Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document Private Sector Case Management Study Cambodia 2015

www.ACTwatch.info Copyright © Population Services International (PSI). All rights reserved.

Released July 21, 2016

Suggested citation ACTwatch Group and PSK. (2016). ACTwatch Study Reference Document: Cambodia Private Sector Case Management Study 2015. Washington DC: PSI.

Contact Dr. Megan Littrell Claire Stokes ACTwatch Principal Investigator Country Representative | Population Services Khmer PSI | 1120 19th St NW Suit 600 No. 29, 334 Street, P.O. Bo 258, Boeung Keng Kang 1 Washington DC 20036 Chamkarmon, Phnom Penh, Cambodia [email protected] [email protected]

Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation, UNITAID, and the UK Department for International Development. This study was implemented by Population Services International (PSI).

PSK Fieldwork Team Claire Stokes Bodany Kimsean Sarin Chim Abigail Pratt Bopha Ke Savattey Sok Dianna Long Borin Phuong Savoeurn Sambo Sochea Phok Brasith Iv Kham Seila Sok Mean Phou Chamnab Ao Socheat Ly Pisidh Voe Chamreunodam Phok Sodaneath Van Chankhanha Sim Sokcheath Koeng Cambodia NMCP Chanlita Eng Sokhan Chun Dr. Huy Rekol Chanra Pech Sokhoeurn Chun Dr. Lek Dysoley Dano Morn Sokhoun Seng Dr. Siv Sovannaroth Dany Han Sokhun Chea Dr. Teng Poly Darith Neat Sonai Kaing Davuon Khun Sophea Chhoy ACTwatch Team Hay Dano lmut Sophoeun Min Andrew Andrada Keoratha Chheng Sorphea Chum Erick Auko Khuoch Koch Sotheary Bun Dr. Katie Bates Koemtin San Sovann Nhoueng Dr. Desmond Chavasse Kosal Ouch Sovannra Ngoun Kevin Duff Kunthea Tay Sovon Yeng Keith Esch Kuntheavy Mao Sreymach Ung Anna Fulton Lim Sun Sreyroth Dieb Tarryn Haslam Linda Oun Tekngun Oeng Catherine Hurley Minea Leng Theary Say Dr. Beth Kangwana Narath Eng Thida Lay Gloria Kigo Narith Chan Vanna Kong Dr. Megan Littrell Navann Hay Vanthy Soeng Dr. Kathryn O’Connell Phalnida Em Vattey Kriel Julius Ngigi Phirum Nheb Veasna Ven Ricki Orford Physophea Tath Vuth Yun Stephen Poyer Physopheak Tath Dr. Justin Rahariniaina Piroath Sroun Christina Riley Piseth Hoy Dr. Andria Rusk Rasmy Thorn Julianna Smith Rath Phat Kate Thanel Samnit Nou Rachel Thompson Samoeurn Loeurng Cynthia Whitman San Chheun www.ACTwatch.info Page 1

Table of Contents

List of Tables ...... 3 List of Figures ...... 4 Definitions ...... 6 Introduction ...... 8 Summary of Methods and Data Collection ...... 9 Summary of Key Findings ...... 12 Tables ...... 2 Annex 1: ACTwatch Background ...... 16 Annex 2: Country Background ...... 18 Annex 3: Case Management Survey Methods ...... 27 Annex 4: Sampled Communes ...... 30 Annex 5: Questionnaire ...... 34 Annex 6: Sampling Weights ...... 59 Annex 7: Indicator Definitions ...... 60

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List of Tables

Table 1: Description of outlets ...... 7 Table 2: Description of patients seeking treatment for symptoms of malaria, by outlet type ...... 8 Table 3: Malaria blood testing and test result provided during patient consultation*, by outlet type ...... 9 Table 4: Antimalarial treatment by test result, by outlet type ...... 10 Table 5: Patient comprehension of malaria diagnostic testing and ACT prescription ...... 11 Table 6: Factors associated with malaria blood testing ...... 12 Table 7: Diagnosis provided to patients during consultation ...... 15 Table X1. Sampled communes ...... 30

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List of Figures

Figure 1: Diagram for outlet inclusion in the CM study, Cambodia, 2015 ...... 10 Figure 2: Diagram for patient inclusion in the CM study, Cambodia, 2015 ...... 11 Figure 3. Percent of patients present at the outlet ...... 12 Figure 4. Percent of patients who sought previous treatment for the current illness at a different source of care, across outlet type ...... 12 Figure 5a. Percent of patients who received a malaria blood test ...... 2 Figure 5b. Percentage of patients who received a malaria ...... 2 Figure 6. Percent of patients who received a malaria blood test, across outlet type, patient sex and patient age ...... 3 Figure 7. Map of patient test results ...... 4 Figure 8: Diagram for malaria blood testing results ...... 5 Figure 9: Diagram for treatment of malaria positive and negative cases ...... 6

Figure X1. Cambodia provinces and municipalities ...... 19

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Acronyms

ACT Artemisinin combination therapy AETD Adult equivalent treatment dose AMFm Affordable Medicines Facility – malaria ASAQ Artesunate amodiaquine ASMQ Artesunate Mefloquine BMGF The Bill and Melinda Gates Foundation CHW Community Health Worker DFID Department for International Development DHA-PPQ Dihydroartemisinin piperaquine EMA European Medicines Agency GFATM Global Fund to Fight AIDS, TB, and Malaria G6PD Glucose-6-phosphate-deydrogenase deficiency GMS Greater Mekong Subregion GPS Global Positioning System IV Intravenous injection IM Intramuscular injection Mg Milligrams kg Kilogram MMW Mobile Malaria Worker MEAF Malaria Elimination Framework (for Cambodia) MOH Ministry of Health n Number NGO Non-governmental Organization Oral AMT Oral artemisinin monotherapy PSI Population Services International PPS Probability Proportional to Size Pf Plasmodium falciparum Pv Plasmodium vivax QA ACT Quality-assured artemisinin combination therapy RDT Rapid diagnostic test USAID United States Agency for International Development VMW Village Malaria Worker

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Definitions

Survey Methods Definitions

Outlet Any service delivery point or point of sale for commodities. Outlets are not restricted to stationary points of sale and may include mobile units or individuals. Outlet survey The Case Management study was conducted as part of the 2015 national ACTwatch outlet survey. The outlet survey included a census of all public and private sector outlets with the potential to distribute antimalarials within a nationally-representative sample of communes. Outlets with antimalarials and/or malaria testing (malaria rapid diagnostic test or microscopy) in stock on the day of the survey or within the past three months were eligible for interview. The interview included an audit/inventory of all available antimalarials and malaria tests, as well as provider questions to assess malaria case management knowledge. Cluster The primary sampling unit, or cluster, for the outlet and Case Management surveys. It is an administrative unit that hosts a population size of approximately 10,000 to 15,000 inhabitants. These units are defined by political boundaries. In Cambodia, these were defined as communes Outlets eligible for Outlets were eligible for the Case Management study if they met the following criteria: 1) inclusion in the Private for-profit health facility, pharmacy, drug store or itinerant drug vendor; 2) Artemisinin Case Management combination therapy (ACT) in stock on the day of the outlet survey; 3) Malaria blood testing study available on the day of the outlet survey (malaria rapid diagnostic test or microscopy). Patient eligible for Criteria in the National Treatment Guidelines for Malaria in Cambodia were used to identify inclusion in the patients that should receive a malaria blood test. According to the most recent version of the Case Management national guidelines dated December, 2014, criteria for malaria diagnostic testing include: fever, chills or sweats, and/or two of the following: headache, nausea, vomiting, diarrhea, study forest travel in the past one month, confirmed malaria in the past month, travel to a malaria endemic area from a non-endemic area, and live or work around others with a recently confirmed malaria diagnosis.

Patients were eligible for the Case Management study if they met the following criteria: 1) Patient age 15 or older; 2) Illness that includes fever or history of fever, chills or sweats, and/or forest travel in the past one month, and/or confirmed malaria diagnosis in the past one month; 3) Presenting for treatment for this illness at this outlet for the first time; 4) Uncomplicated illness (not severe or life threatening); an 5) Not pregnant. A patient could be eligible for the study if they met all criteria and were either present at the time of the study, or a friend/caregiver was seeking treatment on their behalf at the outlet. Consultation A structured observation checklist was completed by an interviewer observing the interactions observation that the patient had with providers as she/he was provided with services at the outlet. The observation was concerned primarily with provider behaviors including their clinical assessment of the patient, proper RDT administration, and counseling for treatment with ACT. Patient exit A brief exit interview was completed with the patient after the patient visit was complete. The interview exit interview captured information about all medicines prescribed/obtained, and assessed patient understanding of the test result(s), diagnosis, and medication regimens prescribed. Provider interview A brief series of questions were administered to providers to assess demographic characteristics, qualifications, training, and knowledge of the first-line treatment.

Malaria Product Indicator Definitions

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Antimalarial Any medicine recognized by the WHO for the treatment of malaria. Medicines used solely for the prevention of malaria were excluded from analysis of key indicators in this report. Dosing/treatment The posology or timing and number of doses of an antimalarial used to treat malaria. This regimen schedule often varies by patient weight. Artemisinin and its Artemisinin is a plant extract or synthetic plant extract used in the treatment of malaria. The derivatives most common derivatives of artemisinin used to treat malaria are artemether, artesunate, and dihydroartemisinin. Artemisinin-based An antimalarial that combines artemisinin or one of its derivatives with an antimalarial or Combination antimalarials of a different class. Therapy (ACT) Non-artemisinin An antimalarial medicine that does not contain artemisinin or any of its derivatives. therapy First-line treatment The government recommended treatment for uncomplicated malaria. Cambodia’s first-line treatment is dihydroartemisinin piperaquine (DHA PPQ) or fixed-dose combination artesunate mefloquine (ASMQ). Quality-assured QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Artemisinin-Based Quality Assurance Policy. A QAACT is any ACT that appeared on the Global Fund's indicative list Combination of antimalarials meeting the Global Fund's quality assurance policy prior to data collection (see Therapies (QAACTs) http://www.theglobalfund.org/en/healthproducts/qualityassurance/) or that previously had C-status in an earlier Global Fund quality assurance policy. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®.

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Introduction

This reference document is a detailed presentation of the 2015 national ACTwatch Case Management (CM) study conducted in Cambodia. The 2015 study was completed as part of the national ACTwatch outlet survey. The 2015 outlet survey followed previous survey rounds conducted by ACTwatch in Cambodia in 2009, 2011, 2013 and 2015. Outlet survey findings from Cambodia are available at www.actwatch.info.

ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence. The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID, and DFID. See Annex 1 for more information about the ACTwatch project.

Recent efforts to improve malaria case management have focused on improving access to two key commodities – rapid diagnostic tests (RDT) for confirmatory testing before treatment, and artemisinin-based combination therapy (ACT – effective treatment for P. falciparum and P. vivax malaria in Cambodia). There is now evidence in Cambodia that availability of malaria blood testing and quality-assured ACT has improved dramatically in recent years.1 However due to the complexities of measuring malaria case management outcomes, there is less information available on the extent to which improved access to RDTs and ACT is facilitating consistent appropriate management of suspected malaria cases. In other words, are available RDTs consistently used to confirm all suspected malaria cases, and are ACTs administered to confirmed cases only? These questions are important to address given national and regional malaria elimination goals.

Following on the significant investments made to improve access to malaria diagnostics and treatment, there is a need to document the uptake of these tools. This includes uptake of RDTs and ACT within sources of care that are frequently accessed by people seeking fever treatment. In Cambodia, private providers at private for-profit health facilities, drug shops, pharmacies and itinerant drug vendors are commonly accessed for fever care, and yet information on management of cases is typically not tracked in any systematic way. Health provider behaviour is complex and multiple factors influence case management practices and outcomes. As compared with the more highly regulated and supervised public health sector, the set of factors influencing case management outcomes may be particularly complex and yet not well-documented in the private sector.

The CM study documents key aspects of the interactions between private sector providers and patients seeking treatment for illness with symptoms of malaria including fever, and/or risk factors including recent forest travel. These include two case management outcomes: 1) confirmatory malaria blood testing; and 2) appropriate treatment according to test result. This research complements available evidence currently used to track progress in malaria case management. The ACTwatch outlet surveys track trends in RDT and antimalarial availability, price, and market share. The CM research component documents the extent to which recent and current efforts to improve availability of key malaria commodities are sufficient for facilitating appropriate management of suspected malaria cases. This research will provide information to inform interventions designed to close gaps between availability of quality-assured malaria diagnostics and medicines and their routine use in managing clients and ultimately guide elimination efforts in the region.

Report notes

 This document is a complete reference for the 2015 Fever CM survey. Please see annexes for information about the study context, design, implementation and data analysis.  Grey text for data appearing in report tables indicates that the estimate provided was derived from a small sample size. Specifically, grey text is used to indicate point estimates derived from an n of less than 50.

1 ACTwatch Goup, Novotny J, Singh A, Dysoley L, Sovannaroth S, Rekol H. (2016). Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys. Malaria Journal, 15:194. www.ACTwatch.info Page 8

Summary of Methods and Data Collection

National Outlet Survey

A representative antimalarial outlet survey was conducted at national level in Cambodia between August 27th and October 1st, 2015. A full description of research design and methods is provided in the Cambodia outlet survey Reference Document available at www.actwatch.info. Briefly, a representative sample of communes was selected from the two national malaria control and elimination domains, Tier 1 and Tier 2 (see Annex 3). Within selected clusters, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was completed. Outlets were screened to determine eligibility. Outlets eligible for the survey met at least one of three criteria: 1) one or more antimalarials were in stock on the day of the survey; 2) one or more antimalarials were in stock in the three months preceding the survey; and/or 3) malaria blood testing (microscopy or RDT) was available. A structured questionnaire was used to complete an audit of all antimalarials and RDTs as well as a provider interview

Case Management Survey

Private sector outlets meeting eligibility criteria for the CM survey were identified during the outlet survey and were revisited for CM data collection. Eligibility criteria for the CM survey component were as follows: 1) Private for-profit health facility, pharmacy, drug store or itinerant drug vendor; 2) ACT in stock on the day of the outlet survey; and 3) malaria blood testing (malaria RDT or microscopy) available on the day of the outlet survey.

Fieldworkers dedicated to the CM study revisited eligible outlets identified during the outlet survey and completed patient screening for a maximum of two days. All patients visiting eligible outlets were screened to determine eligibility for the study. Once an interviewer completed patient consultation observation and exit interviews with an eligible patient, the interviewer proceeded to the next outlet. Patients were invited to participate in the study if they met the following eligibility criteria:  Patient age 15 or older  Illness that includes fever or history of fever, chills or sweats, and/or forest travel in the past one month, and/or confirmed malaria diagnosis in the past one month  Presenting for treatment for this illness at this outlet for the first time  Illness that is not severe, defined as response of “yes” to a question regarding referral for this illness to a doctor or health facility because this illness is very severe or life threatening.  Women of reproductive age who do not respond “yes” to the question, “are you currently pregnant.”  Provides consent to participate in the study

Following informed consent procedures, a structured observation checklist was completed by an interviewer observing the interactions that the patient had with providers as she/he was provided with services at the outlet. The observation was concerned primarily with provider behaviors including assessment, proper RDT administration, and counseling for treatment with ACT. After the patient visit was complete, a brief exit interview was administered with the patient. The exit interview was concerned with capturing information about all medicines prescribed/obtained, and assessing patient understanding of the test result(s), diagnosis, and medication regimens prescribed. Full details of survey methodology are available in Annex 4 and the CM questionnaire is available in Annex 5.

