Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys

For over a decade, Cambodia has implemented a number of policies and innovative strategies to increase access to quality malaria case management services and address the drivers of multi-drug resistance. This paper utilizes outlet survey trend data collected by the ACTwatch project to demonstrate how changes in Cambodian policy and strategies have led to shifts in anti-malarial markets. Anti-malarial ACTwatch outlet surveys were conducted in Cambodia in 2009 (June-July), 2011 (June-August) and 2013 (September-October). A census of all outlets with the potential to sell or distribute anti-malarials was conducted within a nationally representative sample of communes. Drug information, sales/distribution in the previous week, and retail price were collected for each anti-malarial in stock. Information on availability of malaria blood testing was also collected. A total of 7833 outlets were enumerated in 2009, 18,584 in 2011, and 16,153 in 2013. The percentage of public health facilities with at least one anti-malarial in stock on the day of the survey increased between 2009 (65.8%) and 2011 (90.0%) and remained high in 2013 (82.0%). Similar trends were found for village malaria workers (VMW). Overall, private sector availability of anti-malarials declined over time and varied by outlet type. By 2013 most anti-malarial stocking public health facilities (81.5%), VMW (95.4%), private for-profit health facilities (64.8%), and pharmacies (71.9%) had the countries first-line artemisinin-based combination therapy (ACT) treatment in stock. In 2013, 60% of anti-malarials were delivered through the private sector, 40% through the public sector, and the most common anti-malarial to be sold or distributed was the first-line ACT, comprising 62.8% of the national market share. Oral artemisinin monotherapy, which had accounted for 6% of total anti-malarial market share in 2009, was no longer reportedly sold/distributed in 2013. Malaria blood testing availability remained high over time among public facilities and VMW, with availability over 90% in 2011 and 2013. Moderate availability was observed in the private sector. Continued implementation of successful public and private sector strategies in support of evolving malaria drug treatment policies will be important to protect the efficacy of anti-malarial medicines and ultimately facilitate malaria elimination in Cambodia by 2025.