Cost Analysis of Management of Malaria Using ACT in the Private Sector of Zimbabwe: a Regulatory...

Cost Analysis of Management of Malaria Using ACT in the Private Sector of

Zimbabwe: a Regulatory Implication

Travor Mabugu BPharm (HONS), MSc, MPSSchool of Pharmacy, College of Health Sciences, University of

Zimbabwe, Harare, Zimbabwe, Health Economics and Policy Research Initiative.

ICIUM Conference presentation, Turkey. 14-18 November

Outline

• Background• Introduction• Methodology• Results• Conclusion• Future research focus


•Background

•Introduction

•Objectives

•Methodology

•Results

•Implications of Results

•Future research focus

Burden of disease• Over 50% of the population of Zimbabwe are at risk of

Malaria

• 3rd 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


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


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)


Barriers to access Malaria Treatment


Patient level factors

Health system factors

Primary focus of the study


Doctor, Pharmacist versus no

consultation

CQ&SP versus

ACTs (AL)

RDTs versus Microscopy

Regulatory effectsCategory Definition Implication

HR Household Remedy, can be accessed without medical advice e.g. supermarkets, tuck shops

Unlimited access levels

P Pharmacy, 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

PP Prescription Preparation, can be accessed in pharmacies after consulting a doctor

Relatively high barriers to access


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)


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


Possible routes of care


ACTs or CQ&SP

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


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.


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


ACTs versus CQ-SP total costs


Costing category CQ-SP /USD

ACTs/USD

Average cost of anti-malarial per adult course

2.67 13.48

Average consultation fee paid per adult treatment

1.00 20 (15-30)

Average cost of Lab Fee (RDTs) - 12.22 (5.00)

Average cost of therapy per adult 3.67 45.70 (40.58)

Variation in total cost of care by ACTs category


Costing category

HR/P PIM(PID) PP

Consultation 0.00 1.00 20 (15-30)

Diagnostic 0.00 (RDT attached – 5.00) 5.00 (RDT) 12.22 (RDT – 5.00)

Drug costs 13.48 13.48 13.48

Total 13.48 (18.48) 19.48 45.60 (38.38)


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


Decision Process


13.38

19.48

45.60

Average cost of care

Category Calculation Final

HR/P =0.5*0.22*13.48 1.4828

PIM =0.5*0.18*19.48 1.7532

PP =0.5*0.60*45.60 13.680

Total Average cost 16.916


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


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.


Thank youTatenda

Siyabonga


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