1. Private Sector Malaria Case Management: Experience from 7 years of implementation in Cambodia Presented by Dr. Socheat, Director of CNM RBM Working Group on Case Management 8-9 July 2009, Geneva

2. Overview of Presentation  Private Sector in Cambodia  Background  Current Private Sector Interventions  Outcomes of Social-Marketing Program  Challenges with Private Sector Approach  Addressing Challenges/Planned Interventions

3. Private Sector in Cambodia  About 2/3 of people with febrile illness report seeking treatment in the private sector (CMS 2007).  Private providers range from trained medical providers practicing at registered clinics to untrained mobile providers selling drugs alongside household products.  There is wide availability of monotherapies and sub- standard/counterfeit drugs.

4. Background  The public sector is gradually being strengthened with the aim that the population will eventually mainly access affordable effective treatment through the public health facilities.  However the private sector has been and will continue to be an important and popular source of antimalarial treatment.  Unfortunately the quality of care is often inadequate with low rates of diagnosis, low compliance to national guidelines and selling of fake and substandard drugs and artemisinin monotherapies.  In addition, cases of malaria seen by the private sector are not reported to the health information system, making malaria surveillance and control very difficult.  It is vital that there is clear national strategy for the use of antimalarials in the private sector in order to maximise access to affordable effective diagnosis and treatment for patients with malaria, whilst limiting poor practice. 4

5. Current Private Sector Interventions (1)  Cambodia was the first country to pilot and then scale-up the provision of subsidized ACTs in the private sector, in 2002.  AS+MQ is socially-marketed in endemic provinces as Malarine®.  Rapid Diagnostic Tests are also socially-marketed as Malacheck®.  The project is implemented by PSI and financed by Global Fund grants.

6. Current Private Sector Interventions (2)  To support the sale of subsidized products:  PSI sends its sales teams to shops in malaria endemics areas to promote subsidized products and disseminate point of sales materials.  PSI implements a nationwide IEC/BCC campaign using multiple modes of communication, including mass media (TV/radio), mid- media (mobile video units), and interpersonal communications.  PSI also trains private sector providers on proper case management, based on national treatment guidelines.

7. Outcomes of Social Marketing Program (1) Since the start of the program, coverage and penetration of the subsidized products has increased.  In 2004, a year after the start of the program, an outlet survey found that 22% and 6% of the sampled private sector outlets sold adult and child doses of ACTs, while 10.6% stocked Malacheck®.  In 2007, another outlet survey found that penetration of both Malarine® and Malacheck® was just above 40%.

8. Outcomes of Social Marketing Program (2) Use of biological diagnosis before treatment has also increased since the start of the program.  In 2002 surveys, only 18% of interactions between private providers and patients with fever resulted in biological diagnosis.  In 2006 survey, 63.8% of household respondents reported taking a blood test the last time they had malaria symptoms; 34% reported generally (“always/often”) taking a blood test.

9. Challenges with Private Sector Approach (1) Low adherence to recommended retail prices, reduces equity.  Malarine® and Malacheck® are sold well-above the recommended retail price printed on the box ($0.50 and $0.25, respectively).  Average price of Malarine = $1.07 (range $0.63-$3.75)  Average price of Malacheck = $0.37 (range $0.25-$1.25)  Frequent stock-outs of Malarine® and Malacheck® is likely contributing to the rise in price of these products.

10. Challenges with Private Sector Approach (2) ACT coverage is still low. Monotherapies have not been ‘driven’ from the marketplace.  The nationally recommended ACT (AS+MQ) composes only 28% of the reported sales in the private sector.  Monotherapies are still widely available in the private sector (see chart on next slide).  With recent evidence of artemisinin tolerant parasites on the Thai-Cambodia border, the use of monotherapies is a particularly serious concern.

11. Volume of sales reported by private commercial sector (by treatment type and % market share)

12. Challenges with Private Sector Approach (3) There is a lack of information about case management practices from the private sector.  There is little data available about case management practices in the private sector, which makes it difficult for the national program to monitor programmatic outcomes.  This is particularly an issue as the program would like to transition to a pre-elimination approach by 2014.

13. Addressing Challenges (1) Reducing the availability of artemisinin monotherapies through strengthened regulation.  The Ministry of Health issued a ban on the sale of artemisinin monotherapies in the private sector in 2008.  The Dept. of Customs and Dept. of Drugs and Food have started to enforce the ban.  The national malaria program is holding meetings with private sector providers to encourage adherence to the ban.

14. Addressing Challenges (2) The national program is piloting a new ‘Public-Private Mix’ (PPM) Approach to improve data collection.  With funding from the Bill and Melinda Gates Foundation, the national malaria program will pilot an approach in 2 Operational Districts to encourage better treatment practices and to collect case data on a regular basis from providers.  The planned PPM includes: mapping private sector providers, training providers on proper case mgt. and reporting, conducting regular supportive supervision and monitoring trips, and rewarding providers with good practices.  The development of a detailed PPM strategy is still in progress.

15. Addressing Challenges (3) Increasing coverage of co-formulated, co-paid ACTs through new initiative.  The national malaria program has applied to the first phase of the Affordable Medicines Facility-malaria (AMFm).  The country’s application includes strengthening existing activities (BCC and training) and piloting new activities (‘Blitz campaign’)with the overall aim of increasing use of ACTs and driving monotherapies out of the market place.  It is expected that AMFm co-paid ACTs will reach end users are a lower price than current ACTs due to lower starting price and higher volumes.

16. Questions?