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Evidence for Malaria Medicines Policy

Outlet Survey

Nigeria

2011 Survey Report

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Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation.

This study was implemented by Population Services International (PSI).

ACTwatch Advisory Committee:

Mr. SuprotikBasu Advisor to the United Nations (UN) Secretary General's Special Envoy for Malaria Mr. Rik Bosman Supply Chain Expert, Former Senior Vice President, Unilever

Ms. Renia Coghlan Global Access Associate Director, Medicines for Malaria Venture (MMV) Dr. Thom Eisele Associate Professor, Tulane University

Mr. Louis Da Gama Malaria Advocacy & Communications Director, Global Health Advocates Dr. Paul Lalvani Executive Director, RaPIDPharmacovigilance Program

Dr. RamananLaxminarayan Senior Fellow, Resources for the Future

Dr. Matthew Lynch Malaria Program Director, VOICES, Johns Hopkins University Centre for Communication Programs Dr. Bernard Nahlen Deputy Coordinator, President's Malaria Initiative (PMI)

Dr. Jayesh M. Pandit Head, Pharmacovigilance Department, Pharmacy and Poisons Board-Kenya

Dr. Melanie Renshaw Chief Technical Advisor, ALMA

Mr. Oliver Sabot Vice-President, Vaccines Clinton Foundation

Ms. Rima Shretta Senior Program Associate, Strengthening Pharmaceutical Systems Program, Management Sciences for Health Dr. Rick Steketee Science Director, Malaria Control and Evaluation Partnership in Africa (MACEPA) Dr. Warren Stevens Health Economist

Dr. Gladys Tetteh Deputy Director Country Programs, Systems for Improved Access to Pharmaceuticals and Services, Management Sciences for Health

Prof. Nick White, OBE Professor of Tropical Medicine, Mahidol and Oxford Universities

Prof. Prashant Yadav Professor of Supply Chain Management, MIT-Zaragoza International Logistics Program Dr. Shunmay Yeung Paediatrician & Senior Lecturer, London School of Hygiene and Tropical Medicine(LSHTM)

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The following individuals contributed as follows to the research study in Nigeria:

Dr. Jide Coker

National Coordinator, National Malaria Control Program, FMOH/Nigeria, assisted with advocacy and survey implementation.

Dr. Audu Bal

M & E Branch Head, National Malaria Control Program, FMOH/ Nigeria, assisted with advocacy and survey implementation.

Dr. Jennifer Anyanti

Director, Technical Services, Research and Evaluation Division, SFH/Nigeria, provided overall guidance during the survey.

Dr. Samson Adebayo

Associate Director, Research and Evaluation Division, SFH/Nigeria, assisted with advocacy and survey implementation.

Wale Adedeji

Director, Field Operations, SFH/Nigeria, provided logistical support during the survey.

Dr. Ronke Ladipo Director, Global Fund, SFH/Nigeria, provided logistical support during the

survey.

Dr. Ernest Nwokolo Associate Director, Global Fund – Malaria, SFH/Nigeria, provided information on the national malaria context in Nigeria.

Uche Ndukwu Deputy Director, Finance, SFH/Nigeria, provided financial oversight during

the survey.

Kene Eruchalu Deputy Director, Procurement, SFH/Nigeria, assisted in procurement of all survey materials.

Mrs. Ekundayo D. Arogundade

ACTwatch Country Program Coordinator, SFH/Nigeria, was responsible for all aspects of implementation and management of the survey.

Hellen Gatakaa Senior Research Associate, ACTwatch Central, provided overall guidance on the analysis and construction of indicators.

Illah Evances Research Associate, ACTwatch Central, assisted the Country Program

Coordinator, conducted data analysis and assisted the coordination and facilitation of trainings, data collection, and data entry.

Dr. Kathryn O’Connell Principal Investigator, ACTwatch Central, provided technical guidance on

the study.

Tanya Shewchuk Project Director, ACTwatch Central, provided project management oversight.

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The ACTwatch Group is comprised of the following individuals:

PSI ACTwatch Central Dr. Kathryn O’Connell, Principal Investigator;

Hellen Gatakaa, Senior Research Associate; Stephen Poyer, Illah Evance, Julius Njogu, Research Associates; Meghan Bruce, Policy Advocate and Communications Specialist, Linda Ongwenyi, ACTwatch Project Assistant, Tanya Shewchuk, Project Director.

PSI ACTwatch Country Program Coordinators

Cyprien Zinsou, ABMS/Benin; Sochea Phok, PSI/Cambodia; Dr. Louis Akulayi, SFH/DRC; Jacky Raharinjatovo, PSI/Madagascar; Ekundayo Arogundade, SFH/Nigeria; Peter Buyungo, PACE/Uganda; Felton Mpasela, SFH/Zambia.

LSHTM Dr. Kara Hanson, Principal Investigator;

Dr. Catherine Goodman, Benjamin Palafox, Edith Patouillard, Sarah Tougher, Immo Kleinschmidt, co-investigators. LSHTM is responsible for the supply chain research component of ACTwatch.

The Independent Evaluator for the Affordable Medicines Facility-malaria Phase 1 Evaluation is

comprised of the following individuals:

LSHTM Dr. Kara Hanson, Principal Investigator, Dr. Catherine Goodman, Sarah Tougher, Dr. Barbara Willey, Dr. Andrea Mann, co-investigators.

ICF International Dr. Fred Arnold, Director, Dr. Yazoume Ye, Dr. Ruilin Run, co-investigators.

Suggested citation:

ACTwatch Group, SFH/Nigeria and the Independent Evaluation Team. (2012). ACTwatch Outlet Survey Report 2011 (Round 3). Endline Outlet Survey Report for the Independent Evaluation of Phase 1 of the Affordable Medicines Facility - malaria (AMFm): Nigeria. Abuja, Nigeria: ACTwatch/PSI/SFH Nigeria.

ACTwatch Contacts

Nigeria

Mrs. Ekundayo D. Arogundade

Society for Family Health/Nigeria

8, Portharcourt Crescent

Area 11, Garki

Abuja, Nigeria

Phone: + 234 8033116065

Email: [email protected]

ACTwatch Central

Dr. Kathryn O’Connell

ACTwatch Principal Investigator

Malaria Control & Child Survival Department

Population Services International

Regional Technical Office

P.O. Box 14355-00800 Nairobi, Kenya

Phone: + 254 20 4440125/6/7/8

Email: [email protected]

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Table of Contents

Acknowledgements .......................................................................................................... ii

Table of Contents ............................................................................................................. v

List of Tables ................................................................................................................... vii

List of Figures ................................................................................................................... xi

Definitions ...................................................................................................................... xii

Classification of ACTs ...................................................................................................... xv

Other ACT Classifications ................................................................................................ xxi

Classification of treatment for severe malaria ............................................................... xxv

Classification of RDTs .................................................................................................. xxvii

List of Abbreviations .................................................................................................. xxviii

Executive Summary ....................................................................................................... xxx

Overview of ACTwatch ............................................................................................................ xxx Overview of the independent evaluation process .................................................................. xxx Endline outlet survey methods .............................................................................................. xxxi Key findings from the outlet survey ...................................................................................... xxxii Key findings on AMFm implementation: process and key contextual factors ....................... xlii

Background ...................................................................................................................... 1

1.1 Overview of ACTwatch and the AMFm phase 1 .................................................................. 1 1.1.1 ACTwatch Research Project ............................................................................................... 1 1.1.2 AMFm phase 1 ................................................................................................................... 2

1.2 Overview of the AMFm Phase 1 Independent Evaluation (IE) ............................................. 3 1.3 Country background – context............................................................................................. 8

1.3.1 Overview of the country .................................................................................................... 8 1.3.2 Description of health care system ..................................................................................... 9 1.3.3 Epidemiology of malaria .................................................................................................. 10 1.3.4 Antimalarial Policies and Regulatory Environment ......................................................... 11 1.3.5 Malaria control strategy .................................................................................................. 12 1.3.6 Malaria financing ............................................................................................................ 13

Methods ........................................................................................................................ 15

2.1 Outlet survey ...................................................................................................................... 15 2.1.1 Outlet survey indicators ................................................................................................... 15 2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators ......................................... 17 2.1.3 Sampling Approach .......................................................................................................... 18 2.1.4 Data collection ................................................................................................................. 20 2.1.5 Data processing ............................................................................................................... 22 2.1.6 Data analysis ................................................................................................................... 23

Results - Outlet survey ................................................................................................... 26

3.1 Characteristics of the sample ............................................................................................. 26 3.2 Availability of antimalarial drugs........................................................................................ 67

3.2.1 Antimalarials in stock ...................................................................................................... 67 3.2.2 Antimalarials in stock by type .......................................................................................... 68 3.2.3 Stockouts of quality-assured ACTs ................................................................................... 75 3.2.4 Population coverage of outlets with quality-assured ACTs ............................................. 76

3.3 Pricing of antimalarials (Affordability) ............................................................................... 77

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3.3.1 Cost to patients of antimalarials ..................................................................................... 77 3.3.2 Gross percentage markup between purchase price and retail selling price .................... 82 3.3. 3 Availability and cost to patients of diagnostic tests (RDT/microscopy) .......................... 88

3.4 Quality-assured ACTs market share ................................................................................... 93 3.5 Provider knowledge of first-line antimalarial treatment and ACT regimen ...................... 96 3.6 AMFm logo ....................................................................................................................... 100

AMFm implementation: process and key contextual factors .......................................... 109

4.1 Introduction ..................................................................................................................... 109 4.2 Methods ........................................................................................................................... 109 4.3 Findings ............................................................................................................................ 109

4.3.1 AMFm intervention process ...........................................................................................109 4.3.2 Implementation of AMFm supporting intervention .......................................................111 4.3.3 Key events and context ..................................................................................................114 4.3.4 Conclusion ......................................................................................................................115

Summary of findings ..................................................................................................... 120

5.1 Quality of data collected .................................................................................................. 120 5.2 Availability of quality-assured ACTs ................................................................................. 120 5.3 Pricing/affordability of quality-assured ACTs .................................................................. 120 5.4 Market share of quality-assured ACTs ............................................................................. 121

References .................................................................................................................... 122

Acknowledgements ....................................................................................................... 125

Appendices ................................................................................................................... 126

8.1 Questionnaire................................................................................................................... 126 8.2 ACTs classified as quality-assured .................................................................................... 138 8.3 Final sample ..................................................................................................................... 146 8.4 Survey team ..................................................................................................................... 149 8.5 Description of outlet types visited for this survey ........................................................... 151 8.6 Sampling weights ............................................................................................................. 153 8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs) ....................... 154 8.8 Child QAACTs .................................................................................................................... 161 8.9 RDT manufacturers submitting to WHO for product testing ........................................... 162

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List of Tables

IE Tables

Table 2.1. 1: Primary AMFm indicators ................................................................................................. 15

Table 2.1. 2:Primary ACTwatch indicators ............................................................................................ 16

Table 3.1. 1: Outlets enumerated by location, drugs stocked and final interview status, [Nigeria], 2011 ...................................................................................................................................................... 61

Table 3.1. 2: Outlets enumerated [Nigeria], 2011 ................................................................................ 62

Table 3.1. 3: Outlets with antimalarials in stock [Nigeria], 2011 ......................................................... 63

Table 3.1. 4: Number of products audited [Nigeria], 2011 ................................................................... 64

Table 3.1. 5: Outlets with at least one staff member who completed secondary school or primary school [Nigeria] 2011 ............................................................................................................................... 65

Table 3.1. 6: Outlets with a staff member with a health-related qualification [Nigeria], 2011 ........... 66

Table 3.2. 1: Outlets with antimalarials in stock in [Nigeria], 2011 ...................................................... 67

Table 3.2. 2: Outlets with non-artemisinin therapy in stock [Nigeria], 2011 ....................................... 68

Table 3.2.3. a: Outlets with artemisinin monotherapy in stock (ALL DOSAGE FORMS)[Nigeria], 201169

Table 3.2. 3.b: Outlets with ORAL artemisinin monotherapy in stock [Nigeria], 2011 ......................... 70

Table 3.2. 4: Outlets with non-quality-assured ACTs in stock [Nigeria], 2011 ...................................... 71

Table 3.2.5. a: Outlets with quality-assured ACTs in stock [Nigeria], 2011 .......................................... 72

Table 3.2.5. b: Outlets with quality-assured ACTs with and without the AMFm logo in stock [Nigeria], 2011 .............................................................................................................................................. 73

Table 3.2. 5. c: Public health facility outlets with quality-assured ACTs among ALL PUBLIC HEALTH FACILITIES screened in [Nigeria], 2011 ................................................................................................. 74

Table 3.2. 6: Outlets with stock-outs of quality- assured ACTs [Nigeria], 2011 .................................... 75

Table 3.2. 7: Percentage of the population living in censused “localities” with outlets with quality-assured ACTs in stock at the time of survey [Nigeria], 2011 ........................................................ 76

Table 3.3. 1: Cost to patients of non-artemisinin therapy, in 2010 US dollars [Nigeria], 2011 ............ 77

Table 3.3. 2: Cost to patients of artemisinin monotherapy, in 2010 US dollars [Nigeria], 2011 .......... 78

Table 3.3. 3: Cost to patients of non-quality-assured ACTs, in 2010 US dollars [Nigeria], 2011 .......... 79

Table 3.3. 4: Cost to patients of quality-assured ACTs, in 2010 US dollars [Nigeria], 2011 .................. 80

Table 3.3.5. a: Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales volumes (SP) for ALL DOSAGE TYPES, in 2010 US dollars [Nigeria], 2011 ................ 81

Table 3.3.5. b: Cost to patients of the most popular antimalarial in terms of national private for-for-profitprofit outlet sales volumes (SP) for TABLETS, in 2010 US dollars [Nigeria], 2011 .............. 81

Table 3.3.5. c: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for ALL DOSAGE TYPES, in 2010 US dollars [Nigeria], 2011 .................... 81

Table 3.3. 5. d: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for TABLETS, in 2010 US dollars [Nigeria], 2011 ...................... 81

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Table 3.3. 6: Gross percentage markup between purchase price and retail selling price of non-artemisinin therapy [Nigeria], 2011 ................................................................................................................ 82

Table 3.3. 7: Gross percentage markup between purchase price and retail selling price of artemisinin monotherapy [Nigeria], 2011 ....................................................................................................... 83

Table 3.3. 8: Gross percentage markup between purchase price and retail selling price of non-quality-assured ACTs [Nigeria], 2011 ........................................................................................................ 84

Table 3.3.9. a: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs [Nigeria], 2011 ........................................................................................................ 85

Table 3.3. 9. b: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs, by presence of the AMFm logo, [Nigeria], 2011 ............................................................ 86

Table 3.3. 10: Median total gross markup between first-line buyer price and retail selling price of quality-assured ACTs bearing the AMFm logo, in US dollars, [Nigeria], 2011 .......................................... 87

Table 3.3. 11: Availability of any diagnostic test for malaria, [Nigeria], 2011 ...................................... 88

Table 3.3. 12: Availability of malaria microscopy, [Nigeria], 2011 ........................................................ 89

Table 3.3. 13: Cost to patients of malaria microscopy in 2010 US dollars [Nigeria], 2011 ................... 90

Table 3.3. 14: Availability of rapid diagnostic tests for malaria, [Nigeria], 2011 .................................. 91

Table 3.3. 15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in US dollars [Nigeria], 2011 ...................................................................................................................................................... 92

Table 3.4. 1: Percentage breakdown of antimalarial sales volumes by antimalarial type, [Nigeria], 2011 ...................................................................................................................................................... 93

Table 3.4. 2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, [Nigeria], 2011 ......................................................... 94

Table 3.4. 3: Percentage breakdown of antimalarial sales volumes by outlet type, [Nigeria], 2011 ... 95

Table 3.5. 1: Provider knowledge of first-line antimalarial treatment, [Nigeria], 2011 ....................... 96

Table 3.5. 2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult. [Nigeria], 2011 .............................................................................................................................. 97

Table 3.5. 3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child, [Nigeria], 2011 .............................................................................................................................. 98

Table 3.5. 4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Nigeria], 2011 .............................................................................................................................................. 99

Table 3.6. 1: Provider recognition of AMFm logo, [Nigeria], 2011 ..................................................... 100

Table 3.6. 2: Provider knowledge of the AMFm logo [Nigeria], 2011 ................................................. 101

Table 3.6. 3: Sources from which providers have seen or heard of the AMFm logo, [Nigeria], 2011 102

Table 3.6. 4: Percentage of antimalarials bearing the AMFm logo, [Nigeria], 2011 ........................... 103

Table 3.6. 5: Provider knowledge of the AMFm program, [Nigeria], 2011 ......................................... 104

Table 3.6. 6: Sources from which providers have seen or heard of AMFm [Nigeria], 2011 ............... 105

Table 3.6. 7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Nigeria], 2011 .......................................................................................... 106

Table 3.6. 8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Nigeria], 2011 .......................................................................................... 107

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Table 3.6. 9: Providers who have received training on antimalarials with the AMFm logo, [Nigeria], 2011 .................................................................................................................................................... 108

Table 4.3. 1: Summary of key factors likely to have supported or hindered achievement of AMFm goals in Nigeria ........................................................................................................................................ 116

Table 8.2. 1: List of Quality-Assured ACTs for availability, price and market share indicators........... 139

Table 8.3. 1: List of clusters/sub-districts sampled and their population, Nigeria, 2011 ................... 146

Table 8.4. 1: List of staff members involved in the survey, [Nigeria], 2011........................................ 149

Table 8.7. 1: AETD Calculation details by antimalarial type ................................................................ 156

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ACTwatch Tables

Table A.1: Availability of antimalarials, by outlet type ......................................................................... 28

Table A.2: Availability of antimalarials, by public health facility outlet type ........................................ 30

Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type ...................................................................................................................................................... 31

Table A.4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type ........... 33

Table A.5: Price of antimalarials, by outlet type ................................................................................... 34

Table A.6: Affordability of antimalarials, by outlet type ....................................................................... 36

Table A.7: Availability of diagnostic tests, by outlet type ..................................................................... 37

Table A.8: Price of diagnostic tests, by outlet type ............................................................................... 38

Table A.9: Availability of diagnostic tests, by public health facility outlet type ................................... 39

Table A.10: Market share, by outlet type ............................................................................................. 40

Table A.11: Provider knowledge, by outlet type ................................................................................... 41

Table A.12: Provider knowledge, by outlet type ................................................................................... 42

Table A.13: Provider perceptions, by outlet type ................................................................................. 43

Table A.14: Availability of antimalarials among outlets stocking at least one antimalarial, by geo-political zones ............................................................................................................................................. 44

Table A.15: Availability of antimalarials among all public health facility, by geo-political zone .......... 47

Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by geo-political zone48

Table A.17: Price of antimalarials, by geo-political zones ..................................................................... 49

Table A.18: Availability of diagnostic tests, by geo-political zones ....................................................... 51

Table A.19: Price of diagnostic tests, by geo-political zones ................................................................ 52

Table A.20: Availability of diagnostic tests in public health facility, by geo-political zones ................. 53

Table A.21: Market share, by geo-political zones (relative to overall total) ......................................... 54

Table A.22: Provider knowledge, by geo-political zones ...................................................................... 55

Table A.23: Provider perceptions, by geo-political zones ..................................................................... 56

Table A.24: Provider knowledge in public health facility, by geo-political zones ................................. 57

Table B.1: Market share by antimalarial category within each outlet type .......................................... 58

Table B.2: Market share by antimalarial category within each geo-political zone ............................... 59

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List of Figures

Figure 1. Availability of antimalarials among all outlets, by outlet type xxxiii

Figure 2. Outlet types stocking antimalarials xxxiv

Figure 3. Availability of QAACTs and any n-AMT, among outlets stocking at least one antimalarial, by outlet type xxxv

Figure 4: Availability of oral-AMT, among outlets stocking at least one antimalarial, by outlet type xxxvi

Figure 5: Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests xxxvii

Figure 6: Median price of antimalarial treatment per AETD in the private sector, by outlet type xxxviii

Figure 7: Market share of AETDs sold/distributed in the past week (7 days) within outlet types xxxix

Figure 8: Market share of AETD sold/distributed in the past week (7 days) across outlet types xl

Figure 9: Provider knowledge of recommended first-line treatment and dosing regimens xli

Figure 1.2. 1: AMFm Phase 1 Results Framework ................................................................................... 4

Figure 1.2. 2: The Independent Evaluation Impact model ...................................................................... 5

Figure 1.2. 3: The Independent Evaluation Design ................................................................................. 6

Figure 1.3. 1: Location of Nigeria ............................................................................................................ 8

Figure 1.3. 2: Malaria prevalence map (MARA prevalence model), Nigeria, 2001 ............................... 11

Figure 3.1. 1: Survey flow diagram ........................................................................................................ 26

Figure 4.3. 1: Timeline of key events related to the AMFm implementation process and context in Nigeria .................................................................................................................................................... 117

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Definitions

Adult Equivalent Treatment Dose (AETD)

An AETD is the number of milligrams (mg) of an antimalarial drug needed to treat a 60 kg adult.

