Abstract
BackgroundContinued progress towards global reduction in morbidity and mortality due to malaria requires scale-up of effective case management with artemisinin-combination therapy (ACT). The first case of artemisinin resistance in Plasmodium falciparum was documented in western Cambodia. Spread of artemisinin resistance would threaten recent gains in global malaria control. As such, the anti-malarial market and malaria case management practices in Cambodia have global significance.MethodsNationally-representative household and outlet surveys were conducted in 2009 among areas in Cambodia with malaria risk. An anti-malarial audit was conducted among all public and private outlets with the potential to sell anti-malarials. Indicators on availability, price and relative volumes sold/distributed were calculated across types of anti-malarials and outlets. The household survey collected information about management of recent "malaria fevers." Case management in the public versus private sector, and anti-malarial treatment based on malaria diagnostic testing were examined.ResultsMost public outlets (85%) and nearly half of private pharmacies, clinics and drug stores stock ACT. Oral artemisinin monotherapy was found in pharmacies/clinics (9%), drug stores (14%), mobile providers (4%) and grocery stores (2%). Among total anti-malarial volumes sold/distributed nationally, 6% are artemisinin monotherapies and 72% are ACT. Only 45% of people with recent "malaria fever" reportedly receive a diagnostic test, and the most common treatment acquired is a drug cocktail containing no identifiable anti-malarial. A self-reported positive diagnostic test, particularly when received in the public sector, improves likelihood of receiving anti-malarial treatment. Nonetheless, anti-malarial treatment of reportedly positive cases is low among people who seek treatment exclusively in the public (61%) and private (42%) sectors.ConclusionsWhile data on the anti-malarial market shows favourable progress towards replacing artemisinin monotherapies with ACT, the widespread use of drug cocktails to treat malaria is a barrier to effective case management. Significant achievements have been made in availability of diagnostic testing and effective treatment in the public and private sectors. However, interventions to improve case management are urgently required, particularly in the private sector. Evidence-based interventions that target provider and consumer behaviour are needed to support uptake of diagnostic testing and treatment with full-course first-line anti-malarials.
Highlights
Continued progress towards global reduction in morbidity and mortality due to malaria requires scale-up of effective case management with artemisinin-combination therapy (ACT)
Percentage of outlets stocking anti-malarials is highest among pharmacies/ clinics (54%) and drug stores (52%), and relatively low among grocery stores (8%) and village shops (2%)
Pharmacies, clinics and drug stores tend to stock the private sector artesunate + mefloquine (ASMQ), Malarine, and stocking of the public sector A+M is uncommon. These results suggest minimal leakage of public sector ACT to the private sector
Summary
Continued progress towards global reduction in morbidity and mortality due to malaria requires scale-up of effective case management with artemisinin-combination therapy (ACT). Factors believed to be contributing to emerging drug resistance in Cambodia include the unregulated sale of artemisinin monotherapies for over 40 years; limited access to ACT; co-blistered ACT which is not coformulated (facilitating continued use of artemisinin monotherapy); and ubiquitous counterfeit and substandard drugs [2]. Cambodia’s resistance containment programme consists of a number of interventions to facilitate early diagnosis and appropriate treatment of malaria. These include a ban on the sale of artemisinin monotherapies introduced in 2009; ongoing efforts to strengthen capacity for drug quality monitoring; a new bureau for policing private drug sellers; and active efforts to close unlicensed pharmacies [2,4,5]. In late 2008, the first-line drug in districts with confirmed multidrug resistance was changed to dihydroartemisinin + piperaquine (DHA+PPQ); public outlets began stocking the drug in 2009 [2]
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