9)
4.8 (2.7, 8.2)
6.7 (4.0, 11.1)
6.3 (4.1, 9.8)
5.6 (3.4, 8.9)
5.1 (3.0, 8.7)
5.2 (3.4, 8.0)
1.5 (0.5, 4.0)
3.3 (1.7, 6.4)
3.0 (1.7, 5.4)
4.1 (2.2, 7.6)
3.4 (1.8, 6.4)
3.5 (2.1, 5.9)
7.1 (4.8, 10.2)
4.3 (2.5, 7.2)
4.8 (3.2, 7.1)
N
1203
* Note that providers could give more than one response to this question. Percentage may add to more than 100
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Table 3.6. 3: Sources from which providers have seen or heard of the AMFm logo, [Madagascar], 2011
Providers stating a specific source where they have seen or heard of the AMFm logo (n) as a percentage of providers that
recognized the AMFm logo (N), by location*
Urban
Rural
Total
Percentage
Percentage
Percentage
Source
(95% CI)
N
(95% CI)
N
(95% CI)
On malaria medicine
packaging
On medicine packaging
On posters
1.9 (0.7, 4.6)
20.3 (15.3,
26.5)
3.9 (2.1, 7.4)
15.8 (11.5,
21.3)
4.6 (2.3, 8.7)
45.5 (36.8,
54.6)
1.3 (0.5, 3.2)
3.8 (2.2, 6.4)
1.8 (1.0, 3.2)
2.2 (1.5, 3.3)
10.7 (7.5,
15.1)
1.8 (0.9, 3.5)
12.5 (6.3,
23.3)
15.0 (10.6,
20.9)
0.7 (0.3, 1.5)
3.4 (1.9, 6.1)
6.0 (3.4,
10.6)
10.5 (7.8,
14.0)
1.9 (1.1, 3.2)
11.5 (6.3,
20.1)
14.6 (10.9,
19.3)
0.7 (0.3, 1.3)
3.5 (2.2, 5.6)
2.7 (1.1, 6.9)
2.7 (1.2, 5.8)
31.2 (24.9, 38.2)
10.4 (5.1, 20.2)
17.6 (12.2, 24.7)
On billboards
6.1 (3.4, 10.9)
On TV/radio
55.2 (49.8, 60.4)
On a prescription
In
newspapers/magazines
In pharmacies/ drug
shops
In private clinics
9.5 (7.2, 12.4)
2.6 (1.5, 4.5)
In public health facilities
6.9 (4.2, 11.1)
In training
12.7 (9.1, 17.4)
From a supplier
From a public event
0.6 (0.1, 3.5)
3.9 (2.6, 6.0)
From a local leader
5.9 (4.0, 8.6)
From a friend/family
member
2.4 (1.6, 3.5)
418
785
22.3 (17.9,
27.5)
5.1 (3.1, 8.4)
16.1 (12.4,
20.7)
4.9 (2.9, 8.1)
47.3 (40.2,
54.6)
1.4 (0.6, 2.9)
N
1203
6.0 (3.7, 9.5)
0.1 (<0.1,
0.6)
Don’t Know
0.5 (0.2, 1.5)
1.5 (0.6, 3.8)
1.3 (0.6, 3.1)
Other source: on clothing
0.8 (0.3, 2.2)
4.4 (2.6, 7.4)
3.8 (2.3, 6.1)
Other source: other other
1.2 (0.5, 2.6)
2.5 (1.2, 5.1)
2.2 (1.2, 4.2)
On the internet
0.6 (0.1, 3.2)
0.0
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Table 3.6. 4: Percentage of antimalarials bearing the AMFm logo, [Madagascar], 2011
Antimalarials bearing the AMFm logo (n) as a percentage of all antimalarials audited (N), by location and antimalarial type
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of antimalarial
(95% CI)
N
(95% CI)
N
(95% CI)
N
Total
All other antimalarials
Total
55.3 (35.8, 73.4)
49.0 (33.9, 64.2)
69.9 (64.8, 74.6)
34.6 (20.3, 52.3)
64.0 (57.3, 70.2)
201
78
569
26
874
52.8 (44.5, 61.0)
45.7 (8.1, 89.0)
83.6 (74.5, 89.9)
10.4 (1.9, 40.5)
46.5 (36.0, 57.2)
1789
7
506
101
2403
53.1 (45.5, 60.6)
47.4 (22.6, 73.4)
76.6 (71.1, 81.4)
11.1 (2.4, 38.5)
50.3 (41.6, 59.0)
1990
85
1075
127
3277
0.8 (0.1, 4.0)
0.0
0.5 (0.2, 1.0)
97
38
1467
0
1602
0.8 (0.3, 2.0)
0.0
0.0
8.8 (1.1, 46.9)
0.3 (0.1, 0.8)
799
6
1470
9
2284
0.8 (0.3, 1.8)
0.0
0.1 (0.1, 0.3)
8.8 (1.1, 46.9)
0.3 (0.2, 0.7)
896
44
2937
9
3886
0.5 (0.3, 0.9)
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Table 3.6. 5: Provider knowledge of the AMFm programme, [Madagascar], 2011
Providers who have heard of “a programme that reduces the prices of antimalarial medicines known as ACTs” (n) as a
percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
17.8 (11.9, 25.7)
65
14.1 (10.2, 19.3)
553
14.5 (10.9, 19.1)
618
25.8 (14.1, 42.3)
25
31.3 (5.7, 77.3)
5
29.2 (10.2, 59.8)
30
50.1 (34.8, 65.3)
34.7 (25.0, 45.8)
14.5 (7.4, 26.3)
9.3 (7.3, 11.8)
26.1 (9.9, 53.0)
0.0
16.2 (12.0, 21.5)
10.3 (7.0, 14.8)
11.1 (8.1, 15.0)
11
1
347
404
0
763
31.4 (16.7, 51.2)
34.3 (25.0, 45.0)
16.0 (12.2, 20.7)
10.1 (7.3, 13.9)
13.9 (11.5, 16.7)
34
71
28
742
0
875
11.5 (9.0, 14.8)
45
72
375
1146
0
1638
33.8 (17.0, 56.0)
15
16.9 (10.1, 27.0)
66
17.3 (10.6, 27.0)
81
1387
12.7 (10.6, 15.1)
2367
Pharmacy
Drug Store
General retailer
Total
Total
15.0 (12.6, 17.7)
980
12.3 (10.0, 15.2)
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Table 3.6. 6: Sources from which providers have seen or heard of AMFm [Madagascar], 2011
Providers stating a specific source where they have seen or heard of “a programme that reduces the prices of antimalarial
medicines known as ACTs” (n) as a percentage of providers that have heard of “a programme that reduces the prices of
antimalarial medicines known as ACTs” (N), by location*
Urban
Rural
Total
Percentage
Percentage
Percentage
Source
(95% CI)
N
(95% CI)
N
(95% CI)
N
On malaria medicine packaging
3.9 (1.5, 10.1)
133
2.7 (1.0, 7.3)
197
2.9 (1.3, 6.5)
On medicine packaging
1.9 (0.5, 7.6)
0.1 (<0.1, 0.7)
0.4 (0.1, 1.5)
On posters
1.6 (0.4, 5.6)
3.8 (0.9, 14.4)
3.5 (0.9, 12.0)
On billboards
0.9 (0.3, 2.4)
2.1 (0.5, 7.9)
1.9 (0.5, 6.5)
On TV/radio
63.3 (56.4, 69.8)
68.6 (57.1, 78.3)
67.8 (58.2, 76.1)
On a prescription
0.0
0.1 (<0.1, 0.6)
0.1 (<0.1, 0.4)
In newspapers/magazines
2.7 (1.1, 6.5)
0.6 (0.1, 4.1)
0.9 (0.3, 2.8)
In pharmacies/ drug shops
2.0 (0.4, 10.8)
0.5 (0.2, 1.5)
0.8 (0.3, 1.9)
In private clinics
0.4 (0.1, 1.5)
2.2 (0.7, 7.1)
1.9 (0.6, 5.9)
In public health facilities
5.4 (2.6, 11.0)
15.8 (9.3, 25.6)
14.1 (8.6, 22.4)
In training
19.3 (13.9, 26.1)
23.3 (12.8, 38.6)
22.6 (13.6, 35.1)
From a supplier
8.7 (5.7, 13.2)
0.7 (0.2, 2.0)
2.0 (1.2, 3.4)
From a public event
6.2 (3.3, 11.3)
3.6 (1.5, 8.7)
4.0 (2.0, 7.9)
From a local leader
0.0
2.2 (0.5, 8.8)
1.8 (0.4, 7.5)
From a friend/family member
1.2 (0.4, 3.1)
3.1 (0.7, 13.1)
2.8 (0.7, 10.6)
SMS messages
0.0
0.0
0.0
On the internet
0.0
0.0
0.0
Don’t Know
0.0
0.1 (<0.1, 0.7)
0.1 (<0.1, 0.6)
330
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Table 3.6. 7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials
with the AMFm logo [Madagascar], 2011
Providers stated that there is a RRP for antimalarials with the AMFm logo (n) as a percentage of outlets with antimalarials
in stock at the time of the survey visit (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
39.7 (29.9, 50.4)
65
27.6 (23.0, 32.9)
553
29.0 (24.6, 33.7)
618
facility
28.2 (15.4, 45.9)
25
82.4 (31.2, 98.0)
5
61.5 (33.6, 83.4)
30
33.5 (20.3, 49.9)
34
16.2 (3.2, 52.9)
11
20.0 (7.0, 45.5)
45
41.5 (23.4, 62.2)
24.0 (11.9, 42.3)
13.8 (9.7, 19.2)
0.0
14.7 (10.2, 20.7)
9.0 (5.0, 15.8)
9.7 (5.9, 15.5)
1
347
404
0
763
41.0 (23.6, 61.0)
15.7 (11.3, 21.4)
9.7 (6.0, 15.3)
18.2 (12.6, 25.6)
71
28
741
0
874
11.0 (7.4, 16.0)
72
375
1145
0
1637
52.5 (25.2, 78.3)
15
27.9 (16.2, 43.6)
66
28.5 (17.0, 43.6)
81
1387
15.4 (11.6, 20.2)
2366
facility
Pharmacy
Drug Store
General retailer
Total
Total
21.0 (16.4, 26.6)
979
14.5 (10.3, 20.1)
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Table 3.6. 8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials with
the AMFm logo [Madagascar], 2011
Providers stated the correct RRP for antimalarials with the AMFm logo (n) as a percentage of providers who responded
that there was a RRP for antimalarials with the AMFm logo (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
None in Madagascar
Pharmacy
Drug Store
General retailer
Total
Total
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Table 3.6. 9: Providers who have received training on antimalarials with the AMFm logo, [Madagascar],
2011
Outlet where at least one staff member has received training on antimalarials with the AMFm logo (n) as a percentage of
outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet
Urban
Rural
Total
Percentage
Percentage
Percentage
Type of outlet
(95% CI)
N
(95% CI)
N
(95% CI)
N
21.8 (12.7, 34.8)
65
14.8 (10.9, 19.8)
553
15.6 (11.9, 20.1)
618
facility
27.8 (14.6, 46.6)
25
31.3 (5.7, 77.3)
5
30.0 (10.7, 60.5)
30
31.1 (17.1, 49.7)
34
0.0
11
7.0 (2.9, 15.6)
45
30.8 (18.5, 46.7)
41.4 (13.6, 76.0)
0.2 (0.1, 0.8)
0.0
8.3 (5.0, 13.6)
0.7 (0.3, 1.8)
1.4 (0.8, 2.2)
1
347
404
0
763
30.5 (18.6, 45.7)
11.8 (7.1, 19.1)
0.7 (0.3, 1.6)
7.1 (4.4, 11.2)
71
28
741
0
874
2.2 (1.5, 3.3)
72
375
1145
0
1637
66.1 (47.4, 80.9)
15
17.0 (6.9, 36.2)
66
18.2 (7.8, 36.8)
81
1387
5.8 (4.3, 7.6)
2366
facility
Pharmacy
Drug Store
General retailer
Total
Total
10.1 (7.0, 14.5)
979
5.1 (3.6, 7.1)
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4. AMFm implementation: process and key contextual factors
4.1 Introduction
In order to document the implementation process of AMFm (supply of copaid ACTs and supporting
interventions) and contextual factors that may influence the effectiveness of AMFm, the
Independent Evaluation team collected data in each AMFm pilot, using key informant interviews
(KII), a structured questionnaire on supporting interventions, and document review. These data
were collected to facilitate an assessment of (1) whether any improvement observed in AMFm
indicators between baseline and endline is likely to be due to AMFm and (2) whether a lack of
improvement in indicators can be reasonably attributed to a failure of AMFm. The methods and
findings for this activity in Madagascar are summarised below.
4.2 Methods
Three types of key informants were included in interviews: those centrally involved in AMFm
implementation, antimalarial importers, and other stakeholders who were knowledgeable about the
AMFm process or other key contextual factors. Twenty-six interviews were conducted in November
and December 2011. Oral consent was obtained for all interviews, and participants were assured of
confidentiality and given the option of whether they wanted their interviews to be recorded. Notes
were taken during all interviews. Interviewers used a semi-structured interview guide that covered
AMFm governance, registration of first-line buyers, ordering and distribution of copaid drugs,
supporting interventions (e.g., communications, training, regulation and recommended retail prices),
diagnostics, and key contextual events (e.g., weather anomalies, economic and political factors,
changes in other malaria control activities and changes in the health system more broadly). Using
the agreed template, the information from each interview was then broken into the appropriate
reporting categories, and findings across interviews were synthesized. In addition, a form for
quantifying supporting interventions was sent to the relevant authorities for completion. Finally, key
documents were reviewed such as policy documents, briefing documents and reports prepared by
Clinton Health Access Initiative (CHAI), Global Fund grant documents, preliminary findings of
research studies, data on first-line buyer orders, and communication materials.