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.

Artemisinin-based Combination Therapy (ACT)

An antimalarial that combines artemisinin or one of its derivatives with an antimalarial or antimalarials of a different class. Refer to Combination Therapy (below).

Artemisinin monotherapy

An antimalarial medicine that has a single active compound, where this active compound is artemisinin or one of its derivatives.

Artemisinin and its derivatives

Artemisinin is a plant extract used in the treatment of malaria. The most common derivatives of artemisinin used to treat malaria are artemether, artesunate, and dihydroartemisinin.

Cluster The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit determined by the Ministry of Health (MOH) that hosts a population size of approximately 10,000 to 15,000 inhabitants. These units are defined by administrative boundaries. In Nigeria, they were defined as localities.

Censused locality A locality where field teams conducted a full census of all outlets with the potential to sell antimalarials.

Child Equivalent Treatment Dose (CETD)

A CETD is the number of milligrams (mg) of an antimalarial drug needed to treat a 10 kg child.

Combination therapy

The use of two or more classes of antimalarial drugs/molecules in the treatment of malaria that have independent modes of action.

Dosing/treatment regimen

The posology or timing and number of doses of an antimalarial used to treat malaria. This schedule often varies by patient weight.

Enumerated Outlets

Outlets that were visited by a member of one of the field teams, and at a minimum basic descriptive information was collected (sections C1-C9 of the outlet survey questionnaire).

First-line treatment

The government recommended treatment for uncomplicated malaria. Nigeria’s first-line treatment is Artemether Lumefantrine (AL) and Artesunate Amodiaquine (ASAQ).

Monotherapy

An antimalarial medicine that has a single mode of action. This may be a

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medicine with a single active compound or a synergistic combination of two compounds with related mechanisms of action.

Nationally registered ACTs

ACTs registered with a country’s national drug regulatory authority and permitted for sale or distribution in-country. Each country determines its own criteria for placing a drug on its nationally registered listing.

Non-artemisinin therapy

An antimalarial medicine that does not contain artemisinin or any of its derivatives.

Outlet Any point of sale or provision of a commodity to an individual. Outlets are not restricted to stationary points of sale and may include mobile units or individuals. Refer to Appendix 8.5 for a description of the outlet types visited for this survey.

Oral artemisinin monotherapy

Artemisinin or one of its derivatives in a dosage form with an oral route of administration. These include tablets, suspensions, and syrups and exclude suppositories and injections.

Quality-assured Artemisinin-Based Combination Therapies (QAACTs)

QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s (GFATM, or Global Fund) Quality Assurance Policy. For the purpose of the Independent Evaluation, a QAACT is any ACT which appeared on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy prior to baseline or endline data collection (see http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General ), or which previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. At endline, QAACTs were defined as any ACT which appeared on the Global Fund’s indicative list of antimalarials meeting its quality assurance policy as at September 2011, or which previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs.

Rapid Diagnostic Test (RDT) for malaria

Malaria rapid diagnostic tests, sometimes called "dipsticks" or malaria rapid diagnostic devices, assist in the diagnosis of malaria by providing evidence of the presence of malaria parasites in human blood. RDTs do not require laboratory equipment, and can be performed and interpreted by non-clinical staff.

Screened An outlet that was administered the screening questions (S1 to S4) of the outlet survey questionnaire (see Screening criteria).

Screening criteria The set of requirements that must be satisfied before the full questionnaire is administered. In this survey, an outlet met the screening criteria if (1) they had antimalarials in stock at the time of the survey visit, or (2) they report having stocked them in the past three months.

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General


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Second-line treatment

The government recommended second-line treatment for uncomplicated malaria. Nigeria’s second-line treatment for malaria is quinine. Second-line treatment includes all dosage forms.

Sub-district (SD)

The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit determined by the Ministry of Health (MOH) that hosts a population size of approximately 10,000 to 15,000 inhabitants. These units are frequently defined by geographical, health, or political boundaries, and are based around wards. In Nigeria the locality administrative unit was selected as the primary sampling unit.

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Classification of ACTs

Term Definition

Quality-assured ACTs [QAACTs]:

For the purpose of the Independent Evaluation, a QAACT is any ACT which appeared on the Global Fund's Indicative List of antimalarials meeting the Global Fund's quality assurance policy as at September

20111, or which previously had C-status in an earlier Global Fund quality

assurance policy and was used in a program supplying subsidised ACTs. In Nigeria, the following quality-assured ACTs were found in outlets:

ARSUAMOON 1-6 YEARS

ARSUAMOON 7-13 YEARS

ARSUAMOON ADULTS

ARTEMEF 12 YEARS AND ABOVE

ARTEMEF 3 YEARS UP TO 7 YEARS


ARTEMETHER + LUMEFANTRINE 3-8 YEARS ARTEMETHER + LUMEFANTRINE 9-14 YEARS

ARTEMETHER + LUMEFANTRINE <3 YEARS

ARTEMETHER + LUMEFANTRINE >14 YEARS

COARSUCAM ADULT +14 YEARS

COARSUCAM CHILD 6-13 YEARS

COARTEM 20/120

COARTEM 20/120 25-35 KG

COARTEM DISPERSIBLE 15-25KG


COMBISUNATE 20/120 15-24 KG


COMBISUNATE 20/120 35+ KG ADULTS


LARIMAL ADULT 14+ YEARS

LARIMAL CHILD 1-6 YEARS

LARIMAL JUNIOR 7-13 YEARS

LUMARTEM 15 TO <25KG


LUMARTEM 35KG AND ABOVE

LUMARTEM 5KG TO <15KG

WINTHROP ADULT +14 YEARS

WINTHROP CHILD 6-13 YEARS

WINTHROP INFANT 2-11 MONTHS

WINTHROP TODDLER 1-5 YEARS

1http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General

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First-line, quality-assured ACTs [FAACTs]:

Government recommended first-line ACTs (any ASAQ regardless of strength) for uncomplicated malaria meeting the quality assured definition. A complete listing of these antimalarials is provided in the appendices. In Nigeria, the following first-line quality-assured ACTs were found in outlets:

ARSUAMOON 1-6 YEARS

ARSUAMOON 7-13 YEARS

ARSUAMOON ADULTS

ARTEMEF 12 YEARS AND ABOVE



ARTEMETHER + LUMEFANTRINE 3-8 YEARS ARTEMETHER + LUMEFANTRINE 9-14 YEARS


ARTEMETHER + LUMEFANTRINE >14 YEARS

COARSUCAM ADULT +14 YEARS

COARSUCAM CHILD 6-13 YEARS

COARTEM 20/120

COARTEM 20/120 25-35 KG





COMBISUNATE 20/120 35+ KG ADULTS


LARIMAL ADULT 14+ YEARS


LARIMAL JUNIOR 7-13 YEARS



LUMARTEM 35KG AND ABOVE


WINTHROP ADULT +14 YEARS

WINTHROP CHILD 6-13 YEARS



www.ACTwatch.info

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Non-quality-assured ACTs [nQAACTs]:

ACTs that do not meet with the definition of being quality-assured. In Nigeria, the following non-quality-assured ACTs were found in outlets:

ACT PRO

ACTIMAX

ACTIVIN

ACTPRO-AL

AMALAR PLUS

AMATEM

AMATEM FORTE

AMDIN 600/750

AMNOQUINE

AMONATE FDC ADULT

AMOSININ JUNIOR

ANATE ADULT

ANATE PEDIATRIC

ARCHY SYNARTEM

ARCO

ARCOFAN

ARENAX PLUS

ARFLOQUIN-600/750

ARMACT

ARMETRINE 20/120

ART LUF FORTE

ARTE-PHIN

ARTECOM

ARTECXIN

ARTEFAN 40/240

ARTEFORTH 80/480

ARTELUM 20/120

ARTELUM 40/240

ARTEMETHER-PLUS

ARTEMETRIN

ARTEMODIAQUINE JUNIOR (7-13 YEARS)

ARTEMODIAQUINE PAEDIATRIC (BELOW 1YEAR)

ARTEPLUS COMBI

ARTEPLUS COMBI ADULTS (14YRS AND ABOVE

ARTEQUICK

ARTEQUIN 300/375 CHILD

ARTEQUIN-600/750

ARTEQUINE PAEDIATRIC

ARTERAKINE

ARTESMODIA 1YR-6YRS

ARTESMODIA LESS THAN 1 YEAR

ARTESUNAT-PLUS

ARTHLON-PLUS

ARTRIN

www.ACTwatch.info

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ARZEMAL

ASKAMETHER

ATHELUTRIN FORTE

ATMAL

ATMAL 20/120

ATMAL-PLUS 80/480

AVROMAL PAEDIATRIC

AXCIN-DP

BG MAL-560

BLOFAST

BOTAMIL PLUS

CAMOSUNATE CHILDREN (1-6 YEARS)

CAMOSUNATE (BELOW 1 YEAR)

CAMOSUNATE ADULT (14 YEAR AND ABOVE)

CAMOSUNATE JUNIOR (7 - 13YEARS)

CELOLUTHER

CO ARINATE FDC ADULT

CO-ARINATE FDC JUNIOR

CO-ARTESIANE

CO-FAN 20/120

COATAL 20/120

COATAL FORTE 80/480

COFETRAN

COLART

COTOKIN

CROTAN 20/120

CROTAN-FORTE 80/480

DART ABOVE 12YEARS

DART FOR CHILDREN 1-6YEARS

DEMAMTRE 20/120

DIASUNATE

DIASUNATE (JUNIOR)

DLANATE-A

DROA-QUINE

DRUTEMAL PLUS

DUO-COTECXIN

DUO-COTECXIN ADULTS

ENAMETRE

EXUS ARTEMETHER

FABITHER

FALCITHER

FAMTER

FAMTER (ADULTS)

FANMET ADULT

FARENAX ABOVE 12 YEARS

FARENAX FOR CHILDREN 2 - 6 YEARS

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FERIFE-DS

FLABORA

FLABORA FORTE

FYNALE

HAVAX

IBASUNATE

ISONATE COMBI

JUSUNATE

LA-TESEN

LEVER PLUS-600/750 ADULTS

LOCEET

LOKMAL

LOKMAL (ADULT)

LOKMAL (JUNIOR)

LOMASYL

LOMASYL DS

LONART

LONART - DS

LONART 20/120

LONART DISPERSIBLE

LUFART 20/120

LUMAL

LUMAL DS

LUMEF

LUMENAT

LUMETHER DISPERSIBLE PAEDIATRIC

LUMETHER FOR ADULT

LYNSUNATE 20/120 5KG TO BELOW 15KG TODD

LYNSUNATE 20/120 CHILD 15KG TO BELOW 25

LYNSUNATE FORTE 80/480 35KG AND ABOVE

MALARWAIP

MALMED (ADULT) FOR AGE ABOVE 13 YEARS.

MALMED(KID) AGE: 1-6YRS

MALTARKA

MD-ARTESUNATE

METAMOQUINE

METHERINE FORTE

MISIQUINE

NEXANATE

NIMARTEM

NKOYO MAL

NORINATE

ODIESHINATE

OGAMAL

OGAMAL QS

P-ALAXIN

PALUEXIT

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PEMAMETRE

PENATE

PERIDON 20/120

PESRIDON

PIPART

QUINARNET

QUINSUNAT

RGI ART-LUF

RGI ART-LUF FORTE

SMT 20/120MG

SOLARTEP

SUNATAB

TALEN

TAMETHER

TAMETHER 40/240

TAMETHER FORT

TAMETHER-20/120

TANMOTERM

VALMONATE

WAIPA ACT

ZEROMAL

ZYMAL

www.ACTwatch.info

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Other ACT Classifications

Child QAACTs QAACTs in a combination of strength and pack size targeted at children. A complete listing of these antimalarials is provided in the appendices. In Nigeria, the following child QAACTs were found in outlets:

ARSUAMOON 1-6 YEARS


ARTEMETHER + LUMEFANTRINE 3-8 YEARS











Nationally registered ACTs:

ACTs registered with a country’s national drug regulatory authority and permitted for sale or distribution in-country. Each country determines its own criteria for placing a drug on its nationally registered listing. A full list of nationally registered antimalarials can be found in the appendices. In Nigeria, the following nationally registered drugs were found in outlets:

ACTIMAX ACTIVIN ACTPRO-AL AMALAR PLUS AMATEM AMATEM FORTE AMDIN 600/750 AMNOQUINE AMONATE FDC ADULT AMOSININ JUNIOR ANATE ADULT ANATE PEDIATRIC ARCOFAN ARENAX PLUS ARMACT ARMETRINE 20/120 ARSUAMOON 1-6 YEARS ARSUAMOON 7-13 YEARS ARSUAMOON ADULTS ART LUF FORTE ARTEFAN 40/240 ARTELUM 20/120 ARTEMEF 12 YEARS AND ABOVE

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ARTEMEF 3 YEARS UP TO 7 YEARS ARTEMEF 7 YEARS UP TO 12 YEARS ARTEMEF 80/480 ARTEMEFAN 80/480 ARTEMETHER-PLUS ARTEMETRIN ARTEMODIAQUINE JUNIOR (7-13 YEARS) ARTEMODIAQUINE PAEDIATRIC ARTE-PHIN ARTEPLUS COMBI ARTEPLUS COMBI ADULTS ARTEQUIN 300/375 CHILD ARTEQUIN-600/750 ARTEQUINE PAEDIATRIC ARTERAKINE ARTRIN ARZEMAL ATMAL 20/120 ATMAL-PLUS 80/480 AVROMAL PAEDIATRIC BG MAL-560 BLOFAST BOTAMIL PLUS CAMOSUNATE CHILDREN (1-6 YEARS) CAMOSUNATE (BELOW 1 YEAR) CAMOSUNATE ADULT (14 YEAR AND ABOVE) CAMOSUNATE JUNIOR (7 - 13YEARS) CELOLUTHER CO ARINATE FDC ADULT CO-ARINATE FDC JUNIOR COARSUCAM ADULT +14 YEARS COARSUCAM CHILD 6-13 YEARS COARTEM COARTEM 20/120 COARTEM 20/120 25-35 KG COARTEM DISPERSIBLE 15-25KG COARTEM DISPERSIBLE 5-15KG CO-ARTESIANE COATAL 20/120 COATAL FORTE 80/480 COFETRAN COTOKIN DART ABOVE 12YEARS DART FOR CHILDREN 1-6YEARS DLANATE-A DUO-COTECXIN DUO-COTECXIN ADULTS CHILDREN OVER 6 YEARS OLD EXUS ARTEMETHER FABITHER FALCITHER FAMTER FAMTER (ADULTS) FANMET ADULT

www.ACTwatch.info

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FARENAX ABOVE 12 YEARS FARENAX FOR CHILDREN 2 - 6 YEARS FERIFE-DS FLABORA FLABORA FORTE FYNALE HAVAX IBASUNATE ISONATE COMBI JUSUNATE LARIMAL ADULT 14+ YEARS LARIMAL CHILD 1-6 YEARS LARIMAL JUNIOR 7-13 YEARS LA-TESEN LOCEET LOKMAL (ADULT) LOKMAL (JUNIOR) LOMASYL DS LONART LONART – DS LONART 20/120 LONART DISPERSIBLE LUMAL LUMAL DS LUMARTEM 15 TO <25KG LUMARTEM 25 TO <35KG LUMARTEM 35KG AND ABOVE LUMARTEM 5KG TO <15KG LUMEF LUMETHER DISPERSIBLE PAEDIATRIC LUMETHER FOR ADULT LYNSUNATE 20/120 5KG TO BELOW 15KG TODDLER LYNSUNATE 20/120 CHILD 15KG TO BELOW 25KG LYNSUNATE FORTE 80/480 35KG AND ABOVE MALMED (ADULT) FOR AGE ABOVE 13 YEARS MALMED(KID) AGE: 1-6YRS METAMOQUINE METHERINE FORTE MISIQUINE NEXANATE NIMARTEM NKOYO MAL NORINATE ODIESHINATE OGAMAL OGAMAL QS P-ALAXIN PALUEXIT PEMAMETRE PENATE PIPART QUINARNET RGI ART-LUF

www.ACTwatch.info

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RGI ART-LUF FORTE SMT 20/120MG SOLARTEP SUNATAB SYNARTEM TAMETHER 40/240 TAMETHER FORT TAMETHER-20/120 TANMOTERM VALMONATE WAIPA ACT WINTHROP ADULT +14 YEARS WINTHROP CHILD 6-13 YEARS WINTHROP INFANT 2-11 MONTHS WINTHROP TODDLER 1-5 YEARS ZEROMAL ZYMAL

www.ACTwatch.info

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Classification of treatment for severe malaria

Term Definition

Any treatment for severe malaria

WHO recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children, with artemether or quinine injections as acceptable alternatives if parenteral

artesunate is not available2.If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether. In Nigeria, the following treatments for severe malaria were in outlets:

QUININE INJECTIONS

AXOQUINE

HAMEXQUINE

LABORATE

LIZOQUIN

MEDIQUIN

NELBPHARQUINE

PENINE

PHILOQUIN

QUINAC

QUININE

QUINIPIN

RINDOQUINE

SINOQUINE

STEROP ARTEETHER/ARTEMOTIL INJECTIONS

EMAL

TERETINE

VOATHERM

ARTEMETHER INJECTIONS

AMTEPINE

ARMEETHER

ARTEJECT-80

ARTEMETHER

ARTENITER-80

ARTESAM

ARTESIANE

ARTHEC

ATERL

ATURMETHER 80

CARITHER 80

2Guidelines for the treatment of malaria, 2nd edition – revision 1.WHO. Geneva: 2010.

www.ACTwatch.info

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DRUTEMAL

EDMETHER

EPIL

EUROMETHER

GVITHER

HILACT

HOCHIEZ ARTEMETHER

HUGO ARTEMETHER

JMETHER

KENBARTH

LABNAT

LARITHER-40

LARITHER-80

MAKIMETHER

MEGAMETHER

METARBUL

MIRACMETHER

PALUEXIT 80MG

PALUTHER

PARALINE

PHILOMETHER

RATMETH-80

REBOK

ROMETHER

SANARTEME

ARTESUNATE INJECTIONS

ARTESUN

ARTESUNAT

JAWA

REKMAL

www.ACTwatch.info

xxvii | P a g e

Classification of RDTs

Term Definition

RDTs from a manufacturer that has submitted a product to WHO Malaria RDT Product Testing Rounds 1-3

RDTs from a manufacturer that has submitted at least one product for testing during rounds 1-3 of the WHO Malaria RDT Product Testing cycle (2008-2011)3. A complete listing of these manufacturers is provided in the appendices. In Nigeria, products from the following submitting manufacturers were found in outlets:

Access Bio, Inc ACON Laboratories, Inc. Guangzhou Wonfo Biotech Co., Ltd Orchid Biomedical Systems Premier Medical Corporation Ltd Standard Diagnostics, Inc. (now Alere Healthcare (Pty) Ltd)

RDTs from a manufacturer that has not submitted a product to WHO Malaria RDT Product Testing Rounds 1-3

RDTs from a manufacturer that has not submitted a product for testing during rounds 1-3 of the WHO Malaria RDT Product Testing (2008-2011). In Nigeria, products from the following non-submitting manufacturers were found in outlets:

Acumen Diagnostics Inc Codix Pharma Ltd Global Device Reagents Omega Diagnostic Ltd Pistis Diagnostic Ltd

3Malaria rapid diagnostic test performance summary results of WHO malaria RDT product testing: rounds 1-3 (2008-2011). WHO. Geneva: 2011.

www.ACTwatch.info

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List of Abbreviations -- No data were available

