An economic analysis of the market for malaria treatment in Cambodia

In developing countries, malaria treatment is often inadequate, notably in retail shops where the majority of people seek care. Shopkeepers are the last link in a chain of wholesalers who have an influence on treatment availability, price and quality. Evidence on competition in retail and wholesale markets is scarce, partly due to the methodological challenges of studying healthcare markets in poor countries. The thesis investigates how market structure, provider conduct, customer demand and regulation affect malaria treatment outcomes in Cambodia. In addition the thesis contributes to the development of methods for studying private drug markets. Cross-sectional surveys and semi-structured interviews of representative samples of antimalarial retailers and wholesalers were conducted to collect data on provider practices and perceptions. The contribution of different empirical methods for identifying and sampling wholesalers and measuring sales volumes was also assessed. Private commercial providers supplied the majority of antimalarial drugs, reflecting the relative proximity, long opening hours, reliable drug stock and friendliness of private retailers. Retail and wholesale competition increased accessibility to malaria treatment but did not lead to optimal supply of affordable quality treatment. Several market failures were evident: intense product differentiation, high concentration, and imperfect consumer information on treatment quality. These provided opportunities for higher mark-ups, although not in all market segments. With high market heterogeneity, higher retail mark-ups did not necessarily translate into higher consumer prices, highlighting the influence of distribution chain structure and wholesaler's price setting decisions. Government failures were also frequent, with poor public sector treatment accessibility and ineffective regulation'. Recommendations include widening distribution networks for artemisinin combination therapy and rapid diagnostic tests; improving product stock reliability; decreasing wholesale and retail product prices; intensifying providers' training; diffusing information to consumers on what constitutes appropriate management of malaria fever; and strengthening regulation and the potential to extend its supportive role.