4.3 Findings
4.3.1 Description of the AMFm implementation process
4.3.1.1 Governance structure for AMFm
The Principal Recipient (PR) of the AMFm program is SALAMA, the public sector central medical
stores in Madagascar. There are a number of sub-recipients (SRs), including Population Services
International (PSI), which has been in charge of designing and disseminating advertising for the
AMFm subsidized drugs, as well as SAF-FJKM, SALFA, and ASOS, three faith-based organizations in
charge of training community health workers (CHWs) on AMFm and malaria case management. CHAI
has also been a key player in the establishment and development of the program, providing key
technical and logistical support. Despite several attempts by the involved parties, a permanent
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AMFm steering committee in Madagascar has not been established. Madagascar’s AMFm grant runs
from May 1, 2010 through June 30, 2012.
4.3.1.2 AMFm copaid ACT supply mechanism
Initially, 12 private sector importers were approached by the Global Fund through point persons at
CHAI and at the National Malaria Control Program (Programme National de Lutte contre le
Paludisme, or PNLP), who set up group information sessions as well as one-to-one meetings with
importers. Eight importers signed contracts to become first-line buyers (FLBs), and they have
proceeded to place orders. There was general consensus among those interviewed for this project
that all of the country’s main importers are involved in the project. The Unité de Gestion de Project
(UGP), the public sector procurement agency linked to the Ministry of Health, is also an FLB and has
placed orders for copaid antimalarials. The first copaid medicines were delivered to private FLBs in
October 2010 and to the public sector FLB, UGP, in February 2011. By December 2011, 1,659,378
doses of AMFm copaid artemisinin-based combination therapies (ACTs) had been delivered to
Madagascar. Roughly 76% of the doses were Artesunate Amodiaquine (ASAQ), the country’s firstline treatment. The rest was Artemether Lumefantrine (AL), the country’s second-line treatment.
Issues related to clearing customs created initial tensions between first-line buyers and the local
authorities. There were month-long delays once the first set of shipments arrived in Madagascar.
Officials at Ivato International Airport in Antananarivo were not familiar with the two invoices
system used, which includes one invoice with the original unsubsidized price of the shipment and
one with the actual amount paid by the FLB. Officials became suspicious upon seeing the
discrepancy and consequently blocked the release of the shipments. SALAMA and the Ministry of
Budget and Finance intervened to clear misunderstandings regarding the invoices, updated officials
on the program, and streamlined the process of clearing customs.
Lead times between approval of an order by the Global Fund and delivery have varied since the start
of the program, ranging from a couple of weeks to nearly six months. FLBs mostly agreed that lead
times had been particularly long in the second half of 2011. These delays seemed to be a source of
frustration and tension between the FLBs and the Global Fund.
4.3.2 Implementation of AMFm supporting interventions
4.3.2.1 Communication
An official launch held in Antananarivo in January 2011, helped to initially spread the word about the
program, which in Madagascar is known as ACTm. Communication activities for different target
audiences were designed and disseminated starting in April 2011. The advertising campaign,
designed by PSI, emphasized three points: that AMFm-funded ACTs were effective, inexpensive and
safe.
Approximately half of the country’s estimated 3,000 private medical practitioners were given
promotional materials with the ACTm logo—1,450 prescription pads, 1,450 informational leaflets on
ACTs and AMFm and 1,450 pens. Promotional materials were also provided for roughly half of the
businesses making up Madagascar’s private supply chain, which is composed of 30 to 40
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wholesalers, 200 pharmacies, and 2,000 drug stores. A total of 1,150 targeted informational leaflets
and 1150 pens were distributed, as well as 100 large posters for retail outlets and 250 standing
posters.
Community health workers (CHWs) were also targeted. Approximately 2,400 “flip books” of images,
which are used as a teaching tool, were produced and distributed, along with 2,400 (each) badges,
pens, baseball caps, t-shirts and bags, all of which had the ACTm logo. The proportion of CHWs
nationwide who were given promotional material is unclear. One respondent mentioned that
between May 2010 and December 2011, the number of CHWs in the country increased from 9,000
to 17,000.
Communication activities for the general population were also designed and disseminated. A TV
commercial, which included a song entitled ‘ACTm, je t’aime’ (meaning ‘ACTm, I love you’), was
produced and broadcast once or twice a day on national television. Radio spots in eight different
Malagasy dialects were also broadcast once or twice a day on national radio, and three to five times
a day on regional radio, starting in April 2011. Emphasis was given to the radio campaign, given that
access to television is relatively limited in Madagascar. However, the abovementioned TV and radio
campaigns came to an end in May 2011. The Drug Agency of Madagascar (Direction d’Agence de
Medicament de Madagascar, or DAMM), which is part of the Ministry of Health, banned the ACTm
public campaign, citing a law that prohibits the advertising of prescription drugs to the general
population, except in cases of national public health emergencies. Although representatives from
CHAI and SALAMA tried to argue that malaria was a serious public health threat, the DAMM refused
to reconsider its decision. Radio and television spots were cancelled and plans for a number of other
promotion activities such as billboards were halted.
As of December 2011, CHAI and SALAMA representatives planned to shift the campaign from
marketing to education in order to meet the DAMM’s guidelines that all advertising had to be nonmedication specific. The effect of the advertising ban on ACT sales is still uncertain; the ban was
implemented at the beginning of the dry season, making it unclear whether decreased sales of ACTs
should be attributed to a seasonal drop in malaria incidence or to the interruption in advertising. It is
important to note, however, that the DAMM’s decision did affect the abovementioned promotional
materials distributed to prescribers, private sector actors and CHWs.
Additionally, the main supplier of copaid ASAQ carried out its own promotional campaign across the
country, conducting information sessions nationwide, which were attended by approximately 1,100
health practitioners and private sector actors. Participants in information sessions were sometimes
given informational posters about the product being advertised as well.
4.3.2.2 Recommended retail price
There is no maximum or recommended retail price for copaid ACTs in Madagascar. The agreement
between FLBs and the Global Fund states that FLBs would add a ‘reasonable margin’ in absolute
terms to the products. During discussions leading to the signing of the contract with the Global Fund,
FLBs agreed that a margin of 150 ariary (or USD0.07) per dose would be added on average across the
different products. Although FLBs are contractually required to maintain this ‘reasonable margin’,
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they are not obligated to maintain the particular 150 ariary margin. However, as of December 2011,
all FLBs were still following the agreed upon 150 ariary margin.
At the retail level, pharmacies have an unofficial margin of 33% for all pharmaceutical products,
which, according to some respondents, is usually also respected. However, prices tend to be higher
in drug stores in remote areas. As was frequently mentioned by respondents, transportation is an
important cost at all levels of the supply chain. Given how remote and inaccessible some rural areas
are, FLBs argued that having to pay for the cost of transportation, compounded by an already low
profit margin, would result in a loss to the business. It was therefore agreed that the cost of
transportation outside of Antananarivo would not be covered by the importers, which is not always
the case with medications that have higher profit margins.
Although there are no taxes on any medications in Madagascar, importers do have to pay some fees
at customs to cover storage, unloading and transit costs. Some of the fees are calculated according
to weight and value of the shipment, while others are standard fees across all shipments. This
arrangement makes it less profitable to import smaller quantities of drugs. The fees apply to all
pharmaceutical products, including copaid medications.
4.3.2.3 Training
Training for medical practitioners on malaria case management, ACTs and pharmacovigilance has
been carried out as planned by the National Malaria Control Program (PNLP). About a third of the
country’s 3,000 medical doctors and 250 paramedics had been trained by December 2011. Some
respondents considered the training of the rest of the country’s medical practitioners to be a key
element in increasing use of ACTs.
Training of community health workers on malaria case management and use of rapid diagnostic
tests (RDTs) and ACTs was done in a cascade-style manner. A total of 88 trainers, 4 for each of
Madagascar’s 22 regions, were coached on how to train CHWs on malaria case management,
diagnosis and treatment in June 2010. Consequently, between July 2010 and June 2011, 2,442 CHWs
were trained nationwide by three FBOs, SAF-FJKM, SALFA, and ASOS. Although by and large the
training seems to have been successful, there were reports that CHW activities had to be halted in
the last few months of 2011 because funds destined for such activities, as well as for advertisement
to the general population, had been frozen.
Additionally, the DAMM trained 44 laboratory technicians between May and June 2011 on ACT drug
quality issues. The training was done in conjunction with the purchase of 22 new microscopes, one
for each region. Furthermore, two medical doctors were trained between November and December
2011 by the Agence Française de Sécurité Sanitaire des Produits de Santé (French Agency for
Sanitary Security of Health Products), on issues related to pharmacovigilance.
CHAI also conducted a pilot training program on medical promotion and its effect on sales of ACTs
starting in the second half of 2011. Medical representatives informed medical professionals and
retailers about the benefits of ACTs in 21 districts covering five regions (Boeny, Sava, FenoarivoAntsinana, Vatovavy-Fitovinany and Anosy) across the East and North-West of the country starting in
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September 2011. As of December 2011, medical representatives had held information sessions with
235 physicians and 234 retail outlets. An evaluation of the effect of the medical representative
activities was scheduled to be carried out in March and August 2012.
Additionally, the University of Antananarivo and the PNLP conducted a pilot study to look at the use
of RDTs among private not-for-profit health providers following training on the importance of
diagnostics and their management. The training, which was provided for 10 health centers in the
coastal town of Toamasina, took place at the end of May 2011. Preliminary findings suggest that
health providers improved their use of malaria diagnostics after the intervention.
4.3.2.4 Other AMFm supporting interventions
RDTs seem to be available in the public sector as well as via CHWs. However, they are very rarely
found in the private sector, and they are mostly sold in a handful of pharmacies that target an
expatriate and more affluent clientele.
Malaria prevention activities, financed by a number of international organizations, were carried out
in the months following the start of the AMFm program in Madagascar. Between 2010 and 2011, the
PNLP expanded its campaign of mosquito net distribution to include a further 20 districts, which
represent roughly a sixth of the districts in the country. In November 2010, PSI, along with several
other partners, including the United States Agency for International Development (USAID), the
President’s Malaria Initiative (PMI), and others, began a large-scale campaign financed by the Global
Fund to distribute nearly 5 million long-lasting insecticidal mosquito nets (LLINs). The campaign
seems to have been carried out in 17-19 of the country’s 22 regions. Additionally, in November
2010, Roll Back Malaria, a partnership of different national and international actors, expanded its
indoor residual spraying (IRS) campaign to include the east coast of the country. These initiatives
may have had an effect on malaria incidence and, consequently, on the demand for treatment.
Furthermore, the Global Fund, through its National Strategy Application (NSA), funded the training
of 34,000 CHWs on integrated management of childhood illnesses (IMCI), including malaria, which is
set to be complete by the end of 2012. Although it is unclear how many CHWs had already been
trained by December 2011, the trainings that had already taken place by then could have had an
effect on dissemination of information about malaria diagnosis and treatment by the time of the
endline survey.
Population Services International (PSI) has also been involved in the sale and distribution of
subsidized ACTs since 2008. Their product, ACTIpal (artesunate-amodiaquine), is branded for use for
children under the age of five years, and it is distributed through both CHWs, and the private sector
supply chain. There are two different age packs (2-11 months and 1-5 years). The original
recommended retail price for both ACTipal products was 100 ariary (about USD 0.05), which was
increased to 200 ariary for drug retailers in November 2010, while the RRP for CHWs remained at
100 ariary. PSI bought 300,000 doses of ACTIpal in February 2010, 100,000 doses in September 2010
and 305,000 doses in August 2011. The presence of copaid ACTs in the market may have increased
interest in, and use of, the product.
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A ban on the importation and sale of chloroquine was set in motion around June 2011, which would
have likely increased the market share of ACTs. However, the ban was recalled late in December
2011, after the legislation service of the Ministry of Health opposed it. A respondent mentioned that
this was likely due to pressure from importers who still had large stocks of chloroquine to sell.
4.3.3 Key events and context
According to most respondents, Madagascar continues to suffer from the consequences of the coup
d’état that took place in March 2009, when Andry Rajoelina ousted Marc Ravalomanana from
power. Although the coup took place before the AMFm program started, most respondents agreed
that the political and economic situation of the country has been steadily deteriorating since 2009,
which may have had multiple effects on the program.
As a result of the coup, Madagascar was suspended from international trade organizations and key
preferential trade agreements, such as the Southern Africa Development Community (SADC) and the
Africa Growth Opportunity Act (AGOA). As key trading partners were lost, it seems that companies
went out of business, unemployment rose and, consequently, the purchasing power of the
population dropped.
Furthermore, it seems that government spending has decreased since the coup. According to some
respondents, this is particularly visible in the closure of public health facilities across the country, as
well as in the lack of upkeep in transportation and telecommunications infrastructure. A
deterioration of the roads may have made transportation of goods more difficult and costly.
The political instability that followed the coup of 2009 may have also had some consequences on the
program. A frequent turnover of Ministers of Health has meant that issues that require ministerial
approval often take a long time to be approved, as the process has to be restarted every time a new
minister takes office. Furthermore, some respondents mentioned that the uncertain political
situation means that political actors often shy away from backing potentially controversial ideas,
such as the ban on importation and sale of chloroquine.
4.3.4 Conclusion
Table 4.3.1 summarizes key factors likely to have supported or hindered achievement of AMFm goals
in Madagascar and Figure 4.3.1 presents a timeline of all key events related to AMFm
implementation and context.
In general terms, the implementation of the AMFm program in Madagascar was mostly successful.