*** Undefined ratio as a non-zero value is being divided by a value of zero

ACT Artemisinin-based Combination Therapy

ADR Adverse Drug Reaction

AETD Adult Equivalent Treatment Dose

AHC Ad Hoc Committee

AL Artemether-Lumefantrine

AMT Artemisinin Monotherapy

AMFm Affordable Medicines Facility – malaria

ANC Antenatal Clinic

ASAQ Artesunate-Amodiaquine

CEM Cohort Event Monitoring

CHAI Clinton Health Access Initiative

CHEW Community Health Extension Worker

CHW Community Health Worker

CI Confidence Interval

CIERPA Centre International d'Études et de Recherches sur les Populations

Africaines

CPC Consumer Protection Council

CRDH Centre de Recherche pour le Développement Humain

CQ Chloroquine

DCs Data Contributors

DfID United Kingdom Department for International Development

DHAP Dihydroartemisinin-Piperaquine

DHS Demographic and Health Surveys

DNDi Drugs for Neglected Diseases initiative

FAACT First-line, Quality-assured Artemisinin Combination Therapy

FLB First-line Buyer

GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund)

FBO Faith-based organization

GDP Gross domestic product

GPS Global Positioning System

HMM Home Management of Malaria

iCCM Integrated Community Case Management

IE Independent Evaluation/Evaluator

IEC Information, Education and Communication

IMCI Integrated Management of Childhood Illness

IMF International Monetary Fund

IPTp Intermittent Preventive Treatmentfor pregnant women

IQR Interquartile Range

IRS Indoor Residual Spraying

ITN Insecticide Treated Net

KII Key Informant Interview

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LGAs Local Government Areas

LLIN Long-lasting Insecticidal Net

LMIS Logistics Management Information Systems

LSHTM London School of Hygiene and Tropical Medicine

M&E Monitoring and Evaluation

MICS Multiple Indicator Cluster Survey

MIS Malaria Indicator Survey

MOH Ministry of Health

n/a Not applicable: Indicates ratios cannot be calculated as the numerator is

zero

NAACT Non-first-line, Quality-assured Artemisinin Combination Therapy

nAT Non-artemisinin Therapy

NAFDAC National Agency for Food and Drug Administration and Control

NGO Nongovernmental organization

NHIS National Health Insurance Scheme

NMCP National Malaria Control Program

nQAACT Non-quality-assured Artemisinin-based Combination Therapy

OR Operations Research

OTC Over-the-Counter

PCN Pharmacists Council of Nigeria

PHC Primary Health Care

PHCC Primary Health Care Centers

PMI President’s Malaria Initiative

PMTCT Prevention of Mother-to-Child Transmission

POP Part one Pharmacies

PPMV Proprietary Patent Medicine Vendor

PPS Probability proportional to size

PSI Population Services International

PSM Procurement and Supply Management

QAACT Quality-assured Artemisinin-based Combination Therapy

RDT Rapid Diagnostic Test

RMCG Role Model Care Giver

SFH Society for Family Health

SP Sulfadoxine-Pyrimethamine

SOP Standard Operating Procedures

UN United Nations

UNICEF United Nations Children’s Fund

USD United States Dollar

WHO/AFRO World Health Organization/Africa region

WHO World Health Organization

YGC Yakubu Gowon Centre

www.ACTwatch.info

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Executive Summary

Overview of ACTwatch

The ACTwatch Outlet Survey (www.actwatch.info) involves quantitative research at the outlet level in

ACTwatch countries (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic

Republic of Congo). Other elements of ACTwatch research include Household Surveys led by Population

Services International (PSI) and Supply Chain Research led by the London School of Hygiene & Tropical

Medicine (LSHTM). This report presents the results of a cross-sectional survey of outlets conducted in

Nigeria between October14thand November 30th, 2011 and also serves as the endline for the Affordable

Medicines Facility – malaria (AMFm) Phase I Independent Evaluation.

The objective of the outlet survey is to monitor levels and trends in the availability, price and volumes of

antimalarials, and providers’ perceptions and knowledge of antimalarial medicines at different outlets.

Price and availability data on diagnostic testing services are also collected. This report presents

indicators on availability, price, volumes, affordability in outlets and provider knowledge of

antimalarials.

Overview of the independent evaluation process

The independent evaluation (IE) is part of a multi-faceted monitoring and evaluation (M&E) framework

developed for Phase 1 of the Affordable Medicines Facility – malaria (AMFm). It is intended to assess

whether, and to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent

evaluation will be summarized in a report to be considered by the Global Fund Board at the end of Phase

1.The four main objectives of AMFm are: (i) to increase ACT affordability, (ii) to increase ACT availability,

(iii) to increase ACT use, including among vulnerable groups, and (iv) to “crowd out” other oral

antimalarials by gaining market share.

Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene and

Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently operational

Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda, and Zanzibar). In

addition, the Global Fund contracted with Data Contributors (DCs) that were responsible for in-country

fieldwork, data analysis and country reports. These institutions are Population Services International

(PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de Recherche pour le Développement

Humain (CRDH).

The ACTwatch Project (www.actwatch.info), which is part of PSI, was responsible for the work in Kenya,

Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health

Institute) and Zanzibar, through funding from both the Bill and Melinda gates Foundation and the Global

Fund. This work was carried out as part of their existing portfolio and funding stream provided by the Bill

and Melinda Gates Foundation for work in Nigeria, Madagascar, and Uganda. DNDi subcontracted with

the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, to undertake the work in

Ghana. CRDH subcontracted with the Centre International d'Etudes et de Recherches sur les Populations

Africaines (CIERPA) to undertake the work in Niger.

http://www.actwatch.info/

www.ACTwatch.info

xxxi | P a g e

The IE is based on a non-experimental design with a pre- and post-test intervention assessment in which

each participating country is treated independently as a case study. In addition to measuring the

changes in key indicators pre- and post-intervention, the evaluation includes an assessment of the

implementation process and a comprehensive documentation of the context both to inform

assessments about causality and to aid in generalizability to other contexts. The current report is based

on the endline assessment in Nigeria conducted by PSI/ACTwatch and Society of Family Health, Nigeria.

The results of the baseline survey can be found in the Nigeria baseline report (ACTwatch, SFH/Nigeria

and the Independent Evaluation Team, 2009), and for all pilots in the Multi-Country Baseline Report

(Independent Evaluation Team, 2011). Analysis of changes between baseline and endline outlet surveys

will be presented in the Multi-Country Endline Report (forthcoming), together with the data the IE team

has compiled from national household surveys. In addition country case studies on context/process

were conducted by the IE, and these case studies are summarized in the present report.

Endline outlet survey methods

A cluster sampling approach was used because there were no reliable lists of all outlets stocking

antimalarials. Clusters were sub-districts/communes, with an average of 10,000 to 15,000 inhabitants. In

Nigeria, 114 clusters were selected with probability proportional to size (PPS)—a sampling technique in

which the probability that a particular sub-district is selected is proportional to its population size. The

sample size was powered to detect a change of 20% percentage points in availability of quality-assured

ACTs (QAACTs) between baseline and endline in rural and urban areas.

The inclusion criteria for this study were outlets that stocked an antimalarial at the time of survey or had

stocked antimalarials in the previous three months. An outlet is defined as any point of sale or provision

of commodities for individuals. Outlets included in the survey were: 1) public health facilities

(government hospitals, health centres and CHWs); 2) pharmacies; 3) private health facilities (private

clinics, private practices, NGO health centres and dispensaries); 4) drug stores (PPMVs); 5) grocery stores

(general retailers); and 6) hawkers (itinerant drug vendors).

A structured endline questionnaire was developed, which included questions to measure indicators for

the Independent Evaluation. Fieldworkers recorded the outlets’ basic details and then asked a screening

question about the availability of antimalarials to decide whether to proceed with the full interview or

not. The questionnaire was administered to a senior person at the outlet to collect data on outlet

identification, outlet characteristics, provider knowledge, antimalarials and rapid diagnostic tests (RDTs)

stocked, and stockouts of quality-assured ACTs. They recorded information on “audit sheets” on all

antimalarials and RDT products stocked in terms of their price and volume sold in the past week. Data

quality control tools used in the field were based on those implemented by ACTwatch for the baseline

survey.

A data entry program was developed by ACTwatch in Access and all data were double entered and

verified. To ensure a high level of data quality, ACTwatch undertook data cleaning using a detailed

guideline provided by the IE team and also followed structured ACTwatch guidelines.

For the analysis, the ACTwatch team used a standardized tabulation plan for all ACTwatch tables

presented in this report and analysis do files in STATA, which produced all the required ACTwatch

indicators. In addition, the IE team provided a tabulation plan for all IE tables presented in this report,

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and analysis do-files in STATA, which produced all the required indicators and automatically generated

the IE tables. All analysis was run using STATA version 11, recording results in a log file.

Key findings from the outlet survey

Data were collected between 7th October and November 30th, 2011. A total of 8,507 outlets were

approached. Of these, 568 outlets were not screened for various reasons: 101 providers refused to be

interviewed; 69 outlets were closed down permanently; 244 outlets were not open at the time of the

survey visit; in 151 outlets, providers were not available for interview at the time of survey visit; 3

providers were unable to be interviewed for other reasons. Overall, 7,939 outlets agreed to participate

in the ACTwatch outlet survey and were screened. Of these, 1,567 outlets met our screening criteria;

however, interviews could not be conducted for 5 outlets. Of the 1,562 interviews conducted, 58

reported having stocked antimalarials at any point in the three months prior to the interview and 1,504

outlets stocked antimalarials at the time of the interview.

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AVAILABILITY OF ANY ANTIMALARIAL:

Stocking rates of any antimalarial varied by outlet type. In the public/not-for-profit sector, 83% of public

health facilities and 71% of private not-for-profit facilities had at least one antimalarial in stock on the day

of interview. Of community health workers, who according to government policy may treat using

antimalarials, 34% stocked an antimalarial. There was substantial variation in the private sector. 87% of

private-for-profit facilities, 100% of pharmacies and 98% of drugs stores, stocked antimalarials. This is in

contrast to 1% of general retailers and 26% of itinerant drug vendors (Figure 1).

Figure 1. Availability of antimalarials among all outlets, by outlet type

0

20

40

60

80

100

N=108 N=14 N=11 N=133 N=100 N=37 N=1,185 N=6,377 N=87 N=7,786 N=7,917

Publichealthfacility

Communityhealthworker

Private notfor profit HF

TOTALPublic / Not

for profit

Private forprofit HF

Pharmacy Drug store Generalretailer

ItinerantDrug

Vendor

TOTALPrivate

TOTAL Alloutlets

Public / Not for Profit Sector Private Sector TOTAL Alloutlets

2011

%

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OUTLET TYPES STOCKING ANTIMALARIALS:

Figure 2 shows the relative distribution of all outlets that had at least one antimalarial in stock. Drug

stores/PPMVs were the most common type of outlet stocking antimalarials, followed by private health

facilities and public health facilities.

Figure 2. Outlet types stocking antimalarials

PHF 5%

CHW 0% Private not for profit

1%

Private Health Facility

7%

Pharmacy 3%

Drug Store/PPMV 78%

Interant Drug Vendor 2%

General Retailer (local Market/Duka)

4%

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AVAILABILITY OF DIFFERENT CLASSES OF ANTIMALARIALS:

Among facilities that stocked antimalarials at any time in the three months preceding the survey, overall

QAACT availability in 2011 was 54%. There was no difference in availability between urban and rural areas

at endline. However, there was considerable variation within the private for-profit sector, in which

availability was 53%. QAACT availability was much higher in pharmacies (99%) than in drug stores (54%) or

private for-profit facilities (51%) or general retailers (23%). In public health facilities that stocked

antimalarials at any time in the three months preceding the survey, QAACT availability was 57%. QAACT

availability was higher among community health workers (CHWs) (82%).

Forty-seven percent of all outlets stocked QAACTs with the AMFm logo at endline. In public health

facilities, 27% of outlets stocked QAACTs with the logo, as compared with the private sector, where 49% of

outlets stocked QAACTs with the logo. A relatively high proportion of outlets stocked QAACTs without the

logo (38% of public health facilities and 14% of private for-profit health facilities [data not shown]). It

should be noted that Nigeria has several nationally-approved ACTs that are included in the non-quality-

assured category.

Availability of nAT remained very high at endline (97% in all outlets). Oral AMT was available in 99.5% of

pharmacies, 18% of private for-profit outlets, 19% of general retailers and 15% of public health facilities.

Figure 3. Availability of QAACTs and any n-AMT, among outlets stocking at least one antimalarial, by outlet type

0

20

40

60

80

100

N=94 N=7 N=9 N=110 N=88 N=37 N=1,163 N=64 N=28 N=1,380 N=1,490




TOTALPublic / Not

for profit



Itinerantdrug vendor

TOTALPrivate

TOTAL Alloutlets


%

Quality Assured ACT (QAACT) QAACTS with AMFm logo Any non-artemisinin therapy

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0

20

40

60

80

100

N=94 N=7 N=9 N=110 N=88 N=37 N=1,163 N=64 N=28 N=1,380 N=1,490

Public healthfacility



TOTAL Public/ Not for

profit




TOTALPrivate

TOTAL Alloutlets


%

Figure 4: Availability of oral-AMT, among outlets stocking at least one antimalarial, by outlet type

www.ACTwatch.info

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AVAILABILITY OF DIAGNOSTIC BLOOD TESTING:

Of outlets stocking antimalarials in the last three months, 87% of private-not-for-profit facilities offered

any test services. Among other outlet types, availability of any testing services was less than 10% across all

outlet types in the private sector, with the exception of private for profit facilities (37%) and public health

facilities (26%). Microscopic testing was generally more available than rapid diagnostic tests.

Figure 5: Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests

0

20

40

60

80

100

N=101 N=10 N=9 N=120 N=94 N=35 N=1,171 N=76 N=39 N=1,415 N=1,535




TOTALPublic / Not

for profit




TOTALPrivate

Total


%

Any diagnostic test Rapid diagnostic tests Microscopic blood tests

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PRICE OF ANTIMALARIALS: Among all outlets, the median price QAACTs per AETD is USD 1.48. In public health facilities, the median price of QAACTs is USD 0.00, indicating the policy of free ACTs in those facilities.

In private for-profit outlets, the median price of QAACTs is USD 1.48. The median price of QAACTs with the

AMFm logo is USD 1.48, where as the median price of QAACTs without the AMFm logo is USD 2.95 (data

not shown).

The ratio of the median price of QAACTs with the AMFm logo to that of the most popular antimalarial is

3.1 times. QAACTs with the AMFm logo were being sold on average for 2.4 times more than the

recommended retail price for an adult dose, which was set at USD 0.59.

In private for-profit outlets, the median price of oral AMT is USD 2.83.

Figure 6: Median price of antimalarial treatment per AETD in the private sector, by outlet type

$-

$1.00

$2.00

$3.00

$4.00

$5.00

$6.00

$7.00

$8.00

$9.00

$10.00

Private for profit HF Pharmacy Drug store General retailer Itinerant drug vendor TOTAL Private

Pri

ce, $

US

Quality Assured ACT (QAACT) QAACTS with AMFm logo Chloroquine Oral artemisinin monotherapy

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VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED:

Measured across all outlets, the market share of QAACTs is 20%. The QAACT share is largest in public

health facilities (48%), followed by private not for profit facilities (40%). QAACT market share in the private

for profit sector is 18%.

The share of non-quality-assured QAACTs is 8% in all outlets.

Market share of nATs in all outlets is 66.3%, and is highest among community health workers (80%)

followed by the private for-profit sector (69%).

Measured across all outlets, the market share of oral AMT is 4.1%, and greatest in pharmacies (9%) and the

private sector generally (4.4%).

The private sector accounted for over 90% of all antimalarials distributed (Figure 7).

Figure 7: Market share of AETDs sold/distributed in the past week (7 days) within outlet types

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PHF CHW Privatenot forprofit

HF

PHF/NFPTotal

Privatefor profit

HF

Pharmacy Drug Shop GeneralRetailer

Itinerantdrug

vendor

PrivateTotal

Total

Public/Not for Profit Sector Private sector Total allsectors

Mar

ket

shar

e w

ith

in o

utl

et t

ype

QAACT with logo QAACT without logo Non-QAACT

SP Chloroquine Other non-artemisinin therapy

Oral artemisinin monotherapy Non-Oral artemisinin monotherapy

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Figure 8: Market share of AETD sold/distributed in the past week (7 days) across outlet types

0

20

40

60

80

100

Public/Not forProfit Sector

Total Private Private for profitfacility

Pharmacy Drug store General retailer Itinerant drugvendor

Non-QAACTs QAACTs SP in public sector

Non-artemisinin therapy Non-oral artemisinin monotherapy Oral artemisinin monotherapy

QAACTs with logo

%

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PROVIDER KNOWLEDGE:

Overall, 53% of providers were able to correctly state ASAQ or AL as the recommended first-line treatment

for uncomplicated malaria in Nigeria. Knowledge was higher among providers at public/not-for-profit

sector outlets, compared to the private sector (82% vs. 51% respectively).

There was substantial variability across outlet types as well. For example, while knowledge was relatively

high for public health facilities (83%), private not for profit outlets (97%) and pharmacies (83%), it was

lower among drug stores (51%) general retailers (27%) and community health workers (22%).

Figure 9: Provider knowledge of recommended first-line treatment and dosing regimens

0

20

40

60

80

100

N=103 N=10 N=9 N=122 N=96 N=38 N=1,184 N=79 N=39 N=1,436 N=1,558



Private notfor profit

HF

TOTALPublic /Not forprofit



Itinerantdrug

vendor

TOTALPrivate

Total


%

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Key findings on AMFm implementation: process and key contextual factors

AMFm implementation: A total of 54 FLBs were registered with the Global Fund as of January 31, 2012

(51 private for-profit, 2 private non-profit and 1 public sector). Orders had been placed by 28private first

line buyers by the end of 2011. The first orders were placed by private for-profit sector FLBs in October

2010, and arrived in Nigeria in January 2011. Approximately 9.5 months elapsed between the arrival of

the first copaid drugs and the midpoint of endline outlet survey fieldwork. Implementation of supporting

interventions trailed the arrival of the first copaid drugs by approximately 3 months, giving about 6

months from the start of implementation of SIs before the midpoint of the endline outlet survey. Some

delays in initiating communications activities were caused by problems of coordination among the

Principal Recipients (PRs). In the interim, a number of activities were undertaken (albeit not at scale) by

other stakeholders such as professional associations and pharmaceutical firms. Private sector BCC

activities only started in August 2011, and some mass media activities did not start until September

2011. The range of activities implemented from April 2011 onwards included advocacy, mass media

communications, community dramas and road shows, training, regulatory changes and an RRP. By the

end of 2011, a total of 67,219,660 copaid ACT doses had been delivered to Nigeria (0.42 doses per

capita, the whole population of Nigeria is considered at risk of malaria), of which 80% were to private

for-profit FLBs, 12% to the public sector and 8% to private not-for-profit FLBs. Only 24% of treatments

requested by Nigeria FLBs in the second half of 2011 were approved due to the application of the Global

Fund’s demand levers.

Context: Important contextual factors include the distribution of LLINs and indoor residual spraying (IRS)

in some states, introducing RDTs into public and private health facilities in 12 states, a large domestic

pharmaceutical manufacturing sector that initially resisted AMFm, and elections in 2011. ACTs had over-

the-counter status.

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Background

1.1 Overview of ACTwatch and the AMFm phase 1

1.1.1 ACTwatch Research Project

In 2008, Population Services International (PSI), in partnership with the London School of Hygiene

and Tropical Medicine (LSHTM), launched a five-year multi-country research project called

ACTwatch. The project is designed to provide a comprehensive picture of the antimalarial market to

inform the evolution of national and international antimalarial drug policy evolution. The research is

designed to detect changes in the availability, price and use of antimalarials over time and between

sectors, and to monitor the effects of policy or intervention developments at country level.

ACTwatch addresses both the supply and demand side of the market. The supply side is evaluated by

collecting level and trend data on antimalarials and rapid diagnostic tests (RDTs) in public and private

sector outlets and wholesalers of antimalarial drugs. To evaluate demand, data are collected at the

household level on consumer treatment-seeking behaviour and knowledge. The research

components thread together both the antimalarial market and consumer behaviour. Findings can

help determine where and to what extent interventions may positively impact access to and use of

quality-assured ACTs and RDTs as well as resistance containment efforts.

The project is being conducted in seven malaria-endemic countries: Benin, Cambodia, the

Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia between 2008 and

2012. Countries were selected with the aim of studying a diverse range of markets from which

comparisons and contrasts could be made. The research in Nigeria is planned as follows: three outlet

surveys (2008, 2009 and 2011); supply chain research (2009); and two household surveys (2009 and

2012).