Double data entry was completed using Microsoft Access. All data cleaning and analysis was performed using Stata 13.1 (©StataCorp, College Station, TX). Data were weighted to account for variation in probability of outlet selection (see Annex 6), and standard error calculation reflected clustering of outlets at commune level. Standard indicators were constructed according to definitions applied across ACTwatch project countries (see Annex 7).

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Figure 1: Diagram for outlet inclusion in the CM study, Cambodia, 2015

A Eligible outlets* [260] Eligible outlets that were not revisited for the CM study ** [34]

B Outlets visited for the CM study** [226] Outlets that did not participate in patient No patients during study period [5] screening [5] C Outlets that participated in patient screening*** [221]

Outlets with no eligible patients [1]

Outlet Type Outlet Location

45 79 9 D 141 140 Outlets with completed 26 patient observation and exit interviews [220] Private For-Profit Health Facility Tier 1 Pharmacy Drug Store Tier 2 Itinerant Drug Vendor #

* Outlets identified during the national outlet survey that met the following criteria: 1) Pharmacy (including clinical pharmacies, pharmacies, depot A, and depot B), private for-profit health facility (including hospitals, clinics, and cabinets), drug store, or itinerant drug vendors; 2) ACT in stock on the day of the outlet survey; 3) malaria testing available on the day of the survey (malaria RDT and/or microscopy). ** 34 eligible outlets were not flagged during the outlet survey as eligible for the CM component and therefore were not included in the study. *** Patient screening was conducted for a maximum of two days or until patient observation and exit interviews were completed for one eligible patient. # Among itinerant drug vendors that participated in the study, more than half (64%) were providers that offer services offsite as well as onsite from a fixed location. The remaining 36% were providers that offered services without any fixed location base or clinic. The majority of itinerant drug vendors (71%) reported ever working at a government or private health facility or pharmacy, and about half (56%) reported currently working at a government or private health facility or pharmacy.

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Figure 2: Diagram for patient inclusion in the CM study, Cambodia, 2015

A Patients screened* [804]

Respondent under 15 [27]

No fever, chills, sweats, confirmed malaria** [343] or forest travel**

Patients that did Follow-up visit to same outlet [73] not meet screening criteria Patient under 15 [127] [584] Pregnant [4]

Severe illness [0]

Refusal [10]

Patient Age Patient Sex

2

B 52 51 Patients with 101 completed 119 observation and 61 54 exit interview [220]

15-24 years 25-34 years Male 35-49 years 50+ years Unknown Female

* Patients were screened when they first approached an outlet to determine eligibility for the CM component. Eligibility criteria were as follows: Patient at least 15 years of age; seeking treatment for fever or other symptoms of malaria (fever, chills), or travel to the forest in the past 1 month, or diagnosis of confirmed malaria in the past 1 month; seeking treatment for the first time for the current illness at this outlet; not reportedly pregnant; and no signs or referral for severe illness for this illness. 10 patients refused to participate. ** Within the past 1 month

The distribution of patient age and sex did not differ significantly across outlet type. Private facilities, pharmacies, drug stores, and itinerant drug vendors had similar patient profiles with respect to patient age and sex.

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Summary of Key Findings

Figure 3. Percent of patients present at the outlet Among all patients with completed consultation observation and exit interviews

Patient present at the outlet

Patient not present (caregiver seeking treatment)

N=220

Eighty percent of patients that were included in the study were present at the outlet at the time of the consultaiton observation and exit interview. The reamining 20% were not present and care was being sought on the patient’s behalf by a family member or friend.

Figure 4. Percent of patients who sought previous treatment for the current illness at a different source of care, across outlet type Among all patients with completed consultation observation and exit interviews

100 90 80 70 60 50 40 30

PERCENTOF PATIENTS 20 10 0 Private For-Profit Facilities Drug Stores & Itinerant All Outlets & Pharmacies Drug Vendors

Ten percent of patients that were included in the study had previously sought treatment for the current illness at a different source of care. Only one patient reported previous treatment seeking in the public sector; all other patients who had previously treatment at another source of care had visited a private sector outlet. Previous treatment-seeking for the current illness was similar for patients at private facilities and pharmacies (9%) compared with drug stores and itinerant drug vendors (11%).

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Figure 5a. Percent of patients who received a malaria blood test Figure 5b. Percentage of patients who received a malaria Among all patients with completed consultation observation and blood test exit interviews, including patients present and not present during Among all patients present during the completed the consult consultation observation and exit interview

=

100

15% 80 Received a malaria blood test 20% 60 Present, did not receive a malaria test 40

Not present (did not receive a malaria test) 20 PERCENTOF PATIENTS 65% 0 N=220

All 220 patients included in the study reported signs and symptoms of malaria during patient screening. These included: fever, chills or sweats, and/or forest travel in the past one month, and/or confirmed malaria diagnosis in the past one month. All patients were at least 15 years of age, not pregnant, not exhibiting signs of severe life-threatening illness, and were visiting the study outlet for the first time for the current illness. As such, according to national malaria treatment guidelines, all 220 patients should have received a malaria blood test.

Malaria blood testing among patients seeking treatment for signs and sympoms of malaria was very low (Figure 7a). Only 15% of patients received a malaria blood test during the patient consultation observation. The vast majority of malaria blood testing was conducted using malaria RDTs and malaria microscopy was uncommon (only 2% of patients tested with microscopy). Two percent of all patients were offered a malaria blood test by the provider and refused testing.

Sixty-five percent of all patients were present at the consult but did not receive a malaria blood test. An additional 20 percent were not present at the consult and were therefore not tested (Figure 7a).

Among patient who were present during the consultation (N=173), 18% received a malaria blood testing during the patient consultation observation (Figure 7b).

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Figure 6. Percent of patients who received a malaria blood test, across outlet type, patient sex and patient age Among all patients with completed consultation observation and exit interviews

100 90 80 70 60 50 40

30 PERCENT OF PATIENTS PERCENTOF 20 10 0 Itinerant Private For- Drug Store Pharmacy 15-24 25-34 35-49 years 50+ years Male* Female Forest Other All Patients Drug Profit years* years* Worker* Occupation Vendor* Facility Outlet Type Patient Age Patient Sex Patient Occupation Total

* Percentage of patients tested for this category is significantly different in relation to the reference (lowest) category, p<0.05. Malaria blood testing was highest among male patients, patients age 15-34, patients seeking treatment at itinerant drug vendors, and patients who reported forest work for their occupation. It is noted that within the study sample (unweighted data), a higher proportion of patients seeking care at an itinerant drug vendor reported forest work (20%) as compared with drug stores (11%), private facilities (8%) and pharmacies (0%) (data not shown).

Among patients seeking care at itinerant drug vendors, 28% received a blood test. Testing among patients seeking care from an itinerant drug vendor who reported ever working at a government or private health facility or pharmacy was higher (32%) as compared with testing among patients seeking care from an itinerant drug vendor who did not report such experience working in a facility or pharmacy (22%) (data not shown).

Although not statistically significant, data trends suggest that patients who recently visited the forest/forest fringe were more likely to be tested (19%) than patients who reported no such travel (9%) (data not shown, see Table 6).

Malaria confirmatory testing was similar among patients who reported a confirmed malaria infection in the past 6 weeks (18%) as compared with patients who did not report a recent infection (14%) (data not shown, see Table 6).

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Figure 7. Map of patient test results Among all patients with completed consultation observation and exit interviews

Patient testing occurred across the study sites and was not limited to a certain geographic area of the country.

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Figure 8: Diagram for malaria blood testing results

All patients [220]

Present [142] Not tested for malaria [189] Not present [47]

Tested for malaria with an RDT or microscopy [31]

Patients not provided with a test result [1]

Patients provided with a test result during the consultation [30]

Test Result Negative [23] Positive, Pf [5] Positive, Pv [1] Positive, mixed [1]

31 patients received a malaria blood test as documented during the patient consultation observation. Among tested patients, 30 were provided with a test result. Seven patients tested positive for malaria, including 5 Pf infections, 1 Pv infection, and 1 mixed infection.

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Figure 9: Diagram for treatment of malaria positive and negative cases

Received DHA PPQ [5]

Received prescription for chloroquine [1] Patients who tested positive for malaria Received referral to public sector [7] for free treatment [1]

Patients who tested negative for malaria Received DHA-PPQ [0] [23]

Patients who did not receive a test for malaria Received DHA-PPQ [1] [189]

Among the 7 patients tested for malaria, 5 exited the outlet with DHA PPQ (Eurartism®, Sigma Tau). All 23 patients who tested negative for malaria were not treated with any antimalarial, including DHA PPQ. Among the 189 patients who were not tested for malaria, 1 patient exited the outlet with DHA PPQ (Euartism®, Sigma Tau). This patient had requested the drug from the provider and the provider recommended a blood test but the patient did not agree to testing.

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Tables

Table 1: Description of outlets Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors % % %

(95% CI) (95% CI) (95% CI) Proportion of outlets* N=166 N=54 N=220 Stocking malaria commodities on the day of the outlet survey 100.0 100.0 100.0 ACT ------4.4 11.6 6.5 Non-artemisinin therapy (1.7, 10.8) (5.1, 24.1) (2.9, 13.8) 100.0 100.0 100.0 Any malaria test ------99.0 100.0 99.3 Malaria RDT (96.1, 99.7) -- (97.2, 99.8) 15.1 11.2 14.0 Malaria microscopy (9.6, 23.0) (5.2, 22.5) (9.1, 21.0) Provider training and knowledge Reported receiving malaria CM training in the past 51.5 26.9 44.4 year** (43.3, 59.7) (14.5, 44.2) (37.2, 51.8) * Outlets with a completed patient observation and exit interview ** Provider reported receiving training, including pre-service training or stand-alone workshops, on malaria diagnosis/malaria RDTs/malaria microscopy and/or treatment on the national malaria treatment guidelines. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 2: Description of patients seeking treatment for symptoms of malaria, by outlet type Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors % % %

(95% CI) (95% CI) (95% CI) Proportion of patients seeking fever N=166 N=54 N=220 treatment: 78.3 83.3 79.7 Present at consultation (70.9, 84.2) (71.0, 91.0) (73.7, 84.7) Reported fever symptoms to a provider 80.0 74.4 78.4 during the consultation (prompted or (72.6, 85.8) (60.8, 84.5) (72.7, 83.2) unprompted) Reported recent travel to a forest/forest 51.3 62.3 54.5 fringe area during the exit interview^ (40.1, 62.3) (48.9, 74.1) (44.7, 63.9) Reported an episode of malaria in the past 6 4.9 7.2 5.5 weeks^ (1.6, 13.6) (2.5, 19.1) (2.7, 11.1) Prior to the current visit for this illness: Sought treatment elsewhere for this 9.0 10.6 9.5 illness (5.2, 15.2) (5.3, 20.2) (6.1, 14.5) 0.3 0.0 0.2 Public (facility, CHW)* (<0.01, 1.8) -- (<0.1, 1.3) 7.6 9.2 8.1 Private (formal or informal)* (4.2, 13.3) (4.3, 18.5) (5.0, 12.7) 0.8 0.0 0.6 Received a malaria blood test (0.2, 2.9) -- (0.1, 2.1) 9.0 10.6 9.5 Received any medicine (5.2, 15.2) (5.3, 20.2) (6.1, 14.5) 0.0 0.0 0.0 Received an antimalarial ------Reported occupation as forest worker during 9.2 18.7 12.0 the exit interview^ (4.8, 17.1) (10.1, 31.9) (7.9, 17.7) * Specific source for previous treatment was missing for 2 individuals; these observations were excluded from these indicators. ^ Consultation observation did not capture whether or not the patient mentioned forest travel, malaria infection during the previous 6 weeks, or forest work as an occupation during the consult. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 3: Malaria blood testing and test result provided during patient consultation*, by outlet type Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors % % %

(95% CI) (95% CI) (95% CI) Proportion of patients who received: N=166 N=54 N=220 10.0 25.5 14.5 Any malaria test (6.4, 15.5) (17.0, 36.4) (10.8, 19.2) 9.0 25.5 13.8 Malaria RDT (5.5, 14.4) (17.0, 36.4) (10.1, 18.5) 1.5 1.6 1.5 Malaria microscopy (0.6, 3.7) (0.3, 9.0) (0.7, 3.4) 0.5 1.6 0.8 Both malaria RDT and microscopy (0.1, 1.8) (0.3, 9.0) (0.2, 2.5) 21.7 57.8 65.2 No malaria test, present at the outlet (15.8, 29.1) (45.1, 69.5) (59.2, 70.8) 21.7 16.7 20.3 No malaria test, not present at the outlet # (15.8, 29.1) (9.0, 29.0) (15.3, 26.3) Provider recommendation to test but refused 2.6 0.0 1.8 testing (0.8, 8.2) -- (0.6, 5.7) n n n

% (95% CI) % (95% CI) % (95% CI) N and Proportion of tested patients**: N=16 N=14 N=30 3 4 7 Confirmed positive for malaria 20.2 (7.5, 44.1) 19.1 (5.7, 47.9) 19.6 (9.1, 37.4) 2 3 5 Confirmed positive for Pf only 13.2 (3.9, 36.3) 15.8 (3.9, 46.0) 14.5 (5.7, 32.3) 1 0 1 Confirmed positive for Pv only 7.0 (1.1, 34.0) 0.0 -- 3.3 (0.5, 18.2) 0 1 1 Confirmed positive for mixed infection 0.0 -- 3.4 (0.5, 19.6) 1.8 (0.3, 10.8) * Measured by direct observation during patient consultation. ** Excluding 1 patient who was tested but a result was not reported back to the patient during the consultation. # Patient was not present during the consult and care was sought on his/her behalf by a family member or friend. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 4: Antimalarial treatment by test result, by outlet type Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors n n n Proportion of patients who received: % (95% CI) % (95% CI) % (95% CI) Malaria test positive N=3 N=4 N=7 2 3 5 DHA PPQ* 65.5 (16.3, 94.9) 72.9 (38.9, 91.9) 69.4 (37.1, 89.7) 0 0 0 Prescription for ACT to fill elsewhere** 0.0 -- 0.0 -- 0.0 -- Malaria test negative: N=13 N=10 N=23 0 0 0 DHA PPQ* 0.0 -- 0.0 -- 0.0 -- 0 0 0 Prescription for ACT to fill elsewhere 0.0 -- 0.0 -- 0.0 -- % % %

