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2. 2 UPDATE ON TANZANIA’S PILOT ACT SUBSIDY PROJECT Roll Back Malaria 13 th Board Meeting 29 November 2007 Addis Ababa

3. 3 Background and context Results to date Implications and areas for further exploration Next steps and timeline Today’s presentation

4. 4 Malaria is one of Tanzania’s greatest health problems, taking a heavy toll on its people and burdening its health system 85% of population at risk of stable, endemic malaria 14 – 18 million malaria cases every year More than 100,000 people killed, most young children Estimated 3.4% reduction in annual GDP due to absenteeism and death Estimated 40% of all hospital admissions due to malaria

5. 5 Over 50% of Tanzanians seek treatment in the private sector, but there are many barriers to effective, affordable treatment Treatment-seeking behavior Over 40% of Tanzanians seek anti-malarial treatment through the private sector: drug stores, general stores and private health facilities –Tanzania is scaling up the Accredited Drug Dispensing Outlet (ADDO) program from 4 regions to nationwide, but this is expected to take until 2010 and in the meantime many patients will continue to seek treatment at drug stores (duka la dawa baridi) Barriers to treatment access in the private sector High cost of ACTs Continuing preference for previously-used, ineffective anti- malarials (e.g., Chloroquine, SP) Dearth of drugstores in most rural, remote areas Continuing classification of ACTs as a prescription-only medicine Limited training of drug store dispensers Poor packaging of drugs Source: Hetzel et al. BMC Public Health

6. 6 The pilot ACT subsidy project aims to both provide data for policymaking as well as to increase access in the target areas Objectives: 1.Inform policymaking at both the national and global levels, particularly related to the introduction of an ACT subsidy, by providing evidence on the impacts of a top-level subsidy of medicines through the private sector 2.Substantially increase access to affordable, effective, high-quality malaria treatment in the targeted intervention areas Key questions: 1.What is the final price paid by patients for subsidized drugs? 2.What is the effect of a package of accompanying interventions (e.g., SRP, repackaging, social marketing) on end-user price and uptake? 3.What is the impact of the subsidy on the purchase and use of ACTs compared to other anti-malarials? Principles: 1.Maximize benefits to patients 2.Ensure rapid initiation and implementation 3.Work at the behest of and in close collaboration with the government and other partners 4.Replicate normal supply chain processes and behavior 5.Minimize leakage

7. 7 The pilot project is being led by the Ministry of Health and Social Welfare and implemented by PSI – Tanzania and the Clinton Foundation Manage procurement of drugs and implementation of supporting interventions Lead communication to global partners Lead partners: TFDA and NMCP Manage relations with local government Conduct dispenser training Implement in-country social marketing and repackaging Build on lessons learned from ACT repackaging/subsidy experiences in other countries Tanzania Pilot ACT Subsidy Project

8. 8 Three rural districts were selected as representative of socioeconomic and malaria conditions in Tanzania and sub-Saharan Africa District selection criteria: High burden of stable, endemic malaria Malaria-related DHS indicators in line with national averages Significant number of local drug shops (duka la dawa baridi) Socioeconomic indicators indicative of rural, poor population Low opportunity for leakage across borders or to large cities Absence of Accredited Drug Dispensing Outlets (ADDOs) Kongwa: price intervention Maswa: subsidy control Shinyanga Rural: control

9. 9 The project has three key components running simultaneously Pilot ACT subsidy project Procurement and distribution Monitoring & evaluation Supporting interventions Key activities Baseline survey of duka la dawa baridi and public/NGO health facilities Ongoing monitoring of metrics including end- user price and anti-malarial volumes sold 1 2 3 Social marketing/behavior change communication activities focused solely in target districts Placement of suggested retail price Repackaging of drugs into Tanzania-specific, user-friendly Kiswahili package Training of drugstore dispensers on proper administration of Coartem and improving malaria knowledge Quantification of quarterly uptake of ACTs through duka la dawa baridi in target districts Procurement of ACTs and resale to national wholesaler at a subsidized price

10. 10 Wholesaler Regional Distributor “Indirect” Regional Distributor “Indirect” Clinton Foundation Drug Shops Drug Shops ACTs procured at public sector price ACTs sold to wholesaler at 90% subsidy ACT Manufacturer Kongwa District Maswa District Regional Stock Point “Direct” Regional Stock Point “Direct” Shops pick up drugs from distributors Trucks/bikes deliver direct to shops Trucks/bikes deliver direct to shops Drugs are distributed through two existing channels to the districts – via a regional distributor or direct to retailer

11. 11 The packaging was designed specifically for Tanzania to encourage effective and responsible ACT distribution Cover photos and color schemes differentiate doses Compelling, high-quality presentation attracts demand National brand is prominent; manufacturer brand included Simple, clear instructions in Kiswahili and pictorially Timing of doses clearly indicated, and reflects other specific elements of National Malaria Treatment Guidelines Prepackaged drug from manufacturer slides into package; ensures quality and removes risk of contamination during repackaging Expiration date on original packaging visible