This report presents the results of a cross-sectional survey of outlets conducted in Nigeria between

October14thand November 30th 2011. Indicators to address the research questions were developed

in consultation with partners and the ACTwatch Advisory Committee. Indicators were selected to

provide relevant information for policy makers in relation to price, availability, volumes, mark-ups

and treatment seeking behaviour, including type of treatment and source. While baseline data were

collected prior to the Affordable Medicines Facility – malaria (AMFm) Phase 1 Independent

Evaluation, data were retrospectively analysed to produce indicators to inform the evaluation. For

the endline evaluation, the ACTwatch questionnaire was adapted to include specific AMFm

indicators. The Independent Evaluator provided technical oversight on the analysis presented in this

report, to ensure that results are aligned as far as possible with the AMFm indicators. The 2011

Nigeria Outlet Survey is being employed as part of the baseline for the Independent Evaluation of

the AMFm Phase 1, and also represents the endline survey (Round 3) results as part of the ACTwatch

Project.

Information on other ACTwatch studies can be found at www.actwatch.info.

http://www.actwatch.info/

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1.1.2 AMFm phase 1

The success of malaria control efforts depends on a high level of coverage and use of effective

antimalarials, such as artemisinin-based combination therapies (ACTs). Although these antimalarials

have been procured in large amounts by countries, evidence suggests that ACT use still remains far

below target levels. Reasons suggested for the low uptake of ACTs include interruptions in public

sector supply; limited availability outside major urban centers; the high prices of the drugs,

particularly in the private sector; lack of provider adherence to new recommendations; and patient

self-treatment with other more common and cheaper antimalarials (Sabot, Mwita et al. 2009).

Lowering the cost of ACTs to the end user through a subsidy mechanism could be an effective way to

increase their uptake (Arrow 2004).

In response to these issues, the Affordable Medicines Facility – malaria (AMFm) hosted by The

Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM, or the Global Fund) was set up. As

described by Adeyi and Atun (Adeyi and Atun 2010), AMFm is a financing mechanism designed to

incorporate three elements: (1) price reductions through negotiations with manufacturers of ACTs;

(2) a buyer subsidy, via a co-payment at the top of the global supply chain by AMFm on behalf of

eligible buyers from the public, private for-profit and private not-for-profit sectors; and (3) support

for interventions to promote appropriate use of ACTs. Examples of these “supporting interventions”

include training providers and outreach to communities to promote ACT utilization. AMFm is being

tested in a first phase that includes 9 pilots in 8 countries: Cambodia, Ghana, Kenya, Madagascar,

Niger, Nigeria, Tanzania (mainland and Zanzibar) and Uganda.

It is expected that in the last quarter of 2012, the Global Fund Board will make a decision regarding

the future of the AMFm on the basis of evidence gathered during Phase 1 regarding progress toward

achieving its four stated objectives: (i) increased ACT affordability, (ii) increased ACT availability, (iii)

increased ACT use, including among vulnerable groups, and (iv) “crowding out” oral artemisinin

monotherapies, chloroquine and Sulfadoxine-Pyrimethamine (SP) by gaining market share. The

AMFm Phase 1 Independent Evaluation has been commissioned to address the need for evidence on

which to base the Global Fund Board decision.

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1.2 Overview of the AMFm Phase 1 Independent Evaluation (IE)

Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene

and Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently

operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and

Zanzibar), and Uganda)4. In addition, the Global Fund contracted Data Contributors (DCs) to be

responsible for in-country fieldwork, data analysis and country reports. These institutions are

Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de

Recherche pour le Développement Humain (CRDH). PSI was responsible for the work in Kenya,

Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health

Institute) and Zanzibar. PSI's ACTwatch Project (www.actwatch.info) has contributed evidence for

the baseline work in Nigeria and Madagascar, which was conducted prior to the IE surveys. DNDi

subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi,

to undertake the work in Ghana. CRDH subcontracted with the Centre International d'Etudes et de

Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.

The purpose of the IE is to assess how AMFm has evolved in each pilot, and estimate changes

between the baseline and endline surveys in the values of key measures (availability, price, market

share and use of quality-assured ACTs) to inform decisions regarding the future of AMFm beyond

Phase 1. The IE is based on the AMFm (Phase 1) Monitoring and Evaluation (M&E) Results

Framework, with a focus on Outputs and Outcomes (Figure 1.2.1).

4In March 2011, the AMFm Ad Hoc Committee (AHC) decided to removeCambodia from the evaluation due to the lack of an eligible ACT for subsidy.

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Figure 1.2.1: AMFm Phase 1 Results Framework

ACTs: Artemisinin-based combination therapies; IEC: Information Education and Communication; GF: Global Fund, AMTs: Artemisinin monotherapy; SP: Sulfadoxine-pyrimethamine, CQ: Chloroquine; TA: Technical Assistance, SIVs: Supporting Interventions

Source: Global Fund, AMFm Phase 1 Monitoring and Evaluation Framework, 2009

The IE is therefore designed to answer four questions related to the availability, affordability, market

share and use of ACTs. These questions are formulated as follows:

1. Has the AMFm mechanism helped increase the availability of quality-assured ACTs to

patients across public, private for-profit and not-for-profit sectors, in rural/urban areas?

2. Has the AMFm mechanism helped to reduce the cost of quality-assured ACTs to patients at

public, private for-profit and not-for-profit outlets in rural/urban areas to a price comparable

to the price of most popular antimalarials?

3. Has the AMFm mechanism helped increase use of quality-assured ACTs, including among

vulnerable groups, such as poor people, rural residents and children?

4. Has the AMFm mechanism helped increase the market share of quality-assured ACTs

relative to all antimalarial treatments in the public, private for-profit and not-for-profit

sectors in rural/urban areas?

To answer these questions, building on the AMFm results framework, the IE impact model (Figure

1.2.2) foresees that subsidizing ACTs, accompanied by effective supporting interventions, will lead to

a decrease in the ACT price. It is therefore anticipated in the model that if ACT price decreases, more

outlets will be willing to stock the product and thereby increase availability. The increase in

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availability, and the substantial decrease in price, will potentially lead to an increase in use.

Figure 1.2.2: The Independent Evaluation Impact model

While an evaluation based on a quasi-experimental design would have provided stronger evidence

to attribute any change in primary outcomes to the intervention, it is challenging to execute such a

study design for an evaluation of a complex public health program such as the AMFm, which is

implemented on a national scale with multiple players. The IE therefore uses a pre- and post-

test/intervention design (Figure 1.2.3) in which each participating country is treated independently

as a case study. As the literature suggests, for the evaluation of such a complex

intervention(Habicht, Victora et al. 1999; Craig, Dieppe et al. 2008; World Health Organization 2009;

Adeyi and Atun 2010), in addition to measuring the changes in key indicators pre- and post-

intervention, the evaluation includes an assessment of the implementation process to determine

whether any lack of impact reflects implementation failure or genuine ineffectiveness. It also

includes comprehensive documentation of context, both to inform assessments about causality and

to aid in generalizability to other contexts.

Price reductions

through

negotiations

with

manufacturers,

a subsidy in the

form of a buyer

co-payment,

and supporting

interventions

ACT Price

Decreased

ACT

Availability

Increased

ACT

Access and

Use

Increased

Malaria

Burden

Decreased

Outputs Outcomes ImpactInputs, Process

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Figure 1.2.3: The Independent Evaluation Design

The evaluation, therefore, includes two major components: (1) a pre- and post-intervention study of

key outcomes through outlet surveys and use of secondary household survey data, and (2)

documentation of key features of the context at baseline and endpoint, and the implementation

process in each pilot. The descriptions of context and implementation process provide the

information needed to interpret the changes in outcomes over the implementation period, and to

judge whether any observed changes are likely due to AMFm.

The evaluation is based on primary data collected from outlet surveys conducted at baseline and

endline (for questions related to availability, affordability and market share of ACTs); secondary data

from national household surveys (for question related to use of ACT), such as Demographic and

Health Surveys (DHS), Malaria Indicator Surveys (MIS), Multiple Indicator Cluster Surveys (MICS) and

ACTwatch household surveys; in-depth interviews with key stakeholders involved in the drug supply

chain in the country; and review of documents such as reports from AMFm operations research,

malaria treatment guidelines, pharmacy regulations, country-level reports from MOH and donor

partners, including national malaria control strategy documents, results from national surveys, and

any other documents relevant to the context data described above.

For each country, relevant indicators will be computed for the baseline and endpoint from the outlet

surveys. For secondary data from existing national household surveys, appropriate indicators will be

extracted from existing reports. To assess change, the IE will calculate the percentage point change

or the percent change (whichever is relevant for each indicator) between the baseline and the

endpoint. Contextual information will then be processed to help in the interpretation of these

results.

Pilot-specific case studies will be produced, making use of the qualitative and quantitative

approaches described above, to document and describe how the AMFm has evolved in each country.

The evaluation will distinguish two parts: (i) the upstream part, with emphasis on the business model

of the AMFm as a financing platform; and (ii) the downstream part, with emphasis on service

Baseline

Assessment

Endpoint

Assessment

ACT

availability, price,

market share and

use

ACT

availability, price,

market share and

use

Intervention

(Financing platform in

place and functional)

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delivery to increase access to and use of ACTs, including by poor people. In the case studies, findings

from nationally representative outlet surveys will be compared before and after the introduction of

the AMFm, taking into account relevant contextual information and results from operational

research that become available to help learn how and why the new model unfolds in a variety of

contexts, while drawing lessons that can help future operations.

While this section gives an overview of the IE to provide the reader with the relevant context, this

report presents the country process, context and results of the endline outlet survey for Nigeria. This

is Step 3 of a four-step process. Step 1 included the baseline outlet survey and the Nigeria country-

specific baseline report. Step 2 integrated these results into a “Multi-country Baseline Report”

produced by the Independent Evaluation Team. Findings from this endline outlet survey will be used

to inform Step 4, the development of the full AMFm Phase 1 Independent Evaluation report, which

will include results from all operational phase 1 pilots, to be submitted to the Global Fund.

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1.3 Country background – context

1.3.1 Overview of the country

Nigeria is located in the West Africa sub-region and is bordered by Niger to the north, Chad to the

northeast, Cameroun to the east and Benin to the west (Figure 11). The country has approximately

850 km of coastline along the Atlantic Ocean, stretching from Badagry in the west to the Rio del Rey

in the east. With a total land area of 923,768 square kilometres, Nigeria is the fourteenth largest

country in Africa. It is the most populous nation in Africa and the eighth most populous country in

the world, with a total population of 158 million (UN Population Division, 2010). Fifty percent of the

population is estimated to live in urban areas. There are more than 250 ethnic groups, the largest of

which are the Hausa, Fulani, Igbo, Yoruba, and Kanuri. The official language of Nigeria is English; with

Hausa, Fulani, Igbo, Yoruba, and Kanuri the most widely spoken Nigerian languages.

Nigeria has a varied climate. Distinct climatic zones can be distinguished, progressing from south to

north. The southern part of the country has an equatorial monsoon climate, while the central

regions are tropical and the northern-most parts are arid. In the south, there is rainfall during most

of the year, with a short break around August and a longer dry period from December to January.

The central regions experience rains between March and October, and a pronounced dry season

(including the Harmattan) between November and March. Temperatures are high during the dry

season but fall during the rains.

Figure 1.3.1: Location of Nigeria

Source: Central Intelligence Agency, The World Factbook 2009,

https://www.cia.gov/library/publications/the-world-factbook/index.html

Between 2000 and 2009, Nigeria’s Gross Domestic Product (GDP) grew at an average 6% year-on-

year (mostly driven by oil revenues) compared to a population growth rate estimated at 2% (World

Bank, 2010). During the same period GDP per capita rose from $1,456 to $2,001, an increase of 38%

(World Bank, 2010). Despite this recent positive economic growth, an estimated 84% of the

population continues to live on less than$2 a day, and the country ranks 142nd out of 169 in the

2010 Human Development Index. Under-five mortality has dropped significantly, from 201 per 1000

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births between 1998 and 2003, (National Population Commission, 2004) to 157 per 1000 births

between 2003 and 2008 (National Population Commission, 2009). Only 23% of children are fully

vaccinated. Malaria remains largely unchecked and leads to an estimated 300,000 deaths in children

under five each year (Federal MOHa, 2009).

Nigeria is sub-divided into 6 geopolitical zones, 36 states (plus the Federal Capital Territory, Abuja),

and 774 Local Government Areas (LGAs). The public health system in Nigeria operates through three

tiers, linked to the three levels of health care. At the highest level, the Federal Ministry of Health

(FMOH) provides policy and technical guidance for the health sector. The FMOH also supports and

manages tertiary level care, research and academic “centres of excellence”. State Ministries of

Health (SMOH) fund and manage state hospitals, maternities, and teaching colleges. SMOHs are also

responsible for the professional development of health sector staff for secondary and primary health

care (PHC), from midwives and nurses to Community Health Extension Workers (CHEWS). At the

third tier, LGAs are tasked with planning, managing, staffing, supporting and implementing primary

health care (PHC) services. Seventy-one percent of Nigerians have access to a PHC facility within five

kilometres of their home (Federal MOH, 2009); however, many of these centres are not functional

due to lack of equipment, essential supplies, and qualified staff.

1.3.2 Description of health care system

A national health facilities census was conducted in 2007. According to the census, the public sector

includes42 teaching hospitals and federal medical centres; 533 secondary-level hospitals, including

general and specialist hospitals; and 14,635 primary-level facilities, including 4,149 dispensaries

(National Primary Healthcare Development Agency, 2007).

The private health care system consists of formal tertiary-, secondary- and primary facilities, and

pharmacies, as well as informal proprietary patent medicine vendors (PPMVs) and drug sellers.

Private health facility figures for the period 1999 to 2001 include 2,147 secondary facilities and 7,000

PHC facilities (Federal MOH, 2009b). For the same period, there were a total of 2,751 registered

pharmacies, and an estimated 36,000 PPMVs (2002 estimate). The private sector provides over 65%

of healthcare delivery in Nigeria (Onwujekwe O et al., 2005). PPMVs are usually the first choice in

health care and are a recognized primary source of manufactured drugs for both rural and urban

populations, especially the poor (Uzochukwu & Onwujekwe, 2004; Uzochukwu et al., 2008; Oladepo

et al., 2008). In addition to selling drugs, they are also a major source of advice about illness and

drug therapy (Ross-Degnan et al., 1996).

As a general policy, healthcare consumers are expected to pay for curative services, but preventive

services are often subsidized. Health financing has been largely out of pocket and efforts are made

to provide public assistance to the socially and economically disadvantaged segments of the

population (Federal MoH, 2004a). To reduce the financial barriers that prevent people in Nigeria,

especially children, from accessing healthcare services, pre-payment schemes such as the National

Health Insurance Scheme (NHIS) are being introduced (Federal MoH, 2006).

The public and private sectors have distinct and independent drug supply chains, although both are

regulated by the National Agency for Food and Drug Administration and Control (NAFDAC). Quality

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control is provided by NAFDAC at the point of entry for imported products and at the factory gate

for locally-manufactured products.

The public sector system is highly fragmented, with each disease having its own supply chain system.

Government agencies and partners are first-line buyers and purchase medicines directly from

manufacturers. Manufacturers bid to supply the government through local and international

competitive bid processes, managed by the Tenders Unit of the FMOH. However, donors also supply

commodities directly to state-level medical stores, and both States and LGAs have funding for

procurement. In anticipation of the AMFm pilot, donors are supporting the development of an

improved logistics management information system for malaria commodities (President’s Malaria

Initiative (PMI), 2010).

Procurement in the private sector is informed by government treatment guidelines, but

predominantly driven by demand. In-country manufacturers are a key source of commodities for

Nigerian wholesalers and distributors: there are almost 40 nationally-registered ACTs that are

manufactured in-country (PMI, 2010). For products manufactured outside of Nigeria, it is common

practice for an importer to act as the sole agent for a manufacturer. While importers are free to

choose their suppliers, a tendency to enter into exclusivity agreements is fostered by the stringency

of the registration requirements, the amount of time that it takes to develop a relationship with the

supplier, and the amount of investment that goes into developing the local market for the imported

product.

1.3.3 Epidemiology of malaria

Malaria is endemic in Nigeria and 97% of the population is at risk. The country exhibits five

ecological strata from south to north which define the seasonality and intensity of malaria

transmission, and vector species dominance: mangrove swamps, rain forest, guinea-savannah,

Sudan-savannah and Sahel-savannah. The duration of the transmission season decreases from

perennial in the south to around 3 months in the northern border region with Chad. In the northern

part of the country, transmission is highly endemic during the short wet season as compared with

general low transmission during the long dry season. In the southern part of the country,

transmission is stable and uniform throughout the year. Malaria prevalence in the population has

been modelled by the Mapping Malaria Risk in Africa (MARA) collaboration (Figure 12).

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Figure 1.3.2: Malaria prevalence map (MARA prevalence model), Nigeria, 2001

Source: Kleinschmidt I. et al. 2001. Map available online at http://www.mara.org.za

Malaria is considered to be a major public health problem in Nigeria. It causes more than 50% of the

disease burden (Federal MoH, 2005) and almost 50% of all-cause health expenditure (Onwujekwe O,

et al., 2000). Twenty percent of all hospital admissions, 30% of outpatient visits, and 10% of hospital

deaths are attributable to malaria, and half of Nigeria’s population is exposed to at least one episode

of malaria every year (Okeke et al., 2006). Results of a modelling exercise presented in the National

Malaria Control Program (NMCP) Strategic Plan 2009-2013 show that malaria accounts for an

estimated 300,000 deaths in children under five each year, and 11% of the maternal mortality

burden in Nigeria. Malaria is responsible for 25% of all infant-related mortality and 30% of child-

related mortality (National Population Commission, 2009). In relative terms, Nigeria contributes

more than a third of the total African malaria burden (Roll Back Malaria, 2008).

Health facility data show that between 2001 and 2007 there was an increase in the number of

malaria deaths: from 4,317 in 2001 to 10,289 in 2007 (all ages), and 721 to 2,695 for under five year

olds. This upward trend may be due to improvements in reporting of cases (World Health

Organization, 2008).

1.3.4 Antimalarial Policies and Regulatory Environment

In January 2005 the NMCP adopted artemether-Lumefantrine (AL) as the first-line treatment for

uncomplicated malaria (Federal MoH, 2004b). Artesunate amodiaquine (ASAQ) is recommended as

the alternative first-line treatment, should AL not be available. At the time of the policy change, AL

and ASAQ were prescription-only medications; NAFDAC reclassified these medicines as over-the-

counter (OTC) in 2006.

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Parenteral quinine is recommended for the treatment of severe malaria and as pre-referral

treatment. In addition, artemether and artesunate injections are included on the list of current

medicines for severe malaria. Artesunate suppositories are also used at peripheral health facilities

where parenteral treatment cannot be administered (they are included in the national policy on

malaria treatment as a pre-referral treatment only).

Oral artemisinin monotherapies have been banned in Nigeria since 2006, under legislation that

prohibits their importation and local production. In order to support broader adoption of ACTs,

NAFDAC stopped registering new artemisinin monotherapies in 2006. Licenses for the sale of oral

artemisinin monotherapies were not renewed when they expired (which was by late 2009). In order

to mitigate the risk of artemisinin monotherapy stockpiling prior to the end of valid registration,

NAFDAC provided several incentives to importers, including a reduction in the cost of registering

ACTs.

1.3.5 Malaria control strategy

The core interventions for malaria control in Nigeria include long lasting insecticide-treated net

(LLIN) distribution through antenatal care clinics, immunization visits, large-scale stand-alone

campaigns, and subsidized and at-cost sales in the commercial sector; intermittent preventive

treatment for pregnant women (IPTp); case management following prompt diagnosis at all levels of

health care; and, to a more-limited extent, indoor residual spaying (IRS).

Up to late 2008, public sector bed net distribution campaigns focused on the most vulnerable

groups: children under five and pregnant women. Initially starting with insecticide-treated nets

(ITNs), distribution switched to LLINs in 2006. Nigeria has removed import tariffs on bed nets (M-

TAP, 2010). More than 19 million ITNs were distributed during 2009 (WHO, 2010a), a substantial

increase on previous years. Results from the 2008 DHS show low net ownership and use: an

estimated 8% of households own at least one ITN, and only 6% of children under five are reported to

have slept under an ITN the night before the survey. Looking to the future, sufficient donor funds

have been mobilised to enable the procurement of more than 62 million nets, enough to achieve

universal coverage with two LLINs per household (PMI, 2010).

Large-scale IRS campaigns have not been conducted in Nigeria since the mid-1970s, and present

institutional capacity for spraying is weak. Several trials have been conducted in recent years, with

the support of insecticide manufacturing companies, and World Bank-supported campaigns are

present in 7 states. The NMCP Strategic Plan 2009-2013 includes an increased role for IRS in specific

situations (such as where ITN usage rates remain low, and in more densely populated areas), and

sets a target of 20% of households covered by IRS by 2013.

