title: Who continues to stock oral artemisinin monotherapy? Results of a provider survey in Myanmar.
abstract: Artemisinin-based combination therapy (ACT) is a key strategy for global malaria elimination efforts. However, the development of artemisinin-resistant malaria parasites threatens progress and continued usage of oral artemisinin monotherapies (AMT) predisposes the selection of drug resistant strains. This is particularly a problem along the Myanmar/Thailand border. The artemisinin monotherapy replacement programme (AMTR) was established in 2012 to remove oral AMT from stocks in Myanmar, specifically by replacing oral AMT with quality-assured ACT and conducting behavioural change communication activities to the outlets dispensing anti-malarial medications. This study attempts to quantify the characteristics of outlet providers who continue to stock oral AMT despite these concerted efforts.
  
  
  
  A cross-sectional survey of all types of private sector outlets that were stocking anti-malarial drugs in 13 townships of Eastern Myanmar was implemented from July to August 2014. A total of 573 outlets were included. Bivariate and multivariable logistic regressions were conducted to assess outlet and provider-level characteristics associated with stocking oral AMT.
  
  
  
  In total, 2939 outlets in Eastern Myanmar were screened for presence of any anti-malarial drugs in August 2014. The study found that 573 (19.5 %) had some kind of oral anti-malarial drug in stock at the time of survey and among them, 96 (16.8 %) stocked oral AMT. In bivariate analyses, compared to health care facilities, itinerant drug vendors, retailers and health workers were less likely to stock oral AMT (33.3 vs 12.9, 10.0, 8.1 %, OR = 0.30, 0.22, 0.18, respectively). Providers who cut blister pack or sell partial courses (40.6 vs 11.7 %, OR 5.18, CI 3.18-8.44) and those who based their stock decision on consumer demand (32.8 vs 12.1 %, OR 3.54, CI 2.21-5.63) were more likely to stock oAMT. Multivariate logistic regressions produced similar significant associations.
  
  
  
  Private healthcare facilities and drug shops and providers who prioritize consumers' demand instead of recommended practices were more likely to stock oral AMT. Malaria elimination strategies should include targeted interventions to effectively reach those outlets.
authors.affiliation: Population Services International Myanmar, 16 West Shwe Gone Dine Fourth Street, Yangon, Myanmar.
authors.forename: Si Thu
authors.initials: ST
authors.lastname: Thein
authors.affiliation: Department of Epidemiology and Biostatistics and Global Health Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94116, USA. May.Sudhinaraset@ucsf.edu.
authors.forename: May
authors.initials: M
authors.lastname: Sudhinaraset
authors.affiliation: Population Services International Myanmar, 16 West Shwe Gone Dine Fourth Street, Yangon, Myanmar.
authors.forename: Hnin Su Su
authors.initials: HS
authors.lastname: Khin
authors.affiliation: Department of Epidemiology and Biostatistics and Global Health Sciences, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94116, USA.
authors.forename: Willi
authors.initials: W
authors.lastname: McFarland
authors.affiliation: Population Services International Myanmar, 16 West Shwe Gone Dine Fourth Street, Yangon, Myanmar.
authors.forename: Tin
authors.initials: T
authors.lastname: Aung
mesh_terms: D000328:Adult; D000368:Aged; D000962:Antimalarials / Q000600:supply & distribution*; D037621:Artemisinins / Q000600:supply & distribution*; D003132:Commerce; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D002052:Myanmar; D010594:Pharmacies; D017149:Private Sector; D011795:Surveys and Questionnaires; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin
keywords: AMTR; Malaria elimination; Oral artemisinin monotherapy; Outlet survey; Private health care providers