(95% CI) (95% CI) (95% CI) Not tested for malaria N=149 N=40 N=189 0.5 0.0 0.3 DHQ PPQ* (0.1, 2.9) -- (0.1, 2.1) 0.0 0.0 0.0 Prescription for ACT to fill elsewhere ------* DHA PPQ was the only antimalarial administered to patients participating in the CM survey ** 1 patient testing positive for Pv was given a prescription for chloroquine to fill elsewhere. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 5: Patient comprehension of malaria diagnostic testing and ACT prescription Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors % % %

(95% CI) (95% CI) (95% CI) N=166 N=54 N=220 Proportion of fever patients who correctly recall 98.1 100.0 98.7 whether or not a malaria test was performed (95.0, 99.3) -- (96.3, 99.5) during the consultation* N=17 N=14 N=31 Proportion of fever patients who correctly recall 13 13 26 the malaria test result (positive, negative), among patients who were tested during the 75.8 (51.9, 90.0) 94.8 (74.4, 99.1) 85.4 (70.4, 93.5) consultation ** N=3 N=1 N=4 Proportion of fever patients who correctly cite 2 1 3 the dosing regimen, among patients prescribed 59.4 (13.3, 93.3) 100.0 -- 66.7 (19.2, 94.4) DHA PPQ*** * Among 31 tested, 28 reported testing. Among 189 not tested, 188 reported no testing. ** Among 7 with a positive test, 6 reported a positive test. Among 23 with a negative test, 20 reported a negative test. *** Comprehension is defined as correctly citing the number of tablets to take, times per day, and number of days that match with a regimen of DHQ PPQ according to the patient age. This was measured among the 4 patients who received a package of DHA PPQ that was not part of a drug cocktail. 2 additional patients received DHA PPQ cut blisters as part of a drug cocktail and questions on correct dosing were not administered. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 6: Factors associated with malaria blood testing

% Tested Odds Ratio

Proportion of patients tested, by patient and % OR provider/outlet factors N of Patients (95% CI) (95% CI) 220 14.5 -- All patients (10.8, 19.2) Type of outlet 4.2 ref Pharmacy 26 (0.88, 20.0) 6.8 1.7 Drug Store 9 (1.0, 35.0) (0.1, 23.5) 11.1 2.8 Private For-Profit Facility 140 (6.8, 17.6) (0.5, 17.4) 28.3 9.0 Itinerant Drug Vendor 45 (18.7, 40.5) (1.5, 53.9)* Outlet location 9.5 ref Tier 2 79 (3.81, 21.6) 17.0 2.0 Tier 1 141 (12.7, 22.4) (0.7, 5.4) Patient sex 7.0 ref Female 119 (2.9, 15.9) 22.4 3.82 Male 101 (16.2, 30.1) (1.32-11.07)* Patient age 4.0 ref 50 years or older 52 (1.0, 14.7) 7.5 1.9 35-49 years 61 (3.3, 15.9) (0.4-10.4) 26.3 8.6 25-34 years 54 (14.5, 42.8) (1.7-44.9)* 21.1 6.5 15-24 years 51 (12.8, 32.7) (1.4, 29.8)* Present at consultation 0.0 Patient not present 47 --

18.2 Patient present 173 -- (13.7, 23.7) Reported fever symptoms to a provider during the consultation (prompted or unprompted) 3.7 ref Did not report fever 47 (1.0, 12.6) 17.5 5.6 Reported fever 173 (12.5, 23.9) (1.3-24.1)* Reported recent travel to a forest/forest

fringe area during the exit interview^ 9.3 ref Did not report recent forest travel 117 (4.4, 18.6) 18.9 2.3 Reported recent forest travel 103 (12.9, 26.8) (0.8, 6.2)

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Table 6: Factors associated with malaria blood testing

% Tested Odds Ratio

Reported an episode of malaria in the past

6 weeks^ 14.3 ref Did not report recent malaria 212 (10.4, 19.3) 18.2 1.3 Reported recent malaria 8 (5.0, 48.2) (0.3, 6.1) Prior to the current visit for this illness: Did not seek treatment elsewhere for this 13.2 ref 192 illness (9.4, 18.2) Sought treatment elsewhere for this 27.1 2.5 28 illness (14.6, 44.8) (1.0-5.9)* Reported malaria blood test for this illness

prior to the consultation 14.0 ref Not tested previously 217 (10.3, 18.7) 38.5 3.8 Tested previously 2 (4.5, 89.2) (0.3-52.4) Reported receiving medicine for this

illness prior to the consultation 13.2 ref Not treated previously 192 (9.4, 18.2) 27.1 2.4 Treated previously 28 (14.6, 44.8) (1.0-5.9)* Reported occupation as forest worker

during the exit interview^ 12.3 ref Not a forest worker 199 (8.2, 18.0) 30.8 3.2 Forest worker 21 (15.7, 51.5) (1.0, 9.8)* Provider with recent malaria CM training# All outlets 12.8 ref Trained provider 89 (7.8, 20.1) 15.6 1.3 Untrained provider 131 (10.5, 22.4) (0.6-2.6) Pharmacy 6.8 -- Trained provider 19 (1.4, 27.6) 0.0 -- Untrained provider 7

Private for-profit health facility 14.1 1.6 Trained provider 59 (7.0, 26.1) (0.5, 5.2) 9.0 ref Untrained provider 81 (4.2, 18.3)

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Table 6: Factors associated with malaria blood testing

% Tested Odds Ratio

Price of malaria testing ## 11.6 ref Below median price ($0.99) 100 (7.2, 18.3) 18.0 1.7 Median price ($0.99) or higher) 112 (11.8, 26.5) (0.8-3.7) * p<0.05 ** p<0.01 ***p<0.001 ^ Consultation observation did not capture whether or not the patient mentioned forest travel, malaria infection during the previous 6 weeks, or forest work as an occupation during the consult. # Provider reported receiving training, including pre-service training or stand-alone workshops, on malaria diagnosis/malaria RDTs/malaria microscopy and/or treatment on the national malaria treatment guidelines. Most but not all of the providers who reported training were within private for-profit health facilities or pharmacies. We examined these outlet types separately for this reason. ## Price for the least expensive testing option (RDT or microscopy) available at the outlet on the day of the survey. A median was calculated across all outlets and outlets were classified as providing testing that was above median cost or median and below. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Table 7: Diagnosis provided to patients during consultation Private For-Profit Drug Stores and Facilities and Itinerant Drug All Outlets Pharmacies Vendors % % %

(95% CI) (95% CI) (95% CI) N=166 N=54 N=220 55.1 43.7 51.8 No diagnosis given1 (47.4, 62.5) (31.3, 57.0) (45.0, 58.5) 14.4 2.5 11.0 Chronic disease2 (9.6, 21.0) (0.6, 20.5) (7.3, 16.1) 18.0 25.5 20.2 Fever/cold/flu3 (12.6, 24.9) (13.9, 42.3) (15.1, 26.4) 5.9 7.8 6.4 Typhoid (3.0, 11.1) (2.7, 20.5) (3.7, 11.0) 3.9 7.9 5.0 Stomach/intestinal4 (1.9, 7.5) (2.8, 20.2) (2.9, 8.6) 1.8 4.9 2.7 Malaria (0.7, 5.0) (1.5, 14.9) (1.3, 5.7) 1.0 7.7 2.9 Other5 (0.3, 3.5) (2.4, 22.2) (1.1, 7.5) 1 Includes patients with no observed or recorded diagnosis during the consultation, as well as patients with negative test results (e.g. no fever). 2 Includes: Cancer, arthritis, diabetes/glucose, kidney problems, high cholesterol. 3 Includes: Fever, cold, cough, flu, headache, throat irritation. 4 Includes: Stomach pain, parasites, intestinal problems, ulcers. 5 Includes: Skin problems, trauma. Source: ACTwatch Fever CM Survey, Cambodia, 2015.

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Annex 1: ACTwatch Background

ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. Project countries include: Benin, Cambodia, the Democratic Republic of Congo, Kenya, Laos, Madagascar, Myanmar, Nigeria, Tanzania (currently mainland only, previous work in Zanzibar), Thailand, Uganda, Vietnam, and Zambia. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID, and DFID.

ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence.2 The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. ACTwatch is monitoring antimalarial markets in the context of policy shifts and investments in the scale-up of first-line ACT and blood testing using RDTs. This has included adaptation of project methods for the evaluation of the Affordable Medicines Facility-malaria (AMFm) pilot.3 Project scale-up in the Greater Mekong sub-Region (GMS) in 2015 was designed to deliver key indicators for informing and monitoring strategies and policies for malaria elimination. The project implements a set of research tools designed to:

1) Provide a picture of the total market for malaria case management including: all providers carrying antimalarials and RDTs and providing case management services; the relative antimalarial market share for each provider type; the antimalarial supply chain; and price markups within the supply chain for antimalarials and RDTs.

2) Monitor the readiness of market components for appropriate malaria case management, including: availability of antimalarials and malaria blood testing; consumer price of antimalarial treatment and malaria blood testing; and provider qualifications, training and knowledge.

3) Monitor the performance of market components for appropriate malaria case management, including: the relative market share for quality-assured ACT relative to other antimalarial medicines; the demand for appropriate malaria case management captured through consumer knowledge, attitudes, and fever treatment seeking behavior; and the quality of provider service delivery measured against national policies, guidelines and minimum standards.

ACTwatch research tools for malaria market monitoring include:

1. Outlet surveys

Outlet surveys entail collecting quantitative data from all outlets and providers with the potential to sell or distribute antimalarials and/or provide malaria blood testing. These include health facilities, community health workers, pharmacies, drug stores, retail outlets, market stalls, and mobile providers. A screening process identifies outlets that provide antimalarials and/or malaria blood testing. Among these eligible outlets, service providers are interviewed and all antimalarials and RDTs are audited. The audit collects information about each antimalarial and RDT in stock (e.g. brand name, drug active ingredients and strengths, manufacturer, etc.) and retailer reports on consumer price and sale/distribution volumes for each product. A representative sample of outlets is identified within target study domains such that findings from the outlet survey provide estimates of antimalarial and RDT availability, price, and relative market share across the entire market as well as within key market channels.4

2 Shewchuk T, O’Connell KA, Goodman C, Hanson K, Chapman S, Chavasse D. 2011. The ACTwatch project: methods to describe anti-malarial markets in seven countries. Malaria Journal, 10: 325. 3 AMFm Independent Evaluation Team. 2012. Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi- country independent evaluation report: final report. Calverton, MD and London: ICF International and London School of Hygiene and Tropical Medicine. 4 O’Connell KA, Poyer S, Solomon T, et al. 2013. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malaria Journal, 12: 52. www.ACTwatch.info Page 16

From 2008 through 2014, ACTwatch conducted 35 national outlet surveys across the 10 project countries.5 Reports are available at www.actwatch.info, and peer-reviewed publications have appeared in Malaria Journal and The Lancet.6

2. Supply chain studies

Supply chain studies employ quantitative and qualitative research methods to effectively map the antimalarial supply chain in a given country. The supply chain is mapped from the antimalarial outlets (service delivery points) identified during an outlet survey to national importers and distributors with identification of all mid-level distributers in between. Retail prices are documented along the supply chain to facilitate calculation of commodity mark-ups. From 2008 through 2012, ACTwatch conducted 8 national supply chain studies. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in PLoS One.7

2015 outlet surveys in the Greater Mekong sub-Region include a component to collect additional information about the supply chain for oral artemisinin monotherapy (oral AMT, e.g. artesunate tablets). Oral AMT identified during the outlet surveys was further investigated and research teams identified and visited named suppliers to collect further information about the supply chain.

3. Population-based surveys

Population-based surveys are conducted among consumers to document fever treatment-seeking behavior. A representative sample of the target population (caregivers of children and/or adults according to burden and risk) is identified, and a screening tool is used to identify individuals who have recently experienced fever. The surveys investigate the extent to which health care was sought, as well as common sources of care received. Respondent reports of malaria blood testing and antimalarials acquired are documented and summarized. The survey includes measures of demographic and other individual, household/family, and community characteristics that can be used to develop consumer profiles as well as monitor equity in access to malaria case management. From 2008 through 2012, ACTwatch conducted 14 household surveys focused on fever treatment-seeking behavior. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in Malaria Journal.8

4. Fever case management quality of care

Fever case management quality of care is monitored using a set of research tools designed to measure aspects of the interaction between providers and clients. ACTwatch launched fever case management quality of care studies in 2015 in a subset of project countries. The following research tools were integrated into the outlet surveys in Cambodia and Uganda and were implemented among private sector outlets providing malaria testing and treatment:

 Exit interviews conducted with target consumers immediately after receiving fever case management services in the private sector. A structured interview documented client reports about key aspects of service delivery including malaria blood testing, test results, medicines recommended/prescribed and obtained, counseling, and costs of services and commodities received. Exit interviews were also used to measure client recall and comprehension of provider counseling including instructions for completing prescribed drug regimens, as well as client satisfaction with services provided.

5 Surveys in the DRC (2) and Myanmar (3) were sub-national. 6 O’Connell K, Gatakaa H, Poyer S, et al. 2011. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malaria Journal, 10: 326. Tougher S, the ACTwatch Group, Ye Y, et al. 2013. Effect of the Affordable Medicines Facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet, 380: 1916-26. 7 Palafox B, Patouillard E, Tougher S, et al. 2014. Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries. PLoS One, 9(4). 8 Littrell M, Gatakaa H, Evance I, et al. (2011). Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 10: 327.

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 A consultation observation checklist was used to document aspects of the provider-client interaction in the private sector. A trained observer completed the checklist designed to document provider compliance with standard practice and procedures as well as aspects of client demand for specific products or services. The observer remained silent during the consultation.

ACTwatch in Country

ACTwatch baseline surveys were conducted in Cambodia in 2009 including an outlet survey (2009) and a household survey (2009). Follow-up outlet surveys were conducted in 2011, 2013 and 2015. A supply chain study was conducted in 2011 and a follow-up household survey was conducted in 2012. All reports are available at www.actwatch.info.

