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
ICIUM Conference presentation, Turkey. 14-18 November
•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
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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)
ICIUM Conference presentation, Turkey. 14-18 November
Barriers to access Malaria Treatment
ICIUM Conference presentation, Turkey. 14-18 November
Patient level factors
Health system factors
Primary focus of the study
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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)
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
Possible routes of care
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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.
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
ACTs versus CQ-SP total costs
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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)
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
Decision Process
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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
ICIUM Conference presentation, Turkey. 14-18 November
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.
ICIUM Conference presentation, Turkey. 14-18 November
Thank youTatenda
Siyabonga
ICIUM Conference presentation, Turkey. 14-18 November
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