Numerous background studies carried out by the World Bank have recognised the underperformance of malaria case management in Zambia and identified several causes. These include frequent stock-outs of artemisinin-based combination therapies (ACTs) in public health facilities, price barriers and lack of awareness about ACTs and Malaria Rapid Diagnostic Tests (RDTs) in the private sector, as well as relatively limited coverage of Community Health Workers that are trained in, and have access to, ACTs and RDTs. In order to improve malaria case management the Zambia Access to ACT Initiative (ZAAI) has been designed to implement and evaluate the effectiveness of a combination of public and private sector strategies for improving access to ACTs and diagnostics in the country.
In January 2009, Crown Agents was awarded a contract to manage a distribution pilot designed to improve the delivery of drugs to health centres in Zambia. The pilot was originally designed for ACTs but was extended to all essential medicines. The distribution pilot was designed and implemented by Crown Agents through its management of Zambia's central medical stores (MSL) and involved the World Bank as donor, John Snow Inc. conducting the training and evaluation, and MSL covering the operations. The pilot's objective was to improve drug availability to the health centres, which are currently supplied via District Centres who are in turn supplied by MSL.
Two different distribution methods were tested: 1) cross-docking, where health centre consumption is captured at central level, and orders are packed and labelled for health centres and passed through the district centres unopened; and 2) using commodity planners, where stock is delivered to the district centre as normal but an MSL Commodity Planner is based in the district to increase capability by capturing health centre usage and calculating replenishment stock to the district. For the pilot, 16 districts were used to test both models with eight districts used as a control.
The pilot officially ends in June 2010, but the initial evaluation results are very promising, with significant improvements seen in drug availability and information capture. The World Bank hosted a major press event in Lusaka in conjunction with World Malaria Day, where the full results of the project evaluation were presented and plans for the rollout of the optimal model were developed.
As a result of the success of the distribution pilot supplying the public sector health centres, Crown Agents has also been awarded a contract to manage a second pilot, which is examining a method to distribute Coartem® and RDTs to remote rural areas using the private sector and subsidising the cost of the product to make it cheaper than less effective older drugs (chloroquine and sulfadoxine-pyrimethane ). The pilot involves accrediting local pharmacies and retail outlets to carry both the tests and the drug; in some areas a large proportion of people who have fever are sold anti-malarials but are suspected not to have malaria. Promoting the test is therefore an important innovation, as well as being in line with new WHO guidelines for treatment of malaria, which emphasise testing before treatment. Crown Agents is project managing the pilot as well as carrying out the quantification, procurement, freight forwarding and financial management. MSL is responsible for testing, storage and distribution to the private sector, and the Malaria Consortium is marketing products as well as conducting monitoring and evaluation.