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Tanzania Pilot ACT Subsidy: Baseline Data Collection Results
September 28, 2007
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations of the study
Issues for further exploration and implications for the Global ACT subsidy
Next steps
3
The pilot ACT subsidy project aims to both provide data for policymaking as well as to increase access in the target areas
Objectives:
1. Inform policymaking at both the national and global levels, particularly related to the introduction of an ACT subsidy, by providing evidence on the impacts of a top-level subsidy of medicines through the private sector
2. Substantially increase access to affordable, effective, high-quality malaria treatment in the targeted intervention areas
Key questions:
1. What is the final price paid by patients for subsidized drugs?
2. What is the effect of a package of accompanying interventions (e.g., SRP, repackaging, social marketing) on end-user price and uptake?
3. What is the impact of the subsidy on the purchase and use of ACTs compared to other anti-malarials?
Principles:
1. Maximize benefits to patients 2. Ensure rapid initiation and implementation3. Work at the behest of and in close collaboration with the government and other partners4. Replicate normal supply chain processes and behavior5. Minimize leakage
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The pilot project is jointly implemented by the Ministry of Health and Social Welfare, PSI – Tanzania and the Clinton Foundation
• Manage procurement of drugs and implementation of supporting interventions
• Lead communication to global partners
• Lead partners: TFDA and NMCP• Manage relations with local
government• Conduct dispenser training
• Implement in-country social marketing and repackaging
• Build on lessons learned from ACT repackaging/subsidy experiences in other countries
Tanzania Pilot ACT Subsidy
Project
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The project has three key components running simultaneously
Pilot ACT subsidy project
Procurement and distribution
Monitoring & evaluation
Supporting interventions
Key activities• Baseline survey of duka la dawa baridi and
public/NGO health facilities• Ongoing monitoring of metrics including end-
user price and anti-malarial volumes sold
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3 • Social marketing/behavior change communication activities focused solely in target districts
• Placement of suggested retail price• Repackaging of drugs into Tanzania-specific,
user-friendly Kiswahili package• Training of drugstore dispensers on proper
administration of Coartem and improving malaria knowledge
• Quantification of quarterly uptake of ACTsthrough duka la dawa baridi in target districts
• Procurement of ACTs and resale to national wholesaler at a subsidized price
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations of the study
Issues for further exploration and implications for the Global ACT subsidy
Next steps
7
The project focuses on tracking price and volume, and the factors that influence those outcomes
Principal research questions:•What is the final price paid by consumers for subsidized drugs?•What is the impact of the subsidy on the purchase and use of ACTs compared to other anti-malarials?
Additional research questions:•What impact does the inclusion of a suggested retail price (SRP), the use of Kiswahili repackaging, and associated social marketing have on price and volume?•How do the price and volume differ based on the characteristics of the drug purchaser, including factors such as socioeconomic status and level of education?•How do the primary outcomes differ based on the age of the patient for whom the drugs are purchased (i.e., children under 5 vs. children over 5 and adults)?•How do price and volume differ based on the location of the retailer (e.g., proximity to competitors and public facilities)? •What are the primary factors driving patient choice of a particular anti-malarial?•Are anti-malarials sold to drug purchasers in the original packaging or in other forms?
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Three rural districts were selected as representative of socioeconomic and malaria conditions in Tanzania and sub-Saharan Africa
District selection criteria:
• High burden of stable, endemic malaria
• Malaria-related DHS indicators in line with national averages
• Significant number of local drug shops (duka la dawa baridi)
• Socioeconomic indicators indicative of rural, poor population
• Low opportunity for leakage across borders or to large cities
• Absence of Accredited Drug Dispensing Outlets (ADDOs)Kongwa:
price intervention
Maswa:subsidy control
Shinyanga Rural:control
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Wholesaler
Regional Distributor“Indirect”
Regional Distributor“Indirect”
Clinton Foundation
Drug Shops
DrugShops
ACTsprocured at
public sector price
ACTs sold to wholesaler at 90% subsidy
ACT Manufacturer
Kongwa DistrictMaswa District
Regional Stock Point
“Direct”
Regional Stock Point
“Direct”Shops pick up
drugs from distributors
Trucks/bikes deliver direct to shops
Trucks/bikes deliver direct to shops
Drugs will be distributed through two existing channels to the districts – via a regional distributor or direct to retailer
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Four different data collection methods are being employed to ensure robust data capture
Mystery shopper
Public/NGO sector audit
Exit interview
Retail auditMetric
• Types/brands of anti-malarials sold/stocked (incl. subsidized product)
• Volume of subsidized ACT and other anti-malarial sales
• Sale price per dose• Package conditions – loose, original, etc. • Availability and stocks of Coartem in nearby
public/NGO sector health facilities
• Intended recipient of drugs • Age and gender of patient• Socioeconomic status of purchaser’s
household • Reason for purchase
• Location (peri-urban vs. rural) and clustering
GPS
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations of the study
Issues for further exploration and implications for the Global ACT subsidy
Next steps
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Data was collected across four major categories
Stocking and volume
• Types/brands of anti-malarials sold/stocked (incl. subsidized product), broken out by branded originator, branded generic and unbranded generic
• Volume of subsidized ACT and other anti-malarial sales
Drugstore characteristics
• Impact of competition (e.g., number of other stores within given radius)
Consumer characteristics
• For whom drugs were purchased - self or other• Age and gender of patient• Socioeconomic status of purchaser’s household (per Tanzania
2004 AIDS Indicator Survey categories)• Education level of purchaser• Reason for purchase – e.g., price, seller recommendation, etc.