Nationwide, an estimated 58% of pregnant women have access to antenatal care (ANC) from a

skilled provider, but only 5% receive the recommended two doses of Sulphadoxine-Pyrimethamine

(SP) for IPTp (National Population Commission, 2009). These figures vary widely by State, and

coverage is greater in urban areas than in rural areas. IPTp is free when given through antenatal

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clinics (ANC) at public and NGO health facilities. However, due to the supply chain problems, it is

unclear if LGAs have sufficient stocks of SP to meet demand for IPTp.

Case management for malaria is based on prompt treatment with effective ACT. The NMCP’s desire

that such treatment be available close to home is aided by the classification of AL and ASAQ as over-

the-counter (OTC) medicines, and the policy supporting community case management of malaria

with ACTs. The National Antimalarial Treatment Policy states that parasitological diagnosis is

essential for all suspected cases of malaria, with microscopy providing the gold-standard. However,

there is an understanding that the cost and capacity for providing laboratory services present a

barrier to achieving coverage with microscopy, and as such RDTs should be introduced in facilities

with no microscopes. Within the public sector, policy states that ACT is available free of charge for

both under-fives (as of 2006) and over-fives (as of 2009).

1.3.6 Malaria financing

Despite government and donor funding increasing from $18.5 million in 2005 to $84.5 million in

2008 there is no evidence of a systematic decline in malaria burden in Nigeria (WHO, 2008). The

NMCP delivered about 17 million insecticide treated bed nets during 2005-2007, enough to cover

only 23% of the population at risk. The programme delivered 4.5 million courses of ACT in 2006 and

9 million in 2007 which is far below the country's total requirements (WHO, 2008).

A subsidy program run by SFH and funded by the Global Fund has made child doses of ASAQ

available since 2008 through private sector health facilities, pharmacies and PPMVs in 18 of the 36

states and the Federal Capital Territory. These products, with brand names Arsuamoon and Larimal,

were sold for a wholesale purchase price of 5 NGN (US$ 0.03) per treatment with an approved retail

price set at 30 NGN (US$ 0.20). However, the subsidized Arsuamoon and Larimal products

distributed under this program had identical packaging to their non-subsidized commercial

equivalents that were being concurrently sold by private sector wholesalers and retailers across the

entire country at considerably higher prices. Therefore, to ensure that the target retail price was

achieved and also to minimize leakage of the subsidized product outside of program areas and

target retail outlet types, SFH chose to bypass private sector wholesalers and distributed these

subsidized products directly to target outlets in the participating states from their own warehouses

and only in limited quantities (e.g. PPMVs were permitted to purchase 2 packages from SFH per

transaction). Subsidized ASAQ was also distributed through several civil society partners (Africare

Nigeria, Errand Express, Planned Parenthood Federation of Nigeria) strategically selected by SFH in

order to improve coverage in underserviced rural areas. In 2007, a total of 17.5 million doses of ACTs

(AL and ASAQ) were distributed in the public and NGO sectors or sold in the private sector at

subsidized prices through SFH. While this represents notable progress compared to 2006 when less

than half of this volume was distributed, it still only provided treatment for about 25% of the

estimated number of malaria cases (FMOH, 2009).

Since 2007 funding for malaria control has dramatically increased. Nigeria signed a $461 million

Global Fund Round 8 grant in 2008, and additional funds were made available through the World

Bank Malaria Booster Program and the UK Department for International Development (DfID). The

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Round 8 grant will contribute to providing universal coverage with LLINs; continued roll-out of ACT;

and increased access to malaria diagnostics, including roll-out of RDTs to primary health facilities.

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Methods

2.1 Outlet survey

2.1.1 Outlet survey indicators

The following table shows the AMFm Phase 1 primary indicators to be measured through the outlet

survey, and presented in this report. Results are presented by urban and rural locations and

nationally. They will also be presented by outlet type (though there may not be sufficient power to

detect statistical differences between outlet types).

Table 2.1.1: Primary AMFm indicators

Availability indicators

1.1 Proportion of censused outlets that have any antimalarials in stock at the time of survey visit in rural and

urban areas

1.2 Proportion of outlets that have non-artemisinin monotherapy or non-artemisinin combination therapy in

stock among outlets with any antimalarials in stock at the time of survey visit in rural and urban areas

1.3 Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in

stock at the time of survey visit in rural and urban areas

1.4 Proportion of outlets that have non-quality-assured ACTs in stock among outlets with any antimalarials in

stock at the time of survey visit in rural and urban areas

1.5 Proportion of outlets that have quality-assured ACTs in stock at the time of survey visit among outlets with any

antimalarials in stock at the time of survey visit in rural and urban areas

1.6 Proportion of outlets with antimalarials in stock at the time of survey visit that have been out of stock of

quality-assured ACTs for at least 1 day in the last 7 days in rural and urban areas

1.7 Proportion of the population living in a “sub-district” where there is at least one outlet that had a quality-

assured ACT in stock at the time of the survey visit in rural and urban areas

Pricing indicators

2.1 Median cost to patients of one adult equivalent treatment dose (AETD) of quality-assured ACTs in rural and

urban areas

2.2 Median cost to patients of one AETD of non-quality-assured ACTs in rural and urban areas

2.3 Median cost to patients of one AETD of artemisinin monotherapy in rural and urban areas

2.4 Median cost to patients of one AETD of non-artemisinin monotherapy or non-artemisinin combination

therapy in rural and urban areas

2.5 Median percentage markup between retail purchase and selling price of quality-assured ACTs in rural and

urban areas

2.6 Median total markup from first-line buyer purchase price to retail selling price for quality-assured ACTs

Market share indicators

3.1 Total volume of quality-assured ACTs sold or distributed in the last week, as a proportion of the total volume

of all antimalarials sold or distributed in the last week in rural and urban areas

The following table shows the primary ACTwatch indicators measured through the outlet survey,

and presented in this report. Results are presented nationally and by endemicity. They will also be

presented by outlet type (though there may not be sufficient power to detect statistical differences

between outlet types).

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Table 2.1.2:Primary ACTwatch indicators

Availability indicators

Proportion of censused outlets that have any antimalarials in stock at the time of survey visit.

Proportion of outlets that have any ACTs in stock among outlets with any antimalarials in stock at the time of survey,

including:

Quality-assured ACTs

o First-line quality-assured ACTs (FAACTs)

o Non-first-line quality-assured ACTs (NAACTs)

Non-quality-assured ACTs (nQAACTs)


Proportion of outlets that have any non-artemisinin therapy (nAT) in stock at the time of survey visit, including:

Chloroquine

Sulfadoxine-Pyrimethamine

Quinine

Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in stock at the

time of survey visit, including


Non-oral artemisinin monotherapy

Stock outs

Proportion of outlets that report no disruption in stock of any antimalarial, among outlets with any antimalarial in

stock or reported stock outs in the last three months.

Proportion of outlets that report no disruption in the first-line quality-assured ACT, among outlets with any

antimalarials in stock or reported stock outs in the last three months.

Pricing indicators

Median cost to patients of one adult equivalent treatment dose (AETD) of ACTs, including:


o First-line quality-assured ACTs

o Non-first-line quality-assured ACTs (NAACTs)

Non-quality-assured ACTs


Median cost to patients of one AETD of any non-artemisinin therapy, including:

Chloroquine

Sulfadoxine-Pyrimethamine

Quinine

Median cost to patients of one AETD of artemisinin monotherapy , including



Affordability

Median cost to patients of one adult equivalent treatment dose (AETD) of first-line quality-assured ACTs relative to

the most popular antimalarial treatment.

Median cost to patients of one AETD of first-line quality-assured ACTs relative to the minimum legal daily wage.

Median cost to patients of one AETD of first-line quality-assured ACTs relative to the international reference price.

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Market share indicators

Total volume of ACTs sold or distributed in the last week, as a proportion of the total volume of all antimalarials sold

or distributed in the last week.

Provider knowledge

Proportion of providers that can correctly state the recommended first-line treatment for uncomplicated malaria,

among outlets with any antimalarials in stock or reported stock outs in the last three months.

Proportion of providers that can state the dosing regimen of the first-line treatment for an adult among outlets with

any antimalarials in stock or reported stock outs in the last three months.

Proportion of providers that can state the dosing regimen of the first-line treatment for a two year old, among outlets

with any antimalarials in stock or reported stock outs in the last three months.

2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators

While there are many similarities between the AMFm Phase 1 and ACTwatch indicators, there are

notable differences, particularly in terms of the types of antimalarial classifications, denominators

for some provider indicators, prices (notably the use of different exchange rates and presentation of

median prices for tablet vs. other formulations) and the presentation of indicators in the report. The

following subsection helps to explain these differences by providing background on: 1) antimalarial

classifications 2) ACTwatch primary indicators and 3) AMFm Phase 1 primary indicators.

Classification of antimalarials

Antimalarials are presented within three broad policy-relevant categories:

Non-artemisinin Therapy (nAT)

Artemisinin Monotherapy (AMT)

Artemisinin-based Combination Therapy

ACTs are further sub-divided as:

Quality-assured ACTs (QAACTs), which include:

o First-line, Quality-assured ACTs (FAACTs),

o Non-first-line Quality-assured ACTs (NAACTs)


For further details on this classification see section 2.1.5.3 Classification of antimalarials.

ACTwatch versus AMFm classifications

Given the objectives of the AMFm Phase 1, indicators focus on the following antimalarial

classifications: 1) non-artemisinin therapy, 2) artemisinin monotherapy, 3) QAACTs and 4) non-

quality-assured ACTs.

In addition to these classifications, ACTwatch also presents data on FAACTs, NAACTs, and nationally

registered antimalarials, which are relevant for national policy. Artemisinin monotherapy is also

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further classified as oral and non-oral artemisinin monotherapy as per WHO recommendations that

intravenous artesunate should be used as first-line treatment in the management of severe P.

falciparum malaria in African children and adults (WHO, 2010b). ACTwatch further classifies non-

artemisinin therapy into chloroquine, Sulfadoxine-Pyrimethamine and quinine.

ACTwatch versus AMFm denominators

Provider knowledge

The ACTwatch indicator on provider knowledge of the first-line antimalarial treatment includes

outlets that had an antimalarial at the time of survey or in the previous three months. For the AMFm

Evaluation Indicator, only outlets that had an antimalarial in stock at the time of survey are included

in the denominator. Therefore, there are slight differences in the results for these knowledge

indicators.

Rapid diagnostic tests and malaria microscopy

The ACTwatch indicator on availability of RDTs and malaria microscopy includes outlets that had an

antimalarial at the time of survey or in the previous three months. For the AMFm Evaluation

Indicator, only outlets that had an antimalarial in stock at the time of survey are included in the

denominator. Therefore there are slight differences in the results for these diagnosis indicators.

ACTwatch versus AMFm evaluation exchange rates

Price Price data were collected in local currencies and converted to their US$ equivalent. The US$

conversion used in this report (for ACTwatch indicators) is equivalent to the average interbank rate

for the period of data collection. This approach is used to facilitate comparisons over time between

other rounds of ACTwatch data collection, and between other ACTwatch countries. This differs from

the AMFm approach, which uses the average 2010 exchange rate over the whole year in which data

collection took place. Given these differences, separate tables for price indicators were provided to

the Independent Evaluator (IE) for AMFm, using the 2010 exchange rate. The prices presented in this

report are therefore slightly different from those presented in the “Multicountry Baseline Report”

produced by the Independent Evaluation Team, which synthesizes results from all pilot AMFm

countries.

In addition, a notable difference between the price measures for the AMFm indicators and the

ACTwatch indicators is the presentation of price for tablets and other formulations. Price measures

for ACTwatch only include tablet formulations. The price of non-tablet formulations, such as

powders for reconstitution, suspensions, suppositories and syrups, are excluded. In contrast to this,

the AMFm indicators present information for both tablet and non-tablet formulations.

2.1.3 Sampling Approach

The sampling approach was based on that used in ACTwatch outlet surveys conducted in previous

survey rounds (including outlets in the public, private for-profit, and not-for-profit

sectors)(Shewchuk, O'Connell et al. 2011).

Sample size determination

The outlet survey is designed to measure differences in indicators over time and between outlet

types. It will measure a) differences over time for a given outlet type (e.g. changes in ACT availability

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in pharmacies at baseline versus ACT availability in pharmacies at follow-up); and b) differences

between outlet types at a given point in time (e.g. differences in ACT availability between public

health facilities versus availability in pharmacies at baseline). Denominators for this survey are the

numbers of outlets at a particular time. The required sample size for each year of the program is

therefore calculated using the formula:

Where:

n = desired sample size

P1 is the hypothesized value of the indicator at year X (time 1)

P2 is the expected value of the indicator at year X+1 (time 2)

P= (P1+P2)/2

Z is the standard normal deviate value for an type I error

Z1- is the standard normal deviate value for a c type II error

Deff is the design effect in case of multi-stage cluster sample design

The required sample size has been calculated on the basis of the following assumed values of the key

parameters:

P1is the value of the key outcome indicators at time 1= 40% (40% is used to maximize the

sample size and ensure that a 20% difference can be detected as the true value is unknown)

P2is the expected value of the indicator at the second instance (time 2). A 20% difference will

be detected (assuming that a 20% point increase is the minimum necessary to justify the

importance in public health policy terms).

P = (P1 + P2)/2,

Zα = 1.96 (5% significance) is the standard normal deviate value for an α type I error,

Z1 − β = 0.84 (80% power) is the standard normal deviate value for a c (or 1 − β) type II error, and

Deff = 4 (estimated from ACTwatch data from selected countries)

Then a conservative number of 305 outlets that have any kind of antimalarial in stock at the time of

the survey is needed in each domain to detect a statistically significant difference of 20 percentage

points in the QAACT availability indicator (with 80% power, 95% significance, and a design effect

estimated at 4 to address one-stage cluster sampling), where P1 is the hypothesized value of the

indicator at time one [40%] and P2 is the hypothesized value of the indicator at time 2 [60%]. By

applying these estimated parameters, the ultimate number of sub-districts/locations required to

reach the estimated number of outlets was 39 in the urban domain and 85 in the rural domain,

giving a total of 124 sub-districts/localities required in Nigeria.

The proportion of outlets with any ACT, estimated to be 40%, was the primary outcome measure. A

minimum of 291 outlets with antimalarials in stock were needed to provide detectable changes in

212

2

221111 1112

PP

PPPPZPPZdeffn

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ACT availability per stratum (urban, rural) and between the public and private sectors. With this

number, 39 clusters selected from the urban stratum and 85 clusters from the rural stratum

provided a representative sample to detect a 20% point increase in availability at 80% power, setting

the level of significance at 5% and adjusting for an estimated design effect of 3.

Selection procedure of the sub-districts

The desired cluster size for the outlet survey was approximately 10,000 to 15,000 inhabitants, which

corresponded most closely to localities in Nigeria. It is notable that there were a wide range of

population sizes, from as few as 930 people per locality to 420,000. Each locality was classified

according to one of the six geo-political zones. Facility listings obtained from the Pharmaceutical

Council of Nigeria (PCN) and the Federal Ministry of Health Facility List were used to confirm the

location of public sector and pharmacies.

Multi-staged sampling was conducted. The sampling frame used was the list of the 70,476 localities

in 6geo-political zones of Nigeria, using information from the 1999 Population Census. At the first

stage, locations were selected proportional to the population. The sample was stratified into urban

and rural areas. Implicit stratification was achieved by separating the urban and rural domains

according to geopolitical areas, so each domain was stratified into 6stratareflecting the

6geopolotical areas in Nigeria.

Localities were selected proportional to the population. A probability sample of 39 localities out of

2788 localities was selected from urban domains and 85 localities out of 67688 were selected from

rural domains, giving a total of 124 localities. For selected locations with population sizes above

50,000, these were segmented into smaller segments of approximately 20000 inhabitants. One

segment was then randomly selected as the AMFm cluster.

All outlets that stocked antimalarials at the time of survey or in the past three months were eligible for interview.

2.1.4 Data collection

Preparatory phase

The study received ethical clearance from the National Health Research Ethics Committee of Nigeria

(NHREC) on the 8th of September 2011 (Ref No: NHREC/01/01/2007-02/09/2011).

The questionnaire mirrored the ACTwatch questionnaire employed in Nigeria in 2010(Shewchuk,

O'Connell et al. 2011). However, the IE team made several adaptations to the questionnaire at

endline in Nigeria to ensure that the IE indicators were included and other requests from key

stakeholders were met (e.g., the addition of questions on stockouts of quality-assured ACTs, training

courses attended, and knowledge of proper dosing of quality-assured ACTs).

Paper questionnaires were used for data collection. The questionnaire contained four modules: 1) a

screening module identified outlets that were eligible for the audit and provider interview; 2) a

provider module collected information on outlet demographics (e.g., health qualifications of staff,

number of staff that prescribe or dispense medicines), provider knowledge of the first-line

treatment, and provider perceptions; and 3) an antimalarial audit module collected data for each

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antimalarial stocked, including information on brand name, generic name and strengths, package

type and size, recall of volumes sold over the week before the survey, recall of last purchase price

and selling price and 4) an RDT audit which determined brand name, price and manufacturer of

RDTs. The questionnaire was translated into Hausa, Yoruba and Igbo.

Standardized ACTwatch training materials modified by the Independent Evaluator were adapted to

the national setting, and were administered by SFH/Nigeria and ACTwatch central staff. There were

two trainings carried out for the field workers during the endline. A total of 41 fieldworkers

participated in the first 6-day outlet survey training in Abuja, Nigeria between October 3rd and 8th,

2011. This was followed by another training of 54 field workers, from 19th to 24th October, 2011 in

Lagos, Nigeria. Supervisors and quality controllers who were selected based on their performance in

the training and received additional 2-day training.

Field workers’ training sessions covered completing the questionnaire, informed consent,

conducting the census, and identifying outlet types. Interviewers were also trained on how to

identify anti-malarial medicines, including the differences between ACTs and non-ACTs, trade names

and generics, packaged and loose tablets, and the various formulations. The supervisor and quality

controller training sessions covered roles and responsibilities, coding of questionnaires, error checks

for questionnaire validity, field monitoring and reporting and back checking of questionnaires.

Standard Operating Procedures (SOPs) developed by ACTwatch were used to help ensure high

quality data. The SOPs outline each element of data collection and management, e.g., questionnaire

translation, questionnaire pretesting, fieldworker training, and double data entry.

Fieldwork

Data collection started on October14thand ended November 30th, 2011. Six teams were organized for

the data collection in the northern region, each consisting of one team supervisor, one quality

controller and four interviewers. In the southern region, there were six teams, with four teams

consisting of one team supervisor, one quality controller and 5 interviewers and the other two

teams consisting of one team supervisor, one quality controller and 6 interviewers.

Official lists of pharmacies operating in all localities were obtained from the Pharmaceutical Council

of Nigeria (PCN), and official lists of the public health facilities were obtained from the Federal

Ministry of Health Facility List. These outlets were listed according to their location in the localities

and used to identify pharmacies and public health facilities in advance of data collection. During data

collection, survey teams consulted with locality government area level officials, who reviewed the

health facility listings and maps. Any new registered pharmacies and public health facilities were

updated in the original list. Officials and community elders also helped to define location boundaries

and to identify other outlets with the potential to sell drugs. A snowball technique was also used:

outlets included in the survey were asked to identify other outlets stocking or with the potential to

stock medicine in the locations.

In rural areas, interviewers first covered the main trading center and then asked the outlet

owners/providers for the locations of other outlets found in their village. In urban areas,

interviewers were allocated different streets, and outlets were approached in a logical manner. In

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both urban and rural areas, key features such as roads were used as markers to avoid double

coverage.

For each outlet that was identified during the census, the outlet type and location were noted, along

with its longitude and latitude coordinates (obtained via hand-held Global Positioning System (GPS)

units). The fieldworker then proceeded to identify the senior staff member currently present at the

outlet, and screening questions were administered. For outlets that were eligible, the interviewer

then read the information sheet to the senior staff person and obtained verbal consent. Consenting

providers were interviewed. A maximum of three call backs were made to outlets that were either

closed at the time of interview, or where the interview was interrupted.

Once questionnaires had been thoroughly checked by both the supervisor and the quality controller,

the questionnaires were then collected by the regional coordinators and sent to Abuja. At the end of

the survey, before data entry, questionnaires were again reviewed by the quality controllers,

supervisors & ACTwatch central staff.

