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ATM | 06 June 20081 |
MMV Access Symposium 2008 Accra, Ghana
Expanding Reach of ACTs in the Private Sector: Dialogue with Countries
ATM | 06 June 20082 |
The State of ACT Access in AFRO Countries
Dr Nathan Bakayita, WHO AFRODr Jackson Sillah, WHO/IST West Africa
Dr Felicia Owusu-Antwi, WHO Country Office, Ghana
Accra, Ghana, 2 June 2008.
ATM | 06 June 20083 |
Outline of presentation
• Introduction – Global overview of malaria treatment policy change and implementation
• Impact of implementing ACT treatment policies • ACT procurements • Appropriate treatment coverage in AFRO• Challenges of implementing ACT treatment
policies• Conclusions and recommendations
ATM | 06 June 20084 |
Global Status of ACT Implementation
Countries which need ACT policy
Countries which adopted ACT Countries Deploying ACTs Countries with ACTs at Community level
Update: Update: May 2008May 2008
ATM | 06 June 20085 |
76 countries have adopted ACTsContinent Countries Drug Line
Burundi, Cameroon, Congo, Côte d'Ivoire, Democratic Republic of Congo, Eq. Guinea, Gabon, Ghana, Guinea, Liberia, Madagascar, Eritrea, Mali, Mauritania, Senegal,
Sao Tomé & Principe (ST&P), Sierra Leone, Sudan (S), Tchad, Zanzibar
AS + AQ 1st
Angola, Benin, Botswana, Burkina Faso, Central African Republic, Comoros, Ethiopia,Gambia, Guinea Bissau, Kenya, Malawi, Mozambique, Namibia, Niger, Nigeria, Rwanda,
Uganda, S. Africa, Tanzania, Togo, Zambia, Zimbabwe
AL 1st
Côte d'Ivoire, Djibouti, Gabon, Sudan (N), ST&P, Zanzibar AL 2nd
AFRICA
Djibouti, Somalia, Sudan (N) AS + SP 1st
Cambodia, Malaysia, Thailand AS + MQ 1st
Bangladesh, Bhutan, Laos, Myanmar, Philippines, PNG, Solomon Islands, Sri Lanka,Vanuatu,
AL 1st
Indonesia AS + AQ 1st
Afghanistan, India, Iran, Pakistan, Saudi Arabia, Tajikistan, Yemen AS + SP 1st
Viet Nam, China DP 1st
ASIA
Iran, Papua New Guinea, Saudi Arabia AL 2nd
Ecuador, Peru AS + SP 1st
Bolivia, Colombia, Peru, Venezuela AS + MQ 1st
SOUTHAMERICA
Brazil, Colombia, Guyana, Suriname AL 1st
58 are deploying ACTs
58 are deploying ACTs
Updated May 2008
AQ=amodiaquine; AL=artemether/lumefantrine; AS=artesunate; DP=dihydroartemisinin/piperaquine; MQ=mefloquine; SP=sulfadoxine/pyrimethamine;
ATM | 06 June 20086 |
ACT adoption and implementation in AFROSource: WHO Reports.
20
3436
40 41
0 14 4
11
19
25
7
1 3
36
0
5
10
15
20
25
30
35
40
45
20012002
20032004
20052006
20072008
Y
Num
ber O
f Cou
ntrie
s
• Implementation
• Adoption
ATM | 06 June 20087 |
WHAT HAS BEEN THE IMPACT OF POLICY CHANGE
TO ACTS?
ATM | 06 June 20088 |
Malaria Notifications in KwaZulu Natal before (2000) and after (2001 – 2002) effective residual spraying w DDT and deployment of artemether-lumefantrine
0
1000
2000
3000
4000
5000
6000
7000
Jan Mar May July Sep Nov
Artemether-lumefantrine implemented in January 2001
2000
2001
2002
ATM | 06 June 20089 |
ATM | 06 June 200810 |
Proportion of confirmed malaria cases: ZanzibarSource: NMCP Zanzibar Report October 2007.
0.6%
40.7%
0
20000
40000
60000
80000
100000
120000
2003 2004 2005 2006 2007
# B
lood
slid
es
0.0%5.0%10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%
% p
ositi
ve s
lides
BS Grand Total BS positive Grand Total Positivity Rate
ATM | 06 June 200811 |
WHAT VOLUMES OF ACTSHAVE BEEN SUPPLIED?
ATM | 06 June 200812 |
ACT ProcurementsSource: Andrea Bosman GMP/WHO (personal communication) 140508
• Procurements– 2006 : 82.7 million doses– 2007 : 97 million doses
• Forecasts for Coartem®– 2008: 107 million doses– 2009: 113 million doses
• Funding for ACTs from GFATM
ATM | 06 June 200813 |
Adoption and deployment of ACTs procurement and forecast
0.5 0.6 2.1 5
31.3
82.7
97
140
0
20
40
60
80
100
120
140
2001 2002 2003 2004 2005 2006 2007 20080
10
20
30
40
50
60
70
80
ACT procured No countries: ACT 1st line No countries deploying
Mill
ions
of A
CT
trea
tmen
tco
urse
s
Cum
ulat
ive
num
bero
f cou
ntrie
s
Forecast
ATM | 06 June 200814 |
WHO ARE THE DRUGS REACHING? AND HOW?
