The Role of the Private Sector: Examining Emerging Trends in Malaria Healthcare

This month as the global health community recognizes April 25 as World Malaria Day 2014, CHMI has been combing through our 1,200 program profiles to learn about innovations in privately delivered malaria healthcare. Approximately 70 of these programs work in malaria care and services. With our colleagues at the University of Toronto, we have now launched a brief, Innovations in Privately Delivered Malaria Healthcare: Exploring the Evidence Behind Emerging Practices" summarizing our findings. This blog post draws upon some of our research and analysis.

Market Based Approaches in Malaria

In many countries, households rely on private sector retail outlets and private providers to access malaria drugs, in part due to persistent stock outs in the market place. In Cambodia, patients first seek care from private providers in 90% of fever cases,1 while in Laos, initial treatment was sought in the private sector in 63% of fever cases.2  Worldwide, as much as 50% of anti-malarial medications are distributed by the informal retail sector, such as pharmacies. 3 4 The private sector has also played a large role in the supply and distribution of commodities supporting the prevention and diagnosis of malaria, including insecticides, insecticide-treated nets (ITNs), medicines, and diagnostic tests.   

In response to the important role the retail sector plays in malaria control, innovators from social enterprises, nonprofits, corporations and governments have experimented with new approaches aimed at improving availability, access, and affordability of malaria care and key commodities through leveraging the private sector. Market based approaches profiled by CHMI, which seek to expand access to malaria care and are better studied, include social marketing and vouchers, subsidizing the private sector supply of ACTs, and increasing access to diagnostic services through community health worker owned franchises.  An emerging approach in the private sector with less evidence but significant excitement in the global health community is the use of mobile phones to track supply chain and distribution of malaria health products. 

Social Marketing and Vouchers: Thirteen CHMI analyzed malaria programs use social marketing or commercial marketing techniques such as vouchers to encourage the uptake of health products.  One market based program which reports results to CHMI is Living Goods, a network of franchised community health providers who provide health education and sell health products at affordable prices in Uganda and Kenya.  Living goods has also piloted a voucher program to jumpstart client demand for priority malaria commodities such as bednets. The program reports that its prices are 10-30% below market as a result of its buying power prior to voucher use, resulting in more affordable products to target populations. Living Goods is also currently undergoing a randomized control trial (RCT) to measure the impact of its program on under-5 child mortality and morbidity.

Subsidizing the Private Sector Supply of ACTs: Four CHMI programs have distributed subsidized ACTs, including the Global Fund’s Affordable Medicines Facility – Malaria (AMFm), a multinational initiative which launched in 2009 and ran through 2012.  The AMFm negotiated prices with ACT manufacturers and subsidized medicines in both the public and private distribution channels.  Evidence indicated that subsidized ACTs could result in reduced prices for consumers from about US$6-10 per treatment to about US$0.20-0.50. 5 6 7 8 9 Unfortunately, while prices were reduced, stock outs of ACTs (both of AMFm and non AMFm products) remained an issue, and prices charged by retailers remained higher than countries suggested retail prices. 

Increasing access to diagnostic services through community health worker owned franchises: The development of RDTs, which quickly test for the presence of malaria parasites through a one-time-use device, has been a major technological advancement and contributed to the scale up of malaria diagnosis in both the public and private sectors.  Social Franchise programs like MicroClinic International in Ghana and Uganda and AMUA in Kenya are operating community health worker-owned franchises to increase access to diagnostic testing, especially in remote locations. 

Mobile Phones to Track Supply Chain and Distribution of Malaria Health Products:  Mobile phone platforms which improve the flow of malaria commodities, such as bed nets, have the potential to significantly reshape private sector malaria care.  Four malaria programs profiled by CHMI use mobile phones to track supply chain inventory levels.  These programs, such as SMS for Life, typically allow health workers to SMS stock details to supply managers in order to proactively replenish stocks. While technologies like this can be used in both the public and private sector, given the large role the private sector plays in malaria care we expect to see this become a strong tool in the private sector, such as in pharmacies, for reducing stock outs of malaria goods. 

The Future of Privately Delivered Malaria Healthcare: 

As the private sector is a major contributor to malaria care internationally, CHMI will continue to track and highlight its innovative practices, both established and emerging, in the field.  For more information be sure to read our latest database brief: [“Innovations in Privately Delivered Malaria Healthcare: Exploring the Evidence Behind Emerging Practices.”  

Photo: A health worker in Kalangala District, Uganda, tests a client for malaria using a Rapid Diagnostic Test. © 2012 Ritah Mwagale/UHMG, Courtesy of Photoshare                                       ___________________________________________________________________________

1 Yeung S, Damme WV, Socheat D, White NJ, Mills A. (2008) Access to artemisinin combination therapy for malaria in remote areas of Cambodia. Malaria Journal 7: 96.

2 Nonaka D, Vongseththa K, Kobayashi J, Bounyadeth S, Kano S, et al. (2009) Public and private sector treatment of malaria in Lao PDR. Acta Tropica 112(3): 283-287.

3 Seidel R, Pennas T, Kovach T, Kim P, Divine B, et al. (2012) The strategic framework for malaria communication at the country level: 2012-2017. Geneva: WHO.

4 Schellenberg D (2010) The control of malaria 2005-15: progress and priorities towards Eradication. The sixth report of the all-party parliamentary group on malaria and neglected tropical diseases (APPMG). London: APPMG.

 5 Tahar R, Sayang C, Ngane Foumane V, Soula G, Moyou-Somo R, et al. (2013) Field evaluation of rapid diagnostic tests for malaria in Yaounde, Cameroon. Acta Tropica 125: 214–219.

6 Yamey G, Schaferho M, Montagu D (2012) Piloting the Affordable Medicines Facility-Malaria: what will success look like? Bulletin of the World Health Organization 90: 452–460.

7 AMFm Independent Evaluation Team (2012) Independent evaluation of phase 1 of the Affordable Medicines Facility - malaria (AMFm), multi-country independent evaluation report: final report, September 28, 2012. London: London School of Hygiene & Tropical Medicine.

8 Sabot OJ, Mwita A, Cohen JM, Ipuge Y, Gordon M (2009) Piloting the global subsidy: the impact of subsidized artemisinin-based combination therapies distributed through private drug shops in rural Tanzania. PLoS ONE 4: e6857

9 Clinton Health Access Initiative (CHAI) (2012) Price subsidies increase the use of private sector ACTS: evidence from a systematic review.