Sales-related characteristics
• Sale price per dose• Package conditions – loose, original, etc. • Availability and stocks of Coartem in nearby public/NGO sector
health facilities
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Nearly all stores stocked SP and AQ, while only one reported stocking any ACT
Percent of duka la dawa baridi stocking particular anti-malarials% of 200 stores audited
85%
84%
33%
12%
1%
SP
AQ
Quinine
Artemisinin monotherapy
ACT
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The products purchased varied significantly between adults and children under 5, but SP and AQ were by far the most popular
Breakdown of products purchased % of exit interviews
ACT + monotherapy
SP
Amodiaquine
QuinineOther
1% 0%
64%
8%
26%
4%
5%
90%
1%1%
458100% = 79
Adult Children U5
15
800 800
400
600 600
800
The median price paid for the most popular products ranged from US$ 0.32 to 0.64 per complete adult dose, with little differencebetween branded and generic products
Branded originator SP
Exit interviews
Mystery shoppers
Branded generic SP
Unbranded generic AQ
Median price paid per full adult dose by exit interviewees and mystery shoppersTanzanian shillings
US$ 0.64 US$ 0.48-64 US$ 0.32-48
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14% 18%36%7%
29%
23%
79%
53%41%
~80% of purchases were intended for adults, which does not reflect the census breakdown or fever prevalence by age
Under 5
5-15
Adult
608100% = 829,451
Exit interviews
2002 census of target districts
~ 2.1 million
2002 census adjusted by fever prevalence
Comparison of intended recipient of exit interview purchases vs. census age breakdown and fever prevalence by age
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Previous use and shopkeeper recommendation were the largest reported drivers of patient choice, not price
Most important reason cited for purchase of selected anti-malarial% of 608 exit interviews
29%
26%
14%
13%
10%
6%
Previous use
Shopkeeper recommendation
Prescription
Most effective
Price
Only one available
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35%
28% 26%
17%
34%
50%
23%
43% 43%
28%
35%39%
Customers from higher SES categories tended to pay more for anti-malarials
0-499 TSH
Quintile 2
Quintile 3
Quintile 4
Price paid for anti-malarials
500-799 TSH 800+ TSH
Quintile 5
Price paid for adult anti-malarials by SES% of 458 exit interview customers purchasing for adults
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A third of health facilities reported a stockout in the previous three months, and most frequently for the infant dose
Percent of health facilities reporting a stockout in the past three months, by dose% of 105 public/NGO health facilities audited
24%
11%
14%
15%
Infant (5-<15 kg)
Child (15-<25 kg)
Juvenile (25-<35 kg)
Adult (35+ kg)
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GPS mapping demonstrated that drug stores and health facilities tend to cluster together – the impact on key outcomes is still being analyzed
Cluster of 15 stores around 1 health facility
Cluster of 9 stores around 3 health facilities
90% of stores are within 1 km of at least one other
store
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations of the study
Issues for further exploration and implications for the Global ACT subsidy
Next steps
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It is important to recognize the inherent limitations of this project in interpreting the results
Specific limitations of project
• Covers relatively small sample(population of 3 districts = 830,000) in country of 40 million
• Subnational scale puts results at risk for skewing by leakage and inefficiencies
• Results subject to seasonality of malaria in Tanzania, as baseline data collection occurred during low transmission season
General study biases and mitigation
• Hawthorne effect: minimize interactions between study team and businesses
• Social desirability bias: ensure data collection tools and methods are free of any leading questions
• Recall bias: conduct monthly data collection for retail audits
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations of the study
Issues for further exploration and implications for the Global ACT subsidy
Next steps
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The initial findings highlight potential implications for the global ACT Subsidy and areas for further exploration
Area Implication
Socioeconomic status • No consumers from lowest SES quintile implications for equity through global ACT subsidy
Access for children U5 • Drug shops seem not to be the preferred access point for caregivers of children under 5
Drivers of product choice
• The importance of shopkeeper recommendation how to ensure appropriate knowledge and incentives?