Both supervisors and quality controllers accompanied interviewers during field collection, and

conducted spot checks. Regional coordinators, SFH/Nigeria, the National Malaria Control Program,

and ACTwatch Central teams also provided additional supervision, ensuring that a census had been

adequately completed. These staff also helped to review the questionnaires.

The quality controller on each team conducted the back checks. Each quality controller categorized

the outlets to be checked into either ‘eligible’ or ‘ineligible’ and then randomly selected at least 5%

from each outlet category for back checks. Special attention was given to refusals, or questionnaires

with substantial missing data and/or non-response.

2.1.5 Data processing

Double data entry of 8552 questionnaires was performed using Microsoft Access by 16 data entry

clerks. The entry was conducted between November28th 2011 and December 21st2011. ACTwatch

central staff and a trained data manager were responsible for validating the double data entry. After

the first round of data entry, errors were flagged and corrected with reference to the hard-copy

questionnaires. This process continued until the two data entry files were identical. The two Access

database files were sent to ACTwatch Central on January 16th 2012 where final verification and

posting was done to achieve the final dataset. As data entry progressed, ACTwatch central staff

verified the quality of data entered and gave feedback to the entry teams.During data cleaning, any

entries requiring clarification were documented and raised with SFH/Nigeria. SFH/Nigeria staff

responded to these requests by making reference to the hard-copy questionnaires. In addition to the

hard-copy questionnaires, the electronic data entry files are backed up at SFH/Nigeria. Additional

electronic copies are kept at ACTwatch Central.

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2.1.6 Data analysis

Data analysis process

Detailed data cleaning guidelines giving step-by-step instructions on how to clean each section of the

data using range and consistency checks were utilized during the analysis process. Commands

executed for data cleaning were documented using a “syntax file”, and the results of running these

commands using a “log file”.

A standardized tabulation plan was used for all tables presented in this report, which were produced

using standard analysis “do-files” in STATA. Analysis was run using STATA version 11, recording

results in a “log file”.

Accounting for the survey design in data analysis

We accounted for three aspects of the sampling design during the analysis:

Sampling weights: Sample weights were calculated for the outlet survey data to allow for 1)

difference in sampling probabilities due to variation in the size of strata, 2) the oversampling for

the booster sample, and 3) the sampling strategy, which involves a census of outlets in locations

of varying size, selected using probability proportional to size (PPS) sampling. Weights were

based on sampling probabilities and were calculated by the IE after data cleaning was complete.

Appendix 8.6 provides a detailed description of the calculations performed and weights used.

Clustering: As the sample was clustered at the level of the sub-district for other outlets, the

calculation of the standard errors takes the clustering into account because outlets in a given

cluster are likely to be more similar to each other than to outlets in other clusters. (The standard

errors did not take into account clustering of products within outlets because a complete list of

all relevant products in each outlet was obtained and no sampling was performed).

Stratification: As locations were sampled separately in each stratum, it was necessary to adjust

for this in the calculation of standard errors.

To account for these design features in the tabulations, we used the STATA commands for analyzing

complex survey data (“svy” commands) to weight the data and calculate confidence intervals (CI)

which account for clustering and stratification. We declared the primary sampling unit (locality), the

weight variable (wt), the strata and the finite population correction (fpc) equaling the sampling

fraction for each stratum (the number of sampled localities in a stratum divided by the total number

of localities in the stratum, or 0.5 if the sampling fraction was greater than 50 percent) This was

specified as:

svyset locality [pweight=wt], strata (strata) fpc (fpc)

We calculated a proportion and its 95 percent confidence interval (CI) as:

svy: proportion VariableName

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Classification of antimalarials

For the purpose of the analysis, antimalarials were split into three broad policy relevant categories:

non-artemisinin therapy (nAT), artemisinin monotherapy (AMT) and artemisinin-based combination

therapy (ACT).

- ACTs were further sub-divided into quality-assured ACTs (QAACTs) and non-quality-assured

ACTs. QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and

Malaria’s Quality Assurance Policy. For the purpose of the Independent Evaluation, a QAACT

is any ACT which appeared on the Global Fund's indicative list of antimalarials meeting the

Global Fund's quality assurance policy prior to baseline or endline data collection (see

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General), or

which previously had C-status in an earlier Global Fund quality assurance policy and was

used in a program supplying subsidized ACTs. At endline, QAACTs were defined as any ACT

which appeared on the Global Fund’s indicative list of antimalarials meeting its quality

assurance policy as at September 2011, or which previously had C-status in an earlier Global

Fund quality assurance policy and was used in a program supplying subsidized ACTs. A list

of all ACTs qualifying as QAACTs at the time of the endline survey is included in Appendix

8.2.

- ACTs were further sub-divided into First-line Quality-assured ACTs (FAACTs) and Non-first-

line Quality-assured ACTs (NAACTs), and nationally registered antimalarials, which are

relevant for national policy (WHO, 2010b). FAACTs are government recommended first-line

ACTs (i.e., ASAQ in Madagascar) for uncomplicated malaria meeting the quality-assured

definition. NAACTs are ACTs that are not the government’s recommended first-line

treatment for uncomplicated malaria (i.e., AL in Madagascar), but which do meet the

quality-assured definition. FAACTs and NAACTs are only presented for the ACTwatch

indicators.

- ACTs were also classified as nationally registered ACTs. Nationally registered ACTs are ACTs

registered with a country’s national drug regulatory authority and permitted for sale or

distribution in-country. Each country determines its own criteria for placing a drug on its

nationally registered listing. A list of nationally registered ACTs at the time of data collection

is given in the appendix. Nationally registered ACTs are only presented for the ACTwatch

indicators.

- AMT were further classified into oral and non-oral AMT, to distinguish between non-oral

AMT, which are recommended for treatment of severe malaria, versus oral AMT, which are

targeted for removal from the market as a key policy goal.

- nATs were further classified into chloroquine, Sulfadoxine-Pyrimethamine, quinine,

amodiaquine or other nATs that may be found in the dataset (e.g., Halofantrine). These

categories are only presented for the ACTwatch indicators.

Calculation of antimalarial volumes, prices and markups

Antimalarial volume and price data are reported in terms of adult equivalent treatment doses

(AETDs) using an AETD calculator developed by ACTwatch with some modifications (Shewchuk,

O'Connell et al. 2011). An AETD is defined as the number of milligrams (mg) of an antimalarial drug

needed to treat a 60 kg adult (refer to Appendix 8.7 for details). The number of mg/kg used to

calculate one AETD was defined as what was recommended for a particular drug in the treatment


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guidelines for uncomplicated malaria in areas of low drug resistance issued by WHO (as of 5 April

2011). Where WHO treatment guidelines did not exist, such as for Halofantrine (Halfan), or

Dihydroartemisinin, AETDs were based on the product manufacturer’s treatment guidelines. In the

case of ACTs, which have two or more active antimalarial ingredients packaged together (either co-

formulated or co-blistered), the strength of the artemisinin-based component was used as the basis

for the AETD calculations. Information collected on the medicine strength and unit size, as listed on

the product packaging, was then used to calculate the number of AETDs contained in each unit.

Market share was calculated by dividing the number of AETDs of a particular antimalarial category

sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked

antimalarials, but some or all sales volumes were missing, we did not impute for missing values.

For ACTwatch, price data were collected in local currencies and converted to their US$ equivalent

using the average interbank rate for the period of data collection (US$ = 161.31 Naira, source:

www.oanda.com). This differs from the IE approach, which uses the average 2010 exchange rate for

the baseline surveys. For the IE, price data were collected in local currencies and adjusted to 2010

prices in order to facilitate comparisons to baseline estimates which were adjusted to 2010 prices

for all pilots. Prices were adjusted using the ratio of the average national consumer price index for

2011 to the national average consumer price index for 2010 (International Monetary

Fund(IMF),2011).These 2010 prices were then converted to their U.S. Dollar (USD)equivalent using

the average interbank rate for 2010 (USD = 152.803 Naira, source www.onanda.com). Price data are

reported using median and inter-quartile range, which are appropriate for describing distributions

likely to be skewed.

Retail gross percentage markups were calculated for each product as the difference between selling

price and purchase price, divided by purchase price. In cases where an outlet received an

antimalarial for free from its supplier and distributes the product for free, the retail markup was set

to 0%. In cases where an outlet received an antimalarial for free from its supplier, but does not

distribute the product for free, the retail markup was set to missing. The tables that present markup

data indicate the number of observations set to missing for this reason.

www.ACTwatch.info

Page 26

Results - Outlet survey

3.1 Characteristics of the sample

Throughout the document, reference will be made to the letters in this flow diagram (A to E) as a

reminder of which subset of outlets a given table is referring to.

Figure 3.1.1: Survey flow diagram

Interview interrupted : [0]

Eligible respondent not available/Time not convenient for interview :

[151]

Outlet not open at the time : [244]

Outlet closed permanently : [69]

Other : [3]

Refused : [101]

Interview interrupted: [3]

Eligible respondent not available/Time not convenient for interview :

[2]

Outlet not open at the time : [0]

Outlet closed permanently : [0]

Other : [0]

Refused : [0]

Outlets enumerated*[8,507]

Outlets screened [7,939]

Outlets not screened [568]

Outlets which met screening criteria:

1=[1,509] or 2= [58]

Outlets which did not meet Screening criteria

[6,372]

Outlets interviewed**[1,562]

Outlets not interviewed[5]

Outlets with antimalarialsin stock on day of visit

[1,504]

Outlets with not antimalarials in stock on

day of visit***[58]

A

B

C

D

E

*Enumerated means were visited and filled in at a minimum basic descriptive information (questions C1-C9 of questionnaire) **Interviewed means that final interview status was completed or interview interrupted ***but had antimalarials in stock in previous 3 months Note: The outlet type was recorded for 8,506 of the 8,507 outlets enumerated (99.9%). One outlet was missing outlet type information and this outlet fell into the category: did not meet screening criteria. This outlet case was excluded from the analysis.

Screening Criteria: 1: Antimalarials in stock on day of visit; 2: No antimalarials in stock on day of visit, but antimalarials in stock in previous 3 months.

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Page 27

ACTwatch Indicators

www.ACTwatch.info

Page 28

Table A.1: Availability of antimalarials, by outlet type

Public Health Facility

Community Health Worker

Private not for-profit

HF

TOTAL Public / Not

for-profit

Private for-profit

HF Pharmacy Drug Store

General retailer

Itinerant drug vendor

TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=108 N=14 N=11 N=133 N=100 N=37 N=1,185 N=6,377 N=87 N=7,786 N=7,919

Antimalarials in stock at the time of survey visit

5

82.8 33.8 71.2 77.4 87.1 100 97.8 0.9 25.6 17.9 19.0

(68.1, 91.5) (7.0, 77.6) (29.8, 93.5) (64.7, 86.5) (76.8, 93.2) (95.5, 98.9) (0.5, 1.4) (20.0, 32.1) (15.7, 20.4) (16.8, 21.5)

Any ACT 52.8 27.6 62.2 52.1 52.4 100 56.9 0.2 4.4 10.3 11.1

(39.0, 66.3) (4.5, 75.4) (32.0, 85.2) (40.7, 63.4) (36.0, 68.2) (45.9, 67.3) (0.1, 0.4) (1.7, 10.9) (9.2, 11.5) (9.9, 12.3)

Quality-assured ACT (QAACT) 46.9 27.6 62.2 47.5 44.6 99.8 53.0 0.2 0.3 9.5 10.2

(35.2, 59.0) (4.5, 75.4) (32.0, 85.2) (36.9, 58.3) (30.7, 59.4) (98.1, 100.0) (42.8, 63.0) (0.1, 0.4) (<0.1, 2.0) (8.4, 10.7) (9.1, 11.4)

First-line (FAACT) 46.9 27.6 62.2 47.5 44.6 99.8 53.0 0.2 0.3 9.5 10.2

(35.2, 59.0) (4.5, 75.4) (32.0, 85.2) (36.9, 58.3) (30.7, 59.4) (98.1, 100.0) (42.8, 63.0) (0.1, 0.4) (<0.1, 2.0) (8.4, 10.7) (9.1, 11.4)

Non-first-line (NAACT) -- -- -- -- -- -- -- -- -- -- --

Any child QAACT 23.8 27.6 47.3 27.3 22.4 50.0 29.2 0.1 0.0 5.1 5.6

(13.9, 37.7) (4.5, 75.4) (25.2, 70.5) (17.9, 39.2) (12.7, 36.3) (26.8, 73.1) (21.6, 38.2) (<0.1, 0.2) - (4.2, 6.3) (4.5, 6.8)

QAACTs with the AMFm logo

22.4 3.7 60.4 26.0 39.3 80.9 49.4 0.1 0.3 8.7 9.0

(14.5, 32.9) (0.7, 18.4) (31.5, 83.4) (17.7, 36.5) (26.1, 54.3) (50.1, 94.7) (39.4, 59.3) (0.1, 0.3) (<0.1, 2.0) (7.7, 9.8) (8.0, 10.1)

Non-quality-assured ACT 20.8 0.0 0.5 16.5 21.1 99.8 25.4 0.2 4.1 4.9 5.1

(11.3, 35.2) - (0.1, 4.8) (9.4, 27.2) (11.3, 36.2) (98.3, 100.0) (18.4, 33.9) (0.1, 0.4) (1.5, 10.5) (4.0, 5.9) (4.2, 6.2)

Nationally Registered ACT 43.6 26.3 49.4 43.1 46.1 99.8 46.8 0.2 2.4 8.6 9.2

(30.3, 58.0) (4.0, 75.3) (26.3, 72.7) (31.5, 55.4) (31.0, 62.0) (98.1, 100.0) (37.6, 56.2) (0.1, 0.4) (0.3, 16.7) (7.6, 9.7) (8.2, 10.3)

Any non-artemisinin therapy 62.4 32.5 58.7 59.6 74.8 100 97.3 0.8 21.7 17.6 18.4

(47.5, 75.3) (6.5, 77.0) (26.5, 84.8) (48.1, 70.1) (64.2, 83.1) (95.2, 98.5) (0.5, 1.4) (15.5, 29.7) (15.4, 20.1) (16.1, 20.9)

Sulfadoxine-Pyrimethamine (SP) 49.1 29.0 29.8 44.9 39.4 99.7 77.7 0.7 20.7 13.9 14.5

(34.6, 63.7) (5.1, 75.8) (5.8, 74.6) (34.3, 56.0) (26.6, 53.9) (98.3, 99.9) (68.0, 85.1) (0.4, 1.3) (14.1, 29.4) (12.6, 15.3) (13.1, 15.9)

Chloroquine 32.8 29.8 49.4 34.8 60.2 92.8 94.0 0.7 6.3 16.5 16.9

(21.7, 46.2) (5.4, 76.0) (26.3, 72.7) (25.2, 45.7) (48.2, 71.0) (60.7, 99.1) (91.8, 95.6) (0.4, 1.2) (2.2, 16.7) (14.3, 19.1) (14.6, 19.4)

Oral Quinine 5.4 0.0 0.5 4.3 10.1 51.7 7.9 0.0 0.2 1.6 1.7

(1.8, 14.8) - (0.1, 4.8) (1.4, 12.2) (4.7, 20.5) (26.1, 76.4) (4.8, 13.0) - (<0.1, 2.6) (1.1, 2.3) (1.2, 2.3)

Quinine Injection (IM/IV)**§ 9.5 0.0 13.9 9.3 17.9 19.6 2.2 <0.1 0.2 0.7 0.8

(3.9, 21.3) - (2.1, 54.4) (4.2, 19.3) (11.1, 27.6) (4.9, 53.4) (0.8, 5.5) (<0.1, <0.1) (<0.1, 1.8) (0.4, 1.2) (0.5, 1.4)

Amodiaquine 0.0 0.0 0.5 0.1 2.8 61 9.7 0.04 2.0 1.9 1.8

- - (0.1, 4.8) (0.0, 0.5) (0.7, 10.8) (39.3, 79.1) (6.0, 15.4) (<0.1, 0.2) (0.2, 15.8) (1.3, 2.7) (1.3, 2.7)

Continued on next page

5 The indicator excludes 19 outlets not interviewed or which had partial interviews due to incomplete audits. The Ns shown for this indicator do not capture fluctuations due to incomplete audits.

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Page 29

Table A.1: Availability of antimalarials, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=108 N=14 N=11 N=133 N=100 N=37 N=1,185 N=6,377 N=87 N=7,786 N=7,919

Any artemisinin monotherapy 24.3 0.0 33.1 23.6 31.8 99.8 37.3 0.2 0.2 6.8 7.1

(15.1, 36.7) - (8.3, 73.0) (15.8, 33.7) (21.6, 44.1) (98.1, 100.0) (28.5, 47.1) (0.1, 0.4) (<0.1, 2.6) (5.8, 8.1) (6.0, 8.4)

Oral artemisinin monotherapy 12.4 0.0 24.1 13.0 15.4 99.5 35.4 0.2 0.2 6.3 6.4

(6.4, 22.5) - (4.7, 67.4) (7.5, 21.6) (7.5, 28.9) (97.3, 99.9) (27.0, 44.8) (0.1, 0.4) (<0.1, 2.6) (5.3, 7.4) (5.4, 7.6)


19.8 0.0 33.1 20.1 27.6 60.1 5.9 0.0 0.0 1.6 1.9

(11.4, 32.1) - (8.3, 73.0) (12.9, 29.9) (17.5, 40.6) (36.1, 80.0) (2.7, 12.5) (n/a) (n/a) (1.0, 2.5) (1.3, 2.9)

Artesunate IV/IM*§

0.1 0.0 9.0 1.3 0.9 4.4 0.0 0.0 0.0 0.04 0.1

(0.0, 0.8) - (1.2, 44.1) (0.2, 7.2) (0.1, 5.7) (0.7, 23.7) (<0.1, 0.2) - - (<0.1, 0.1) (<0.1, 0.1)

Rectal Artesunate*§

-- -- -- -- -- -- -- -- -- -- --

Artemether IV/IM **§

19.7 0.0 24.1 18.8 25.1 59.5 5.7 0.0 0.0 1.5 1.8

(11.3, 32.0) - (4.7, 67.4) (11.5, 29.2) (15.0, 38.9) (35.6, 79.7) (2.6, 12.4) - - (0.9, 2.5) (1.2, 2.9)

Artemotil IV/IM **§

1.4 0.0 0.5 1.2 4.8 12.2 0.2 0.0 0.0 0.1 0.2

(0.3, 5.6) - (0.1, 4.8) (0.3, 4.5) (1.6, 13.2) (2.9, 39.0) (<0.1, 0.8) - - (0.1, 0.4) (0.1, 0.4)

Any treatment for severe malaria (artesunate IV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

24.1 0.0 35.3 23.7 38.0 60.3 7.0 0.004 0.2 1.9 2.3

(14.7, 37.0) - (9.1, 74.7) (15.7, 34.1) (28.5, 48.6) (36.3, 80.2) (3.3, 14.1) (<0.1, 0.03) (<0.1, 1.8) (1.2, 3.0) (1.6, 3.4)

*WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children [Guidelines for the treatment of malaria, 2nd

edition – revisions 1]. **Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available [Guidelines for the treatment of malaria, 2

nd edition – revisions 1].

§ If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are

options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.

Source: ACTwatch Outlet Survey, Nigeria, 2011.