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Annex 2: Country Background

Cambodia is located in the Greater Mekong Sub-region of Southeast Asia. It is bordered by Thailand to the west, Laos and Thailand to the north, the Gulf of Thailand to the southwest, and Vietnam to the east and the south. It has a population of 15.7 million people, almost 80% of which live in rural areas.9 Cambodia has a tropical climate with two distinct seasons: the dry season from November to February, and the wet season from May to October. Cambodia is composed of 25 provinces and four municipalities (see Figure X1). A sixth of Cambodia’s population lives below the poverty line.10 Nearly half of the labor force works in the agricultural sector (which includes mainly rice culture), whilst the growing services sector employs over one third of the labor force.11

Figure X1. Cambodia provinces and municipalities

Healthcare system

The health system in Cambodia has undergone several periods of changes through decades of civil conflict and social and economic transition. In 2008, the Cambodian Ministry of Health developed the second Health Sector Strategic Plan 2008-2015 designed to improve coverage of primary healthcare and increase financial allocations for provincial health departments.12 In addition, the plan created operational districts (ODs) and established community‐based programs, such as for immunizations and birth spacing.13 The third Health Sector Strategic Plan 2016-2020 is currently underway, with main priorities being an increase in health spending and efficiency, stable financial sources and management, expanded social health protection, and improved harmonization and alignment.14

Health outcomes have improved recently. The under-five mortality rate decreased from 83 per 1,000 live births in 2005 to 38 per 1,000 live births in 2013.15 Between 2000 and 2013, maternal mortality ratio decreased from 540 to 170 deaths per 100,000 live births.16 Life expectancy at birth for both sexes increased from 60 to 73 between 2000- 2013.17 Health expenditures comprise 7.5% of the GDP, and 83% of the national disease burden is due to communicable diseases.18

9 Central Intelligence Agency. (2016). The World Factbook. Retrieved from https://www.cia.gov/library/publications/the-world- factbook/geos/cb.html. 10 Ibid 11 Ibid 12 Kingdom of Cambodia Ministry of Health. (2008). Health Strategic Plan 2008-2015. Phnom Penh: Ministry of Health. 13 Ibid 14 Veasnakiry, L. (2014). Financing Arrangments in Health Sector under Sector-Wide Management [PowerPoint slides]. Retrieved from http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/About_IHP_/mgt_arrangemts___docs/Core_Team/CHTM_ 2014/Day_two_presentations/EN-KH-IHP_December_2014_Dr._Kiry.pptx. 15 WHO. (2015). Cambodia: WHO statistical profile. Geneva, Switzerland: WHO. 16 Ibid 17 WHO. (2015). World Health Statistics 2015. Geneva, Switzerland: WHO. 18 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. www.ACTwatch.info Page 19

Nonetheless, challenges remain. The Cambodian public healthcare system is financed through a national budget, donor funding and user fees. One goal of the health care system is to have appropriate funding mechanisms for the population to acquire health care without deepening poverty. The 1996 National Health Financing Charter established a right for government facilities to implement user fees, which has helped to control under-the-table payments but has also created a barrier for poor patients seeking care in the public sector19. To address this issue, decentralized health equity funds (HEFs) were created in 2000 as third-party payers for poor patients. Eligible patients are reimbursed for associated healthcare costs and are provided with healthcare free of charge at government health facilities.20 However, according to the 2014 Demographic and Health Survey, HEFs represent only 4% of the source of expenditures for transport and health care; across all sectors, wages/income is the most common source of funding (64%), followed by savings (31.3%).21

Over two-thirds of care-seeking visits are to the private or non-medical sectors22, where a wide range of providers operates, including hospitals, clinics, pharmacies, cabinets, mobile providers, drug shops and grocery sellers. Some of these private practices are run by government doctors or nurses during off-hours. Many private sector providers have limited or no health qualifications but are still widely used, especially by poor patients and in remote areas where communities have limited access to the formal health sector.23

Malaria risk and burden

The malaria burden in Cambodia has been greatly reduced over the past few years, with confirmed malaria cases experiencing a general decline since 2009 (see Figure X2). However, of Cambodia’s 25 provinces, 21 are still considered to be endemic, and an estimated 48% of the population, or approximately 7.4 million people, live in high transmission areas.24 Malaria incidence is highest in the northeastern regions of the country (see Figure X3). In 2014, public health facilities reported 26,278 total treated cases, 1,515 severe cases and 18 reported deaths from malaria, with around 55% of confirmed cases being Plasmodium falciparum (Pf) malaria, and 44% being Plasmodium vivax (Pv) malaria.25 Roughly 29,993 and 15,894 cases were reported treated by VMWs and in the private sector, respectively.26 The proportion of cases due to Pf versus Pv is variable across the country, with Pf cases being more common in the southwest and northeast, and Pv cases dominating the northwest and central regions. Transmission of malaria in Cambodia is associated with the rainy season, which occurs from May until October, peaking around August/September, and the primary malaria vectors are the Anopeheles dirus, A. minimus, A. maculatus, and A. sundaicus mosquito species.27

19 Bigdeli, M., & Annear, P.L. (2009). Barriers to access and the purchasing function of health equity funds: lessons from Cambodia. Bulletin of the World Health Organization 2009;87:560-564. doi: 10.2471/BLT.08.053058 20 Ibid 21 National Institute of Statistics, Directorate General for Health, and ICF International. (2015). Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF International. 22 Ibid 23 Patouillard E, Palafox B, Tougher S, Goodman C, Hanson K, Sochea P, O’Connell K and the ACTwatch Study group. 2012. A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Cambodia, 2009. Nairobi: ACTwatch project, Population Services International. 24 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. 25 National Center for Parasitology, Entomology and Malaria Control (2014). Malaria Situation 2014. Retrieved from http://www.cnm.gov.kh/userfiles/Malaria_Situation_2014.pdf 26 Ibid 27 WHO. (2015). World Malaria Report 2015. Geneva, Switzerland: WHO. www.ACTwatch.info Page 20

Figure X2. Malaria treated cases and deaths (Public Health Facilities), 2009-201528

Figure X3. Malaria confirmed cases per 1000 population, 201529

Artemisinin resistance in Pf malaria, characterized by slow parasite clearance and treatment failure, was observed in northwest Cambodia as early as 2002.30 By 2005, multiple studies had documented high failure rates of artesunate mefloquine (ASMQ), especially near the Thai-Cambodia border.31,32 In 2008 dihydroartemisinin piperaquine (DHA PPQ) was recommended to treat resistant cases. As malaria control efforts intensified between 2008 and 2010 and the number of Pf malaria cases declined, artemisinin drug pressure increased and the proportion of patients treated with DHA PPQ that remained parasitemic on day 3 increased from 26% to 45% between 2008 and 2010.33 In June 2015, DHA PPQ failure rates had surpassed 60% in Siem Reap province.34 Continued high DHA PPQ treatment failure rates prompted the use of atovaquone-proguanil to treat cases in Pailin province and other areas with resistance in western Cambodia in 2012. Less than a year after adopting atovaquone-proguanil, resistance conferring mutations were detected in Pf malaria35, so ASMQ has been reintroduced as the first-line treatment in areas with drug resistance. Malaria case management guidelines

28 National Center for Parasitology, Entomology and Malaria Control (2016). Malaria Situation 2015. Retrieved from http://www.cnm.gov.kh/userfiles/12c_Web_CNM_Malaria situation_2015.pdf 29 Ibid 30 Dondorp, AM, Nosten, F, Yi, P et al. Artemisinin resistance in Plasmodium falciparum malaria. N Engl J Med. 2009; 361: 455–467 31 Denis MB, Tsuyuoka R, Poravuth Y, Narann TS, Seila S, Lim C, et al. Surveillance of the efficacy of artesunate and mefloquine combination for the treatment of uncomplicated falciparum malaria in Cambodia. Trop Med Int Health. 2006;11:1360–6 32 Vijaykadga S, Rojanawatsirivej C, Cholpol S, Phoungmanee D, Nakavej A, Wongsrichanalai C. In vivo sensitivity monitoring of mefl oquine monotherapy and artesunate-mefloquine combinations for the treatment of uncomplicated falciparum malaria in Thailand in 2003. Trop Med Int Health. 2006;11:211–9 33 WHO (2011). Global report on antimalarial efficacy and drug resistance: 2000-2010. 34 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. 35 Cottrell, G., Musset, L., Hubert V., et al. Emergence of Resistance to Atovaquone-Proguanil in Malaria Parasites: Insights from Computational Modeling and Clinical Case Reports. Antimicrobail Agents and Chemotherapy. 2014; 58(8):4504-4514. www.ACTwatch.info Page 21

The 2014 national treatment guidelines state that all suspected malaria cases should receive parasite-based diagnosis, and no treatment should be initiated until diagnosis is confirmed except in cases of severe malaria.36 The recommended first-line treatment for uncomplicated malaria in adults is fixed dose combination DHA PPQ (40mg/320mg) or ASMQ (25mg/50mg or 100mg/200mg) for Pf, Pv, Plasmodium ovale (Po) and malariae (Pm) malaria. ASMQ is to be used in all provinces with drug resistance but is being considered for use throughout the whole country. However, there have been challenges surrounding procurement of ASMQ, with the manufacturer being unwilling to produce such low quantities of pediatric ASMQ.37 In addition to treatment with DHA PPQ or ASMQ, uncomplicated Pf malaria should be treated with a single low dose of primaquine (PQ) on the first day of artemisinin-based combination therapy (ACT) treatment, while Pv and Po malaria should be treated with a standard dose of PQ on a weekly basis for 8 weeks or daily for 14 days, depending on likelihood of patient adherence. However, use of PQ has not yet been implemented beyond a few sentinel sites, due to challenges surrounding glucose-6-phosphate dehydrogenase (G6PD) deficiency and how to regulate use of PQ in the private sector.38

Atovaquone-proguanil is permitted only with special permissions from the National Center for Parasitology Entomology and Malaria Control (CNM) and must be used in combination with another antimalarial drug. The second- line treatment for uncomplicated malaria remains quinine taken with either doxycycline or tetracycyline.

The recommended treatment for severe malaria is intramuscular (IM) artemether, or intravenous or IM artesunate, followed by a full course of DHA PPQ or ASMQ FDC when the patient can swallow. Rectal artesunate suppositories may be given as pre-referral treatment in severe cases that are delayed from immediate admission to a referral hospital. Recommended first-line treatment for malaria in pregnancy is quinine in the first trimester of pregnancy and the recommended ACT (ASMQ or DHA PPQ) in second and third trimesters of pregnancy.

Malaria control and elimination strategies

In 2014, the World Health Organization (WHO) used available evidence about artemisinin resistance to define a 3-tier stratification system for targeting action to address drug resistance. Areas designated as Tier 1 were prioritized for immediate multifaceted response to contain or eliminate resistance. Areas designated as Tier 2 were prioritized for intensified malaria control to reduce transmission and/or limit the risk of emergence or spread of resistant parasites. Tier 3 areas had no evidence of artemisinin resistance and limited contact with Tier 1 areas. Figure X4 displays the distribution of the tiers across the GMS.

36 2014 National Treatment Guidelines for Malaria in the Kingdom of Cambodia. 37 CAP-MALARIA. (2015). Control and Prevention of Malaria (CAP-Malaria), Cambodia, Annual Progress Report (October 1, 2014 to September 30, 2015). Washington, DC: USAID. 38 Ibid www.ACTwatch.info Page 22

Figure X4. WHO Emergency Response to Artemisinin Resistance Tier Map, Sep 201439

The 2015 outlet survey in Cambodia was designed according to the WHO tier stratification, with tiers 1 and 2 representing each of the survey domains. At this time, the CNM was using the tier stratifications to guide private sector engagement, with the CNM managing private sector providers in tier 1 provinces and PSK managing those in tier 2 provinces.

However, beginning in 2016, the Cambodia Malaria Elimination Action Framework, 2016-2020 outlines a new stratification system that will be used for operations and targeting, which is based on both evidence of multidrug resistance as well as measures of burden and operational capacity.40 The new strategy for elimination will stratify ODs into one of four categories:

 Elimination-targeted ODs: low average annual parasite index (API; less than 1 per 1000 population), and surrounding ODs with API between 1-10 per 1000 population and either in the same province, with few malaria cases, and/or with little to no evidence of multidrug resistance.  Transitional ODs: API higher than elimination-targeted ODs and evidence of multidrug resistance. Will become elimination-targeted ODs during the following year.  Burden reduction ODs: API more than 10 per 1000 population  Malaria free ODs: no local malaria transmission41

39 WHO GMP (2014). Status report on artemisinin resistance September 2014. 40 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. 41 Ibid www.ACTwatch.info Page 23

Figure X5. 2016 Operational district stratification42

Given progress in malaria control in recent years, Cambodia has set the goal of eliminating malaria by 2025, with the initial focus being on the elimination of Pf by 2020.43 Beginning in 2007, the CNM and its partners have implemented many strategies to contain the spread of artemisinin resistance, such as scaling up the Village Malaria Worker (VMW) program, including training VMWs to administer rapid diagnostic tests (RDTs), directly-observed therapy (DOT) on days 0-2 for test-positive cases, and to prepare blood smears on days 0, 3, 7, and 28 for analysis by a trained laboratory technician.44 VMWs are trained and authorized to manage uncomplicated malaria, malaria in pregnancy, and malaria in children under five but must refer severe/complicated malaria cases to a public health facility for treatment. Since 2009, over 2,000 new VMWs have been trained across 10 new provinces45, covering 2,030 villages by the end of 2013 and present in 44% of villages in ODs with high malaria prevalence.46 The CNM has estimated the hiring and training of an additional 1,100 VMWs by the end of 2016 and 1,965 new VMWs by the end of 2017.47 Additionally, migrant populations have been targeted through a network of Mobile Malaria Workers (MMWs),48 and long-lasting insecticide- treated nets (LLINs) are being distributed through employers of migrant workers.49

Malaria diagnosis and treatment is free in the public sector. The CNM purchases subsidized ACTs through the Global Fund copayment mechanism.50 Historically, Cambodia’s malaria commodities supply chain has experienced frequent stock-outs in both the public and private sector.51 In response, the Malaria Control in Cambodia Project, implemented by University Research Co. LLC (URC), worked with the CNM to integrate RDTs and ACTs into the primary healthcare- related supply chain, leading to a decrease in malaria commodity stock-outs at the health center level.52 In addition, the Malaria Consortium, the Clinton Health Access Initiative (CHAI), and the CNM began piloting an SMS system for

42 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. 43 Ibid 44 University Research Co., LLC (2014). Monitoring drug-Resistant Malaria through Intensified Case Finding at the Village Level in Cambodia. Phnom Penh: University Research Co., LLC. 45 Ibid 46 Maude, R.J., Nguon, C., Bunkea, T., Ngor, P.,…Chuor, C.M. (2014). Spatial and temporal epidemiology of clinical malaria in Cambodia 2004- 2013. Malaria Journal, 13:385. doi:10.1186/1475-2875-13-385 47 CAP-MALARIA. (2015). Control and Prevention of Malaria (CAP-Malaria), Cambodia, Annual Progress Report (October 1, 2014 to September 30, 2015). Washington, DC: USAID. 48 Canavati, S., Chea, N., Guyant, P., Roca-Feltrer, A., & Yeung, S. (2013). Strategy to address migrant and mobile populations for malaria elimination in Cambodia. Ministry of Health Cambodia, London School of Hygiene and Tropical Medicine, Malaria Consortium. 49 University Research Co., LLC (2014). Monitoring drug-Resistant Malaria through Intensified Case Finding at the Village Level in Cambodia. Phnom Penh: University Research Co., LLC. 50 Mellor, S. (2013). Moving towards malaria elimination: developing innovative tools for malaria surveillance in Cambodia. Retrieved from http://www.malariaconsortium.org/pages/learning-papers.htm 51 Patouillard, E., Palafox, B., Tougher, S., Sochea, P., O’Connell, K. & the ACTwatch Study group (2011). ACTwatch 2009 Supply Chain Survey Results, Cambodia. Nairobi: ACTwatch project, PSI 52 University Research Co., LLC (2011). Malaria Control in Cambodia: Advocacy to Improve the Supply Chain for Malaria. Phnom Penh, Cambodia: University Research Co., LLC www.ACTwatch.info Page 24 monitoring drug supplies in 2011, where biweekly stock level reports update a map of participating health centers, providing a visual of impending malaria commodity stock-outs and enabling national staff to reallocate commodities accordingly.53 Currently, the CNM is developing a new system called the Logistic Management Information System (LMIS) which will contain information on quantification, LLIN demand, forecasting, and stock, and which will aim to provide monthly rather than quarterly reports.54

