Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia

Abstract

Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme.The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.

Scaling-up malaria treatment: a review of the performance of different providers

“…A study in the country highlighted the need for intense communication/education, support, and monitoring of programmes [47]. Another study, also in Cambodia, confirmed these findings and added that despite the popularity of the private sector, with good availability of medicines, the sale of medicine cocktails that did not in fact contain any anti-malarials was prevalent.…”

Private Sector Drug Shops in Integrated Community Case Management of Malaria, Pneumonia, and Diarrhea in Children in Uganda

“…Although increasing prompt access to ACT through the private sector through subsidies has been shown to be feasible,7 this access may well come at the expense of rational use when ACT is used to treat fever presumptively. The experience of introducing ACT and malaria RDT in the private sector in Cambodia over the last 10 years has shown challenges in maintaining constant supply and determining effective incentives for private providers and consumers to use the RDT and adhere to their results 17. There may also be inadvertent effects on the use of antibiotics.…”

Willingness-to-pay for a rapid malaria diagnostic test and artemisinin-based combination therapy from private drug shops in Mukono district, Uganda

“…In Cambodia, where there has been a nationwide programme of subsidized, socially marketed RDTs and ACTs for almost 10 years, the subsidized wholesale price of RDTs was recently reduced to US$0.05 per test, with a recommended retail price (RRP) of US$0.24, in order to incentivize the use of RDTs. This compares with a wholesale price of US$0.42 and RRP of US0.61 for an adult course of recommended ACT (Yeung et al 2011). …”