Eight private sector FLBs and one public sector FLB signed contracts with the Global Fund and placed
orders between the end of 2010 and 2011. Initial issues related to delays at customs have generally
been resolved. However, the long lead times between the order approval at the Global Fund and the
arrival of the order seem to be creating frustration among FLBs, as are the low profit margins that
private FLBs are earning from the sale of the AMFm products.
The national communication campaign started out well, with simple and regionally-targeted
messages on both radio and television. However, the subsequent ban of advertisements by the
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DAMM has possibly hindered the effort to inform the general population about the program. The
precise effect on demand for ACTm products has yet to be determined. Between one-third and onehalf of medical practitioners and private sector actors have been given training or information about
AMFm, as have more than 2, 400 CHWs.
The difficult political and economic situation that Madagascar is facing may have had an effect on
the program, as it is likely that the population’s purchasing power has declined. Furthermore, a
decrease in government spending, which seems to have led to the closure of health facilities and to
the lack of upkeep of transportation and telecommunications infrastructure, may be making access
to health more difficult and expensive.
Table 4.3. 1. Summary of key factors likely to have supported or hindered achievement of AMFm goals in
Madagascar
Factors which are likely to have supported
achievement of AMFm goals
 Increase in CHWs
 Low mark-ups agreed on by actors
 Research project on medical representatives
 Training of doctors and health practitioners in
ACT use
Factors which are likely to have hindered achievement
of AMFm goals
 Delays in delivery from manufacturer
 Fluctuating costs of transportation and inadequate
road upkeep
 2/3 of doctors not trained, continuation of
prescription of other drugs
 Ban on TV and radio advertising
 Political and economic crisis leading to fall in
purchasing power
 Frozen funds for CHW activities
 Decrease in number of public health facilities
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Figure 11: Timeline of key events related to AMFm implementation process and context in Madagascar
2010
Activity
2011
2012
Early Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
CHAI/PNLP: Hold meetings with 12 potential first-line buyers
PSI: Purchase of 300,000 doses of ACTIpal
Start of AMFm Phase 1
Baseline outlet survey – ACTwatch
PNLP: Training of trainers of health agents on malaria case management, ACTs and
pharmacovigilance
SALFA, SAF-FJKM, ASOS: Training of CHWs
PNLP: Training of health agents on malaria case management, ACTs and
pharmacovigilance
First-line buyers (private sector): Approval by Global Fund of private sector orders of
copaid ACTs
NSA: Training of 34,000 CHWs in IMCI
PSI, USAID, PMI, UNICEF, Canadian Red Cross: Campaign to distribute 5 million nets
Roll Back Malaria (multi-actor initiative): Expansion of indoor residual spraying (IRS)
campaign to include Eastern region
UGP: Approval by Global Fund of public sector orders of copaid ACTs
First-line buyers (private sector): Arrival of private sector orders of copaid ACTs
CHAI/SALAMA: National launch of AMFm program
UGP: Arrival of public sector order of copaid ACTs
SANOFI: Information sessions about ASAQ Winthrop
CHAI/SALAMA: Radio and television campaign
PSI/SALAMA: Distribution of IEC supports for health agents
PSI/SALAMA: Distribution of IEC supports for CHWs
PSI/SALAMA: Distribution of IEC supports for wholesalers, pharmacies and depots
DAMM: Training on laboratories and minilabs
DAMM: Ban on AMFm public advertising campaign
MOH: Introduction of chloroquine ban
CHAI: MR training of health agents as part of pilot study
Endline outlet survey
MOH: Withdrawal of chloroquine ban
PNLP: Launch of indoor residual spraying (IRSA) campaign financed by Global Fund
Round 7
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5. Summary of findings
5.1 Quality of data collected
During data collection quality control (QC) persons travelled with the field teams and visited a
sample of the outlets visited by the data collectors. The QCs went to 5%of outlets which met the
screening criteria and 5% which did not. They asked basic background questions to the outlet
attendants, and audited a selection of drugs present. Data were reviewed with supervisors on a daily
basis. Completed questionnaires were also reviewed by the supervisors, by exporting data to Excel at
the end of the day. Any issues were fed back to field teams, which minimised problems that arose in
the field. In addition, regular communication with ACTWatch Central ensured that problems could
be resolved quickly when issues arose in the field. Building on lessons learnt from the first outlet
survey (conducted in 2008), additional field monitoring tools were used to help keep track of the
number of outlets sampled and number of antimalarials audited.
No major issues appeared during data cleaning or analysis.
5.2 Availability of quality-assured ACTs
Among facilities that stocked antimalarials at any time in the three months preceding the survey,
overall QAACT availability in 2011 was 28%, and this was lower in the private for-profit sector (9%)
than in the public not-for-profit sector (92%). However, there was considerable variation within the
private for-profit sector. QAACT availability was much higher in pharmacies (99%) than in drug stores
(56%) or private for-profit facilities (36%). A very high number of general stores were screened for
the outlet surveys, and it was common for them to have antimalarials in stock (21%), meaning that
they represented a high proportion of private for-profit antimalarial outlets, thereby pulling down
average QAACT availability in the private for-profit sector as a whole. For drug stores, QAACT
availability was substantially higher in urban areas than in rural areas (88% versus 53%). There was
also significantly higher QAACT availability in the urban private for-profit sector as a whole (19%
versus 8% in rural areas).
In public health facilities that stocked antimalarials at any time in the three months preceding the
survey, QAACT availability was 94%. QAACT availability was also high among community health
workers (CHWs) (92%).
Availability of ACTipal (artesunate-amodiaquine) is also presented in this report. ACTipal is an ACT
subsidy program that PSI has been operating in Madagascar since 2008, with distribution through
CHWs and in the private sector, via pharmacies and drug stores (Dépôts de medicaments).ACTipal
was available with 76% of community health workers stocking antimalarials at any time in the three
months preceding the survey. It was rarely available in other outlet types (<16%), including
pharmacies (0%) or drug stores (4%).
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In public facilities and private for-profit health facilities and pharmacies, availability of QAACTs with
and without the AMFm logo was very similar, but in drug stores, availability of QAACTs with the logo
was 51% compared with only 12% for QAACTs without the logo.
5.3 Pricing/affordability of quality-assured ACTs
In the public and private not-for-profit sectors, the median QAACT price was USD0.00, reflecting the
policy of free ACT provision. Pooling all sectors, the median price also remained at zero.
While data is not shown in this report for the 2010 findings of the outlet survey, it is important to
note that the median price of QAACTs in the private for-profit sector increased significantly between
2010 and 2011, from USD 0.14 to USD 0.67 per AETD. The 2010 price reflects the paediatric ACT
subsidy program for ACTipal (artesunate-amodiaquine) that PSI had been operating in Madagascar
since 2008 with distribution through CHWs and in the private sector, pharmacies and depots (drug
stores).
The median price of non-quality-assured ACTs in the private for-profit sector was much higher than
for QAACTs (USD 8.37 versus USD 0.67).
The median price for a QAACT with the logo in private for-profit outlets (USD 0.51) was 1.6 times the
median price of the most popular non-QAACT (chloroquine) in private for-profit outlets, whether
this was measured in tablet form or among all dosage types.
5.4 Market share of quality-assured ACTs
Overall market share of QAACTs was 21% in2011, with nATS accounting for 79% of the overall
market share. In the private for-profit sector, market share of QAACTs was 22%. In public health
facilities, QAACT market share was low (13%), given that QAACT availability was 91% in all public
health facilities, with nATs accounting for 79% of market share in public health facilities. Overall
market share of oral AMTs was zero. QAACTs with the AMFm logo accounted for 86% of all QAACTS
dispensed overall and 95% of all QAACTs dispensed in the private for-profit sector.
The private for-profit sector was responsible for 70% of all antimalarials sold or distributed in 2011.
Drug stores and retailers accounted for 50% of the total volumes sold or distributed over the
previous week.
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6. References
Action Santé Organisation Secours (2009). Rapports des activités des ONG ASOS et SALFA,
Madagascar.
ACTwatch (2009). Outlet Survey Report (Baseline) Republic of Madagascar, 2008-2009, accessed 10
March 2011,
<http://www.ACTwatch.info/downloads/results/Madagascar%20Outlet%20Baseline,%20AC
Twatch%2012-09.pdf>.
Adeyi, O. and Atun, R. (2010). "Universal access to malaria medicines: innovation in financing and
delivery," Lancet376(9755): 1869-1871.
Andriantsoanirina, V. et al. (2009). "Plasmodium falciparum drug resistance in Madagascar: facing
the spread of unusual pfdhfr and pfmdr-1 haplotypes and the decrease of
dihydroartemisinin susceptibility,"Antimicrob.Agents Chemother. 53(11):4588-4597.
Andriantsoanirina, V., Menard, D., Tuseo, L. and Durand, R.(2010). "History and current status of
Plasmodium falciparum antimalarial drug resistance in
Madagascar,"Scand.J.Infect.Dis.,42(1):22-32.
Arrow, K., Panosian, C.B. and Gellband H. (2004). Saving Lives, Buying Time: Economics of malaria
drugs in an age of resistance, National Academies Press, Washington, DC.
Banque Mondiale(2010). Document sur le secteur privé dans le domaine de la santé, Archive Banque
Mondiale, Madagascar.
Banque Mondiale(2010). Rapport de l'étude de l'impact des crises socio politique sur la santé,
Madagascar.
Central Intelligence Agency (2011). The World Fact Book: Madagascar, accessed 10 March 2011,
<https://www.cia.gov/library/publications/the-world-factbook/geos/ma.html>.
Craig, P., Dieppe P. et al. (2008). Developing and evaluating complex interventions: new guidance,
Medical Research Council, <www.mrc.ac.uk/complexinterventionsguidance>.
de Savigny, D. and Adam T., eds. (2009). Systems thinking for health systems strengthening, Alliance
for Health Policy and Systems Research and WHO, Geneva.
Direction de l’Agence des Médicaments(2010). Arrêté contre la vente illicite des médicaments,
Ministère de la Santé Publique, Madagascar.
Direction de la Gestion des Intrants de Santé, du Laboratoire et de la Médecine Traditionnelle(1971).
Dossier de constitution de dépôt de médicament, Archive Direction de la Gestion des
Intrants de Santé, du Laboratoire et de la Médecine Traditionnelle, Madagascar.
152 | P a g e
www.ACTwatch.info
Listes des dépôts de médicaments de 2009, Ministère de la Santé Publique, Madagascar.
Projets de loi sur le retrait de la Choloroquine, Ministère de la Santé Publique, Madagascar.
Projet de loi sur la prescription des ACT par les agents communautaires, Ministère de la
Santé Publique, Madagascar.
Direction des Agences de Médicaments(2010). Liste des pharmacies et dépôts de médicaments.
Archive DAM, Madagascar.
Direction du Développement des Districts Sanitaires(2010). Document sur l'évolution des CSB de
Madagascar, Archive Direction du Développement des Districts Sanitaires du Ministère de
la Santé Publique, Madagascar.
Global Fund to Fight AIDS, Tuberculosis and Malaria (2010). Global Fund Quality Assurance Policy for
Pharmaceutical
Products<http://www.theglobalfund.org/documents/psm/PSM_QAPharm_Policy_en.pdf>,
Geneva.
Habicht, J.P., Victora C.G., et al. (1999). "Evaluation designs for adequacy, plausibility and probability
of public health programme performance and impact,"International Journal of Epidemiology 28:
10-18.
Independent Evaluation Team (2011), Outlet Survey Results for Madagascar: 2010 and 2011,
PowerPoint presentation.
Institut National de la Statistique(1999). Base de sondage des communes et fokontany de
Madagascar, Archive de l’INSTAT, Madagascar.
Institut National de la Statistique(2009). Cartographie censitaire de la population, Archive de
l’INSTAT, Madagascar.
Institut National de la Statistique and ICF Macro (2005). Enquête Démographique et de Santé de
Madagascar 2003-2004, INSTAT and ICF Macro, Calverton, MD.
Institut National de la Statistique and ICF Macro (2009). Enquête Démographique et de Santé de
Madagascar 2008-2009, INSTAT and ICF Macro, Calverton, MD.
International Monetary Fund (IMF), 2011. World Economic Outlook Database. [online] Available at:
<http://www.imf.org/external/pubs/ft/weo/2011/01/weodata/index.aspx>
153 | P a g e
www.ACTwatch.info
Kindermans, J.M., Pilloy, J., Olliaro, P., and Gomes,M.(2007)."Ensuring sustained ACT production and
reliable artemisinin supply,"Malar.J. 6(125).
Menard, D., et al.(2007). "Randomized clinical trial of artemisinin versus non-artemisinin
combination therapy for uncomplicated falciparum malaria in Madagascar,"Malar.J. 6 (65).
Ministére de la Santé Publique (2007). Annuaire statistiques du secteur santé de Madagascar, 2007,
Service de Statistique Sanitaire, Ministère de la Sante Publique, Madagascar. .
Ministére de la Santé Publique (2009). Annuaire statistiques du secteur santé de Madagascar,
Service de Statistique Sanitaire, Ministère de la Sante Publique, Madagascar.
Ministère de la Santé Publique, (2004). Arrêté interministériel numéro 5228/2004, Archive Ministère
de la Santé Publique, Madagascar.
Ministère de la Santé Publique (2009). Décret portant institution de la mise à contribution des
utilisateurs dans la prise en charge des cas de paludisme au niveau des formations sanitaires
et au niveau communautaire. Archive Ministère de la Santé Publique, Madagascar.
Ministère de la Santé Publique (2005). Document de Politique National de Traitement du paludisme à
Madagascar Ministère de la Santé Publique, Madagascar.
Ministere de la Sante Publique(2007). Plan Stratégique de lutte contre le paludisme : Du contrôle vers
l’élimination du paludisme à Madagascar 2007-2012 accessed 11 March 2011,
<http://www.usaid.gov/mg/bkg%20docs/Plan%20Strategique%20Malaria%2020072012%20Madagascar.pdf>.