Current behavior change communication (BCC) strategies in Cambodia strive to deliver culturally-appropriate and gender-sensitive communication surrounding malaria prevention.55 In early 2015, a technical working group was formed with the aim of developing updated and adaptive BCC strategies for reaching mobile and migrant populations in Cambodia.56 One example is the training of monks, nuns, and elderly women in Battambang Province to provide malaria education to mobile migrants visiting local pagodas.57 CAP-Malaria delivers BCC using strategies that consider social and occupational differences, including the likelihood of men working in forested areas and the higher risks associated with pregnancy.58 PSI regularly delivers communications surrounding the appropriate use of malaria commodities in order to generate demand by consumers and providers, including TV, radio, and billboard advertising coinciding with product launches, distribution of point-of-sale educational materials, short films screened in rural areas, and medical detailing to educate and support providers.59 Finally, a positive deviance project in northwest Cambodia aiming to increase informed demand and improve behaviors surrounding malaria prevention, diagnosis, and treatment found that community role models can be effective tools for achieving these outcomes.60

Private sector engagement and regulation

There has been a continued and increasing regulation of antimalarial sales in the private sector. Following a ban on import and sales of oral artemisinin monotherapies (AMTs) in 2009, the Cambodian Ministry of Health created the “Justice Police”, giving them the authority to close down pharmacies found to be selling oral AMTs or counterfeit, substandard, or expired drugs.61 In 2013 and 2015, the ACTwatch Outlet Survey found no oral AMT sold or distributed in Cambodia, suggesting that regulatory efforts have been highly effective.62,63

Malaria diagnosis and treatment is highly subsidized in the private sector. Population Services International (PSI) has managed a nationwide subsidized private sector malaria treatment program in Cambodia since 2003, reaching approximately 1,500 outlets per month through sales representatives by the end of 2013.64 As of 2016, PSI provides licensed private providers (health facilities) access to subsidized ASMQ in nine provinces with demonstrated drug resistance and DHA PPQ (Eurartesim®) in 12 provinces where DHA PPQ remains efficacious. Subsidized RDTs were sold under the brand name Malacheck® until 2014, which initially just tested for Pf infections. In 2010, the diagnostic kit changed to test for both Pf and Pv infections and is currently sold unbranded, in line with the national program. Licensed private sector providers are authorized to test and treat uncomplicated malaria regardless of geographic location, but they are required to refer cases of severe malaria, pregnant women, children under five years of age, and cases of suspected treatment failure to a public health facility. In addition, since 2013, PSI and other partners have

53 Mellor, S. (2013). Moving towards malaria elimination: developing innovative tools for malaria surveillance in Cambodia. Retrieved from http://www.malariaconsortium.org/pages/learning-papers.htm 54 USAID-PMI. (2016). President’s Malaria Initiative, Greater Mekong Sub-region, Malaria Operational Plan FY 2016. Washington, DC: USAID. 55 Cambodia Country Coordinating Mechanism (CCM) (2009). Proposal Form – Round 9. Submission to the Global Fund to Fight AIDS, Tuberculosis and Marlaria, Geneva, Switzerland. 56 WHO (2015). Behaviour change communication is a key tool for reaching mobile migrant populations. Retrieved from http://www.who.int/malaria/areas/greater_mekong/lao-pdr-behaviour-change-communication/en/ 57 Ibid 58 CAP-Malaria (2012). Vector control. Retrieved from http://capmalaria.org/about-us/what-we-do/vector-control 59 Montagu, D. (2010). Large-Scale Malaria Treatment in the Private Sector: A Case Study of the Cambodian Experience. San Francisco: The Global Health Group, Global Health Sciences, University of California, San Francisco. 60 Shafique, M., & George, S. (2014). Positive deviance: An asset-based approach to improve malaria outcomes. Retrieved from: http://www.malariaconsortium.org/media-downloads/301 61 Asia Pacific Leaders Malaria Alliance (2014). The Cambodia Justice Police: Pragmatic approaches can work to clamp down on monotherapies and counterfeit drugs. Poster presented at the 2nd Access to Quality Medicines and Other Technologies Task Force (AQTMF) Meeting, Manila, Philippines. 62 ACTwatch Group, PSK. (2014). ACTwatch Study Reference Document: Cambodia Outlet Survey 2013. Washington DC: PSI 63 ACTwatch Group, PSK. (2016). ACTwatch Study Reference Document: Cambodia Outlet Survey 2015. Washington DC: PSI 64 ACTwatch Group, Novotny, J., Singh, A., Dysoley, L., Sovannaroth, S., & Rekol, H. (2016). Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys. Malaria Journal, 15:194. doi: 10.1186/s12936-016-1200-2 www.ACTwatch.info Page 25 established a network of plantation malaria workers (PMWs) throughout Cambodia, who are provided with the necessary training and supplies for malaria diagnosis and treatment and can in turn provide free malaria case management to plantation workers. The PMWs are required to report their cases either monthly or every 3 months (depending on the supervisory organization) in exchange for new supplies.65,66

In 2011, the CNM and the Ministry of Health (MoH) established a public-private partnership (PPM) program to further engage the private sector and provide commodities, training, and supervision to registered PPM providers.67 The PPM program also allows for collection of case-load reports from PPM providers. The program was scaled up in 2013, and by the end of 2014, in partnership with PSI and URC, there were nearly 1,200 registered PPM providers in 34 ODs out of a total of 45 malaria endemic ODs.68

The national strategic plan outlines increasingly regulated private sector involvement in malaria case management from 2016 to 2020. There has been an effort to strengthen PPM in order to improve quality of care for malaria cases. This mechanism aims to train licensed and registered private providers who provide malaria case management on appropriate malaria diagnosis, treatment, and referral procedures, allowing for a more regulated inclusion of the private sector in case management while still adhering to national guidelines.69 Beginning in 2016, a two pronged PPM strategy will offer an adjusted approach for provinces with evidence of multi-drug resistance (formerly tier 1 provinces). These nine provinces will be managed by CNM, and private providers will attend bimonthly meetings at the OD, where they will be supplied with free malaria commodities in exchange for the submission of used RDTs and paper reports.70,71 In addition to mandatory attendance at bimonthly meetings, CNM’s PPMs will adhere to a policy of quality assurance checks by the OD health centers. Private providers in other provinces (formerly tier 2 provinces) will be managed by PSK, utilizing the original methodology that has proven successful since 2013. Private providers will be sold RDTs and ACTs by PSK sales teams, at their place of work and at a subsidized price, submitting either paper based or electronic reports, used RDTs, and participating in scheduled Quality Assurance assessments and biannual refresher trainings. In 2018, once both methodologies of the PPM program have been evaluated, the PSK network will begin to transition the management of private providers to CNM.72

Additionally, the CNM plans to map both licensed and unlicensed private providers, and all eligible providers will be encouraged to join the PPM network.73 Unlicensed providers who do not qualify for enrollment in the PPM program will not be permitted to provide malaria case management or to sell malaria commodities.74 These new strategies for the PPM network aim to bring in more qualified private providers into the system in order to improve oversight, provision of commodities, and quality of national data.

65 Partners for Development. (2015). The Role of Partners for Development in Malaria Prevention and Control in Cambodia, 2004-2014. Phnom Penh: Partners for Development. 66 PSI/Cambodia. (2015). Interventions in Private Plantations in Cambodia: Bringing malaria services – prevention, diagnosis, treatment and referral – to communities at risk [PowerPoint slides]. Retrieved from: http://static1.1.sqspcdn.com/static/f/471029/26204246/1430965269273/Session9_Pratt_PSI_Plantations_apmen.pdf?token=HS4oZoWXdRin SyWjCvBV3BPwv8Y%3D 67 Ibid 68 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. 69 Malaria Consortium (2013). Private sector SMS referral system pilot. Cambodia: Malaria Consortium. 70 Akhlaghi, Laila, and Michael Egharevba. (2015). Technical Report: CAMBODIA: Malaria Commodities Quantification 2016-2017. Arlington, VA: USAID | DELIVER PROJECT, Task Orders 7. 71 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. 72 Ibid 73 ACTwatch Group, Novotny, J., Singh, A., Dysoley, L., Sovannaroth, S., & Rekol, H. (2016). Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys. Malaria Journal, 15:194. doi: 10.1186/s12936-016-1200-2 74 Kingdom of Cambodia Ministry of Health. (2016). Malaria elimination action framework 2016–2020. Phnom Penh: Ministry of Health. www.ACTwatch.info Page 26

Annex 3: Case Management Survey Methods

Design and Study Population

The study population for the Case Management (CM) survey included providers and patients seeking fever treatment at private sector outlets including private for-profit health facilities (hospitals, clinics and cabinets), pharmacies (clinical pharmacies, pharmacies, depot A, and depot B), drug stores, and itinerant drug vendors. The Fever CM survey was concerned with the management of suspected malaria cases in people age 15 and above. Criteria in the National Treatment Guidelines for Malaria in Cambodia were used to identify patients that should receive a malaria blood test. According to the most recent version of the national guidelines dated December, 2014, criteria for malaria diagnostic testing include: fever, chills or sweats, and/or two of the following: headache, nausea, vomiting, diarrhea, forest travel in the past one month, confirmed malaria in the past month, travel to a malaria endemic area from a non-endemic area, and live or work around others with a recently confirmed malaria diagnosis.

The CM study was a cross-sectional quantitative survey with a patient consultation observation component and a patient exit interview component.

The CM Survey was conducted as part of the 2015 ACTwatch national Outlet Survey in Cambodia. Methods and results from the 2015 outlet survey are summarized in the 2015 Outlet Survey Report available at www.actwatch.info. Briefly, a census of all outlets with the potential to provide malaria testing or treatment was completed within 160 communes. In Cambodia, censused outlet types included: public health facilities, community health workers (e.g. Village Malaria Workers), private not-for-profit health facilities, private for-profit health facilities, pharmacies, drug stores and itinerant drug vendors. Outlets with malaria testing and/or treatment available on the day of the survey or within the past three months were eligible for a full interview. The interview included an audit/inventory of all available antimalarial medicines, malaria rapid diagnostic tests, and malaria microscopy services. The interview also included a provider module to assess fever case management knowledge and practices. The study was designed to provide national estimates as well as estimates for malaria control and elimination zones designated as Tier 1 and Tier 2. Key indicators include malaria testing and treatment availability, price and market share.

Private sector outlets identified during the Outlet Survey that met study eligibility criteria were included in the CM study.

Eligibility Criteria

Private for-profit health facilities, pharmacies, drug shops and itinerant drug vendors were eligible for the CM study if they had ACT in stock on the day of the survey and if they had malaria blood testing available on the day of the survey. All public sector outlets (government and non-government not-for-profit facilities and CHWs) as well as private sector outlets that did not have ACT and malaria blood testing available were excluded from the study.

The CM study included observation and interviews with patients seeking care for symptoms associated with suspected malaria. Clients seeking treatment for these symptoms at an eligible outlet were invited to participate in the study if they met the following eligibility criteria:  Patient age 15 or older  Illness that includes fever or history of fever, chills or sweats, and/or forest travel in the past one month, and/or confirmed malaria diagnosis in the past one month  Presenting for treatment for this illness at this outlet for the first time  Illness that is not severe, defined as response of “yes” to a question regarding referral for this illness to a doctor or health facility because this illness is very severe or life threatening.  Women of reproductive age who do not respond “yes” to the question, “are you currently pregnant.”  Provides consent to participate in the study

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Sample Size

Sample size calculations specifically for the CM study were not completed. A series of calculations was completed to identify minimum sample size requirements for the outlet survey. Details are available in the outlet survey report (www.actwatch.info).

Sampling

Eligible CM outlets were identified in the course of the national ACTwatch outlet survey. Outlets eligible for the CM survey included private for-profit health facilities, pharmacies, drug shops, and itinerant drug vendors. Where the outlet survey identified these outlet types with ACT and malaria blood testing available on the day of the survey, dedicated fieldworkers trained in the CM survey were deployed the following day.

Among eligible outlets with consenting providers, patients seeking treatment for symptoms consistent with suspected malaria were sampled for inclusion in the study. All patients meeting eligibility criteria as outlined above were invited to participate in the study until a quota of one person age 15 and above participated in the study at a given outlet. Fieldworkers conducted patient screening at eligible outlets for two days during which if the patient quota was not met, the field team moved to the next outlet.

Data Collection

Interviewers, supervisors, and quality controllers received training that included an orientation to the study, questionnaire, classroom training on completing observation and exit interviews, and a field exercise. Following training, data collection was implemented from August 27th to October 1st, 2015.

The CM survey team typically revisited eligible outlets identified during the outlet survey within a few days after completing the outlet survey, and spent two days screening patients at the outlet. Members of the survey team were stationed outside of the outlet for patient screening. As each individual approached the outlet, a member of the survey team asked the patient for permission to administer a set of screening questions. The screening questions were administered to determine eligibility for the survey according to criteria summarized above.

Following informed consent procedures, a structured observation checklist was completed by an interviewer observing the interactions that the patient had with providers as she/he was provided with services at the outlet. The observation was concerned primarily with provider behaviors including assessment, proper RDT administration, and counseling for treatment with ACT. A brief exit interview was completed with the patient after the patient visit was complete. The exit interview was concerned with capturing information about all medicines prescribed/obtained, and assessing patient understanding of the test result(s), diagnosis, and medication regimens prescribed. The full CM questionnaire is available in Annex 5.

If the primary provider (responsible for diagnosis and treatment of the patient) was not interviewed as part of the outlet survey, then he/she was asked a brief series of questions to assess provider demographic characteristics, qualifications, training, and knowledge of the first-line treatment. Providers who were interviewed as part of the outlet survey had already completed these questions as part of the outlet survey.

Data Entry, Processing, and Analysis

Data collection was paper-based. Double data entry was completed using an Access database (©Microsoft, Redmond, WA). All data cleaning and analysis was completed using Stata 13.1 (©StataCorp, College Station, TX). Sampling weights were applied to account for variations in probability of selection (see Annex 6) and standard error estimation accounted for clustering at the sub-district levels. Indicator definitions are provided in Annex 7.

