1. Cost Analysis of Management of Malaria Using ACT in the Private Sector of Zimbabwe: a Regulatory Implication Travor Mabugu BPharm (HONS), MSc, MPS School of Pharmacy, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe, Health Economics and Policy Research Initiative. ICIUM Conference presentation, Turkey. 14-18 November

2. Outline Background Introduction Methodology Results Conclusion Future research focus ICIUM Conference presentation, Turkey. 14-18 November Background Introduction Objectives Methodology Results Implications of Results Future research focus

3. Burden of disease Over 50% of the population of Zimbabwe are at risk of Malaria 3 rd commonest cause of mortality & morbidity in Zimbabwe, coming after HIV/AIDS & TB across all age groups 1.5million malaria episodes are reported per year and associated mortality of 1000 Malaria accounts for 30% out patients visits and 40% hospital admissions ICIUM Conference presentation, Turkey. 14-18 November

4. Intervention strategies Intervention strategies include: – Preventative strategies e.g. vector control, prophylactic measures etc – Treatment strategies e.g. use of medicines such as ACTs The decision to adopt ACTs in Zimbabwe was made in 2004, implementation was delayed for more than 3years due to resource constraints – During which combination therapy of Chloroquine and Sulphadoxine/pyrimethamine was used To date ACTs are now being used as first line treatment of uncomplicated Malaria ICIUM Conference presentation, Turkey. 14-18 November

5. ACT policy Most African countries adopted the use of ACTs for management of uncomplicated malaria mainly because; – Efficacy reasons – Increased resistance to traditional regimens (WHO, 2002) Two major pitfalls are associated with this adoption; – Even though CEA studies favoured the move Coleman et al, 2004; Morel et al, 2005), this never meant that there are cheaper – Confirmatory parasitological test comes as a condition to ACT initiation. (WHO, 2009) This hence pauses some barriers to access – Financial barriers (chief) ICIUM Conference presentation, Turkey. 14-18 November

6. Barriers to access Malaria Treatment Suspected Malaria patient Accessibility of healthcare facilities Availability and costs of diagnostic services Availability of healthcare personnel Availability of ACTs Exit price of ACTs ICIUM Conference presentation, Turkey. 14-18 November Patient level factors Health system factors Facility level factors

7. Primary focus of the study Consultation fee Diagnostic costs Medicine price ICIUM Conference presentation, Turkey. 14-18 November Doctor, Pharmacist versus no consultation CQ&SP versus ACTs (AL) RDTs versus Microscopy

8. Regulatory effects CategoryDefinitionImplication HR Household Remedy, can be accessed without medical advice e.g. supermarkets, tuck shops Unlimited access levels PPharmacy, can be accessed only in a pharmacy upon request Fair access levels PIM (PID)Pharmacist Initiated medicine (drugs), can be accessed in pharmacies only after consulting the pharmacist. Slight barriers to access PPPrescription Preparation, can be accessed in pharmacies after consulting a doctor Relatively high barriers to access ICIUM Conference presentation, Turkey. 14-18 November

9. Aim To analyze the variation in cost in the management of uncomplicated malaria using the recently introduced ACT in contrast to the old regimen Chloroquine (CQ)& Sulfadoxine and Pyrimethamine (SP) ICIUM Conference presentation, Turkey. 14-18 November

10. Specific objectives To obtain a cost estimate (patient perspective) for the management of uncomplicated adult malaria case at the following levels: – Consultation – Diagnostic (parasitological) – Medicine costs ICIUM Conference presentation, Turkey. 14-18 November

11. Possible routes of care Patient enters healthcare system Doctor (PP) RDT Microscopic test Pharmacist (PIM) RDT No consultation (HR/P) ICIUM Conference presentation, Turkey. 14-18 November ACTs or CQ&SP

12. Sub-analysis We also assessed malaria care seeking behaviours by potential patients. – Exit patient interviews Retail/community pharmacies – Target areas Harare – Metropolitan Karoi and Bindura - Non-Metropolitan centres ICIUM Conference presentation, Turkey. 14-18 November

13. Methodology Activity Based Costing was conducted in stages – Identification of activities of consumption of care – Identification of resource use per activity – Valuation of each activity (patient perspective) – Aggregation of total cost of consumption of care Patient perspective to costing was taken – Limited to out of pocket expenditure Time horizon (for costing) – Restricted to episode of malaria. ICIUM Conference presentation, Turkey. 14-18 November

14. Methodology Operational definition – Access was defined as position in which the antimalarial was in the hands of the consumer (ready for consumption) A function of availability and affordability and acceptability Limitation of the definition – We did not track benefits or outcomes of consumption of care For costing purposes this was adequate ICIUM Conference presentation, Turkey. 14-18 November

15. ACTs versus CQ-SP total costs ICIUM Conference presentation, Turkey. 14-18 November Costing categoryCQ-SP /USD ACTs /USD Average cost of anti-malarial per adult course 2.6713.48 Average consultation fee paid per adult treatment 1.0020 (15-30) Average cost of Lab Fee (RDTs)-12.22 (5.00) Average cost of therapy per adult3.6745.70 (40.58)

16. Variation in total cost of care by ACTs category ICIUM Conference presentation, Turkey. 14-18 November Costing category HR/PPIM(PID)PP Consultation0.001.0020 (15-30) Diagnostic0.00 (RDT attached – 5.00)5.00 (RDT)12.22 (RDT – 5.00) Drug costs13.48 Total13.48 (18.48)19.4845.60 (38.38)

17. ICIUM Conference presentation, Turkey. 14-18 November

18. Patient level effects 40.2% of patients who took ACTs did not seek a physician – Access of ACTs was restricted due to regulatory barrier 55% did not have a confirmatory diagnosis – Wastage, resistance due to uncontrolled use 14.8% accessed it as a Pharmacy (P) drug 87.5% of patients who took CQ-SP did not seek a physician ICIUM Conference presentation, Turkey. 14-18 November

19. Decision Process Individual at Risk MalarialHR/PPIMPP No Malaria ICIUM Conference presentation, Turkey. 14-18 November 13.38 19.48 45.60

20. Average cost of care CategoryCalculationFinal HR/P=0.5*0.22*13.481.4828 PIM=0.5*0.18*19.481.7532 PP=0.5*0.60*45.6013.680 Total Average cost16.916 ICIUM Conference presentation, Turkey. 14-18 November

21. National Implications Low uptake of the Anti-malarials Financial barriers are created by the regulatory framework However these need to be weighed against various issues; Knowledge gap (patient level) Uncontrolled access – risk of resistance development Management of limited and expensive commodities ICIUM Conference presentation, Turkey. 14-18 November

22. Future Research focus Regulatory policies creates financial barriers to access – These need to weighed in line with positive implications of such regulatory measures e.g. Wasting resources, resistance etc – Hence net benefits would be ideal indicators of the implications of regulation Training of pharmacists, Community health workers on use of RDTs could be a possible solution. ICIUM Conference presentation, Turkey. 14-18 November

23. Thank you Tatenda Siyabonga ICIUM Conference presentation, Turkey. 14-18 November