Ministère de la Santé Publique(2009). Prise en Charge Intégrée des maladies des Enfants
Communautaires (PCIMEC), Ministère de la Santé Publique, Madagascar.
Ministére de la Santé Publique(2010). Rapport préliminaire du sur la campagne d’aspersion intradomiciliaire 2009-2010Ministère de la Santé Publique, Madagascar.
Morisset, J. ed.(2010). Vers un agenda de relance économique, Banque Mondaile., Madagascar
Ordre National des Médecins(2010). Documents de l'Ordre National des Médecins sur la fonction
médicale et prescription, Archive ONM, Madagascar.
Ordre National des Médecins(2010). Liste des cabinets médicaux libéraux et cabinets médicaux
privés, Archive ONM, Madagascar.
Ordre National des Pharmaciens (2010). Liste des médicaments disponibles chez les grossistes au
mois d’octobre 2010Archive ONP, Madagascar.
154 | P a g e
www.ACTwatch.info
President’s Malaria Initiative (2011). Country Profile, President’s Malaria Initiative (PMI)
Madagascar, accessed 11 March 2011,
<http://www.fightingmalaria.gov/countries/profiles/madagascar_profile.pdf>.
Programme National de Lutte contre La Paludisme(2005). Document sur les ACT, Archive PNLP,
Madagascar.
Programme National de Lutte contre La Paludisme (2010). Données sur la fréquence des d'épidémies
à Madagascar, Archive PNLP/ SUR EPI, Madagascar.
Programme National de Lutte contre le Paludisme(2005). Nouvelle politique de traitement du
paludisme, Ministère de la Santé Publique, Madagascar.
Randrianarivelojosia, M., et al. (2001). "Madagascan isolates of Plasmodium falciparum showing low
sensitivity to artemether in vitro," Ann.Trop.Med. Parasitol. 95(3): 237-243.
Rason, M.A., Randriantsoa, T., Andrianantenaina, H., Ratsimbasoa, A., and Menard, D.(2008).
"Performance and reliability of the SYBR Green I based assay for the routine monitoring of
susceptibility of Plasmodium falciparum clinical isolates,"Trans.R.Soc.Trop.Med.Hyg. 102(4):
346-351.
Ratsimbasoa, A., et al. (2006). "Use of pre-packaged chloroquine for the home management of
presumed malaria in Malagasy children," Malar.J. 5(79).
Sabot, O.J., Mwita A., Cohen, J.M., Ipuge Y., Gordon, M., Bishop, D., Odhiambo, M., Ward, L and
Goodman, C. (2009). "Piloting the global subsidy: The impact of subsidized artemisinin-based
combination therapies distributed through private drug shops in rural Tanzania,"PLoS One 4(9):
e6857
SALFA (2010). Carte des interventions des ONG ASOS, SALFA dans le cadre de l'AMFM, Archive ONG
SALFA, MadagascarService de la Législation du Ministère de la Santé Publique(1962).
Politique de santé, Archive Ministère de la Santé Publique, Madagascar.
Shewchuk, T., O'Connell, K. A. et al. (2011). "The ACTwatch project: methods to describe antimalarial markets in seven countries," Malar J10: 325.
United Nations Development Programme (2010). International Human Development Indicators,
accessed 11 March 2011, <http://hdrstats.undp.org/en/countries/profiles/MDG.html>.
United Nations Population Division (2010). World Population Prospects: The 2010 Revision, accessed
11 March 2011, <http://esa.un.org/unpd/wpp/index.htm>.
World Health Organization (2010a). World Malaria Report 2010, WHO Press, Geneva.
World Health Organization (2010b). Guidelines for the treatment of malaria, second edition, WHO
Press, Geneva.
World Health Organization (2009). Systems thinking for health systems strengthening, Geneva.
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7. Acknowledgements
This report presents the results of the 2011 Madagascar Outlet Survey. It is a comprehensive,
nationally representative outlet survey designed to the evaluation of the Affordable Medicines
Facility for malaria.
This report would not have been possible without the efforts of a large number of people who
assisted with the data analysis, data processing, and preparation of the report, as well as those who
worked tirelessly to collect the endline survey data and analyze the results. We particularly
appreciate the efforts of the Madagascar National Malaria Control Program for providing overall
support for the survey. Additional thanks are expressed to PSI/Madagascar for providing project
management support and for implementing the field work and PDA programming. We would also
like to thank the Global Fund and the Bill and Melinda Gates Foundation for their support.
We would like to express our thanks to the field teams and individuals involved in the survey. Their
names are presented in Appendix 8.4.
Finally, we would like to thank the thousands of providers who took time to complete the interview.
Without them, it would not be possible to provide these results.
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8. Appendices
8. 1 Questionnaire
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8.2 ACTs classified as quality-assured
Key indicators for the Independent Evaluation of AMFm measure the price, availability and market
share of quality-assured ACTs (QAACT). A QAACT is defined as any ACT that meets the Global Fund
to Fight AIDS, Tuberculosis and Malaria’s (The Global Fund) quality-assurance policy. According to
this policy, a quality-assured product must be either WHO pre-qualified and/or authorized for
marketing by a Stringent Drug Regulatory Authority. Products that have not yet been WHO prequalified or approved by a Stringent Drug Regulatory Authority must be evaluated and
recommended for use by an independent panel of technical experts hosted by World Health
Organization’s Department for Essential Medicines and Pharmaceutical Policies (The Global Fund
2010).
The list of antimalarials that complies with the quality-assurance policy varies over time.
Consequently, an operational definition that would establish a fixed list of QAACTs was adopted for
the purpose of the Independent evaluation endline outlet survey as follows: a QAACT is any ACT
which appeared on the Global Fund's Indicative List of antimalarials meeting the Global Fund's
quality assurance policy as at September 201129, or which previously had C-status in an earlier
Global Fund quality assurance policy and was used in a programme supplying subsidised ACTs.
In September 2011, the Global Fund provided the Independent Evaluator with the indicative list of
antimalarials that met the quality-assurance policy. Since brand names are not pre-qualified by the
WHO or registered when recommended by the Expert Review Panel, the Independent Evaluator
contacted each manufacturer on the list to get details on all of the brand names used for each
product appearing on the list and produced at the approved manufacturing site. In addition, qualityassured products are also often re-packaged and re-branded for the use in domestic social
marketing or subsidy programmes. Details on the brand names used in in-country marketing
programmes were compiled by contacting national authorities, or the organization involved in the
marketing campaign (e.g., PSI and MENTOR).
For the availability, price, markup and market-share indicators, products were classified as qualityassured ACTs if the brand name, generic name, strength, manufacturer and country of manufacturer
matched one of the entries in Table 8.2.1.
For the stockout indicator, a prompt card showing photographs of the ACTs classified as qualityassured was used so the interviewer and respondent could identify QAACTs in stock during the
survey visit or in stock in the previous 4 weeks. Photographs of QAACTs used for social
marketing/subsidy programme were not included in the prompt card, unless the country in which
data collection took place had a social marketing or subsidy programme which used a QAACT.
29
Refer to http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General for the most up to date list.
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Table 8.2.1: List of Quality-Assured ACTs for availability, price and market share indicators
Brand Name
Generic Name
Strength
Manufacturer
Country of
manufacture
Package Size
(tablets per pack)
FDC
Notes
ACT WITH A LEAF 4
MONTHS TO <3
YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6 or 30
Yes
Repackaged by PSI
for distribution in
Uganda
ACT WITH A LEAF 3
YEARS TO <7 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
12 or 60
Yes
Repackaged by PSI
for distribution in
Uganda
ACT WITH A LEAF 7
YEARS TO <12 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
18 or 90
Yes
Repackaged by PSI
for distribution in
Uganda
ACT WITH A LEAF 12
YEARS AND ABOVE
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
24 or 120
Yes
Repackaged by PSI
for distribution in
Uganda
ACTIPAL
ARTESUNATE +
AMODIAQUINE
25mg + 67.5mg
SANOFI AVENTIS or
MAPHAR
Morocco
3
Yes
ACTIPAL
ARTESUNATE +
AMODIAQUINE
50mg + 135mg
SANOFI AVENTIS or
MAPHAR
Morocco
3
Yes
ACTIPAL
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
STRIDES ARCO LABS
India
6
No
C-status product.
Repackaged by PSI
for distribution in
Madagascar
C-status product.
Repackaged by PSI
for distribution in
Madagascar
C-status product.
Repackaged by PSI
for distribution in
Madagascar
ARTEMEF 4 MONTHS
UP TO 3 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
6
Yes
QAACT – over
branded for Nigeria
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ARTEMEF 3 YEARS UP
TO 7 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
12
Yes
QAACT – over
branded for Nigeria
ARTEMEF 7 YEARS UP
TO 12 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
18
Yes
QAACT – over
branded for Nigeria
ARTEMEF 12 YEARS
AND ABOVE
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
24
Yes
QAACT – over
branded for Nigeria
ARTEQUIN 600/1500
ARTESUNATE +
MEFLOQUINE
200mg + 250mg
MEPHA
Switzerland
9
No
Not included on the
prompt card used for
the stockout
indicator
ARSUAMOON 1-6
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 150mg
GUILIN
PHARMACEUTICAL
CO. LTD
China
6 or 150
No
ARSUAMOON 7-13
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 150mg
GUILIN
PHARMACEUTICAL
CO. LTD
China
12 or 300
No
ARSUAMOON
ADULTS
ARTESUNATE +
AMODIAQUINE
50mg + 150mg
GUILIN
PHARMACEUTICAL
CO. LTD
China
24 or 600
No
ARTEFAN 20/120 514KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
6 or 180
Yes
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
12 or 360
Yes
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
18 or 540
Yes
ARTEFAN 20/120 35+
KG ADULTS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
24 or 720
Yes
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ARTEMETHER +
LUMEFANTRINE
<3 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
IPCA LABORATORIES
LTD
India
6, 60 or 180
Yes
ARTEMETHER +
LUMEFANTRINE
3-8 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
IPCA LABORATORIES
LTD
India
12,120, or 360
Yes
ARTEMETHER +
LUMEFANTRINE
9-14 YEARS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
IPCA LABORATORIES
LTD
India
18, 180, or 540
Yes
ARTEMETHER +
LUMEFANTRINE
>14 YEARs
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
IPCA LABORATORIES
LTD
India
24, 240, or 720
Yes
ARTESUNATE +
AMODIAQUINE CHILD
1-6 YEARS
ARTESUNATE +
AMODIAQUINE
JUNIOR 7-13 YEARS
ARTESUNATE +
AMODIAQUINE
ADULT
ARTESUNATE +
AMODIAQUINE CHILD
1-6 YEARS
ARTESUNATE +
AMODIAQUINE
JUNIOR 7-13 YEARS
ARTESUNATE +
AMODIAQUINE
ADULT
COARSUCAM INFANT
2-11 MONTHS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
6 or 60
No
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
12 or 120
No
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
24 or 240
No
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
6 or 60
No
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
12 or 120
No
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
24 or 240
No
ARTESUNATE +
AMODIAQUINE
25mg + 67.5mg
SANOFI AVENTIS or
MAPHAR
Morocco
3 or 75
Yes
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COARSUCAM
TODDLER 1-5 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 135mg
SANOFI AVENTIS or
MAPHAR
Morocco
3 or 75
Yes
COARSUCAM CHILD
6-13 YEARS
ARTESUNATE +
AMODIAQUINE
100mg + 270mg
SANOFI AVENTI or
MAPHAR
Morocco
3 or 75
Yes
COARSUCAM ADULT
+14 YEARS
ARTESUNATE +
AMODIAQUINE
100mg + 270mg
SANOFI AVENTI or
MAPHAR
Morocco
6 or 150
Yes
COARTEM 20/120 515 KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6, 30 or 180
Yes
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
12, 60 or 360
Yes
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
18, 90 or 540
Yes
COARTEM 20/120
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6, 24, 216, 720
Yes
COARTEM
DISPERSIBLE 5-15KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
USA
6 or 180
Yes
COARTEM
DISPERSIBLE 15-25KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
USA
12 or 360
Yes
COARTEM
DISPERSIBLE 25-35KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
USA
18 or 540
Yes
COARTEM
DISPERSIBLE
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
USA
6 or 216
Yes
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COARTEM E FIXE 515KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6
Yes
Distributed by
MENTOR in Angola
COARTEM E FIXE 1525KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
12
Yes
Distributed by
MENTOR in Angola
COARTEM E FIXE
DISPERSIBLE 5-15KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6
Yes
Distributed by
MENTOR in Angola
COARTEM E FIXE
DISPERSIBLE 15-25KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
12
Yes
Distributed by
MENTOR in Angola
CO-FALCINUM 5-14
KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
6
Yes
QAACT – over
branded for Kenya
CO-FALCINUM 1524KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
12
Yes
QAACT – over
branded for Kenya
CO-FALCINUM 2534KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
18
Yes
QAACT – over
branded for Kenya
CO-FALCINUM 35KG
AND ADULTS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
24
Yes
QAACT – over
branded for Kenya
COMBISUNATE
20/120 5-14KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
6
Yes
QAACT – over
branded for Nigeria
COMBISUNATE
20/120 15-24KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
12
Yes
QAACT – over
branded for Nigeria
COMBISUNATE
20/120 25-34KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
18
Yes
QAACT – over
branded for Nigeria
COMBISUNATE
20/120 35+ KG
ADULTS
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
AJANTA PHARMA LTD
India
24
Yes
QAACT – over
branded for Nigeria
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DAWA MSETO YA
MALARIA ALU
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6, 12, 18, 24
Yes
FALCIMON KIT
YOUNG CHILDREN UP
TO 6 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
CIPLA PHARMA LTD
India
6
No
FALCIMON KIT
CHILDREN 7-13
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
CIPLA PHARMA LTD
India
12
No
FALCIMON KIT
ADULTS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
CIPLA PHARMA LTD
India
24
No
LA COARTEM
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6, 12
Yes
LARIMAL CHILD 1-6
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
6
No
LARIMAL JUNIOR 713 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
12
No
LARIMAL ADULT 14+
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
24
No
LARIMAL CHILD 1-6
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
6
No
LARIMAL JUNIOR 713 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
12
No
LARIMAL ADULT 14+
YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153.1 mg
IPCA LABORATORIES
LTD
India
24
No
LUMERAX
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
IPCA LABORATORIES
LTD
India
24
Yes
Repackaged by PSI
for distribution in TZ
Repackaged by PSI
for distribution in
Malawi
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LUMARTEM 5KG TO
<15KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
6 or 180
Yes
LUMARTEM 15 TO
<25KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
12 or 360
Yes
LUMARTEM 25 TO
<35KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
18 or 540
Yes
LUMARTEM 35KG
AND ABOVE
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
India
24 or 720
Yes
LUMARTEM 5KG TO
<15KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
Uganda
6 or 180
Yes
LUMARTEM 15 TO
<25KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
Uganda
12 or 360
Yes
LUMARTEM 25 TO
<35KG
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
Uganda
18 or 540
Yes
LUMARTEM 35KG
AND ABOVE
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
CIPLA PHARMA LTD
Uganda
24 or 720
Yes
MALARIAKIT
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
IPCA LABORATORIES
LTD
India
6
No
Repackaged by PSI
for distribution in
Sudan
MALARPACK
COARTEM
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6, 12
Yes
Repackaged by PSI
for distribution in
Myanmar
PRIMO
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6 or 12
Yes
Repackaged by PSI
for distribution in
Rwanda
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SERENA DOSE
ENFANTS 1-5 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 153mg
CIPLA PHARMA LTD
India
6
Yes
Repackaged by
PSI/Manufacturer for
distribution in DRC
TIBAMAL
ARTEMETHER +
LUMEFANTRINE
20mg + 120mg
NOVARTIS PHARMA
AG
China or USA
6 or 12
Yes
Repackaged by
manufacturer for
distribution in Kenya
WINTHROP INFANT
2-11 MONTHS
ARTESUNATE +
AMODIAQUINE
25mg + 67.5mg
SANOFI AVENTIS or
MAPHAR
Morocco
3 or 75
Yes
WINTHROP TODDLER
1-5 YEARS
ARTESUNATE +
AMODIAQUINE
50mg + 135mg
SANOFI AVENTIS or
MAPHAR
Morocco
3 or 75
Yes
WINTHROP CHILD 613 YEARS
ARTESUNATE +
AMODIAQUINE
100mg + 270mg
SANOFI AVENTI or
MAPHAR
Morocco
3 or 75
Yes
WINTHROP ADULT
+14 YEARS
ARTESUNATE +
AMODIAQUINE
100mg + 270mg
SANOFI AVENTI or
MAPHAR
Morocco
6 or 150
Yes
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8.3 Final sample
Table 8.3. 1: List of clusters/sub-districts sampled and their population, Madagascar, 2011
Region
District
Sub-district
Population
Location
(urban/rural)
REGION
ANALAMANGA
DISTRICT
Sub-district
POPULA
TION
Location
(urban/rural)
Censused
Sub-district or
booster
sample?