Protection of Human Subjects

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The CM study was submitted for ethical review together with the national outlet survey. The application was reviewed and approved by the Ministry of Health National Ethics Committee as part of the application for approval for the 2015 national Outlet Survey. The PSI Research Ethics Board ceded review to the ethics committee in Cambodia. Provider interviews, patient consultation observation, and patient exit interviews were completed only after administration of a standard informed consent form and patient/provider consent to participate in the study. Patients and providers had the option to end the interview at any point during the study. Standard measures were employed to maintain confidentiality and anonymity.

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Annex 4: Sampled Communes

Table X1. Sampled communes PROVINCE DISTRICT COMMUNE TIER POPULATION BATTAMBANG BANNAN CHAENG MEANCHEY 1 9296 BATTAMBANG BANNAN SNAENG 1 16867 BATTAMBANG BATTAMBANG CHOMKAR SAMRAONG 1 17179 BATTAMBANG BATTAMBANG PREK PREAH SDACH 1 13277 BATTAMBANG BATTAMBANG TOUL TA EK 1 18276 BATTAMBANG BAVEL BAVEL 1 26182 BATTAMBANG BAVEL KHLEANG MEAS 1 11639 BATTAMBANG KAMRIENG KAMRIENG 1 6485 BATTAMBANG KAOS KROLOR HAB 1 2915 BATTAMBANG MOUNG RUESSEI KEAR 1 17703 BATTAMBANG MOUNG RUESSEI PREY TOUCH 1 11314 BATTAMBANG PHNUM PROEK BOUR 1 19603 BATTAMBANG RATANAK MONDUL PHLOV MEAS 1 7431 BATTAMBANG RUKHAK KIRI MUK REAH 1 9052 BATTAMBANG SAMLOUT OU SAMRIL 1 5195 BATTAMBANG SAMPOV LUN SERIE MEANCHEY 1 11901 BATTAMBANG THMOR KOUL CHREY 1 14884 BATTAMBANG THMOR KOUL OU TAKI 1 16158 KAMPONG SPEU AORAL REAKSMEI SAMEAKKI 1 3130 KAMPONG SPEU BASEDTH KAT PHLUK 1 8682 KAMPONG SPEU BASEDTH POU ANGKRANG 1 16540 KAMPONG SPEU BASEDTH TUOL AMPIL 1 10678 KAMPONG SPEU CHBAR MON SOPOAR TEP 1 7129 KAMPONG SPEU KONG PISEI PREAH NIPEAN 1 13668 KAMPONG SPEU KONG PISEI SNAM KRAPEU 1 13453 KAMPONG SPEU ODONGK CHEUNG ROAS 1 7339 KAMPONG SPEU ODONGK PEANG LVEA 1 8224 KAMPONG SPEU ODONGK VEAL PONG 1 13657 KAMPONG SPEU PHNUM SRUOCH KRANG DEI VAY 1 7457 KAMPONG SPEU PHNUM SRUOCH TANG SYA 1 9665 KAMPONG SPEU SAMRAONG TONG PNEAY 1 12349 KAMPONG SPEU SAMRAONG TONG SAMBOUR 1 8811 KAMPONG SPEU SAMRAONG TONG TRAPEANG KONG 1 15647 KAMPONG SPEU THPONG PRAMBEI MUM 1 10520 KAMPONG THOM BARAY BALLANGK 1 16310 KAMPONG THOM BARAY CHHUK KHSACH 1 13825 KAMPONG THOM BARAY KOKIR THUM 1 9099 KAMPONG THOM BARAY TNAOT CHUM 1 8727 KAMPONG THOM KAMPONG SVAY KAMPONG SVAY 1 14027 KAMPONG THOM KAMPONG SVAY TBAENG 1 14234 KAMPONG THOM PRASAT BALLANGK SAKREAM 1 9378 KAMPONG THOM PRASAT SAMBOUR SAMBOUR 1 13818 KAMPONG THOM SANDAN NGAN 1 8001 KAMPONG THOM SANTUK KAMPONG THMA 1 9397 KAMPONG THOM SANTUK TI POU 1 9728 KAMPONG THOM STOUNG KAMPONG CHEN CHEUNG 1 6995 KAMPONG THOM STOUNG PREAH DAMREI 1 5974 KAMPONG THOM STUENG SAEN KAMPONG KRABAU 1 4794 KAMPOT CHHUK DOUN YAY 1 6394 KAMPOT CHHUK TAKAEN 1 11277 KAMPOT CHUM KIRI CHUMPU VOAN 1 8217 KAMPOT DANG TONG DAMNAK SOKRAM 1 3958

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KAMPOT KAMPOT KAMPONG BAY 1 5447 KAMPOT TUEK CHHOU KANDAOL 1 12310 KAMPOT TUEK CHHOU PREY THNANG 1 9833 KRATIE CHETR BOREI DAR 1 9263 KRATIE CHHLOUNG CHHLOUNG 1 6712 KRATIE CHHLOUNG PREAEK SAMAN 1 9221 KRATIE PREK PRASAB CHROUY BANTEAY 1 10934 KRATIE PREK PRASAB TA MAO 1 7,928 KRATIE SAMBOUR SANDAN 1 8045 KRATIE SNUOL SRAE CHAR 1 16710 ODDAR MEANCHEY ANLONG VEAENG TRAPEANG TAV 1 7354 ODDAR MEANCHEY CHONG KAL CHEUNG TIEN 1 4291 ODDAR MEANCHEY SAMRAONG KOUN KRIEL 1 18723 ODDAR MEANCHEY TRAPEANG PRASAT TRAPEANG PRASAT 1 19669 PAILIN PAILIN TUOL LVEA 1 6229 PREAH VIHEAR CHEY SAEN S'ANG 1 3103 PREAH VIHEAR CHOAM KSANT PRING THUM 1 2046 PREAH VIHEAR PREAH VIHEAR KAMPONG PRANAK 1 8971 PREAH VIHEAR ROVIENG RUMDAOH 1 3487 PURSAT BAKAN BOENG KHNAR 1 13023 PURSAT BAKAN OU TA PAONG 1 16799 PURSAT BAKAN TA LOU 1 20797 PURSAT KANDIENG KAOH CHUM 1 7559 PURSAT KRAKOR ANLONG TNAOT 1 9858 PURSAT KRAKOR KBAL TRACH 1 10135 PURSAT PHNUM KRAVANH LEACH 1 9193 PURSAT PHNUM KRAVANH SANTREAE 1 5755 PURSAT PURSAT PREY NHI 1 5101 BANTEAY MEANCHEY MALAI TA KONG 2 9692 BANTEAY MEANCHEY OU CHROV SAMRAONG 2 7861 BANTEAY MEANCHEY PHNOM SROK PONLEY 2 10804 BANTEAY MEANCHEY POIY PET PAOY PET 2 54106 BANTEAY MEANCHEY POIY PET PSAR KANDAL 2 22624 BANTEAY MEANCHEY PREAH NEATH PREAH PHNUM LIEB 2 15593 BANTEAY MEANCHEY SEREI SOPHORN PHNIET 2 4464 BANTEAY MEANCHEY SVAY CHEK SVAY CHEK 2 19249 BANTEAY MEANCHEY THMOR POUK KUMRU 2 10394 KAMPONG CHAM CHAMKAR LEU CHAMKAR ANDOUNG 2 16567 KAMPONG CHAM CHAMKAR LEU SVAY TEAB 2 23888 KAMPONG CHAM KANG MEAS PEAM CHI KANG 2 9444 KAMPONG CHAM PREY CHOR BOEUNG NAY 2 15159 KAMPONG CHAM PREY CHOR KROUCH 2 7025 KAMPONG CHAM PREY CHOR THMA PON 2 9602 KAMPONG CHAM STEUNG TRANG KPOUP TANGOUN 2 7951 KAMPONG CHAM STEUNG TRANG PREAK BAK 2 10411 KAMPONG CHHNANG BARIBOUR ANHCHANH RUNG 2 5271 KAMPONG CHHNANG BARIBOUR TRAPEANG CHAN 2 5576 KAMPONG CHHNANG KAMPONG CHHNANG KHSAM 2 6240 KAMPONG CHHNANG KAMPONG LEAENG POU 2 5249 KAMPONG CHHNANG KAMPONG TRALACH CHRES 2 9919 KAMPONG CHHNANG KAMPONG TRALACH THMA EDTH 2 5293 KAMPONG CHHNANG ROLEA B'IER PRASNOEB 2 5475 KAMPONG CHHNANG SAMEAKKI MEAN CHEY CHHEAN LAEUNG 2 4612 KAMPONG CHHNANG SAMEAKKI MEAN CHEY SVAY CHUK 2 9394 KAMPONG CHHNANG TUEK PHOS KRANG SKEAR 2 13703 KEP KAEB OU KRASAR 2 7199 KOH KONG KHEMARA PHOUMIN DANG TONG 2 13388 KOH KONG SRAE AMBEL CHROUY SVAY 2 4334 www.ACTwatch.info Page 31

MONDULKIRI KAOH NHEAEK NANG KHI LIK 2 3202 RATANAKIRI BAN LUNG BOENG KANSAENG 2 8753 RATANAKIRI BAR KAEV TING CHAK 2 2842 RATANAKIRI OU CHUM OU CHUM 2 4153 SIEM REAP ANGKOR CHUM CHAR CHHUK 2 9435 SIEM REAP ANGKOR CHUM TA SAOM 2 9780 SIEM REAP BANTEAY SREI PREAH DAK 2 8058 SIEM REAP CHI KRAENG KAMPONG KDEI 2 12280 SIEM REAP CHI KRAENG LVEAENG RUESSEI 2 14573 SIEM REAP CHI KRAENG SANGVAEUY 2 14969 SIEM REAP KRALANH SAMBUOR 2 6953 SIEM REAP PRASAT BAKONG KANDAEK 2 13463 SIEM REAP PUOK KAEV POAR 2 7294 SIEM REAP PUOK PUOK 2 14768 SIEM REAP PUOK TREI NHOAR 2 10175 SIEM REAP SIEM REAP KOK CHAK 2 23427 SIEM REAP SIEM REAP SLA KRAM 2 18263 SIEM REAP SIEM REAP SRANGAE 2 6944 SIEM REAP SOUTR NIKOM CHAN SA 2 9112 SIEM REAP SOUTR NIKOM KHCHAS 2 8656 SIEM REAP SREI SNAM CHROUY NEANG NGUON 2 6872 SIEM REAP SVAY LEU SVAY LEU 2 9490 SIHANOUKVILLE KAMPONG SEILA KAMPONG SEILA 2 6574 SIHANOUKVILLE PREAH SIHANOUK BUON 2 24017 SIHANOUKVILLE PREY NOB CHEUNG KOU 2 10227 SIHANOUKVILLE PREY NOB TUEK THLA 2 5123 STUNG TRENG SESAN TA LAT 2 3130 STUNG TRENG STUENG TRAENG SRAH RUESSEI 2 3714 TAKEO BOREI CHOLSAR DOUNG KHPOS 2 6756 TAKEO KAOH ANDAET PREY YUTHKA 2 4212 TAKEO KIRI VONG KOUK PRECH 2 14274 TAKEO KIRI VONG PREY RUMDENG 2 10273 TAKEO PREY KABBAS PREY PHDAU 2 10326 TAKEO TRAM KAK KUS 2 15280 TAKEO TRAM KAK TRAM KAK 2 12925 TAKEO TREANG ANGKANH 2 6136 TBONG KHMUM DAMBAE CHONG CHEACH 2 16433 TBONG KHMUM DAMBAE TRAPEANG PRING 2 16073 TBONG KHMUM KROUCH CHHMAR KAMPONG TREAS 2 10007 TBONG KHMUM KROUCH CHHMAR TREA 2 9820 TBONG KHMUM MEMOT CHOAM TA MAU 2 9445 TBONG KHMUM MEMOT MEMOT 2 15098 TBONG KHMUM MEMOT TRAMUNG 2 13052 TBONG KHMUM PONHEA KRAEK KANDAOL CHRUM 2 19987 TBONG KHMUM PONHEA KRAEK KRAEK 2 37590 TBONG KHMUM PONHEA KRAEK VEAL MLU 2 7549 TBONG KHMUM TBOUNG KHMUM ANHCHAEUM 2 13226 TBONG KHMUM TBOUNG KHMUM CHOB 2 20694 TBONG KHMUM TBOUNG KHMUM ROKA PO PRAM 2 30120 TBONG KHMUM TBOUNG KHMUM THMA PECH 2 15365

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Figure X2: Additional Maps of sampled areas

Country Outlet Survey, 2015 www.ACTwatch.info Page 33 OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___]

Annex 5: Questionnaire

1. Outlet Information and Provider Consent Outlet Survey ID copied from the outlet survey [___|___]-[___|___|___]-[___|___|___]-[___|___|___]

Q1. Today’s date (dd/mm/yyyy) [___|___]-[___|___]-[_2_|_0_|_1_|_5_]

Q2. Observer’s name [______] Q2a. Interviewer’s code [___|___]

Q3. District [______] Q3a. District code [___|___|___]

Q4. Commune [______] Q4a. Commune code [___|___|___]

Q5. Village [______] Q6. Name of outlet If no name, record “no name” or owner’s name

[______] Q6a. Outlet code [___|___|___] Q7. Type of Outlet 09 Private Hospital 10 Private Clinic / Poly Clinic 11 Clinical Pharmacy / Pharmacy 12 Depot A 13 Depot B [___|___] 14 Cabinet / Health care room 15 Drug Store 18 Mobile Provider - only mobile 19 Mobile Provider - fixed clinic/base + mobile If not 18 and not 19 then skip to consent. Q7a. Have you ever worked at a government or private health facility or pharmacy? 1 = Yes 0 = No Go to consent [___] 7 = Refused Q7b. Do you currently work at a government or private health facility or pharmacy? 1 = Yes [___] 0 = No 7 = Refused Find the provider who was interviewed for the outlet survey. If he/she is not available, speak with the senior member of staff responsible for client services present at the outlet/facility.

Administer the informed consent.

Does the provider consent to proceed with the study? [___]

1 = Yes Go to Patient/Respondent Consent

0 = No Go to Q8

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___]

Date Visit 1 Visit 2 Visit 3 (dd/mm/yy) [___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_] Q7c. Record the number of patients who refused [___|___] [___|___] [___|___] screening Q8. Were patients screened [___] [___] [___] at this outlet? 1 = Yes 0 = No Go to Q11 Q9. Record the number of [___|___] [___|___] [___|___] screened patients Q10. Was a full questionnaire completed? [___] [___] [___] 1 = Yes Go to Q13 0 = No Go to Q12a Q11. Why were no patients [___|___] [___|___] [___|___] screened at this outlet? 01 Provider refusal Go to Q12

02 Outlet closed all day Go to Q12a 03 No visitors to this outlet all day Go to Q12a 04 All patients refused screening Go to Q12a 96 Other specify: [______] Go to Q12a

Q12. Reason for refusal [___|___] [___|___] [___|___]

01 Do not have time Ask respondent for a time they would prefer and note in Q12a

02 Do not want clients observed / interviewed Go to Q13 03 No reason given Go to Q13 96 Other specify: [______] Go to Q13 Q12a. Use this space to record call back details.