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Page 30

Table A.2: Availability of antimalarials, by public health facility outlet type

University Hospital/ Federal Medical Centre

General Hospital/Specialist Hospital

Primary Health Care

Centre Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had:6 N=5 N=13 N=90 N=108

Antimalarials in stock at the time of survey visit 100 100 81.2 82.8

- - (65.7, 90.7) (68.1, 91.5)

Any ACT 100 100 48.7 52.8

- - (34.8, 62.7) (39.0, 66.3)

Quality-assured ACT (QAACT) 100 51.7 45.5 46.9

- (12.0, 89.4) (32.8, 58.8) (35.2, 59.0)

First-line (FAACT) 100 51.7 45.5 46.9

- (12.0, 89.4) (32.8, 58.8) (35.2, 59.0)

Non-first-line (NAACT) -- -- -- --

Any child QAACT 8.6 24.4 24.1 23.8

(0.6, 61.0) (5.0, 66.2) (13.9, 38.6) (13.9, 37.7)

QAACTs with the AMFm logo 91.4 32.4 20.3 22.4

(39.0, 99.4) (7.8, 73.2) (12.2, 31.8) (14.5, 32.9)

Non-quality-assured ACT 91.4 92.8 14.5 20.8

(39.0, 99.4) (65.4, 98.9) (6.1, 30.6) (11.3, 35.2)

Nationally Registered ACT 100 78.2 40.1 43.6

- (31.1, 96.6) (27.3, 54.5) (30.3, 58.0)

Any non-artemisinin therapy 100 98.2 59.2 62.4

- (85.1, 99.8) (43.9, 72.9) (47.5, 75.3)

Sulfadoxine-Pyrimethamine (SP) 100 97.5 44.7 49.1

- (85.7, 99.6) (30.5, 59.9) (34.6, 63.7)

Chloroquine 4.8 69.0 30.9 32.8

(0.3, 44.1) (28.3, 92.6) (19.2, 45.7) (21.7, 46.2)

Oral Quinine 2.9 48.4 2.5 5.4

(0.2, 29.3) (10.7, 88.1) (0.8, 8.0) (1.8, 14.8)

Quinine Injection (IM/IV) 86.6 49.0 5.2 9.5

(34.1, 98.8) (11.1, 88.2) (1.4, 17.1) (3.9, 21.3)

Amodiaquine 0.0 0.0 0.0 0.0

- - - -

Any artemisinin monotherapy 95.2 98.4 17.8 24.3

(55.9, 99.7) (91.5, 99.7) (9.5, 31.1) (15.1, 36.7)

Oral artemisinin monotherapy 0.0 78.3 8.2 12.4

- (36.2, 95.8) (3.5, 18.1) (6.4, 22.5)

Non-oral artemisinin monotherapy 95.2 94.4 13.2 19.8

(55.9, 99.7) (76.3, 98.9) (6.0, 26.6) (11.4, 32.1)

ArtesunateIV/IM 5.7 0.0 0.0 0.1

(0.4, 48.1) - - (<0.1, 0.8)

Rectal Artesunate -- -- -- --

Artemether IV/IM 95.2 92.9 13.2 19.7

(55.9, 99.7) (73.9, 98.4) (6.0, 26.6) (11.3, 32.0)

Artemotil IV/IM 0.0 22.1 0.0 1.4

- (4.2, 64.9) - (0.3, 5.6)


95.2 99.1 17.5 24.1

(55.9, 99.7) (92.3, 99.9) (8.9, 31.7) (14.7, 37.0)


6 The denominator for this table is all screened public health facilities [n=108].

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Page 31

Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Among outlets with an antimalarial in stock, proportion of outlets that had:

N=94 N=7 N=9 N=110 N=88 N=37 N=1,163 N=64 N=28 N=1,380 N=1,490

Any ACT 63.8 81.6 87.3 67.3 60.1 100.0 58.2 26.0 17.1 57.3 58.1

(49.0, 76.4) (32.0, 97.7) (51.2, 97.8) (53.6, 78.7) (42.7, 75.3) (47.2, 68.4) (13.1, 45.0) (5.9, 40.2) (47.0, 67.0) (48.3, 67.2)

Quality-assured ACT (QAACT)

56.7 81.6 87.3 61.3 51.2 99.8 54.2 23.2 1.1 52.9 53.5

(44.1, 68.5) (32.0, 97.7) (51.2, 97.8) (49.6, 71.9) (36.0, 66.2) (98.1, 100.0) (44.1, 64.0) (11.2, 42.0) (0.1, 8.0) (43.4, 62.2) (44.4, 62.4)

First-line (FAACT) 56.7 81.6 87.3 61.3 51.2 99.8 54.2 23.2 1.1 52.9 53.5

(44.1, 68.5) (32.0, 97.7) (51.2, 97.8) (49.6, 71.9) (36.0, 66.2) (98.1, 100.0) (44.1, 64.0) (11.2, 42.0) (0.1, 8.0) (43.4, 62.2) (44.4, 62.4)


Any child QAACT 28.8 81.6 66.4 35.3 25.7 50.0 29.9 8.1 0.0 28.7 29.2

(17.1, 44.2) (32.0, 97.7) (31.7, 89.4) (23.0, 49.9) (14.7, 41.0) (26.8, 73.1) (22.1, 39.0) (3.3, 18.7) - (21.8, 36.7) (22.4, 37.0)


27.1 11.0 84.8 33.7 45.1 80.9 50.5 15.4 1.1 48.5 47.4

(18.0, 38.6) (1.4, 51.9) (52.2, 96.6) (23.1, 46.1) (30.4, 60.8) (50.0, 94.7) (40.6, 60.3) (6.6, 32.0) (0.1, 8.0) (39.7, 57.5) (39.1, 55.9)

Non-quality-assured ACT 25.2 0.0 0.7 21.3 24.3 99.8 25.9 19.1 16.0 27.1 26.6

(13.8, 41.4) - (0.1, 6.2) (11.8, 35.4) (13.5, 39.8) (98.3, 100.0) (18.9, 34.5) (8.1, 38.7) (5.5, 38.3) (20.1, 35.4) (20.1, 34.4)


(37.4, 67.5) (28.0, 96.9) (33.1, 91.2) (41.5, 68.9) (37.4, 68.0) (98.1, 100.0) (38.7, 57.2) (10.2, 41.0) (1.0, 51.1) (38.9, 56.7) (40.1, 56.7)

Any non-artemisinin therapy 75.4 96.1 82.4 77.0 85.9 100 99.5 97.3 85.0 98.2 96.6

(60.1, 86.2) (67.6, 99.7) (34.2, 97.7) (63.8, 86.3) (73.9, 92.9) - (98.6, 99.8) (84.3, 99.6) (63.1, 94.9) (96.8, 98.9) (94.8, 97.8)

Sulfadoxine-Pyrimethamine (SP)

59.3 85.7 41.8 58.0 45.3 99.7 79.4 78.1 81.0 77.4 76.0

(43.3, 73.5) (38.4, 98.3) (10.8, 80.9) (45.6, 69.5) (31.3, 60.1) (98.3, 99.9) (69.9, 86.5) (55.5, 91.1) (55.9, 93.5) (69.9, 83.6) (69.2, 81.7)

Chloroquine 39.6 88.1 69.3 44.9 69.1 92.8 96.1 80.3 24.7 92.2 88.6

(26.9, 53.8) (44.9, 98.5) (33.1, 91.2) (32.9, 57.5) (53.7, 81.2) (60.6, 99.1) (94.1, 97.4) (53.7, 93.5) (7.8, 56.2) (89.0, 94.6) (85.4, 91.3)

Oral Quinine 6.5 0.0 0.7 5.6 11.6 51.7 8.1 0.0 1.0 8.9 8.7

(2.2, 17.6) - (0.1, 6.2) (1.9, 15.3) (5.4, 23.3) (26.1, 76.5) (4.9, 13.3) - (0.1, 9.9) (5.9, 13.3) (6.0, 12.4)

Quinine Injection (IM/IV) 11.4 0.0 19.5 12.1 20.6 19.6 2.2 0.4 0.7 3.8 4.5

(4.7, 25.2) - (3.4, 62.2) (5.6, 24.1) (12.4, 32.1) (4.9, 53.5) (0.9, 5.7) (0.1, 3.3) (0.1, 7.4) (2.2, 6.7) (2.8, 7.1)

Amodiaquine 0.0 0.0 0.7 0.1 3.2 61.0 9.9 5.0 7.9 10.4 9.6

- - (0.1, 6.2) (<0.1, 0.7) (0.8, 12.2) (39.3, 79.1) (6.1, 15.8) (1.4, 16.5) (0.8, 47.0) (6.9, 15.5) (6.4, 14.2) Continued on next page

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Page 32




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=94 N=7 N=9 N=110 N=88 N=37 N=1,163 N=64 N=28 N=1,380 N=1,490

Any artemisinin monotherapy 29.4 0.0 46.5 30.5 36.6 99.8 38.2 19.2 1.0 38.1 37.5

(18.5, 43.3) (n/a) (17.4, 78.3) (20.8, 42.3) (25.5, 49.2) (98.1, 100.0) (29.2, 48.0) (8.7, 37.2) (0.1, 9.9) (29.8, 47.1) (29.8, 45.9)


14.9 0.0 33.9 16.8 17.7 99.5 36.2 19.2 1.0 35.0 33.6

(7.8, 26.6) - (8.0, 75.1) (9.6, 27.7) (8.5, 33.1) (97.3, 99.9) (27.7, 45.6) (8.7, 37.2) (0.1, 9.9) (27.3, 43.5) (26.7, 41.4)


23.9 0.0 46.5 25.9 31.7 60.1 6.0 0.0 0.0 8.8 10.1

(14.0, 37.8) - (17.3, 78.3) (16.9, 37.5) (20.4, 45.6) (36.0, 80.0) (2.8, 12.7) - - (5.3, 14.2) (6.4, 15.3)

ArtesunateIV/IM 0.1 0.0 12.7 1.7 1.0 4.4 <0.1 0.0 0.0 0.2 0.3

(0.0, 1.0) - (2.2, 48.8) (0.3, 8.9) (0.1, 6.5) (0.7, 23.7) (<0.1, 0.2) - - (0.1, 0.7) (0.1, 0.8)

Rectal Artesunate -- -- -- -- -- -- -- -- -- -- --

Artemether IV/IM 23.8 0.0 33.9 24.3 28.8 59.5 5.9 0.0 0.0 8.4 9.6

(13.9, 37.7) - (8.0, 75.1) (14.9, 36.9) (17.5, 43.6) (35.5, 79.7) (2.6, 12.6) - - (4.9, 14.0) (6.0, 15.1)

Artemotil IV/IM 1.7 0.0 0.7 1.5 5.5 12.2 0.2 0.0 0.0 0.8 0.9

(0.4, 6.7) - (0.1, 6.2) (0.4, 5.7) (1.9, 14.9) (2.9, 39.1) (<0.1, 0.9) - - (0.3, 2.1) (0.4, 2.0) Any treatment for severe malaria (artesunate IV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

29.1 0.0 49.5 30.6 43.6 60.3 7.1 0.4 0.7 10.6 12.1

(18.0, 43.5) - (19.1, 80.3) (20.7, 42.7) (32.7, 55.3) (36.3, 80.2) (3.4, 14.4) (0.1, 3.3) (0.1, 7.4) (6.5, 16.7) (8.0, 18.0)


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Page 33

Table A.4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type



Private not for-

profit HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=102 N=10 N=9 N=121 N=93 N=37 N=1,180 N=77 N=39 N=1,426 N=1,547

No disruption in stock in the past 3 months

19.1 7.1 38 20.5 20.1 19.9 13.8 17.9 7.0 14.5 15.0

(9.7, 33.9) (0.9, 38.4) (10.1, 77.0) (11.4, 34.1) (10.8, 34.2) (5.7, 50.3) (11.1, 17.2) (8.3, 34.7) (5.1, 9.5) (11.8, 17.6) (12.5, 17.9)

N=85 N=8 N=9 N=102 N=65 N=36 N=838 N=38 N=9 N=986 N=1,088

No disruption in stock of quality-assured ACT (QAACT) in the past 3 months, among outlets that have stocked QAACT in the past 3 months

19.5 51.3 51.4 25.4 38.3 47.2 31.7 32.8 5.4 32.6 31.9

(10.7, 32.8) (9.5, 91.3) (20.7, 81.1) (15.7, 38.4) (27.6, 50.1) (25.7, 69.8) (25.8, 38.3) (16.3, 55.1) (0.7, 32.2) (27.4, 38.4) (27.1, 37.1)

N=85 N=8 N=9 N=102 N=65 N=36 N=838 N=38 N=9 N=986 N=1,088

No disruption in stock of first-line quality-assured ACT (FAACT) in the past 3 months, among outlets that have stocked FAACT in the past 3 months

19.5 51.3 51.4 25.4 38.3 47.2 31.7 32.8 5.4 32.6 31.9

(10.7, 32.8) (9.5, 91.3) (20.7, 81.1) (15.7, 38.4) (27.6, 50.1) (25.7, 69.8) (25.8, 38.3) (16.3, 55.1) (0.7, 32.2) (27.4, 38.4) (27.1, 37.1)

N=94 N=7 N=9 N=110 N=88 N=37 N=1,162 N=64 N=28 N=1,379 N=1,489

Expired stock of any antimalarial7

10.9 0.0 17.4 11.3 3.1 20.1 6.8 4.1 1.0 6.6 7.0

(5.2, 21.3) - (2.3, 65.4) (5.5, 21.8) (0.9, 10.1) (6.1, 49.1) (4.1, 11.1) (0.8, 17.4) (0.1, 9.9) (4.4, 9.9) (4.9, 9.9)

N=62 N=5 N=8 N=75 N=45 N=36 N=683 N=21 N=2 N=787 N=862

Expired stock of QAACT 13.1 0.0 19.9 13.7 3.7 9.2 4.1 1.5 0.0 4.2 5.0

(4.6, 31.7) - (2.7, 69.2) (5.4, 30.7) (0.7, 16.5) (1.6, 38.3) (1.7, 9.3) (0.2, 11.5) - (2.2, 8.1) (2.9, 8.5)

N=62 N=5 N=8 N=75 N=45 N=36 N=683 N=21 N=2 N=787 N=862

Expired stock of FAACT 13.1 0.0 19.9 13.7 3.7 9.2 4.1 1.5 0.0 4.2 5.0

(4.6, 31.7) - (2.7, 69.2) (5.4, 30.7) (0.7, 16.5) (1.6, 38.3) (1.7, 9.3) (0.2, 11.5) - (2.2, 8.1) (2.9, 8.5)

N=87 N=6 N=7 N=100 N=72 N=35 N=1,158 N=63 N=28 N=1,356 N=1,456

Acceptable storage conditions for medicines

8

95.2 100 100 95.8 94.9 99.5 96.9 98.8 8.3 95.3 95.3

(75.1, 99.2) - - (77.6, 99.3) (81.5, 98.8) (97.7, 99.9) (94.8, 98.1) (96.0, 99.7) (5.5, 12.4) (91.5, 97.4) (91.7, 97.4)


7 Information on expired stock was missing for 0.07% of cases [n=1,490]. The one missing value was for a drug store. 8 Information on acceptable storage condition was unavailable or missing for 2.3% of cases [n=1,490]. Missing values were particularly common for private not -for-profit facilities (22%, n=9) and private for-profit facilities (18%, n=88).

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Page 34

Table A.5: Price of antimalarials, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

% % % % % % % % % % %

Proportion of first-line quality-assured ACT (FAACT) distributed free of cost (by volumes of AETDs)

94.4 3.3 n/a 85.2 <0.1 n/a n/a n/a n/a <0.1 15.5

Median price of a tablet AETD:9 Median [IQR] (N of Antimalarials)

Median [IQR] (N of Antimalarials)











0.00 3.36 1.40 0.00 1.96 1.49 1.40 1.68 1.68 1.40 1.40

[0.00, 0.00] (135) [3.36, 3.36] (8) [0.67, 3.36] (13) [0.00, 0.67] (156) [0.84, 3.36] (45) [0.84, 2.80] (138) [0.84, 2.24] (1663) [1.40, 2.24] (46) [1.40, 1.68] (2) [0.84, 2.24] (1894) [0.84, 2.24] (2050)

First-line (FAACT) 0.00 3.36 1.40 0.00 1.96 1.49 1.40 1.68 1.68 1.40 1.40

[0.00, 0.00] (135) [3.36, 3.36] (8) [0.67, 3.36] (13) [0.00, 0.67] (156) [0.84, 3.36] (45) [0.84, 2.80] (138) [0.84, 2.24] (1663) [1.40, 2.24] (46) [1.40, 1.68] (2) [0.84, 2.24] (1894) [0.84, 2.24] (2050)


0.00 0.00 1.40 0.00 1.96 0.84 1.40 1.68 1.68 1.40 1.40

[0.00, 0.00] (68) [0.00, 6.71] (7) [0.67, 2.80] (8) [0.00, 1.12] (83) [0.84, 3.36] (35) [0.67, 2.24] (111) [0.84, 2.24] (1448) [1.40, 2.24] (41) [1.40, 1.68] (2) [0.84, 2.24] (1637) [0.84, 2.24] (1720)

Non-quality-assured ACT 2.80 -- 2.68 2.80 4.47 3.36 3.15 2.80 1.49 3.36 3.36

[0.00, 5.59] (34) [n/a] (0) [2.68, 3.36] (3) [0.00, 5.59] (37) [3.64, 5.35] (30) [2.80, 4.19] (275) [2.24, 3.92] (718) [1.96, 3.15] (18) [1.49, 1.49] (3) [2.52, 4.19] (1044) [2.52, 4.19] (1081)


0.17 0.39 0.56 0.28 0.56 0.56 0.45 0.39 0.39 0.45 0.45

[0.00, 0.45] (67) [0.39, 0.39] (4) [0.56, 0.56] (5) [0.00, 0.50] (76) [0.39, 0.84] (37) [0.34, 0.84] (208) [0.34, 0.67] (2676) [0.34, 0.67] (93) [0.28, 0.56] (31) [0.34, 0.67] (3045) [0.34, 0.67] (3121)

Chloroquine 0.22 0.05 1.12 0.22 0.11 0.39 0.27 0.27 0.41 0.27 0.27

[0.11, 0.23] (9) [0.05, 0.14] (2) [1.12, 1.12] (3) [0.11, 0.27] (14) [0.11, 0.11] (5) [0.16, 0.56] (44) [0.14, 0.45] (726) [0.19, 0.56] (25) [0.27, 2.29] (10) [0.14, 0.54] (810) [0.14, 0.54] (824)


1.97 -- 5.37 2.68 3.58 3.08 2.68 8.39 3.13 2.68 2.68

[1.88, 9.23] (18) [n/a] (0) [5.37, 23.49] (3) [1.97, 9.23] (21) [2.24, 16.78] (16) [2.52, 9.23] (115) [2.24, 7.55] (799) [2.68, 10.07] (23) [n/a] (1) [2.24, 8.39] (954) [2.24, 8.39] (975)


9 A total of 13,391 antimalarials were found in 1,490 outlets. Of these, 13,015 antimalarials are included in the pricing analysis; price indicators are based on tablet-formulation AETDs. Free antimalarials were found in 4.9% of outlets with

antimalarials, and 215 of the 13,015 antimalarials for which price information was recorded were available for free.

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Page 35

Table A.5: Price of antimalarials, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

Median price of a package of Median [IQR] (N of Antimalarials)











Pediatric QAACT (package appropriate for a two-year old child (10kg))

0.00 0.84 0.84 0.00 1.40 0.56 0.84 0.84 -- 0.84 0.67

[0.00, 0.00] (36) [0.84, 0.84] (5) [0.17, 1.12] (5) [0.00, 0.17] (46) [0.56, 1.68] (11) [0.45, 1.12] (22) [0.56, 1.12] (448) [0.56, 1.23] (9) [n/a] (0) [0.56, 1.12](490) [0.56, 1.12] (536)

Median price of an AETD: Median [IQR] (N of Antimalarials)












5.92 -- 11.83 5.92 18.93 11.83 6.71 5.87 11.83 8. 05 6.71

[0.95, 8.39] (43) [n/a] (0) [0.89, 20.13] (8) [0.95, 10.07] (51) [13.42,23.49](40) [7.83, 23.49] (59) [5.37, 8.05] (193) [n/a] (1) [n/a] (1) [5.92, 16.11](294) [5.37, 13.42] (345)

ArtesunateIV/IM 0.00 -- 0.89 0.89 4.18 0.67 0.45 -- -- 0.67 0.89

[n/a] (1) [n/a] (0) [n/a] (1) [0.89, 0.89] (2) [n/a] (1) [0.67, 0.67] (4) [0.45, 0.75] (6) [n/a] (0) [n/a] (0) [0.67, 0.67] (11) [0.67, 0.89] (13)

Quinine Injection IV/IM 0.95 -- 11.83 5.92 18.93 11.83 5.92 5.87 11.83 7.10 5.92

[0.00, 5.92] (14) [n/a] (0) [11.83, 11.83] (4) [0.00, 5.92] (18) [5.92, 18.93] (16) [11.83, 14.20] (9) [4.73, 9.47] (46) [n/a] (1) [n/a] (1) [4.73, 11.83] (73) [4.73, 11.83] (91)

Source: ACTwatch Outlet Survey, Nigeria 2011.

