This page gives an update on the Containment of Artemisinin Resistance in Eastern Myanmar project, which is being carried out by Population Services International (PSI), was recommended to Good Ventures by the Gates Foundation and is also being funded by the UK's Department for International Development (DFID). Good Ventures contributed to this project as part of an effort to learn from major foundations by co-funding projects with them.
Note: This update reflects the progress of the project through May 2013.
Our last update summarized major project developments through September 2012. This page summarizes developments through May 2013.
This project aims to increase use of artemisinin-based combination therapy (ACT) to treat malaria and reduce the use of artemisinin-based monotherapy (AMT) in order to prevent the development of drug resistance.
After initial delays to the start of the project, the project, as of May 2013, appeared to be on track. It was not yet clear whether the project will be able to displace a large portion of the AMT market.
Published November 2013
- PSI had sold 900,000 doses of ACT to its private-sector partner AA Medical Products as of March 2013. It had originally aimed to sell 1.8 million doses in the first year of the project, but as we reported in our previous update, the start of the project was delayed. Of the 900,000 doses sold to AA, half had been sold to wholesalers and retail outlets by March 2013.1
- The start of the pilot project to promote rapid diagnostic testing (RDT) among private drug providers was initially delayed. The pilot project began in April 2013.2
- We discussed in our previous update that PSI was concerned that AA Medical products had lost market share due to an incomplete ban of artemisinin-based monotherapy (AMT). PSI reports that AA has regained 60% of its former customers.3
- During a site visit in May, DFID found that AMT continued to be sold and the practice of selling partial courses of AMT also continued.4 Though importation of AMT is now banned, distribution companies are permitted to sell their current stocks and some importation may be continuing despite the ban.5 The site visit also found that some patients and providers expressed loyalty to AMTs because of familiarity, convenience, or concerns about side effects of ACTs.6
- Based on reviewing the available evidence, DFID believes that the project is unlikely to be sustainable without continued donor subsidies.7 PSI notes that supplanting AMT over the course of the project may increase the uptake of and familiarity with ACTs, which may have lasting effects on consumer demand.8
Monitoring and evaluation
In our introductory report on the project, we outlined the ways PSI planned to monitor and evaluate the project. Since that report, we have seen some early findings, based on:
- Baseline outlet survey9
- Baseline household survey10
- Baseline supply chain assessment11
- Mystery client survey for RDT pilot12
- Site visit by DFID in May 2013, which included key interviews and visits to 25 outlets13
- The household surveys are unlikely to be useful in evaluating whether more people used ACTs over AMTs after the project than before. This is because those surveyed in the baseline were unable to identify which type of medication they used during their most recent fever episode.14
PSI expected to use these surveys as part of its evaluation of the impact of the project.15
PSI notes that, while it is true that a substantial portion of individuals failed to recall what medicines were taken, it is still possible to draw some conclusions (including change over time) based on the subset of the population that did recall their treatment regimen. Additionally, it may be feasible to draw inferences on the type of care an individual received based on the type of outlet where they sought treatment, which is more consistently recalled.16
- It should still be possible to track the progress of the project through the outlet surveys. PSI completed a baseline outlet survey in March to May 2012.17 This survey documented the availability and sales of various types of antimalarials. At baseline ACTs were 23% of the antimalarial market, oral AMTs were 32%, non-oral AMTs were 6%, and non-artemisinin therapies (particularly chloroquine) were 38%.18 PSI has shared the full methodology and results from the baseline survey.
- Prior to the start of the RDT pilot project, mystery client surveys found that 10.8% of providers offered a malaria test to customers before providing treatment prior to the start of the RDT pilot project. Data on whether the project impacted the use of RDTs are expected to be available in December 2013.19
- The May site visit found that the ACT subsidy was passed to consumers. The retail price of a dose of ACT was similar to that of a typical dose of AMT.20
|Chris White, PSI Myanmar, email to Good Ventures/GiveWell on November 11, 2013||Unpublished|
|Household Survey: Baseline||Unpublished|
|Mid-Term Milestone Review (May 2013)||Source|
|Mid-year Summary of Progress (July 2013)||Unpublished|
|Outlet Survey: Baseline||Unpublished|
|Supply Chain for Antimalarials in Myanmar (October 2012)||Unpublished|
"PSI sales to AA to date: 900,000 QA ACT (Supa-arte) doses (against Year One target of 1,800,000 doses). AA have sold 450,000 courses to 1,400 wholesalers and retail outlets in 66 townships. This indicates a retaining of the market share following cessation of AA Artesunate supply. PSI will revise sales targets based on actual demand." Mid-Term Milestone Review (May 2013), Pg 7.