Q13. Ask the senior-most provider/outlet owner: How many patients with fever come to this outlet in an average week this time of year? [___|___] 97 = Refused Thank the provider.

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] 2. Patient / Respondent Consent Complete 1 form per person screened. Do not screen patients that appear to be 10 years of age or younger (i.e. no young children or babies).

F1. Patient name [______] F1a. Patient code [___|___]

Hello, my name is ______, I work on behalf of PSK. We are conducting an anonymous survey about services for fever in this community. The results will be used to make sure that the services for patients in this community are the best they can be. I would like to ask you a few questions to see if you could be part of the survey. F1b. Does respondent agree to be screened?

1 = Yes [___] 0 = No End the interview

F2. Are you (respondent) 15 years of age or older?

1 = Yes [___] 0 = No End the interview

F3. Did you come to this outlet looking for treatment for an illness that includes fever, either for yourself or on behalf of someone else? [___] 1 = Yes fever Go to F4 0 = No fever

F3_1. Did you come to this outlet looking for treatment for an illness that includes chills, either for yourself or on behalf of someone else? [___] 1 = Yes chills Go to F4 0 = No chills

F3_2. Did you come to this outlet looking for treatment for an illness that includes sweats, either for yourself or on behalf of someone else? [___] 1 = Yes sweats Go to F4 0 = No sweats

F3_3. Have you or has the person you are seeking treatment for traveled to the forest within the past month? [___] 1 = Yes forest Go to F4 0 = No forest F3_4. Have you or has the person you are seeking treatment for had confirmed malaria within the past month? [___] 1 = Yes malaria 0 = No malaria End the interview

F4. Are you seeking treatment for yourself or for another person?

1 = Self [___] 2 = Other person Go to F6 3 = Both self and another person

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] F5. Are you coming here today for the first time for the current illness? Or have you come here before today for current illness and this is a follow-up visit?

1 = First time visit for the current illness Go to F7 0 = Not the first time visit for the current illness; follow up End the interview 8 = Don’t know Go to F7 [___]

F6. Is care for the patient being sought here today for the first time for the current illness? Or has care been sought here for the patient before today for current illness and this is a follow-up visit?

1 = First time visit for the current illness [___] 0 = Not the first time visit for the current illness; follow up End the interview 8 = Don’t know

F7 . Is the patient 15 years of age or older?

1 = Yes [___] 0 = No End the interview

F8. Is the patient currently pregnant?

1 = Yes End the interview 0 = No [___] 5 = N/A (if the patient is male) 8 = Don’t know F9. Has the patient been referred for this illness to a doctor or health facility because this illness is very serious or severe (threatening the life of the patient)?

1 = Yes End the interview [___] 0 = No 8 = Don’t know Patient consent

Administer the informed consent. [___]

Does the patient consent to proceed with the study?

1 = Yes Proceed to observation. 0 = No Thank the respondent and screen the next patient.

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] 3. Observation Code Provider N/A 1=yes 0=no 5=N/A At any time during the visit, did a provider: patient Yes No 8=Observer does not not recall present or does not know O1 Ask about symptoms of the illness [___] O2 Ask if the patient has fever / history of fever [___] O3 Ask if the patient has had malaria in the past 6 weeks [___] O4 Ask about signs of severe illness (convulsions, unable to eat or drink, vomiting [___] everything) O5 Ask if the patient has recently traveled to another area [___] O6 Ask for the patient’s weight or age [___] O7 Weigh the patient using a scale [___] O8 Take body temperature with a thermometer [___] O9 Recommend/offer a blood test for malaria (even if test was refused) [___]

O10 Take blood from a patient’s arm using a needle [___] O11 Recommend/offer any specific treatment to the patient (even if the treatment was refused) [___]

O12 Give a prescription for medicine to be dispensed at another outlet/facility [___]

O13 Dispense/sell any medicine for home use for the patient [___]

O14 Cut a blister / dispense a partial blister of medicine for the patient [___] O15 Combine individual tablets together in a small bag to create a drug cocktail for the patient [___] O16 Give the patient medicine by injection (inject medicine into the patient) [___]

O17 Give the patient medicine or fluid by intra-venous (IV) [___] O18 Refer the patient to a(another) doctor or health facility [___] O19 Give the patient a diagnosis [___] O20 Record the diagnosis 5 = N/A no diagnosis a.

8 = Observer does not recall b.

c.

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] d. O21 Perform a rapid test for G6PD deficiency

[___]

N/A ACT ACT Medicine Prescription / Dispensing Code not given 1=yes 0=no 5=N/A Yes No or 8=Observer does not recall Not or does not know prescribed O22 Did the patient receive ACT drug or ACT drug prescription? [___] For patients receiving ACT drug or prescription, at any time during the visit did a provider offer instructions for taking ACT: O23 How much of the medicine to take (quantity) [___] O24 How many times per day to take the medicine [___] O25 How many days to take the medicine [___] O26 Taking medicine with or without food or milk [___] O27 Taking the full course (all medicine until finished) [___] O28 What to do if the patient vomits [___] O29 What to do if the patient does not improve [___] O30 Ask if the client has any questions [___] O31 Offer medicine to the patient to swallow now (even if the patient refused to take medicine now) [___] O32 Instruct the patient to return back to the outlet for follow-up [___]

Patient / Caregiver Code 1=yes 0=no 5=N/A At any time during the visit, did the patient/ N/A not Yes No 8 = Observer does not caregiver: present recall or does not know O33 Request a blood test for malaria [___] O34 Refuse a blood test recommended/offered by the provider [___]

O35 Request treatment for malaria [___] O36 Refuse a treatment recommended/offered by the provider [___]

O37 Swallow the first dose of a medicine dispensed by the provider [___]

O38 Tell a provider about the symptoms of the illness [___] O39 Tell a provider that the patient has fever / history of fever [___]

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

O40 Tell a provider that the patient has signs of severe illness (convulsions, unable to eat or drink, vomiting [___] everything)

Code RDT Test: N/A 1=yes 0=no 5 = At any time during the visit, did the provider: Patient not N/A Yes No present or 8 = Observer does no RDT not recall or does not test know O41 Perform a malaria RDT [___] When performing the RDT, did the Provider: O42 Put on a new/never used pair of gloves [___] O43 Use the patient’s 4th finger or arm [___] O44 Swab the 4th finger or arm with alcohol [___] O45 Open a new/unused blood lancet/needle for the finger/arm prick [___]

O46 Use pipette to collect blood and deposit onto the RDT [___]

O47 Place buffer in the round hole [___] O48 How much time does the provider wait after adding buffer and before reading the result? Start: [___|___| : |___|___] 95 = N/A 98 = Do not know End: [___|___| : |___|___] [___|___] minutes Where were the following discarded 1 = sharps container 2 = waste bin 3 = not discarded 5 = N/A not used 8 = Observer does not recall or does not know 9 = other, specify: [______] O49 Lancet/needle other, specify: [______] [___] O50 Pipette other, specify: [______] [___] O51 RDT cassette other, specify: [______] [___] O52 Gloves other, specify: [______] [___]

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

Code Blood Slide for Microscopy N/A 1=yes 0=no 5=N/A At any time during the visit, did the provider: Patient not Yes No 8 = Observer does not present or recall or does not no BS test know O53 Take a blood slide for malaria microscopy [___] When preparing the blood slide, did the Provider: O54 Wear gloves [___] O55 Swab the finger or arm with alcohol [___] O56 Open a new/unused blood lancet/needle for the finger/arm prick [___] O57 Where was the lancet/needle discarded 1 = sharps container 2 = waste bin 3 = not discarded [___] 4 = other, specify: [______] 5 = N/A 8 = Observer does not recall or does not know

Code Malaria Blood Test Result (RDT or N/A 1=yes 0=no n Microscopy) Patient not 5=N/A Yes No present or 8 = Observer does not no malaria recall or does not test know O58 Did the provider report a test result to the patient? [___] O59 What was the test result reported to the patient

1 = Positive for falciparum (Pf) malaria 2 = Positive for vivax (Pv) malaria 3 = Positive for mixed infection malaria 4 = Positive for malaria – species not specified [___] 0 = Negative for malaria 6 = Not conclusive / not clear / invalid 5 = N/A 8 = Observer does not know / does not recall

O60. How many different providers did the patient interact with [___|___] at the outlet during this visit?

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

O61. Don’t read: Observation Comments

Find a private place outside of the outlet to conduct the Exit Interview with the patient.

4. Exit Interview G1. What age are you today? Write age in years 97 = Refused [___|___] 98 = Don’t know

G2. Don’t read: Is the respondent male or female?

1 = Male [___] 2 = Female

G3. What is the relationship of the respondent to the patient? Respondent is: 01 = Patient / self go to G7 02 = Parent / guardian of the patient 03 = Child of the patient [___|___] 04 = Other family member 05 = Friend / neighbor 96 = Other, specify: [______]

G4. What age is the patient today? Write age in years

97 = Refused [___|___] 98 = Don’t know

G5. Don't read if patient is present: Is the patient male or female?

1 = Male [___] 2 = Female

G6. Don’t read: Is the patient present with the respondent?

1 = Yes [___] 0 = No

G7. What are the patient’s occupations? A Farmer Prompt “anything else” until the respondent is finished. Circle ALL responses given B Worker (construction, factory, plantation) C Forest worker

D Run own business

E Help family business F No occupation G Don’t know X Other, specify: [______] G8. During the last month, did the patient sleep most nights in this commune? “Most nights” means more than half of the nights in the month 1 = Yes [___] 0 = No 8 = Don’t know

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] G9. Has the patient visited an area with forest or near the forest in the past 1 month? 1 = Yes [___] 0 = No

G10. Has the patient had malaria in the past 6 weeks?

1 = yes [___] 0 = no 8 = Don’t know

G11. When did the current illness begin? 00 = Today 01 = Yesterday 02 = 2 days ago 03 = 3 days ago [___|___] 04 = 4 days ago 05 = 5 days ago 06 = 6 days ago 07 = 1 week or longer 98 = Do not recall / do not know

G12. Did the patient seek advice or treatment at any other place for this illness before coming here today?

1 = Yes [___] 0 = No go to G22 8 = Don’t know go to G22

A Village Malaria Worker / Mobile Malaria Worker / G13. Where was the patient taken for care? Plantation Malaria Worker B Traditional Healer Probe: Anywhere else? Circle all mentioned. C Grocery store / Village shop

D Drug shop

E Clinical pharmacy / pharmacy, depot A, depot B F Private hospital / clinic, clinic, cabinet, health care room G Mission / Faith / NGO hospital, clinic H Public / Government hospital, health center, health post X Other, specify: [______] G14. Did the patient receive a blood test for malaria from of these places? 1 = Yes 0 = No go to G16 [___] 8 = Don’t know go to G16

G15. What was the test result or results reported to the patient A Positive for malaria If multiple test results were received, circle all that apply.

B Negative for malaria

C Do not know / do not recall

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] G16. Did the patient receive any medicine from one of these places?

1 = Yes [___] 0 = No go to G18 8 = Don’t know go to G18

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

G17. What medicines were received for this illness? a. Record western medicines only. Record medicines that were for the patient only. b.

Record 8=Don’t know c.

d.

e.

f.

g.

h.

i.

j. G18. Did the patient receive a prescription from of these places for medicines to purchase at another place? 1 = Yes 0 = No go to G20 [___] 8 = Don’t know go to G20

G19. What medicines were prescribed? Ask to see the a. prescription if available and record the medicine. Record western medicines only. Record medicines that were for the patient only. b.

Record 8=Don’t know c.

d.

e.

f.

g.

h.

i.

j. G20. Did the patient receive a referral for the current illness from one of these places? 1 = Yes 0 = No go to G22 [___] 8 = Don’t know go to G22

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

A This outlet / facility G21. Referral to where? B Village Malaria Worker / Mobile Malaria Worker / Probe: Anywhere else? Circle all mentioned. Plantation Malaria Worker C Traditional Healer

D Grocery store / Village shop

E Drug store F Clinical pharmacy / pharmacy, depot A, depot B G Private hospital / clinic, clinic, cabinet, health care room H Mission / Faith / NGO hospital, clinic I Public / Government hospital, health center, health post

X Other, specify: [______] Interviewer to read to the respondent: Now I will ask a few questions regarding your visit here. G22. Did the provider give the patient a diagnosis today? 1 = Yes 0 = No go to G24 [___] 8 = Don’t recall go to G24

G23. What was the diagnosis? a.

97 = Refusal b. 98 = Don’t remember c. d. G24. Did the patient have a blood test for malaria? 1 = Yes 0 = No go to G28 [___] 5 = Not applicable – patient not present go to G28 8 = Don't know go to G28 G25. Was the test an RDT or a blood slide for microscopy? Show prompt card photos 1 = RDT 2 = Microscopy [___] 3 = Both RDT & Microscopy 8 = Don’t know / not sure

G26. What was the test result reported to the patient/caregiver?

1 = Positive for falciparum (Pf) malaria 2 = Positive for vivax (Pv) malaria 3 = Positive for mixed infection malaria 4 = Positive for malaria – species not specified [___] 0 = Negative for malaria 8 = Do not know / do not recall 7 = Refusal

G27. What was the cost of the test? [___|___|___|___|___] KHR Free = 00000 Don’t know = 99998

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OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

G28. Did you receive a prescription for medicine today that you must take to another place to obtain/purchase? 1 = Yes [___] 0 = No go to G30 7 = Refusal go to G30

G29. Ask to see the prescription and record information about each drug. a.

b.

c.

d.

e.

f.

G30. Did you receive any medicines here today? 1 = Yes ask to see the medicines 0 = No go to G31 [___] 7 = Refusal go to G31

G30a. Don’t read: What type(s) of medicines A Tablets were received here today? B Suppository /Granule Record information in TSG audit sheet Circle all that apply C Non-tablet (e.g. injection, syrup, suspension, drops) Record information in NT audit sheet

X Other (specify) [______] G30b. Don’t read: What does the packaging for A Small bag of different loose tablets and/or cut blisters Record the tablets look like? information in Drug Cocktail audit sheet

Circle all that apply B Small bag of tablets – all the same drug Record information in TSG audit sheet C Blister without a box/package Record information in TSG audit sheet D Blister inside a box/package Record information in TSG audit sheet

X Other (specify) [______]

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FCM DRUG COCKTAIL OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

Drug Cocktail Audit Sheet (complete for drug cocktails only) 1. How many different types of tablets are in this cocktail? If the provider dispensed multiple bags of the same combination of tablets for use [___|___] over multiple days, only record information from one bag. types of tablets 98 = Don’t know 2. Record the drug names and number of tablets for all Drug Name # cocktail contents. Tablets

If the provider dispensed multiple bags of the same 1. [___] combination of tablets for use over multiple days, record the total number of tablets from all bags. 2. [___]

Crosscheck the number of drugs recorded with the 3. [___] number recorded in question #1.

