Using supply side evidence to inform oral artemisinin monotherapy replacement in Myanmar: a case study

Abstract

BackgroundIn 2012, alarmingly high rates of oral artemisinin monotherapy availability and use were detected along Eastern Myanmar, threatening efforts to halt the spread of artemisinin resistance in the Greater Mekong Subregion (GMS), and globally. The aim of this paper is to exemplify how the use of supply side evidence generated through the ACTwatch project shaped the artemisinin monotherapy replacement malaria (AMTR) project’s design and interventions to rapidly displace oral artemisinin monotherapy with subsidized, quality-assured ACT in the private sector.MethodsThe AMTR project was implemented as part of the Myanmar artemisinin resistance containment (MARC) framework along Eastern Myanmar. Guided by outlet survey and supply chain evidence, the project implemented a high-level subsidy, including negotiations with a main anti-malarial distributor, with the aim of squeezing oral artemisinin monotherapy out of the market through price competition and increased availability of quality-assured artemisinin-based combinations. This was complemented with a plethora of demand-creation activities targeting anti-malarial providers and consumers. Priority outlet types responsible for the distribution of oral artemisinin monotherapy were identified by the outlet survey, and this evidence was used to target the AMTR project’s supporting interventions.ConclusionsThe widespread availability and use of oral artemisinin monotherapy in Myanmar has been a serious threat to malaria control and elimination in the country and across the region. Practical anti-malarial market evidence was rapidly generated and used to inform private sector approaches to address these threats. The program design approach outlined in this paper is illustrative of the type of evidence generation and use that will be required to ensure effective containment of artemisinin drug resistance and progress toward regional and global malaria elimination goals.

Insights into the availability and distribution of oral artemisinin monotherapy in Myanmar: evidence from a nationally representative outlet survey

“…The results are somewhat surprising in Eastern Myanmar, given that several strategies have been implemented in this area since 2012 to contain the spread of artemisinin drug resistance [ 10 ]. One of the key strategies has been a project to remove oral AMT from the private sector and replace it with quality-assured ACT through the AMTR project.…”

“…Second, as no other single brand had more than three percent of the market share, another key conclusion from this study is that currently a single product and manufacturer dominates the market. This provides an opportunity, not dissimilar from that of the situation with a key supplier identified in the Eastern part of the country several years ago [ 10 ], to target the top of the supply chain and halt further large-scale distribution of this product. Finally, while oral AMT manufacturers were limited to three countries, the wider range of brand names and one-off products, seems to suggest that oral AMT is not only being imported under official supply chains (e.g.…”

“…The wholesale to retail markup of oral AMT was much higher than that of an ACT in the private sector: 30.2 versus 20.0% for ACT in the context of an ACT subsidy programme [ 7 ]. Coupled with the knowledge that oral AMT shelf life is also double that of ACT (approximately 4 versus 2 years, respectively) [ 10 ], evidence suggests a number of financial incentives for providers to stock and sell this monotherapy over an ACT. Furthermore, the median treatment price for a typical oral AMT treatment dose of two tablets was $0.32.…”

The malaria testing and treatment landscape in Benin

“…There are examples in the literature of innovative strategies that have focused on general retailers and itinerant drug vendors to improve access to quality-assured ACT [24]. There is also a growing body of support for itinerant drug vendors as a means to improve home-based management of malaria [26, 27], and these mobile providers have been cited as a useful means to improve the provision of care for malaria [28].…”

Quality Testing of Artemisinin-Based Antimalarial Drugs in Myanmar

“…In recognition of this widespread problem in Myanmar, an oral artemisinin monotherapy replacement project was implemented in eastern Myanmar, which aimed to remove these drugs from the market through price competition and increased availability of quality-assured artemisinin-based combination therapy (ACT ). 10,11 Despite these efforts, the recent cross-sectional surveys from the ACTwatch project still detected that oral artemisinin monotherapies were available in close to 20% of private-sector drug outlets. 12,13 Besides, the quality of the ACAs was generally not tested.…”