Censused sub-district or
booster sample?
ANKAZOBE
ANKAZOBE
15735 Rural
Censused sub-district
ANKAZOBE
TALATA-ANGAVO
10150 Rural
Booster
ANKAZOBE
Ambohitromby
8138 Rural
Booster
ANKAZOBE
Antotohazo
15184 Rural
Booster
ANKAZOBE
Fihaonana
17085 Rural
Booster
ANKAZOBE
Mahavelona
12752 Rural
Booster
ANKAZOBE
Tsaramasoandro
8563 Rural
Booster
ANKAZOBE
Ambolotarakely
4387 Rural
Booster
ANKAZOBE
Kiangara
9739 Rural
Booster
ANKAZOBE
Miantso
13666 Rural
Booster
BETAFO
MAHAIZA
25002 Rural
BETAFO
BETAFO
29722 Rural
Booster
BETAFO
Andranomafana
4905 Rural
Booster
BETAFO
Tritriva
10734 Rural
Booster
BETAFO
Manohisoa
11399 Rural
Booster
BETAFO
Ambatonikolahy
5681 Rural
Booster
BETAFO
Antohobe
10808 Rural
Booster
BETAFO
ALAKAMISY-MAROSOSONA
7269 Rural
Booster
Ambohimanambola
21942 Rural
Booster
Ankazomiriotra
18070 Rural
Booster
BETAFO
VAKINANKARAT
BETAFO
RA
BETAFO
Vinany
13874 Rural
Booster
BETAFO
Fidirana
22263 Rural
Booster
BETAFO
2824 Rural
Booster
26959 Urban
TSIROANOMANDIDY
Antanambao Ambany
TSIROANOMANDIDYRENIVOHITRA
TSIROANOMANDIDYFIHAONANA
29435 Rural
Booster
TSIROANOMANDIDY
Ambatolampy
12674 Rural
Booster
TSIROANOMANDIDY
Marintampona
3159 Rural
Booster
TSIROANOMANDIDY
Bevato
11438 Rural
Booster
TSIROANOMANDIDY
ANKADINONDRY-SAKAY
26465 Rural
Booster
TSIROANOMANDIDY
Miandrarivo
10561 Rural
Booster
TSIROANOMANDIDY
Tsinjoarivo
12636 Rural
Booster
TSIROANOMANDIDY
Anosy
3091 Rural
Booster
TSIROANOMANDIDY
Ambararatabe
2125 Rural
Booster
TSIROANOMANDIDY
Belobaka
18764 Rural
Booster
TSIROANOMANDIDY
Mahasolo
27623 Rural
Booster
TSIROANOMANDIDY
Bemahatazana
13130 Rural
Booster
TSIROANOMANDIDY
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BONGOLAVA
VATOVAVY
FITOVINANY
TSIROANOMANDIDY
Fierenana
14720 Rural
Booster
FENOARIVO-BE
FENOARIVO-AFOVOANY
19592 Rural
FENOARIVO-BE
Firavahana
35470 Rural
Booster
FENOARIVO-BE
Morarano Maritampona
1822 Rural
Booster
FENOARIVO-BE
FENOARIVO-BE
Kiranomena
Mahajeby
24492 Rural
4452 Rural
Booster
Booster
FENOARIVO-BE
Ambohitromby
18276 Rural
Booster
FENOARIVO-BE
Ambatomainty Atsimo
2665 Rural
Booster
FENOARIVO-BE
Tsinjoarivo
2902 Rural
Booster
IFANADIANA
IFANADIANA
IFANADIANA
Antaretra
1594 Rural
Booster
IFANADIANA
Tsaratanana
23280 Rural
Booster
IFANADIANA
Ranomafana
19171 Rural
Booster
IFANADIANA
Androrangavola
27458 Rural
Booster
IFANADIANA
Ambohimiera
16591 Rural
Booster
IFANADIANA
AMBOHIMANGA-ATSIMO
15847 Rural
Booster
IFANADIANA
Analampasina
7163 Rural
Booster
IFANADIANA
Fasintsara
18175 Rural
Booster
IFANADIANA
Maroharatra
12985 Rural
Booster
MANANJARY
MORAFENO
11186 Rural
MANANJARY
Mananjary
31525 Urban
Booster
MANANJARY
MAHATSARA-ATSIMO
7544 Rural
Booster
MANANJARY
Tsiatosika
19846 Rural
Booster
MANANJARY
Andranambolava
6429 Rural
Booster
MANANJARY
Vohilava
19102 Rural
Booster
MANANJARY
Mahela
19373 Rural
Booster
MANANJARY
Ambohitsara Est
3777 Rural
Booster
MANANJARY
Ambohinihaonana
16170 Rural
Booster
MANANJARY
Marofototra
18188 Rural
Booster
MANANJARY
AMBODINONOKA
22211 Rural
Booster
MANANJARY
Kianjavato
6637 Rural
Booster
MANANJARY
Anosimparihy
9979 Rural
Booster
MANANJARY
Namorona
16022 Rural
Booster
MANAKARA ATSIMO
MANAKARA-TANAMBE
40196 Urban
MANAKARA ATSIMO
Tataho
9461 Rural
Booster
MANAKARA ATSIMO
Marofarihy
10387 Rural
Booster
MANAKARA ATSIMO
Ambila
14899 Rural
Booster
MANAKARA ATSIMO
MIZILO-GARA
5295 Rural
Booster
MANAKARA ATSIMO
Sahasinaka
13408 Rural
Booster
MANAKARA ATSIMO
Amboanjo-Ifaho
16964 Rural
Booster
MANAKARA ATSIMO
Vohimasy
5106 Rural
Booster
MANAKARA ATSIMO
Ivatana
1442 Rural
Booster
MANAKARA ATSIMO
Ambalaroka
2789 Rural
Booster
MANAKARA ATSIMO
Vohimanitra
3502 Rural
Booster
MANAKARA ATSIMO
Analavory
549 Rural
Booster
MANAKARA ATSIMO
Ambotaka
1629 Rural
Booster
MANAKARA ATSIMO
Onilahy
Rural
Booster
19996 Rural
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ATSIMO
ATSINANANA
MANAKARA ATSIMO
Sakoana
MANAKARA ATSIMO
Mahabako
Rural
Booster
14856 Rural
Booster
MANAKARA ATSIMO
Anteza
4173 Rural
Booster
IKONGO
IKONGO
36762 Rural
IKONGO
Ambolomadinika
2106 Rural
Booster
IKONGO
Maromiandra
1717 Rural
Booster
IKONGO
Ifanirea
23611 Rural
Booster
IKONGO
Sahalanona
1226 Rural
Booster
IKONGO
Tolongoina
25698 Rural
Booster
IKONGO
Ambohimisafy
1682 Rural
Booster
IKONGO
Ankarimbelo
15324 Rural
Booster
IKONGO
Ikalafotsy
1181 Rural
Booster
IKONGO
Antodinga
Rural
Booster
IKONGO
Sahalanonana
1226 Rural
Booster
FARAFANGANA
ANTSERANAMBE
4099 Rural
FARAFANGANA
Farafangana
28232 Urban
Booster
FARAFANGANA
Anosivelo
10978 Rural
Booster
FARAFANGANA
MANAMBOTRA-ATSIMO
5546 Rural
Booster
FARAFANGANA
MAHAFASA-AFOVOANY
8319 Rural
Booster
FARAFANGANA
Amporoforo
7895 Rural
Booster
FARAFANGANA
Ambohigogo
FARAFANGANA
Etrotroka
FARAFANGANA
8109 Rural
Booster
18099 Rural
Booster
EFATSY-ANANDROZA
6230 Rural
Booster
FARAFANGANA
Ambalatany
9506 Rural
Booster
FARAFANGANA
Ihorombe
7401 Rural
Booster
FARAFANGANA
Vohilengo
8104 Rural
Booster
FARAFANGANA
Marovandrika
4926 Rural
Booster
VANGAINDRANO
VANGAINDRANO
26787 Urban
VANGAINDRANO
Ampasimalemy
21780 Rural
Booster
VANGAINDRANO
Bekaraoky
1488 Rural
Booster
VANGAINDRANO
Tsiately
12386 Rural
Booster
VANGAINDRANO
Soamanova
9461 Rural
Booster
VANGAINDRANO
Vohitrambo
27025 Rural
Booster
VANGAINDRANO
Lohafary
17662 Rural
Booster
VANGAINDRANO
Matanga
20080 Rural
Booster
VANGAINDRANO
Nosibe Masianaka
1819 Rural
Booster
VANGAINDRANO
Ambongo
13908 Rural
Booster
VANGAINDRANO
Iara
10547 Rural
Booster
VANGAINDRANO
Karimbary
980 Rural
Booster
VANGAINDRANO
Manambondro
10363 Rural
Booster
VANGAINDRANO
Vohimalaza
1754 Rural
Booster
VANGAINDRANO
AMPARIHY-ATSINANANA
9423 Rural
Booster
VANGAINDRANO
Ampataka
Rural
Booster
VONDROZO
MAHAZOARIVO
11737 Rural
VONDROZO
Vondrozo
22667 Rural
Booster
VONDROZO
Mahatsinjo
13085 Rural
Booster
VONDROZO
Iamonta
1047 Rural
Booster
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ATSINANANA
VONDROZO
Vohimary
14150 Rural
Booster
VONDROZO
AMBOHIMANA
6032 Rural
Booster
VONDROZO
Manato
1706 Rural
Booster
VONDROZO
Ivato
10190 Rural
Booster
VONDROZO
Andakana
4985 Rural
Booster
VONDROZO
Vohiboreka
2365 Rural
Booster
VONDROZO
Anandravy
Rural
Booster
VONDROZO
Manambidala
Rural
Booster
TOAMASINA VILLE
ANJOMA
32337 Urban
TOAMASINA VILLE
TANAMBAO V
46284 Urban
TOAMASINA VILLE
ANKIRIHIRY
59579 Urban
TOAMASINA VILLE
AMBODIMANGA-TOAMASINA I
28120 Urban
Booster
Morarano
49971 Urban
Booster
MANANARA-AVARATRA
41598 Rural
TOAMASINA VILLE
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
MANANARA
AVARATRA
ANALANJIROFO MANANARA
AVARATRA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
FENOARIVO
ATSINANANA
ATSINANANA
Ambodivoanio
1870 Rural
Booster
Antanambaobe
15860 Rural
Booster
Antanananivo
2532 Rural
Booster
Manambolosy
14754 Rural
Booster
9953 Rural
Booster
21333 Rural
Booster
1484 Rural
Booster
Antanambe
18787 Rural
Booster
Saromaona
6018 Rural
Booster
Rural
Booster
Ambodiampana
Sandrakatsy
Ambatoharanana
Vanono
FENOARIVO-ATSINANANAAMBONIVOHITRA
21193 Urban
Mahambo
33773 Rural
Booster
AMPASINA-MANINGORY
33024 Rural
Booster
Vohilengo
34495 Rural
Booster
Ambatoharanana
AMPASIMBEMANANTSATRANA
2965 Rural
Booster
30198 Rural
Booster
Miorimivalana
11028 Rural
Booster
Vohipeno
38217 Rural
Booster
Antsiatsiaka
AMBODIMANGA IIFENOARIVO
ATSINANANA
28506 Rural
Booster
31028 Rural
Booster
VOHIBINANY
ANDEVORANTO
10648 Rural
VOHIBINANY
VOHIBINANY (BRICKAVILLE)
25710 Rural
Booster
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ALAOTRA
MANGORO
VOHIBINANY
ANIVORANO-ATSINANANA
11369 Rural
Booster
VOHIBINANY
Mahatsara
21662 Rural
Booster
VOHIBINANY
Fetraomby
17874 Rural
Booster
VOHIBINANY
Ambalarondra
12454 Rural
Booster
VOHIBINANY
Maroseranana
9925 Rural
Booster
VOHIBINANY
Lohariandava
18248 Rural
Booster
VOHIBINANY
Ambohimanana
7225 Rural
Booster
VOHIBINANY
Anjahamana
8133 Rural
Booster
VOHIBINANY
Razanaka
1271 Rural
Booster
MAHANORO
AMBODIBONARA
24331 Rural
MAHANORO
Mahanoro
40293 Rural
Booster
MAHANORO
Betsizaraina
4134 Rural
Booster
MAHANORO
Tsaravinany
17543 Rural
Booster
MAHANORO
Ambodiharina
30311 Rural
Booster
MAHANORO
Manjakandriana
15548 Rural
Booster
MAHANORO
Masomeloka
34263 Rural
Booster
MAHANORO
Ambinanidilana
26181 Rural
Booster
MAHANORO
Ambinanindrano
32322 Rural
Booster
MAHANORO
ANTANAMBAOMANAMPOTSY
Befotaka
19948 Rural
Booster
ANTANAMBAO-MANAMPOTSY
14460 Rural
Mahela
12781 Rural
Booster
Saivaza
9979 Rural
Booster
Antanandehibe
9236 Rural
Booster
Manakana
9363 Rural
Booster
AMBATONDRAZAKA
ANDILANATOBY
37024 Rural
AMBATONDRAZAKA
Ambatondrazaka
43398 Urban
Booster
AMBATONDRAZAKA
Ambandrika
6008 Rural
Booster
AMBATONDRAZAKA
Ampitatsimo
15915 Rural
Booster
AMBATONDRAZAKA
Ambohitsilaozana
20403 Rural
Booster
AMBATONDRAZAKA
16333 Rural
Booster
AMBATONDRAZAKA
Ilafy
MANAKAMBAHINYANDREFANA
33951 Rural
Booster
AMBATONDRAZAKA
Ambatosoratra
25312 Rural
Booster
AMBATONDRAZAKA
Bejofo
AMBATONDRAZAKA
AMBATONDRAZAKA
Didy
MANAKAMBAHINYANTSINANANA
AMBATONDRAZAKA
Tanambao Besakay
MORAMANGA
MORAMANGA
29615 Urban
MORAMANGA
Ambohibary
22519 Rural
Booster
MORAMANGA
Andasibe
11078 Rural
Booster
MORAMANGA
Vodiriana
3481 Rural
Booster
MORAMANGA
MORARANO-GARA
13995 Rural
Booster
MORAMANGA
Belavabary
9151 Rural
Booster
MORAMANGA
Ambohidronono
9342 Rural
Booster
7323 Rural
Booster
11231 Rural
Booster
9144 Rural
Booster
4150 Rural
Booster
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ANALANJIROFO
BOENY
MORAMANGA
Beforona
19404 Rural
Booster
MORAMANGA
Lakato
19929 Rural
Booster
MORAMANGA
Amboasary
13336 Rural
Booster
MORAMANGA