98 = Don’t know 4. [___] 5. [___]

6. [___]

7. [___]

8. [___]

9. [___]

10. [___] 3. How much was paid for this cocktail?

[___|___|___|___|___] KHR

Free = 00000 Don’t know = 99998 4. Comments:

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FCM DRUG COCKTAIL OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] FCM Drug Cocktail Audit Sheet [__|__] of [__|__]

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FCM TABLET, SUPPOSITORY, GRANULE (TSG) OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] Product 1. Generic name 2. Strength 3. Dosage 4. Brand name 5. Manufacturer number form/formulation (Include weight and age information) [__|__] [__|__|__] [__|__|__|__|__].[__]mg 1 = Tablet/capsules

[__|__|__] [__|__|__|__|__].[__]mg 2 = Suppository

3 = Granule [__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg [___]

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__] DK=99998.0 6. Country of 7. Does product have 8. Amount 9. Price for this medicine 10. What is the correct way for the patient to take this manufacture the green leaf logo? medicine? The patient received a total of How much was paid for the 1 = Yes medicine? a. How many days? [___|___] 0 = No [___|___|___|___] record 99 for 99 days or more; 98=Don’t know 8 = Don’t know [___|___|___|___|___] KHR tablets/ suppositories/ granule b. How many times per day? [___|___]

sachets Free = 00000 record 99 for variation; 98=Don’t know [___] Including TSG received during Don’t know = 99998 the visit c. How many tablet/suppository/sachet should take at a time? [___|___] . [___] record 99 for variation ; 98=Don’t know [__|__|__] 11. Comments:

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FCM TABLET, SUPPOSITORY, GRANULE (TSG) OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] FCM Tablet Audit Sheet [__|__] of [__|__] Product 1. Generic name 2. Strength 3. Dosage 4. Brand name 5. Manufacturer number form/formulation (Include weight and age information) [__|__] [__|__|__] [__|__|__|__|__].[__]mg 1 = Tablet/capsules

[__|__|__] [__|__|__|__|__].[__]mg 2 = Suppository

3 = Granule [__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg [___]

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__|__] [__|__|__|__|__].[__]mg

[__|__] DK=99998.0 6. Country of 7. Does product have 8. Amount 9. Price for this medicine 10. What is the correct way for the patient to take this manufacture the green leaf logo? medicine? The patient received a total of How much was paid for the 1 = Yes medicine? a. How many days? [___|___] 0 = No [___|___|___|___] record 99 for 99 days or more; 98=Don’t know 8 = Don’t know [___|___|___|___|___] KHR tablets/ suppositories/ granule b. How many times per day? [___|___]

sachets Free = 00000 record 99 for variation; 98=Don’t know [___] Including TSG received during Don’t know = 99998 the visit c. How many tablet/suppository/sachet should take at a time? [___|___] . [___] record 99 for variation ; 98=Don’t know [__|__|__] 11. Comments:

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FCM TABLET, SUPPOSITORY, GRANULE (TSG) OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

FCM Tablet Audit Sheet [__|__] of [__|__]

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FCM NON-TABLET (NT) OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___] Product 1. Generic name 2. Dosage form/formulation 3. Brand name 4. Amount number (Include weight and age 1 = Syrup information) The patient received a total of [__|__] [__|__|__] 2 = Suspension [___|___] [__|__|__] 3 = Liquid injection

4 = Powder injection bottles, ampoules, or vials [__|__|__] 5 = Drops

6 = Other (specify) [______] [__|__|__] Including NT received during the

visit [__|__|__] [___]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__] 5. Price for this medicine 6. What is the correct way for the patient to take this medicine? 7. Comments How much was paid for the medicine? a. How many days? [___|___] record 99 for 99 days or more ; 98=Don’t know [___|___|___|___|___] KHR b. How many times per day? [___|___] Free = 00000 record 99 for variation ; 98=Don’t know Don’t know = 99998

FCM NT Audit Sheet [__|__] of [__|__]

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FCM NON-TABLET (NT) OUTLET: [___|___]-[___|___|___]-[___|___|___]-[___|___|___] PATIENT: [___|___]

Product 1. Generic name 2. Dosage form/formulation 3. Brand name 4. Amount number (Include weight and age 1 = Syrup information) The patient received a total of [__|__] [__|__|__] 2 = Suspension

3 = Liquid injection [___|___] [__|__|__] 4 = Powder injection bottles, ampoules, or vials

[__|__|__] 5 = Drops

6 = Other (specify) [______] Including NT received during the [__|__|__]

visit [__|__|__] [___]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__|__]

[__|__] 5. Price for this medicine 6. What is the correct way for the patient to take this medicine? 7. Comments How much was paid for the medicine? a. How many days? [___|___] record 99 for 99 days or more ; 98=Don’t know [___|___|___|___|___] KHR b. How many times per day? [___|___] Free = 00000 record 99 for variation ; 98=Don’t know Don’t know = 99998

FCM NT Audit Sheet [__|__] of [__|__]

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G31. Did the patient receive any medicine by injection or IV here today? 1 = Yes 0 = No go to G33 [___] 5 = Not applicable – patient not present go to G33 8 = Don’t know go to G33

G32. What medicines were received inside the outlet by injection or IV a. here today? b.

Record 8=Don’t know c.

G33. What is the total amount of money that you paid for the visit here [___|___|___|___|___|___] KHR today including the cost of all medicines, tests, consultation, and Free = 000000 service fees? Refused = 999997 Don’t know = 999998 G34. How knowledgeable are the providers at this place to handle the type of illness that you came here for today? Read ALL. Probe until the respondent chooses a response. 1 = Very knowledgeable 2 = Somewhat knowledgeable [___] 3 = Not very knowledgeable 4 = Not at all knowledgeable

G35. How often do you seek care for this type of illness at this place? Read ALL 1 = Usually 2 = Sometimes [___] 3 = Rarely 4 = Never - Today is the first time G36. Please explain why

G37. Overall how satisfied are you with the care you received here today? Read ALL. Probe until the respondent chooses a response. 1 = Very satisfied [___] 2 = Somewhat satisfied 3 = Somewhat dissatisfied 4 = Very dissatisfied G38. Please explain why

G39. Don’t read: Exit Interview Comments

End of Exit Interview. Thank the respondent and go to Section 5.

5. Provider Information These questions are for the provider who was responsible for prescribing or recommending treatment to the patient. If medicine was not prescribed or recommended, ask the questions of the primary provider who served the client. www.ACTwatch.info Page 55

H1. Interviewer: is the provider for this patient the person who responded to outlet survey questions? 1 = Yes Go to Q7c |___] 0= No

H2. For how many years have you worked in this outlet/facility? If less than 1 year, enter 01 [___|___] H3. What age are you today? Write age in years 97 = Refused [___|___] 98 = Don’t know

H4. Don’t read: Is respondent male or female?

1 = Male [___|___] 2 = Female

H5. What is the highest level of education you completed?

1 = No formal education 2 = Some primary school 3 = Completed primary school 4 = Some secondary school [___] 5 = Completed secondary school 6 = Some university/college 7 = Completed a university/college degree/diploma

H6. Have you received any training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy? Include pre-service training and stand-alone workshops. [___] 1 = Yes 0 = No 8 = Don’t know

H7. Have you received any training in the last 12 months on the national treatment guidelines for malaria? Include pre-service training and stand-alone workshops.

1 = Yes [___] 0 = No 8 = Don’t know

H8. Do you have any of the following health qualifications? Read list. Record 1 for yes, 0 for no

I. Pharmacist [___] II. Medical Doctor [___] III. Nurse / Nursing Officer [___] IV. Midwife [___] V. Laboratory technician / Lab assistant [___] VI. Pharmacy technician / Pharmacy assistant [___] VII. Health Assistant, Nursing Assistant / Nursing Aid [___] VIII. Village Malaria Worker / Mobile Malaria Worker / Plantation Malaria Worker [___]

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Interviewer: For the following questions record the antimalarial brand name or generic name, and dosage form, in the spaces provided. Ask the provider to show you the medicine if it is in stock to verify the name and dosage form.

H10. In your opinion, for treating uncomplicated malaria in adults (60kg), what is the most effective treatment? Ask the provider to show you the medicine(s) if in stock. 1st medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

nd 2 medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

rd 3 medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

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H12. What treatment for treating uncomplicated malaria in adults (60kg) do you most often recommend to customers? Ask the provider to show you the medicine(s) if in stock. 1st medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

2nd medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

3rd medicine Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

H16. Please name the first line treatment recommended by the government to treat uncomplicated malaria for an adult (60kg).

Do not read list. Circle ALL responses given.

Artesunate Mefloquine (A+M, Malarine) A Dihydroartemisinin Piperaquine (Duo-cotecxin, Eurartesim) B Primaquine C Atovaquone-Proguanil (Malarone) D Artesunate Pyronaridine E Other specify: [______] X Don’t know Z

Go to Q7c.

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Annex 6: Sampling Weights

Sampling weights were applied for analysis of the Cambodia 2015 outlet survey data to account for variations in probability of selection as a result of the sampling design:

1) Stratification: Disproportionate allocation stratification was used to ensure adequate sample size within each of two research domains to allow for domain-specific estimates. The research domains were based on the WHO tier stratification system for targeting action to address drug resistance. A representative sample was selected within each domain.

2) One-stage cluster sampling: Communes were selected from sampling frames within each domain with probability proportional to size. Within each commune, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted.

The sampling weights applied during analysis are the inverse of the probability of selection:

1 푊푖 = M a × α ∑ Mα

Where:

 Mα = estimated cluster (population size)  ΣMα = sum of estimated cluster sizes (population size) in the entire stratum  a = number of clusters selected within the stratum

Sampling weights were calculated at the cluster level and were applied to all outlets within a given cluster, irrespective of outlet type.

The population estimates used to select communes with PPS and to create sampling weights were obtained from a 2010 Ministry of Planning projection based on findings from the 2008 national census. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size.

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Annex 7: Indicator Definitions

Table 1: Description of outlets

Table 1 provides a description of outlets that had one or two patients with a completed observation and exit interview. This includes the type of outlet, location (Tier 1 or Tier 2), types of malaria testing and treatment available at the time of the outlet survey, and provider malaria case management training.

Numerator Number of outlets that meet criteria for each of the stated indicators (e.g. outlet type: number of outlets within each of three outlet categories – private for-profit health facility, pharmacy, and drug store).

Denominator Number of outlets with one or two patients who completed observation and exit interview components.

Calculation Numerator divided by denominator.

Handling Outlets with missing information for provider training do not contribute to the indicator. missing values Notes and considerations

Table 2: Description of patients, by outlet type

Table 2 provides a description of patients who were eligible for the CM study and had completed observation and exit interview components. This includes where the patient was seeking treatment (outlet type, location); patient age and sex; whether or not the patient was present at the consultation; whether or not the patient reported recent forest travel; and whether or not fever symptoms were reported during the consultation. The table also summarizes previous treatment seeking for the current illness, including where treatment was sought previously and if malaria testing and/or treatment was received.

Numerator Number of patients that meet criteria for each of the stated indicators (e.g. outlet type: number of patients within each of three outlet categories – private for-profit health facility, pharmacy, and drug store).

Denominator Number of patients eligible for the study with completed observation and exit interview components.

Calculation Numerator divided by denominator.

Handling Patients with missing information for a specific indicator will not contribute to the indicator. missing values Responses of “don’t know” will be excluded from indicators for patient age, previous treatment seeking, and previous treatment for the current illness.

Notes and Patient information is self-report and was captured during the exit interview, with the exception considerations of field worker observation of whether or not fever was reported to the provider during the consultation observation.

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Table 3: Malaria blood testing and test result, by outlet type

Table 3 reports testing indicators for all patients, including any test and type of test (RDT, microscopy). The table also includes an indicator constructed from observation data indicating whether or not a provider recommended testing but the patient refused. Test result is reported among patients who were tested for malaria.

Numerator a. Number of patients that received a malaria test, including any test, RDT, and microscopy. b. Number of patients who received a provider recommendation to test but refused testing. c. Number of patients who tested positive for malaria, including any infection, Pf, Pv, or mixed infection.

Denominator a & b. Number of patients with completed observation and exit interview components. c. Number of patients tested for malaria.

Calculation Numerator divided by denominator.

Handling Patients with missing information for a specific indicator will not contribute to the indicator. This missing values includes any instances of an observer report of “do not recall.”

Notes and Malaria blood testing and test result was recorded by the fieldworker during the consultation considerations observation. The fieldworker observed reporting of the test result to the patient and/or the result captured on a patient health card/record.

Table 4: Antimalarial treatment by test result

Table 4 reports the proportion of patients who received ACT treatment (DHA PPQ) among patients who tested positive, tested negative, or were not tested for malaria.

Numerator By test status/result, the number of patients who: a) received DHA PPQ; and b) received a prescription for ACT.

Total number of patients within each testing status/result group (tested positive, tested negative, not tested).

Calculation Numerator for each outlet type divided by the denominator.

Handling Patients with missing information about testing or test result are excluded from the indicator. missing values Notes and Treatment received and prescriptions received were captured during the patient exit interview. considerations

Table 5: Patient comprehension of malaria diagnostic testing and ACT prescription

Table 6 reports patient recall/knowledge for the following: whether or not a malaria test was performed during the consultation; malaria blood test results (among those tested); and correct understanding of the dosing regimen among patients who obtained DHA PPQ at the outlet.

Numerator The number of patients who provided correct information about: a) whether or not a test was performed during the consultation; b) malaria test result; and c) dosing regimen for DHA PPQ according to age and ACT strength.

Denominator a. All patients. b. Patients who were tested for malaria during the consultation.

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c. Patients who obtained DHA PPQ from the outlet.

Calculation Numerator for each outlet type divided by the denominator.

Handling Patients with missing information for a specific indicator are excluded from that indicator. missing values Notes and Malaria blood testing and test result were recorded by the fieldworker during the consultation considerations observation. These observations were compared with patient reports during the exit interview.

Table 7: Factors associated with malaria blood testing

Table 7 reports proportion of patients tested across various patient and provider/outlet characteristics. An odds ratio was calculated for each factor to identify factors with significant association with blood testing.

Proportions:

Numerator Within levels of each factor (e.g. with each outlet type), number of patients tested for malaria (RDT or microscopy).

Denominator Number of patients with completed observation and exit interview components.

Calculation Numerator divided by denominator.

Handling Patients with missing information for a specific indicator will not contribute to the indicator. This missing values includes any instances of an observer report of “do not recall.”

Notes and Malaria blood testing was recorded by the fieldworker during the consultation observation. considerations

Odds ratio: Unadjusted odds ratios were estimated using Stata’s logit command for each individual predictor. The table summarizes ORs with 95% confidence intervals and significance levels.

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