"Objective 3: Increased opportunity, ability, and motivation of private sector providers to conduct a rapid diagnostic test prior to appropriately prescribing and dispensing nationally approved, quality assured ACT. Milestone 1: Pilot of RDTs with informal providers under way in year 1. Delayed. But, now underway, as of May 2013. Initial reasons for delay in the last report." Mid-year Summary of Progress (July 2013), Pgs 5-6.
"The RDT pilot commenced in April 2013 in 6 townships (3 in Mon – Tier 1, and 3 in Shan – Tier 2)… 327 outlets trained and starting activities. Results will be collected monthly, with first collection of data due at the end May 2013. Inter-personal communication has been undertaken to 600 people." Mid-Term Milestone Review (May 2013), Pg 11.
"AA Medical Products Ltd has regained 60% of its former customer base (wholesalers and large retailers) after having lost significant market share temporarily due to the import ban on AA Artesunate (but not, initially at least, the competitor product Artemether), demonstrating excellent market penetration and customer loyalty/trust." Mid-year Summary of Progress (July 2013), Pg 6.
"Good levels of Supa Arte were observed, but also still a lot of AMT and non-QA ACT present during the field trip. There was also a lot of blister cutting still observed showing that people continue to take partial courses." Mid-Term Milestone Review (May 2013), Pg 14.
"Arthemeter was still available at retail and wholesale levels and was still popular with customers/ patients. Some providers reported declines in sales, while others did not, and some even reported increasing sales. This is in contrast to reports from Tier One areas… The central stock levels of oral AMTs by some distributors following the important ban remain unclear. This will be investigated further…
While all providers reported that they procured drugs from distributors within Burma this was hard to verify by observing packaging alone, which is developed at source beyond Burma’s borders (e.g. in Kunming). There are still risks for inflows from China." Mid-Term Milestone Review (May 2013), Pg 8.
"Some beneficiaries and providers stated that Supa Arte had unpleasant side effects, and that they preferred taking fewer tablets of AMTs. Others showed ‘brand loyalty’ or familiarity in their preference for AMTs and non-QA ACTs." Mid-Term Milestone Review (May 2013), Pg 9.
"The project appears not to be sustainable after the completion, and is likely to still need donor funding. Non subsidised ACT costs are too high for the target population; alternatives from the black market are likely to be available; blister cutting of ACTs is likely to take place; and the public sector is unlikely to have scaled up sufficiently." Mid-Term Milestone Review (May 2013), Pg 16.
Chris White, PSI Myanmar, email to Good Ventures/GiveWell on November 11, 2013.
Discussed in Mid-Term Milestone Review (May 2013).
"Methodology: … Visit in Tier Two areas (Lashio and Hensi, Northern Shan) with PSI and DFID. Visit and discussions with – [lists key interviews]. 25 outlet visited, comprising the 5 outlet types as well as drug wholesalers."
Mid-Term Milestone Review (May 2013), Pg 3.
"Among fever cases where treatment was sought, 91% reported that they took modern medicine of some kind, but were unable to verify what this was. 6.1% (N=33) reported receiving an antimalarial of some type, and less than 1% of fever cases (0.7%) reported being treated with an ACT." Household Survey: Baseline, Pg 12.
See our introductory report on the project.
Chris White, PSI Myanmar, email to Good Ventures/GiveWell on November 11, 2013
"Data collection ran from the 1st of March 2012 to 30th of May 2012." Outlet Survey: Baseline, Pg 2.
Outlet Survey: Baseline, Pg 30.
"The mystery client survey showed that 10.8% of providers proposed a malaria test to customers/ patients before providing with treatment in the 3 priority outlet types. This was carried out before the RDT pilot, and represents current practice for use of RDTs among these provider types… Completion of the pilot is due in October 2013, with results disseminated by December 2013. Decision on roll out of results will take place from January 2014." Mid-Term Milestone Review (May 2013), Pg 13.
"Supa Arte retail price matches incomplete AMT dose price, which ranged from K 100 to 500 per one tablet." Mid-Term Milestone Review (May 2013), Pg 8.