MANDIALAZA
25023 Rural
Booster
MORAMANGA
Antanandava
8177 Rural
Booster
MORAMANGA
BEPARASY
11782 Rural
Booster
MORAMANGA
Andaingo
18059 Rural
Booster
VAVATENINA
ANJAHAMBE
26872 Rural
VAVATENINA
Vavatenina
37327 Rural
Booster
VAVATENINA
Maromitety
16805 Rural
Booster
VAVATENINA
Ambohibe
20959 Rural
Booster
VAVATENINA
Ampasimazava
15023 Rural
Booster
VAVATENINA
Andasibe
23848 Rural
Booster
VAVATENINA
Miarinarivo
17340 Rural
Booster
VAVATENINA
Sahatavy
12126 Rural
Booster
VAVATENINA
Ambodimangavalo
13223 Rural
Booster
MAHAJANGA-VILLE
MAHABIBO
85246 Urban
MAHAJANGA-VILLE
76838 Urban
18074 Rural
MAEVATANANA
MAHAJANGA
MAEVATANANAAMBANIVOHITRA
MAEVATANANAAMBONIVOHITRA
13824 Urban
Booster
MAEVATANANA
Beratsimanina
1351 Rural
Booster
MAEVATANANA
Mahazoma
12115 Rural
Booster
MAEVATANANA
Mahatsinjo
2734 Rural
Booster
MAEVATANANA
Antsiafabositra
MAEVATANANA
Tsararano
MAEVATANANA
Maria
MAEVATANANA
Andriba
MAEVATANANA
Morafeno
MAEVATANANA
Madiromirafy
MAEVATANANA
Ambalajia
Marovoay
31741 Urban
MAROVOAY
MAROVOAY-AMBONIVOHITRA
ANTANAMBAOANDRANOLAVA
2498 Rural
Booster
MAROVOAY
MAROVOAY-AMBANIVOHITRA
21871 Rural
Booster
MAROVOAY
Anosinalainolona
1528 Rural
Booster
MAROVOAY
Ambolomoty
18707 Rural
Booster
MAROVOAY
Marosakoa
1179 Rural
Booster
MAROVOAY
Ankazomborona
24987 Rural
Booster
MAROVOAY
Manaratsandry
29408 Rural
Booster
MAROVOAY
Antanimasaka
1742 Rural
Booster
MAROVOAY
Bemaharivo
11707 Rural
Booster
MAROVOAY
Ankaraobato
653 Rural
Booster
Tsaratanana
TSARAROVA
9270 Rural
TSARATANANA
Tsaratanana
17003 Rural
Booster
TSARATANANA
Bekapaika
10840 Rural
Booster
TSARATANANA
Betrandraka
7330 Rural
Booster
MAEVATANANA
BETSIBOKA
BOENY
BETSIBOKA
9468 Rural
Booster
13434 Rural
Booster
7206 Rural
Booster
24659 Rural
Booster
1018 Rural
Booster
2297 Rural
Booster
Rural
Booster
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SOFIA
ATSIMO
ANDREFANA
TSARATANANA
Keliloha
5539 Rural
Booster
TSARATANANA
Sarobaratra
11564 Rural
Booster
TSARATANANA
Ampandrana
2658 Rural
Booster
TSARATANANA
Andriamena
14109 Rural
Booster
TSARATANANA
Ambakireny
12599 Rural
Booster
TSARATANANA
Brieville
10296 Rural
Booster
TSARATANANA
Manakana
8514 Rural
Booster
Analalava
AMBOLOBOZO
10479 Rural
ANALALAVA
Analalava
12094 Rural
Booster
ANALALAVA
Ambarijeby Atsimo
1242 Rural
Booster
ANALALAVA
Ambaliha
9663 Rural
Booster
ANALALAVA
Maromandia
18395 Rural
Booster
ANALALAVA
Marovatolena
8825 Rural
Booster
ANALALAVA
Andriambavontsona
6887 Rural
Booster
ANALALAVA
Angoaka Atsimo
995 Rural
Booster
ANALALAVA
Ankaramy
7526 Rural
Booster
ANALALAVA
Mahadrodroka
4568 Rural
Booster
Bealanana
AMBATOSIA
15371 Rural
BEALANANA
Bealanana
17151 Rural
Booster
BEALANANA
Beandrarezona
11782 Rural
Booster
BEALANANA
Antananivo Ambony
788 Rural
Booster
BEALANANA
Antsamaka
6942 Rural
Booster
BEALANANA
Ambodiampana
2111 Rural
Booster
BEALANANA
AMBATORIHA
8161 Rural
Booster
BEALANANA
Ambovonomby
5812 Rural
Booster
BEALANANA
Anjozoromadosy
1362 Rural
Booster
BEALANANA
Mangindrano
11055 Rural
Booster
BEALANANA
Ambararata Sofia
965 Rural
Booster
BEALANANA
MAROTOLANA
7567 Rural
Booster
BEALANANA
Ambodiadabo
12397 Rural
Booster
TOLIARA VILLE
TANAMBAO I
13597 Urban
TOLIARA VILLE
BETANIA
19870 Urban
TOLIARA VILLE
Tanambao II
23596 Urban
Booster
TOLIARA VILLE
Mahavatse I
14816 Urban
Booster
TOLIARA VILLE
Mahavatse II
20641 Urban
Booster
TOLIARA VILLE
Besakoa
28063 Urban
Booster
BEROROHA
BEROROHA
18903 Rural
BEROROHA
Bemavo
1976 Rural
Booster
BEROROHA
Fanjakana
5081 Rural
Booster
BEROROHA
Behisatsy
6718 Rural
Booster
BEROROHA
Marerano
9381 Rural
Booster
BEROROHA
Mandronarivo
6472 Rural
Booster
BEROROHA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
Tanamary (Tahamary)
620 Rural
Booster
AMPANIHY
Behavandra
AMBOROMPOTSY
12366 Rural
AMPANIHY-ANDREFANA
25939 Rural
Booster
1153 Rural
Booster
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ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
AMPANIHY
ANDREFANA
MENABE
ANDROY
Ankilizato
6880 Rural
Booster
Antaly
11620 Rural
Booster
Ejeda
28395 Rural
Booster
7234 Rural
Booster
Beahitse
14462 Rural
Booster
Androka
22177 Rural
Booster
Vohitany
8161 Rural
Booster
Fotadrevo
31786 Rural
Booster
Tanantsoa
2355 Rural
Booster
BELAFIKE-AMBONY
Itampolo
26866 Rural
Booster
MORONDAVA
MORONDAVA
37410 Urban
MORONDAVA
Bemanonga
11592 Rural
Booster
MORONDAVA
Analaiva
12029 Rural
Booster
MORONDAVA
Befasy
6366 Rural
Booster
MORONDAVA
BELO-MARINY-RANOMASINA
4408 Rural
Booster
BELON'I TSIRIBIHINA
BELON'I TSIRIBIHINA
BELON'I TSIRIBIHINA
Ankirondro
1928 Rural
Booster
BELON'I TSIRIBIHINA
Tsimafana
2478 Rural
Booster
BELON'I TSIRIBIHINA
Beroboka Nord
749 Rural
Booster
BELON'I TSIRIBIHINA
Tsaraotana
1491 Rural
Booster
BELON'I TSIRIBIHINA
Masoarivo
916 Rural
Booster
BELON'I TSIRIBIHINA
Ankalalobe
7602 Rural
Booster
BELON'I TSIRIBIHINA
Bemangily II
1233 Rural
Booster
BELON'I TSIRIBIHINA
Begidro
1189 Rural
Booster
BELON'I TSIRIBIHINA
SOASERANA
4818 Rural
Booster
BELON'I TSIRIBIHINA
Andimaka
1474 Rural
Booster
BELOHA
TRANOVAHO
12686 Rural
BELOHA
Beloha
23326 Rural
Booster
BELOHA
Kopoky
9634 Rural
Booster
BELOHA
Marolinta
12983 Rural
Booster
BELOHA
Tranoroa
16751 Rural
Booster
BELOHA
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
Behabobo
3220 Rural
Booster
AMBOVOMBE
24042 Rural
AMBANISARIKA
11492 Rural
Ambovombe
67782 Rural
Booster
Ambohimalaza
1927 Rural
Booster
Ambonaivo
5791 Rural
Booster
Maroalopoty
2061 Rural
Booster
Sihanamaro
17988 Rural
Booster
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ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
AMBOVOMBE
ANDROY
ANOSY
ANDROY
ATSIMO
ANDREFANA
ANTANIMORA-ATSIMO
18071 Rural
Booster
Andalatanosy
24167 Rural
Booster
Jafaro
20019 Rural
Booster
Imanombo
12075 Rural
Booster
Ampamata
1186 Rural
Booster
Anjeke Ankilira (Antseky)
2422 Rural
Booster
Erada
1068 Rural
Booster
BETROKA
BETROKA
13653 Urban
BETROKA
Tsaraitso
4945 Rural
Booster
BETROKA
Naninora
3190 Rural
Booster
BETROKA
Ambalasoa
5160 Rural
Booster
BETROKA
Ivahona
8673 Rural
Booster
BETROKA
Ianabinda
8489 Rural
Booster
BETROKA
BENATO-TOBY
9331 Rural
Booster
BETROKA
Mahabo
13691 Rural
Booster
BETROKA
BEAMPOMBO I
4935 Rural
Booster
BETROKA
MAHASOA-ATSINANANA
4509 Rural
Booster
BETROKA
Bekorobo
9462 Rural
Booster
BETROKA
BETROKA
IABOROTRA
Isoanala
3978 Rural
24596 Rural
Booster
Booster
BETROKA
Nagnarena
1759 Rural
Booster
BETROKA
Andriandampy
8300 Rural
Booster
BETROKA
Sakamahily-Ouest
746 Rural
Booster
BETROKA
Ambatomivary
12357 Rural
Booster
BEKILY
AMBATOSOLA
BEKILY
MORAFENO-BEKILY
BEKILY
7747 Rural
10339 Rural
Booster
ANKARANABO-AVARATRA
5457 Rural
Booster
BEKILY
Manakompy
6507 Rural
Booster
BEKILY
Tanambao Tsiradragny
207 Rural
Booster
BEKILY
Ambahita
25252 Rural
Booster
BEKILY
Maroviro
1468 Rural
Booster
BEKILY
BELINDO-MAHASOA
11990 Rural
Booster
BEKILY
Beteza
7952 Rural
Booster
BEKILY
Tanandava
11321 Rural
Booster
BEKILY
Bekitro
18064 Rural
Booster
BEKILY
ANIVORANO-MITSINJO
2890 Rural
Booster
TOLIARA-II
ANDRANOVORY
TOLIARA-II
Betsinjaka
9793 Rural
Booster
TOLIARA-II
2040 Rural
Booster
TOLIARA-II
Behompy
IANANTSONY (SAINTAUGUSTIN)
17605 Rural
Booster
TOLIARA-II
Soalara
1100 Rural
Booster
TOLIARA-II
Ambolofoty
6948 Rural
Booster
18242 Rural
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SAVA
DIANA
SAVA
TOLIARA-II
Ankilimalinika
10727 Rural
Booster
TOLIARA-II
Marofoty
7485 Rural
Booster
TOLIARA-II
Tsianisiha
10978 Rural
Booster
TOLIARA-II
Manombo
15399 Rural
Booster
TOLIARA-II
Analamisampy
23439 Rural
Booster
TOLIARA-II
Beheloka
9483 Rural
Booster
TOLIARA-II
Milenaka
1022 Rural
Booster
BENENITRA
IANAPERA
18073 Rural
BENENITRA
Benenitra
7036 Rural
Booster
BENENITRA
Ambalavato
1151 Rural
Booster
BENENITRA
Ehara
6085 Rural
Booster
SAMBAVA
AMBOANGIBE
18288 Rural
SAMBAVA
Sambava
32364 Urban
Booster
SAMBAVA
Ambohimalaza
7720 Rural
Booster
SAMBAVA
Nosiarina
9916 Rural
Booster
SAMBAVA
Anjinjaomby
6580 Rural
Booster
SAMBAVA
Ambohimitsinjo
5972 Rural
Booster
SAMBAVA
Marogaona
7399 Rural
Booster
SAMBAVA
Andrahanjo
8209 Rural
Booster
SAMBAVA
Andrembona
2450 Rural
Booster
SAMBAVA
AMBODIAMPANA
11285 Rural
Booster
SAMBAVA
Maroambihy
11588 Rural
Booster
SAMBAVA
Ambatoafo
1015 Rural
Booster
SAMBAVA
Antsahavaribe
13467 Rural
Booster
SAMBAVA
Bevonotro
16738 Rural
Booster
ANDAPA
ANDAPA
21447 Urban
ANDAPA
Tanandava
6435 Rural
Booster
ANDAPA
ANKIAKABE-AVARATRA
7418 Rural
Booster
ANDAPA
BELAOKA-MAROVATO
4258 Rural
Booster
ANDAPA
AMBODIMANGA I
6440 Rural
Booster
ANDAPA
Marovato
6662 Rural
Booster
ANDAPA
Andrakata
4550 Rural
Booster
ANDAPA
Matsohely
5230 Rural
Booster
ANDAPA
Andranomena
4678 Rural
Booster
ANDAPA
Ambalamanasy II
16280 Rural
Booster
ANDAPA
Ambodiangezoka
27920 Rural
Booster
ANDAPA
BELAOKA-LOKOHO
5710 Rural
Booster
ANDAPA
Anoviara
10029 Rural
Booster
ANDAPA
Doany
17485 Rural
Booster
ANDAPA
Antsahamena
3710 Rural
Booster
ANTSIRANANA I
ANTSIRANANA ATSINANANA
31789 Urban
ANTSIRANANA I
ANTSIRANANA ANDREFANA
30406 Urban
Booster
ANTSIRANANA I
ANTSIRANANA AFOVOANY
24438 Urban
Booster
VOHIMARINA
FANAMBANA
15268 Rural
VOHIMARINA
VOHIMARINA
10241 Urban
Booster
VOHIMARINA
Milanoa
14070 Rural
Booster
VOHIMARINA
Bobakindro
8541 Rural
Booster
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VOHIMARINA
Tsarabaria
17887 Rural
Booster
VOHIMARINA
Nosibe
7785 Rural
Booster
VOHIMARINA
ANDRAFAINKONA
5729 Rural
Booster
VOHIMARINA
AMBINANIN'ANDRAVORY
9238 Rural
Booster
VOHIMARINA
MAROMOKOTRA
5048 Rural
Booster
VOHIMARINA
ANTSIRABE-AVARATRA
27407 Rural
Booster