12. 12 Background and context Results to date Implications and areas for further exploration Next steps and timeline Today’s presentation

13. 13 Four different data collection methods are being employed to ensure robust data capture Mystery shopper Public/NGO sector audit Exit interview Retail audit Metric Types/brands of anti-malarials sold/stocked (incl. subsidized product) Volume of subsidized ACT and other anti- malarial sales Sale price per dose Package conditions – loose, original, etc. Availability and stocks of Coartem in nearby public/NGO sector health facilities Intended recipient of drugs Age and gender of patient Socioeconomic status of purchaser’s household Reason for purchase Location (peri-urban vs. rural) and clustering/competition GPS

14. 14 The subsidized ACTs have quickly gained market share, appearing to displace AQ for adults… Breakdown of products purchased in August vs. November % of adult exit interviews Non- subsidized ACT + monotherapy SP Amodiaquine Quinine Other 1%2% 64% 26% 4% 5% 15% 4% 1% 458100% =343 AugustNovember 17% Subsidized ACT

15. 15 … and children Breakdown of products purchased in August vs. November % of exit interviews purchasing for a child under 5 SP Amodiaquine Quinine Other 8% 57% 90% 1% 6% 79100% =87 AugustNovember 26% Subsidized ACT 11%

16. 16 Price paid for subsidized ACTs is in line with other commonly- available anti-malarials, and the SRP appears to be effective In the price intervention district, the maximum price paid did not exceed the SRP of TSH 1200 Mean and standard deviation of price paid % of adult exit interviews buying a full dose Tanzanian Shillings

17. 17 The majority of patients are getting a full course of anti-malarials Share of patients purchasing a full dose % of 440 exit interviews Subsidized ACT Any SP Any AQ

18. 18 The importance of shopkeeper recommendation is reinforced, particularly for subsidized ACTs Subsidized ACT Reasons for buying each drug % of 443 exit interviews Any SP Any AQ Shopkeeper recommendationPrescribed Previous use Most effective Price

19. 19 There continues to be no consumers from the poorest socioeconomic quintile purchasing anti-malarials in drugstores Quintile 2 “Poor” Quintile 3 “Neither rich nor poor” Quintile 4 “Richer” Breakdown of consumers by SES: August vs. November % of 608 (Aug.) and 443 (Nov.) exit interview customers Quintile 5 “Richest” August November

20. 20 The occurrence and duration of stock outs in public/NGO health facilities varies significantly by district, perhaps acting as a driver for private sector treatment-seeking behavior Percent of public/NGO health facilities reporting a stock out in last 3 months % of 104 facilities surveyed Maswa Kongwa Shinyanga Rural Maswa also has the highest numbers of consumers seeking anti- malarial treatment in the private sector

21. 21 Background and context Results to date Implications and areas for further exploration Next steps and timeline Today’s presentation

22. 22 The preliminary Month 1 findings from highlight potential areas for further exploration on private sector treatment-seeking in general… Continuing lack of consumers from lowest SES quintile in private sector drugstores  how can they be reached? Drug shops seem not to be the preferred access point for caregivers of children under 5 The importance of shopkeeper recommendation  how to ensure appropriate knowledge and incentives? Socioeconomic status AreaImplication Access for children U5Drivers of product choice The number of people seeking treatment in the private sector may be linked to public sector ACT availability Treatment-seeking in public vs. private sectors

23. 23 … and specifically on subsidized ACTs SRP adherence appears to be high, although price is lower in the non-SRP district AreaImplication Pricing Stocking of subsidized ACTs by store owners has occurred rapidly, although it will take time to penetrate all stores It appears that the subsidized ACT is most displacing AQ, as SP and other anti-malarials’ sales are staying relatively constant Uptake and displacement

24. 24 Background and context Results to date Implications for global and national ACT subsidy efforts Next steps and timeline Today’s presentation

25. 25 The project will run for one full year, with quarterly procurement, data collection and reporting June 2007 JulyAug.Sept.Oct.Nov.Dec.Jan.Feb.Mar.Apr.MayJuneJulyAug. 2008 Baseline data collection Supporting interventions – social marketing, marking of SRP Month 1 data collection Q2 data collection Q3 data collection Q4 data collection Q1 ACT procurement + distribution Q2 ACT procurement + distribution Q3 ACT procurement + distribution Q4 ACT procurement + distribution Selection + contracting of M&E and social mkting orgs Selection + contracting of wholesaler partner Q1 data collection Sept.

26. 26 The lessons learned from the pilot will directly inform the planned nationwide scale-up, funded by Global Fund Round 7 Tanzania’s Global Fund Round 7 grant provides for a nationwide subsidy of ACTs for Under-5s in private sector drug shops – both duka la dawa baridi and ADDO Key elements will include: – Repackaging – Dispenser training – Social marketing The Ministry of Health and Social Welfare, with the support of partners, will be moving towards rapid implementation

27. 27 ASANTENI SANA!