Pricing • Consumers paid more on average for pediatric doses, and for less-than-complete adult doses
Branded vs. generic differences
• Preferences differ significantly for branded vs. generic products between SP and AQ, although prices of branded vs. generic products show little difference
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Today’s discussion
Background and objectives
Methodology
Preliminary results
Limitations
Issues for further exploration and implications for Global ACT subsidy
Next steps
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The project will run for one full year, with quarterly procurement, data collection and reporting
June
2007
July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Apr. May June July Aug.
2008
Baseline data collection
Month 1 data collection
Q2 data collection
Q3 data collection
Q4 data collection
Selection + contracting of M&E and social mkting orgs
Selection + contracting of wholesaler partner
Month 2 data collection
Month 3data collection
Sept.
Q1 ACT procurement + distribution
Q2 ACT procurement + distribution
Q3 ACT procurement + distribution
Q4 ACT procurement + distribution
Supporting interventions – social marketing, marking of SRP
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ASANTE SANA!
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APPENDIX
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Difference in products purchased, adult exit interviews vs. mystery shoppers
SP
Branded originator
Branded generic
Unbranded generic
Amodiaquine
Branded generic
Quinine
ACT
Artemisinin monotherapy
64%69%
24%24 %
36%40 %
4%5 %
25%19 %
1%4 %
25%16 %
4%2 %
1%5%
0%1%
Exit interviewsMystery shoppers
Unbranded generic
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Difference in products purchased, exit interviews vs. mystery shoppers for children under 5
SP
Branded originator
Branded generic
Unbranded generic
Amodiaquine
Branded generic
Unbranded generic
Quinine
ACT
Artemisinin monotherapy
8%25%
2%3%
16%10%
1%10 %
0%3%
0%3%
Exit interviewsMystery shoppers3%
9%
3%13%
90%58 %
73%48 %
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800
600
800
600
Difference in price paid by number of pills
Branded originator SP
2 tablets
3 tablets (full adult dose)
Branded generic SP
32
20
7
13
60%
80% of anti-malarial purchases were intended for adults
Child 5-15
Child under 5
Adult purchasing for themselves
Another adult
Intended recipient of all anti-malarial purchases % of 608 exit interviews
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No consumers from the lowest SES quintile were captured, although the distribution across the remaining 4 varied significantly by district
Anti-malarial purchasers by SES category (per 2004 Tanzania AIDS Indicator Survey categories)% of 608 exit interviews
4 825
11
27 24
48
33
3143
17
28
3825
1128
100% = 63 354 191 608
Kongwa Maswa Shinyanga Rural
TotalQ2
Q3
Q4
Q5
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150
2000
600
2250
8000
25001800
150
1800
400
1800
3000
Range in price paid by adult exit interviewees
SP
Minimum
Median
Maximum
Range of prices paid for anti-malarials
AQ Artemisinin monotherapy
ACT
35
71
51
9195
647475
52
85
The target districts are similar across most key characteristics
# of DLDBs
Population/ DLDB(‘000)
Population/ health facility(‘000)
Literacy rate(%)
Employment in agriculture(%)
Shinyanga Rural (control)
Maswa (subsidy control)
Kongwa (price intervention)
3.93.2 3.3
9.99.8
8.6
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The packaging template, developed by PSI for Rwanda, contains key elements for effective and responsible ACT distribution
• Cover photos and color schemes differentiate doses• Compelling, high-quality presentation attracts demand• National brand is prominent; manufacturer brand included
• Simple, clear instructions in both local language and pictures• Timing of doses clearly indicated
• Prepackaged drug from manufacturer slides into package; ensures quality and removes risk of contamination during repackaging• Overbrand approach enables use of any manufacturer; sustainable communication• Expiration date on original packaging visible
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…including
• Clear IMCI danger signs• Importance of referral to health professional if signs persist – alignedw/ IMCI• Summary of key contraindications(e.g., first trimester of pregnancy)
• Agreement of inclusion of technical information w/ manufacturer• Alignment of packaging w/ national drug regulatory requirements• Reinforcement of key messages & branding
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…resulting in important differences in the final packaging, though use of the template led to design efficiencies
Instructions modified &translated into Kiswahili
Number of pictogramsreduced to align w/
existing communications
Branding aligned w/national campaign
Color scheme per dosealigned w/ guidelines
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A “cost-plus” method examining costs and profit margins at each level was used to arrive at the SRP in Tanzania
Sale price to national wholesaler
Operating costs
Freight cost
Profit margin
Sale price to regional distributor
Reg. distributormarkup
Sale price to retailer
Variable costs
Fixed costs
Profit margin
Sale price to consumer
Markups through supply chain per dose(Weighted average price across weight bands, assuming indirect distribution)US$
0.160.02 ~0 0.01 0.19
0.07 0.260.02
0.16
0.13 0.57
86% subsidy
from total cost
price
45% of total cost price
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