4314 Rural
Booster
VOHIMARINA
Ampisikinana
ANTSIRAMBAZAHA (HELLDIANA
NOSY-BE
VILLE)
23387 Urban
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8.4 Survey team
Table 8.4. 1: List of staff members involved in the survey, [Madagascar], 2011
Name
Responsibility/role
ANDRIANARISON MADINIRINA SANDANIAINA
ANDRIANARIVONY HERY LANTONANDRIANINA
RABOTOVAO SOLO ANDRIAMANJAKONY Elmard
RAKOTOBE SITRAKAMAMPIANINA
RAMAHENINJOHARY Mika
RANDRIAMANANTENA Tojonirina
RANDRIATSIMIHATA Hery Lazavonjy
RASOLOFOJAONA HERINIAINA MANOHISOA
RAZAFIMIANDRY Honoré
Harinirina Prisca Rollande
NAHAFENOHARAVOANA MADIO SAROBIDY
RAHARISON Andriatiana Rakotomanga
RAIVOARISOA Josiane Raymonde
RASAMINANA Soafara
RASOANARIVO Deborah Herivola
RAZAFISON Tiana Lovasoa Domoinaharinoro
RAZAKAMANANA Andrianavosoa Heidy
TONGASOA LYDIA
ANDRIAMANALINA Claudio Lawrence
ANDRIANIRINA Andoniaina
ANDRIANJAFY Fanantenana Haingotiana
BINAHARITOVONTSOA Mazurain Viot
BOTOMAVO Norlain
IMBOALAHY Harison Francis Hervé
MIANGALISEHENO Temirova Vahatriniaina
RABARIMANANA Mihajaritoetra Antso
RADAOROHARISOA Onitsiry Miora
RAFANOMEZANTSOA Onitiana Daniella
RAHARIVOLOLONA Dimbinirina
RAHERISOAMALALA Angeline
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
SUPERVISOR
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
QUALITY CONTROLLER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
INTERVIEWER
RAHOBISOA Mialy Tiana
RAKOTOARIMANANA Heriniaina Nomenjanahary
RAKOTOARIMANANA TIANA ANDRISOA
RAKOTOARISON Nadia Marie Natacha
RAKOTONANDRASANA Sedraniaina
RAKOTOVAHOAKA Hanitriniaina Clara
RAMAROSON Nirina Patricia Lys
RANDRIANATREHANA Nambinintsoa Mampionona
RANOMENJANAHARY Hantanirina Felana
RASAMIMANAJANAHARY Landy Salohy
RASOLONJATOVO Lova Dani
RAVAHISON Fidèle Rindra Albert
RAVELONJATO Antsa Nofy Hanitrarilala
RAZAFIMANDIMBY Roméo
TSANGAMBELO Bernard Yacinthe
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8.5 Description of outlet types visited for this survey
Public Health Facilities
Description
National university hospital centre
Regional hospital
District hospital
Community health centre, with doctor
[centre de santé de base (CSB) niveau 2]
Community health centre, without doctor
[centre de santé de base (CSB) niveau 1]
Centre Hospitalier de District
Private, not-for-profit facilities
Non-Governmental Organization
(NGO) Health Centre
Faith Based Organization Health Centre
Public health facilities provide prescription medicine and medical
consultations and/or malaria diagnosis. They are manned by qualified
health practitioners. The health delivery system consists of a fourstep pyramidal system. The lowest level health centres are CBS1
(staffed by a nurse or health worker) and CBS2 (staffed by a doctor).
District hospitals form the next level and offer emergency surgery and
comprehensive obstetrical care. Regional hospitals offer secondary
referral services and university hospitals offer comprehensive
national referral services.
Centre de Sante de Base niveau 2
(CSB 2)
Centre de Sante de Base niveau 1
(CSB 1)
Description
Non-governmental organizations that provide medical
consultations, diagnoses, and prescription medicines at a
nominal cost.
Non-Governmental Organization (NGO)
Health Centre
Non-Governmental Organization (NGO)
Health Centre
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NGO
Non-NGO
NGO Community agent
Pharmacy
Description
A network of volunteers that provide health education and
promotion to families in their villages. They are supervised by
NGOs.
A network of volunteers that provide health education and
promotion to families in their villages. They are supervised by the
government.
NGO Community agent
Governmental Community agent
Description
Registered pharmacy
Registered Pharmacy
Registered pharmacies are licensed by the National Drug Authority
(NDA) and sell prescription medicines at a commercial rate. These
pharmacies are typically located in urban areas and sell all classes
of medicines (A, B and C). Oversight is provided by a pharmacist.
These outlets are highly regulated by the National Drug Authority
and the Pharmacists’ Council.
Registered Pharmacy
Registered Pharmacy
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Drug Store
Description
Rural pharmacy
[dépôt de medicament]
Dépôt de medicament
Private for-profit
Typically located in rural areas, these are small pharmacies that are
licensed by the NDA and sell only over the counter medicines at a
commercial rate. These outlets are manned by qualified health
dispensers/practitioners.
Description
Private clinic
Private clinics are smaller than hospitals and include a consultation
and/or an examination room. These facilities provide medicines at
commercial rates and only sell class B and C medicines. These
outlets are manned by qualified health dispensers/practitioners
(doctors, nurses, clinical officers) and are registered by the Ministry
of Health.
Private practice [médecin libre]
These are qualified and trained doctors with their own practice,
who provide medical consultation services. These are registered
with the Ministry of Health, though it is recognized that an
unknown proportion of ‘médecins libre’ are not registered. These
doctors provide consultations, prescribe medicines, and may sell
products provided by NGOs at a subsidized price.
Private clinic
Private practice
Private practice
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General retailer
Description
Grocery store [epicerie]
Small businesses which sell food, beverages, and household
products. Grocery stores may also sell medicines, usually
antipyretics. They are unlicensed.
Grocery store with bar [epi bar]
A grocery store that includes a bar providing alcoholic beverages.
Grocery store with gargote
[epi-gargote]
A grocery store that includes a gargote, selling food for customers
to eat at the outlet.
Bar
Bars are outlets that sell alcoholic beverages. In Madagascar, some
bars are known to sell medicines.
Gargote
Gargotes are wooden stalls which sell food/fast-moving consumer
goods. There is a small area for customers to sit and eat; this is
what distinguishes gargotes from other informal outlets such as
kiosks.
Other
Includes market sellers.
Grocery store with bar
Grocery store
Grocery store with gargote
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8.6 Sampling weights
Sampling weights are needed to analyze the survey data if PPS cluster sampling is applied.
Otherwise, bias may be introduced in the calculated statistics if the sub-districts/communes are very
different in size. If a complete sampling frame is available for applying PPS sampling, with the
measure of size being the population, sampling weights are easy to calculate. Assuming that the
distribution of the outlets is proportional to the population within each sampling stratum and that a
booster sample is applied, then for all the outlets enumerated in the selected sub-district not
including the public health facilities and the part one pharmacies (there is a separate weighting
procedure for these weights shown later), sampling weight is the inverse of the selection probability
of the selected sub-district, calculated as:
 M hi
nh M h i
Wh i =
where
Whi = the sampling weight for the ith selected sub-district/commune of stratum h,
 M hi = the total number of population (or total number of households) in the stratum h
n h = the number of sub-districts/communes selected in stratum h, and
M hi = the number of population (or number of households) in the ith selected sub-district/commune
of stratum h
If no explicit stratification is used in the sample selection, then h=1.
The sampling weight for all the public health facilities and registeredpharmacies, which are included
in the sample from the entire district including the ones in the selected sub-district, is calculated
similarly but with the above parameters replaced by district-level characteristics:
Whj* =
 M hj*
nh* M hj*
where
Wh*j
= the sampling weight for the jth selected district (a district is selected if one or more of its subdistricts are selected in the sample) of stratum h,
 M h*j
n
*
h
M hj*
= the total number of population (or total number of households) in stratum h
= the number of districts selected in stratum h, and
= the number of population (or number of households) in the jth selected district of stratum h
With the above calculated district-level weights (posterior weights because there is no direct
selection of districts in the sampling procedure), a booster sample outlet should be counted only
once in the data analysis even if two or more sub-districts/communes are selected from the same
district.
The above calculated sampling weights are cluster-wide weights. This means that all the outlets
interviewed in the same sub-district/commune share the same sampling weight, for both public
health facilitiesand registered pharmacies and all other facilities.
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8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs)
Introduction
Antimalarial medicines are manufactured using a variety of active pharmaceutical ingredients,
dosage forms, strengths and package sizes. To analyze prices and volumes across products with
different characteristics, they are standardized using the AETD. Indicators based on price and
volume data, namely market share and antimalarial prices, are presented in terms of AETDs.
