Using supply side evidence to inform oral artemisinin monotherapy replacement in Myanmar: a case study

Abstract

Background: In 2012, alarmingly high rates of oral artemisinin monotherapy availability and use were detected along Eastern Myanmar, threatening efforts to halt the spread of artemisinin resistance in the Greater Mekong Subregion (GMS), and globally. The aim of this paper is to exemplify how the use of supply side evidence generated through the ACTwatch project shaped the artemisinin monotherapy replacement malaria (AMTR) project's design and interventions to rapidly displace oral artemisinin monotherapy with subsidized, quality-assured ACT in the private sector.

Methods: The AMTR project was implemented as part of the Myanmar artemisinin resistance containment (MARC) framework along Eastern Myanmar. Guided by outlet survey and supply chain evidence, the project implemented a high-level subsidy, including negotiations with a main anti-malarial distributor, with the aim of squeezing oral artemisinin monotherapy out of the market through price competition and increased availability of quality-assured artemisinin-based combinations. This was complemented with a plethora of demand-creation activities targeting anti-malarial providers and consumers. Priority outlet types responsible for the distribution of oral artemisinin monotherapy were identified by the outlet survey, and this evidence was used to target the AMTR project's supporting interventions.

Conclusions: The widespread availability and use of oral artemisinin monotherapy in Myanmar has been a serious threat to malaria control and elimination in the country and across the region. Practical anti-malarial market evidence was rapidly generated and used to inform private sector approaches to address these threats. The program design approach outlined in this paper is illustrative of the type of evidence generation and use that will be required to ensure effective containment of artemisinin drug resistance and progress toward regional and global malaria elimination goals.

Keywords: Antimalarial drug resistance; Malaria elimination; Myanmar; Outlet survey; Program design; Supply survey.

Fig. 1

Samples of common artesunate monotherapy identified by the supply chain

Fig. 2

Availability of different classes of anti-malarials, Eastern Myanmar 2012

Fig. 3

Market share of anti-malarials distributed in the past week, Eastern Myanmar 2012

Fig. 4

PSI Theory of change during the project inception

Fig. 5

Over-packaging ACT treatments in PSI the warehouse

Fig. 6

A map of the PSI target and sales area