ATM | 06 June 200815 |
Proportion of children under five with fever who used any antimalarial in 2005-2007Source DHS, MICS and MIS 2005-2007
0 1 0 2 0 3 0 4 0 5 0 6 0 7 0
Z i m b a b w eR w a n d a
M a l a w iS a o T o m e a n d P r i n c i p e
S e n e g a lA n g o l a
B u r u n d iN i g e r
C ô t e d ' I v o i r eG u i n e a
G u i n e a - B i s s a uB u r k i n a F a s o
T o g oC o n g o
S i e r r a L e o n eB e n i n
C e n t r a l A f r i c a n R e p u b l i cC a m e r o o n
T a n z a n i aZ a m b i aG h a n a
U g a n d aG a m b i a
%
ATM | 06 June 200816 |
Proportion of children with fever who used any antimalarial vs. ACT in relation to the year ACT policy was adopted in selected countries
Country Used Any
Antimalarial % Used ACT % SOURCE Year ACT Policy AdoptedAngola 29 2 MIS (2007) AL (2006)
Burundi 30 3 MICS (2006) AS+AQ (2003)
Cameroon 58 3 MICS (2006) AS+AQ (2004)
Central African Republic 57 3 MICS (2006) AL
Cote d'Ivoire 36 3 MICS (2006) AS+AQ (2003)
Gambia 63 <1 MICS (2006) AL (2005)
Ghana 61 4 MICS (2006) AS+AQ (2004)
Malawi 24 <1 MICS (2006) AL (2007)
Rwanda 19 5 MIS (2007) AL (2005)
Sao Tome and Principe 25 6 MICS (2006) AS+AQ (2004)
Sierra Leone 52 1 MICS (2006) AS+AQ (2004)
Togo 48 1 MICS (2006) AL
Uganda 62 1 DHS (2006) AL(2004)
Zambia 58 13 MIS(2006) AL (2002)
Source : DHS, MICS and MIS (2006-2007)
ATM | 06 June 200817 |
Use of any antimalarials and ACTs by children with a malaria episode in UgandaSource: Adapted from Uganda MOH-MMV household survey, 2007.
38.9
24.428.9
20.1
46.5
31.5
0
10
20
30
40
50
Kamuli (N=711) Pallisa (578) Soroti (545)
%
24 hrs from onset of fever 48 hrs from onset of fever
Any antimalarial: Less than 30% ACT: Less than 4%
3.2 3.8 3.55.5 6.6 5.1
0
10
20
30
40
50
Kamuli (N=711) Pallisa (N=578) Soroti (N=545)%
Within 24 hours Within 48 hours
Source: MoH-MMV household surveys
ATM | 06 June 200818 |
Source of antimalarials for under 5s by socio-economic quintiles (e.g Uganda)Source Uganda MOH-MMV Household Surveys, 2007.
0% 20% 40% 60% 80% 100%
Lowest quintile(n=111)
Second quintile(n=165)
Middle quintile(n=89)
Fourth quintile(n=181)
Highest quintile(n=159)
Govt healthfacility
CMD
Private disp. /clinic
Drug shop
Pharmacy
Other
ATM | 06 June 200819 |
WHAT ARE THE CHALLENGES?
ATM | 06 June 200820 |
Challenges at Country Level
• Limited capacity of NDRA to register appropriate ACTs, enforce withdrawal of monotherapies, etc
• Weak procurement and supply chain management system (monitoring stock levels, quantification and re –ordering mechanisms, drug distribution systems)
• Limited capacity of central medical stores and NMCPs to handle bulkier medications with short shelf-life, multiple course-of-therapy packs (per different age-groups; paediatric formulation) and relatively higher volume of goods.
• Synchronisation of policy-change activities • Funding uncertainities.. dependance on donor agencies (e.g GF)
ATM | 06 June 200821 |
Challenges at Country Level
• Poor diagnostics and declining malaria transmission in some countries leading to wastage.
• Presence of counterfeit medications and low quality ACTs in the market.
• Weak surveillance, monitoring and evaluation systems
• Getting affordable ACTs into the private sector and at community level
• Price regulation in the public and private sectors
ATM | 06 June 200822 |
Challenges at Global/Regional Levels
• Compliance of ACT manufacturers with international quality standards as set by WHO pre-qualification programme
• Forecasting and quantification of demand for Artemisinin and ACTs
• Impending ACT shortage 2009-2010 (expected API reduction in the market due to low price of Artemisinin in 2007 – 2008 with consequent farmers withdrawal, and several API producers run bankrupt).
• Continue marketing of Oral Artesunate monotherapy in some countries.
ATM | 06 June 200823 |
Summary conclusions• Most countries have adopted ACTs and have begun
implementation.• Scaling up use of ACTs reduces malaria morbidity
and mortality. • Coverage of ACTs for children under 5 yrs old is still
very low. • Majority of patients still seek care from the private
sector.
ATM | 06 June 200824 |
• There is need to urgently address issues limiting access to ACTs.
• Countries need to put in place measures that are appropriate to their country context to ensure broader coverage of ACTs.
• All possible channels including the private sector should be used to increase access to ACTs.
Recommendations
ATM | 06 June 200825 |
THANK YOU FOR YOURKIND ATTENTION
Meda mo ase pii !!!!!!.