Assumptions for calculating AETDs
One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat a 60
kilogram (kg) adult. For each antimalarial medicine category, the number of mg in one AETD is set to
what was recommended in the treatment guidelines for uncomplicated malaria in areas of low drug
resistance issued by the WHO. Where WHO treatment guidelines did not exist, AETDs were based on
peer reviewed research, or the product manufacturer’s recommended treatment course for a 60kg
adult. A list of AETDs by antimalarial category prepared by PSI for the ACTwatch project (Shewchuk,
O'Connell et al. 2011)was reviewed and updated by the Independent Evaluator in April 2010. Refer
to Table 8.7.1 for the list used for the endline report.
Additional assumptions
1) For combination therapies, which have two or more active antimalarial ingredient packaged
together (either co-formulated or co-blistered) the AETD is based on the total amount of one
of the active ingredients. For ACTs, the artemisinin derivative was used as the basis of the
AETD.
2) Co-blistered combinations are assumed to be in a 1:1 ratio of tablets, with the following
exceptions:
 Amodiaquine + Sulfadoxine + Pyrimethamine manufactured under the brand name
Dualkin;
 Artesunate + Amodiaquine manufactured under the brand names Amonate Junior
and Amonate Adult;
 Artesunate + Mefloquine manufactured under the brand names Artequin 600/1500,
Artequn 300/750, A + M1, A + M2, A + M3, A + M4, A + M5, Malarine for Adults,
Malarine for Teenagers, and Malarine for Children;
 Artesunate + Sulfadoxine + Pyrimethamine manufactured under the brand names
SulamonPlus 500, Malosunat, Amalar, Artescope, Farenax, Artidox, Artedar,
Asunatedenk 100, Asunatedenk 200, Co-arinate, Arte-Plus.
3) Sulfamethoxypyrazine-pyrimethamine is assumed to have the same full adult treatment
dose as Sulfadoxine-pyrimethamine.
4) Artequick lacking strength information is assumed to contain Artemisinin 62.4mg and
Piperaquine phosphate 375mg.
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Methods for calculating price and market share indicators
Information collected on the medicine’s strength and unit size, as listed on the product packaging,
was used to calculate the total amount of each active ingredient found in the package. Next, the
number of AETDs in a unit was calculated.30 For monotherapies, the number of AETDs in the unit
was calculated by dividing the total amount of the active ingredient contained in the unit, by the
AETD (i.e. by the total number of mg required to treat a 60kg adult). For combination therapies, the
number of AETDS in the unit was calculated by dividing the total amount of the active ingredient
that was used as the basis for the AETD by the AETD.
Calculating price indicators
Pricing indicators (Indicators 2.1-2.4) are presented in terms of the cost to patients for one AETD. For
each antimalarial audited, the cost to patients for one unit was computed based on the retail selling
price reported by the respondent for that product. This was then divided by the number of AETDs in
the unit to get the cost to patients for one AETD. (An exception is the pediatric price indicator for
quality-assured ACT (Indicator 2.1) where AETDs were not used. Rather, the price for a 2 year-old
child was calculated including only pediatric formulations whose age (weight) range includes a 2
year-old (10kg) child.)
Calculating market share
For each antimalarial audited, the number of AETDs sold over the past 7 days was calculated by
multiplying the number of units sold as reported by the respondent by the number of AETDs in the
unit.
Market share was then calculated by summing this for all antimalarials audited belonging to a
particular category, which was then divided by the sum of AETDs of all antimalarials sold.
Market share was calculated by dividing the number of AETDs of a particular antimalarial category
sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked
antimalarials, but some or all sales volumes were missing, we did not impute for missing values.
30
The unit depends on the antimalarial medicine’s dosage form. For antimalarials in tablet, suppository or granule dosage form , the unit is
the package. For antimalarials in injectable dosage form, the unit is the ampoule. For antimalarials in syrup or suspension dosage for m, the
unit is the bottle.
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Table 8.7.1: AETD Calculation details by antimalarial type
Antimalarial Category
Dose used for calculating
1 AETD
(mg required to treat a
60kg adult)
Generic product used for AETD mg
dose value
Amodiaquine
1800mg
Amodiaquine-SulfadoxinePyrimethamine
1800mg
Amodiaquine
Atovaquone-Proguanil
3000mg
Atovaquone
Chloroquine
1500mg
Chloroquine-SulfadoxinePyrimethamine
1500mg
Chloroquine
Chlorproguanil-Dapsone
360mg
Chlorproguanil
Halofantrine
Hydroxychloroquine
Mefloquine
Notes
WHO Model Formulary, 2008
Info available only for Amodiaquine
(not the combination)
1500mg
Info available for P.vivax malaria
WHO Guidelines for the treatment of
nd
malaria 2 edition, 2010
Info available for P.vivax malaria
Info only available for Chloroquine (not
the combination)
nd
Manufacturer Guidelines
(LapDap – GSK)
900mg
900mg
Primaquine
45mg
nd
1500mg is for halofantrine
hydrochloride, as the strength is
normally reported in this manner. The
total dose for halofantrine base is 1398
mg.
One tablet of 200mg
hydroxychloroquine sulfate is
equivalent to 155mg base.
1500mg or 1398mg
Mefloquine-Sulfadoxine-Pyrimethamine
Source
(Halfan – GSK)
(Plaquenil – Sanofi Aventis)
Mefloquine
Info only available for Mefloquine (not
the combination)
This dose is for the gametocytocidal
treatment of P. falciparum.
nd
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Quinacrine
Quinimax
Recommendations for malaria
treatment are very dated. This value is
the treatment regimen for giardiasis,
which has also been used in the
treatment for malaria.
The Gardner & Hill article specifies
dosing is usually 100 mg three times a
day over 5 to 7 days for adults.
2100mg
Gardner, T. B. and Hill, D. R. 2001.
Treatment of Giardiasis. Clinical
Microbiology Reviews. 14(1): 114-128
http://cmr.asm.org/cgi/content/full/14
/1/114#T2
(Quinimax – Sanofi Aventis)
10500mg
12600mg is for quinine sulfate, a salt, as
quinine strengths are normally reported
for salts.
The total dose for quinine base based
on 24mg/kg is 10408mg for a 60kg
adult.
Both dosages are based on treatment
lasting 7 days.
12600mg is for quinine sulfate, a salt, as
quinine strengths are normally reported
for salts.
The total dose for quinine base based
on 24mg/kg is 10408mg for a 60kg
adult.
Both dosages are based on treatment
lasting 7 days.
Info available only for Quinine (not the
combination)
Quinine
12600mg or
10408mg
Quinine-Sulfadoxine-Pyrimethamine
12600mg or
10408mg
Quinine
Sulfadoxine-Pyrimethamine
1500mg
Sulfadoxine
Arteether
1050mg
Artemether
960mg
WHO Use of Antimalarials, 2001
Artesunate
960mg
Dihydroartemisinin
480mg
(Cotecxin – Holleypharm; MALUether –
Euromedi)
1050mg is for 7 days of treatment
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Artemether-Lumefantrine
480mg
nd
Artemether
Manufacturer Guidelines for this
product are 1000mg Artemisinin in a
single dose. According to WHO
Guidelines for the treatment of malaria
nd
2 edition, a three day course for ACTs
is recommended.
Artemisinin-Naphthoquine
Artemisinin-Piperaquine
Artemisinin-Piperaquine-Primaquine
2400mg
576mg
576mg
Artemisinin
This treatment dose used is based upon
the WHO Artemisinin-MQ
recommendation 20 mg/kg in a divided
loading dose on the first day, followed
by 10mg/kg once a day for two more
days, plus mefloquine (15-25 mg of
base per kg) as a single or split dose on
the second and/or third day.
Artemisinin
Artemisinin
Krudsood, S. et al. 2007. Dose ranging
studies of new artemisinin-piperaquine
fixed combinations compared to
standard regimens of artemisinin
combination therapies for acute
uncomplicated falciparum malaria.The
Southeast Asian Journal of Tropical
Medicine and Public Health. 38(6): 9718.
http://www.ncbi.nlm.nih.gov/pubmed
/18613536
Tangpukdee, N. et al. 2008. Efficacy of
Artequick versus artesunate-mefloquine
in the treatment of acute
uncomplicated falciparum malaria in
Thailand. The Southeast Asian Journal
of Tropical Medicine and Public Health.
39(1): 1-8
http://imsear.hellis.org/handle/123456
789/33676
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Artesunate-Amodiaquine
Artesunate-Halofantrine
600mg
600mg
Artesunate
Relatively uncommon combination;
dosing information is difficult to find
and the value here is based on the
Artesunate-Amodiaquine, ArtesunateSP, and Artesunate-Mefloquine values.
-
-
Artesunate-Lumefantrine
600mg
Artesunate
Artesunate-Mefloquine
600mg
Artesunate
Artesunate-Piperaquine
600mg
Artesunate
-
-
600mg
Artesunate
Artesunate-Sulfadoxine-Pyrimethamine
600mg
Artesunate
360mg
nd
Artesunate-Pyronaridine
Dihydroartemisinin-Amodiaquine
nd
Artesunate
Dihydroartemisinin
nd
and the value here is based on the most
common Dihydroartemisinincombinations
(Dihydroartemisinin+Piperaquine,
Dihydroartemisinin+SP and
Dihydroarteminn+Mefloquine) with
sources listed in the entries for those
-
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products.
Dihydroartemisinin-Halofantrine
360mg
Dihydroartemisinin
products.
products.
-
Dihydroartemisinin-Lumefantrine
360mg
Dihydroartemisinin
-
Dihydroartemsinin-Mefloquine
360mg
Dihydroartemisinin
(Meflodisin – Adams Pharma)
Dihydroartemisinin-Piperaquine
360mg
Dihydroartemisinin
nd
Dihydroartemisinin-PiperaquineTrimethoprim
256mg
Dihydroartemisinin
(Artecxin – Medicare Pharma; Artecom
– Ctonghe)
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Dihydroartemisinin-Pyronaridine
360mg
Dihydroartemisinin
Dihydroartemisinin-SulfadoxinePyrimethamine
360mg
Dihydroartemisinin
products.
-
(Dalasin – Adams Pharma)
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8.8 Nationally Registered ACTs
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8.9 Child QAACTs
The following products are considered as Child QAACTs for the purpose of ACTwatch:
Artemether Lumefantrine
ACT with a leaf 4 months to <3 years (Novartis)
ACT with a leaf 3 years to <7 years (Novartis)
Artemef 4 months up to 3 years (Cipla)
Artemef 3 years up to 7 years (Cipla)
Artemether + Lumefantrine <3 years (Ipca Laboratories)
Artemether + Lumefantrine 3-8 years (Ipca Laboratories)
Coartem 20/120 5-15kg (Novartis)
Coartem 20/120 15-25kg (Novartis)
Coartem E Fixe 5-15kg (Novartis)
Coartem E Fixe 15-25kg (Novartis)
Coartem E Fixe Dispersible 5-15kg (Novartis)
Coartem E Fixe Dispersible 15-25kg (Novartis)
Co-Falcinum 5-14kg (Cipla)
Co-Falcinum 15-24kg (Cipla)
Combisunate 20/120 5-14kg (Ajanta)
Combisunate 20/120 15-24kg (Ajanta)
Dawa Mseto Ya Malaria Alu (6 and 12 tablet packs, Novartis)
La Coartem (6 and 12 tablet packs, Novartis)
Malarpack Coartem (6 and 12 tablet packs, Novartis)
Primo (6 and 12 tablet packs, Novartis)
Tibamal (6 and 12 tablet packs, Novartis)
Artesunate Amodiaquine
ACTipal 25mg/67.5mg (Sanofi Aventis)
ACTipal 50mg/135mg (Sanofi Aventis)
ACTipal 50mg/153mg (Strides Arco Labs)
Arsuamoon 1-6 years (Guilin Pharmaceutical)
Artesunate + Amodiaquine Child 1-6 years (Ipca Laboratories)
Coarsucam Infant 2-11 months (Sanofi Aventis)
Coarsucam Toddler 1-5 years (Sanofi Aventis)
Falcimon Kit Young Children up to 6 years (Cipla)
Larimal Child 1-6 years (Ipca Laboratories)
Malariakit (Ipca Laboratories)
Serenadose Enfants 50mg/153mg 1-5 years (Cipla)
Winthrop Infant 2-11 months (Sanofi Aventis)
Winthrop Toddler 1-5 years (Sanofi Aventis)
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8.10 RDT manufacturers submitting to WHO for product testing
The following manufacturers have submitted at least one RDT for testing during rounds 1-3 of the
WHO Malaria RDT Product Testing cycle (2008-2011).
Access bio, Inc.
ACON Laboratories, Inc.
Amgenix International, Inc.
AZOG, Inc.
Bhat Bio-Tech India (P) Ltd.
Biosynex
Blue Cross Bio-Medical (Beijing) Co., Ltd.
CTK Biotech, Inc.
Diagnostics Automation/Cortez Diagnostics, Inc.
DiaMed AG
Guangzhou Wonfo Biotech Co., Ltd
HBI Co., Ltd.
Human GmbH
ICT Diagnostics
IND Diagnostic Inc.
Innovatek Medical Inc.
InTec Products, Inc.
Inverness Medical Innovations, Inc.
J. Mitra & Co. Pvt. Ltd.
Orchid Biomedical Systems
Premier Medical Corporation Ltd.
Span Diagnostics Ltd
SSA Diagnostics & Biotech Systems
Standard Diagnostics, Inc.(now Alere Healthcare (Pty) Ltd)
Unimed International Inc.
Vision Biotech (Pty) Ltd.(now Alere Healthcare (Pty) Ltd)
Zephyr Biomedicals
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Evidence for Malaria Medicines Policy
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Madagascar Outlet Endline, ACTwatch 2011

Transcription

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