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Page 36

Table A.6: Affordability of antimalarials, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

Median price of a tablet AETD relative to SP, the ‘most popular’ antimalarial treatment in 201110:

Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio

Quality-assured ACT (QAACT) -- 8.6 2.5 -- 3.5 2.7 3.1 4.3 4.3 3.1 3.1

QAACTs with the AMFm logo -- -- 2.5 -- 3.5 1.5 3.1 4.3 4.3 3.1 3.1

First-line Quality-assured ACT (FAACT)

-- 8.6 2.5 -- 3.5 2.7 3.1 4.3 4.3 3.1 3.1

Median price of a tablet AETD relative to CQ:





-- 59.0 1.3 -- 17.3 3.8 5.1 6.1 4.1 5.1 5.1

Median price of a tablet AETD relative to the minimum legal daily wage ($3.77)11:





-- 0.9 0.4 -- 0.5 0.4 0.4 0.5 0.5 0.4 0.4


Median price of a first-line quality-assured tablet AETD relative to the international reference price ($1.42)12

-- -- 1.0 -- 1.5 0.6 1.0 1.2 1.2 1.0 1.0

% % % % % % % % % % %

Proportion of outlets that: -- N=10 N=9 N=19 N=96 N=38 N=1,186 N=79 N=39 N=1,438 N=1,457

Offer credit to consumers for antimalarials

13

-- 0.0 39.3 27.1 7.9 0.0 0.0 0.0 0.0 0.6 1.0

- (10.2, 78.6) (7.6, 62.7) (2.2, 24.3) - - - - (0.2, 2.3) (0.3, 3.2)


10 SP was the most popular antimalarails (non-ACT) by volumes sold/ distributed in the past week. 11Minimum daily wage information taken from United States Department of State, 2010.Country Reports on Human Rights Practices. Available at: http://www.state.gov/g/drl/rls/hrrpt/2010/index.htm 12International reference price taken from Management Sciences for Health, 2010.International drug price indicator guide. Available at: http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2010_en.pdf. $1.42 is the median listed supplier price for 24

tablets of AL 20mg/120mg. 13 This question was not asked in Public Health Facilities. Information on outlets that offer credit to consumers for antimalarials was missing for 0.1% of cases [n=1,459].

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Page 37

Table A.7: Availability of diagnostic tests, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had:14 N=101 N=10 N=9 N=120 N=94 N=35 N=1,171 N=76 N=39 N=1,415 N=1,535

Any diagnostic test 25.6 0.0 87.3 31.2 37.1 6.0 0.8 0.0 0.0 3.6 5.8

(15.6, 39.0) - (51.2, 97.8) (19.4, 46.0) (23.4, 53.2) (0.8, 33.8) (0.3, 2.4) - - (2.1, 6.2) (3.8, 8.8)

Microscopic blood tests 16.3 0.0 86.9 23.4 32.7 6.0 0.0 0.0 0.0 2.6 4.3

(9.5, 26.7) - (51.7, 97.6) (13.9, 36.8) (19.2, 49.8) (0.8, 33.8) (<0.1, 0.1) - - (1.4, 4.9) (2.5, 7.1)

Rapid diagnostic tests (RDTs) 14.7 0.0 16.9 14.2 8.5 6.0 0.8 0.0 0.0 1.4 2.4

(6.4, 30.0) - (2.4, 62.3) (7.0, 26.5) (3.3, 19.9) (0.8, 33.8) (0.3, 2.4) - - (0.6, 3.4) (1.5, 4.0)

Proportion of outlets that had:15

N=101 N=10 N=9 N=120 N=94 N=35 N=1,171 N=76 N=39 N=1,415 N=1,535


6.6 0.0 16.5 7.3 3.5 0.0 0.7 0.0 0.0 0.9 1.4

(2.6, 15.5) - (2.3, 62.5) (3.3, 15.3) (1.0, 10.8) - (0.2, 2.4) - - (0.3, 2.5) (0.7, 2.8)


7.2 0.0 0.4 6.1 4.6 5.6 0.1 0.0 0.0 0.5 1.0

(2.6, 18.1) - (<0.1, 3.5) (2.2, 15.4) (1.5, 12.7) (0.8, 31.7) (<0.1, 0.5) - - (0.2, 1.2) (0.6, 1.6)

Proportion of outlets that provided diagnostic tests for free, among outlets providing diagnostic tests

N=37 N=0 N=7 N=44 N=39 N=1 N=8 N=0 N=0 N=48 N=92

Any diagnostic test 17.9 -- 0.0 12.8 0.0 0.0 0.0 -- -- 0.0 5.5

(6.1, 42.5) - (4.1, 33.3) - - - - (1.8, 15.6)

N=29 N=0 N=6 N=35 N=35 N=1 N=1 N=0 N=0 N=37 N=72

Microscopic blood tests 10.8 -- 0.0 6.5 0.0 0.0 0.0 -- -- 0.0 2.7

(2.1, 40.7) - (1.2, 28.7) - - - - (0.5, 13.3)

N=19 N=0 N=3 N=22 N=10 N=1 N=7 N=0 N=0 N=18 N=40

Rapid diagnostic tests 21.4 -- 0.0 18.5 0.0 0.0 0.0 -- -- 0.0 9.5

(5.4, 56.5) - (5.0, 49.5) - - - - (2.7, 28.2)


14Information on proportion of outlets that had diagnostic tests was missing for 1.5% of cases [n=1,562]. 15 Excluding outlets with RDTS where the manufacturer could not be identified.

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Page 38

Table A.8: Price of diagnostic tests, by outlet type




HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

Median price of: Median US$

[IQR] (N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(

N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Median US$ [IQR]

(N)

Microscopic blood tests 1.12 -- 1.12 1.12 1.68 26.85 2.24 -- -- 1.68 1.68

[0.56, 1.68](29)

[n/a] (0)

[1.12, 1.68](6)

[1.12, 1.68](35)

[1.12, 3.36](35)

[n/a] (1)

[n/a] (1)

[n/a] (0)

[n/a] (0)

[1.12, 3.36](37)

[1.12, 2.80](72)

Rapid diagnostic tests (RDTs) 1.12 -- 1.68 1.12 2.24 26.85 0.28 -- -- 0.84 1.12

[0.56, 1.68](19)

[n/a] (0)

[1.68, 1.68](3

) [0.56, 1.68](22)

[1.68, 6.71](10)

[n/a] (1)

[0.28, 0.56](8)

[n/a] (0)

[n/a] (0)

[0.28, 2.24](19)

[0.56, 1.68](41)


0.56 -- 1.68 1.68 2.24 -- 0.28 -- -- 0.56 0.56

[0.00,1.68](10)

[n/a] (0)

[1.68,1.68](2)

[0.00,1.68](12)

[2.24,2.24](5)

[n/a ](0)

[0.28,0.56](7)

[n/a] (0)

[n/a] (0)

[0.28,0.84](12)

[0.28,1.68](24)


1.12 -- 1.12 1.12 6.71 26.85 0.39 -- -- 6.71 1.68

[1.12,1.12](9)

[n/a] (0)

[n/a](1)

[1.12,1.12](10)

[1.68,6.71](5)

[n/a] (1)

[n/a](1)

[n/a] (0)

[n/a] (0)

[1.68,26.85](7)

[1.12,6.71](17)


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Page 39

16 Information on proportion of outlets that had diagnostic tests was missing for 1.9% of cases [n=103]. 17 Excluding outlets with RDTS where the manufacturer could not be identified.

Table A.9: Availability of diagnostic tests, by public health facility outlet type

University Hospital/ Federal Medical Centre

General Hospital/Specialist Hospital

Primary Health Care

Centre (PHCC) Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=5 N=13 N=83 N=101

Any diagnostic test 100 81.7 19.6 25.6

(30.8, 97.8) (9.9, 35.1) (15.6, 39.0)

Microscopic blood tests 100 36.7 12.9 16.3

- (9.1, 77.0) (6.5, 23.7) (9.5, 26.7)

Rapid diagnostic tests (RDTs) 0.0 67.2 10.7 14.7

- (24.3, 92.9) (3.5, 28.7) (6.4, 30.0)


N=5 N=13 N=83 N=101


0.0 0.0 7.2 6.6

- - (2.9, 16.8) (2.6, 15.5)


0.0 67.2 3.0 7.2

- (24.3, 92.9) (0.5, 16.2) (2.6, 18.1)


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Page 40

Table A.10: Market share, by outlet type

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed in the past week:

18



Private not for-

profit HF

TOTAL Public / Not for-

profit

Private for-profit


General retailer

Itinerant drug

vendor

TOTAL Private

TOTAL Outlets

% % % % % % % % % % %

Any ACT 3.9 <0.1 0.4 4.3 2.0 2.9 19.0 0.1 <0.1 24.0 28.4

Quality-assured ACT (QAACT) 3.4 <0.1 0.4 3.8 1.4 1.0 13.8 0.1 <0.1 16.4 20.1

First-line (FAACT) 3.4 <0.1 0.4 3.8 1.4 1.0 13.8 0.1 <0.1 16.4 20.1


QAACTs with the AMFm logo 1.0 <0.1 0.3 1.3 1.3 0.8 12.9 0.1 <0.1 15.1 16.4

Non-quality-assured ACT 0.5 -- <0.1 0.5 0.6 1.9 5.2 <0.1 <0.1 7.7 8.2

Nationally Registered ACT 2.1 <0.1 0.3 2.4 1.3 2.5 13.0 0.1 <0.1 16.9 19.3

Any non-artemisinin therapy 2.7 <0.1 0.2 2.9 1.9 5.4 54.7 0.8 0.5 63.4 66.3

SP 1.8 <0.1 0.1 2.0 1.1 3.5 32.9 0.5 0.5 38.5 40.5

Chloroquine 0.8 <0.1 0.1 0.9 0.6 1.7 21.3 0.3 0.03 24.0 24.9

Oral Quinine <0.1 -- <0.1 <0.1 <0.1 0.1 0.2 -- <0.1 0.3 0.3

Quinine Injection (IM/IV) <0.1 -- <0.1 <0.1 <0.1 <0.1 0.1 <0.1 <0.1 0.1 0.1

Amodiaquine -- -- <0.1 <0.1 <0.1 0.1 0.3 <0.1 <0.1 0.4 0.4

Oral artemisinin monotherapy 0.1 -- 0.3 0.4 0.1 0.8 3.2 <0.1 <0.1 4.4 4.1

Non-oral artemisinin monotherapy 0.4 -- 0.3 0.7 0.1 0.1 0.3 -- -- 0.5 1.2

ArtesunateIV/IM <0.1 -- 0.3 0.3 <0.1 <0.1 <0.1 -- -- 0.1 0.4


Artemether IV/IM 0.3 -- <0.1 0.3 <0.1 0.1 0.3 -- -- 0.4 0.8

Artemotil IV/IM <0.1 -- <0.1 <0.1 <0.1 <0.1 <0.1 -- -- <0.1 <0.1

Any treatment for severe malaria 0.4 -- 0.3 0.7 0.1 0.1 0.4 <0.1 <0.1 0.6 1.2


18There were a total of 71,984.7 AETDs(unweighted) sold or distributed in the past 7 days. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-quality-assured ACT; QAACT decompose fully into FAACT and NAACT. Row and column totals exhibit minor rounding errors.

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Table A.11: Provider knowledge, by outlet type



Private not for-

profit HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=103 N=10 N=9 N=122 N=96 N=38 N=1,184 N=79 N=39 N=1,436 N=1,558

Correctly state the recommended first-line treatment for uncomplicated malaria

19

82.9 21.7 97.4 81.5 61.6 83.4 51.3 26.6 8.7 50.6 53.2

(70.0, 91.0) (5.5, 56.9) (81.1, 99.7) (67.9, 90.2) (50.1, 71.9) (53.3, 95.7) (43.0, 59.6) (17.1, 38.8) (1.0, 47.2) (43.3, 57.9) (45.8, 60.4)

-- N=10 N=8 N=18 N=91 N=38 N=1,179 N=77 N=39 N=1,424 N=1,442

State at least one health danger sign in a child that requires referral to a public health facility

20:

-- 78.8 64 68.6 75.2 79.7 65.1 54.1 54.6 65.4 65.4

(32.7, 96.6) (23.6, 91.1) (35.2, 89.8) (62.8, 84.6) (47.5, 94.4) (58.3, 71.3) (39.8, 67.8) (39.9, 68.5) (59.4, 70.9) (59.6, 70.8)

Convulsions -- 73.7 33.5 46.1 40.0 31.3 33.6 26.7 18.9 33.3 33.5

(29.9, 94.8) (9.8, 70.0) (20.6, 73.8) (28.2, 53.2) (14.9, 54.1) (27.9, 39.7) (15.8, 41.5) (9.8, 33.4) (28.1, 39.0) (28.4, 39.1)

Vomiting - 34.9 50.8 45.9 36.7 66.0 41.8 33.5 43.2 41.6 41.6

(6.9, 79.5) (19.8, 81.2) (20.6, 73.5) (26.5, 48.1) (44.9, 82.3) (35.4, 48.4) (22.1, 47.3) (30.6, 56.7) (36.2, 47.1) (36.3, 47.2)

Unable to drink/breastfeed -- 0.0 0.0 0.0 2.2 14.7 4.6 5.4 14.0 4.9 4.8

- - - (0.6, 7.8) (6.2, 31.0) (3.0, 7.0) (1.8, 14.9) (10.4, 18.6) (3.3, 7.2) (3.3, 7.1)

Excessive sleep/difficult to wake up

-- 0.0 30.5 21.0 0.3 1.1 3.1 2.2 9.5 3.0 3.2

- (8.6, 67.1) (5.7, 53.8) (<0.1, 2.4) (0.1, 8.2) (1.9, 5.1) (0.6, 7.8) (5.8, 15.1) (1.9, 4.6) (2.1, 5.0)

Unconscious/coma -- 0.0 30.5 21.0 29.6 19.1 12.4 3.0 1.8 13.1 13.2

- (8.6, 67.1) (5.7, 53.8) (19.4, 42.4) (8.6, 37.2) (8.5, 17.6) (0.6, 12.7) (0.2, 14.8) (9.0, 18.6) (9.2, 18.5)


19 Information on proportion of providers that correctly state the recommended first-line treatment for uncomplicated malaria was missing for 0.3% of cases [n=1,562]. 20 This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for 1.2% of cases [n=1,459]. Providers could state multiple responses and totals may

sum to more than 100%.

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Table A.12: Provider knowledge, by outlet type

University Hospital/

Federal Medical Centre

General Hospital/Speciali

st Hospital

Primary Health Care Centre

(PHCC)

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=5 N=13 N=85 N=103


100.0 99.2 81.4 82.9

- (93.4, 99.9) (67.6, 90.1) (70.0, 91.0)


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Table A.13: Provider perceptions, by outlet type



Private not for-

profit HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that: N=103 N=10 N=9 N=122 N=95 N=38 N=1,181 N=79 N=38 N=1,431 N=1,553

Agree with the statement, “Customers often request an antimalarial by name.”21

16.3 81.3 0.0 17.7 9.4 60 53.8 60.6 54.3 50.9 48.2

(8.5, 29.1) (33.9, 97.4) - (10.0, 29.4) (4.5, 18.8) (30.6, 83.6) (44.8, 62.6) (38.3, 79.3) (41.8, 66.3) (43.6, 58.2) (41.4, 55.0)

Agree with the statement, “I generally decide which antimalarial medicine customers receive.”

90.6 83.7 99.3 91.2 93.5 67.8 76.5 67.9 55.4 76.7 77.9

(81.3, 95.5) (33.5, 98.1) (93.8, 99.9) (83.4, 95.5) (85.1, 97.3) (46.8, 83.4) (68.6, 82.8) (51.5, 80.8) (39.7, 70.0) (69.0, 83.0) (70.7, 83.7)

Report that an ACT is the most effective antimalarial medicine for an adult22

60.6 24.4 56.9 58.4 51.5 97.6 46.2 18.5 8.4 45.5 46.5

(47.0, 72.7) (3.3, 75.2) (18.0, 88.8) (47.1, 68.9) (41.1, 61.6) (85.3, 99.6) (38.7, 53.9) (8.8, 34.8) (1.0, 45.6) (38.7, 52.5) (39.9, 53.3)

Report that an ACT is the most effective antimalarial medicine for a child

75.5 73.1 84.3 76.4 54.0 92.6 48.6 24.7 7.2 47.9 50.2

(62.7, 85.0) (29.1, 94.7) (52.3, 96.4) (64.5, 85.2) (38.7, 68.7) (61.1, 99.0) (41.2, 56.0) (15.4, 37.3) (5.2, 9.9) (41.3, 54.5) (43.7, 56.6)


21 Information on this pair of indicators was missing for no more than 0.6% and 0.3% of cases [n=1,562]. 22 Information on this pair of indicators was missing for no more than 0.1% of cases [n=1,562].

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Table A.14: Availability of antimalarials among outlets stocking at least one antimalarial, by geo-political zones

North-Central North-Eastern North-Western South-Eastern South-South South-Western

TOTAL

Public / Not for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=20 N=283 N=16 N=170 N=20 N=163 N=19 N=132 N=17 N=180 N=18 N=452

Any ACT 74.2 45.7 61.6 60.1 54.0 64.9 53.7 70.2 96.2 63.7 73.6 59.0

(44.7, 91.1) (27.1, 65.5) (40.2, 79.3) (56.0, 64.1) (22.0, 83.0) (51.4, 76.4) (23.8, 81.2) (56.7, 80.9) (75.6, 99.5) (53.4, 72.9) (41.9, 91.5) (39.7, 75.8)


54.9 44.2 61.6 52.3 54.0 58.7 53.2 61.0 92.3 60.8 71.5 55.0

(37.9, 70.9) (25.5, 64.7) (40.2, 79.3) (46.7, 57.8) (22.0, 83.0) (44.9, 71.3) (23.5, 80.9) (49.4, 71.5) (73.4, 98.1) (50.6, 70.2) (40.7, 90.2) (37.4, 71.5)

First-line (FAACT)

54.9 44.2 61.6 52.3 54.0 58.7 53.2 61.0 92.3 60.8 71.5 55.0

(37.9, 70.9) (25.5, 64.7) (40.2, 79.3) (46.7, 57.8) (22.0, 83.0) (44.9, 71.3) (23.5, 80.9) (49.4, 71.5) (73.4, 98.1) (50.6, 70.2) (40.7, 90.2) (37.4, 71.5)

Non-first-line (NAACT)

-- -- -- -- -- -- -- -- -- -- -- --

Any child QAACT

42.6 22.9 25.1 19.2 27.0 19.3 40.7 39.6 16.0 39.7 47.7 33.4

(19.2, 69.8) (10.7, 42.3) (9.0, 53.1) (15.9, 23.0) (6.8, 65.2) (10.2, 33.6) (14.1, 74.1) (34.1, 45.3) (4.3, 44.6) (29.1, 51.5) (19.0, 78.1) (22.0, 47.2)


39.9 38.2 22.6 48.3 8.9 51.7 0.9 55.8 77.9 55.2 64.2 52.9

(22.5, 60.4) (22.9, 56.2) (8.9, 46.6) (42.7, 54.0) (2.3, 29.1) (37.6, 65.6) (0.1, 6.9) (46.6, 64.6) (45.7, 93.7) (43.7, 66.1) (33.4, 86.5) (35.4, 69.7)

Non-quality-assured ACT

30.9 18.6 0.5 28.7 20.4 31.9 0.5 38.7 31.6 34.5 36.6 27.4

(12.0, 59.5) (8.0, 37.4) (0.1, 4.3) (24.5, 33.3) (5.1, 54.9) (25.0, 39.7) (0.1, 3.5) (23.4, 56.7) (7.0, 74.0) (22.9, 48.4) (13.5, 68.3) (15.4, 43.8)

Nationally Registered ACT

55.4 41.4 48.0 48.9 46.5 28.5 53.2 63.8 59.6 54.2 73.6 50.2

(25.5, 81.9) (25.7, 59.1) (26.8, 69.9) (44.7, 53.1) (17.5, 78.1) (18.3, 41.4) (23.5, 80.9) (46.9, 77.9) (19.6, 89.9) (38.7, 69.0) (41.9, 91.5) (32.4, 68.0)


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TOTAL


TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Any non-artemisinin therapy

100.0 100.0 67.7 97.0 63.6 95.6 61.6 95.3 68.0 99.6 78.1 98.2

- - (46.0, 83.8) (95.6, 98.0) (28.6, 88.4) (88.3, 98.4) (31.5, 84.9) (92.0, 97.3) (20.9, 94.5) (98.4, 99.9) (52.3, 92.0) (96.4, 99.1)


72.4 75.0 53.9 83.5 63.2 75.7 41.2 85.0 64.5 91.1 41.5 72.6

(51.3, 86.7) (67.3, 81.4) (30.6, 75.6) (76.9, 88.4) (28.4, 88.1) (65.0, 83.9) (15.4, 72.9) (80.7, 88.5) (20.8, 92.7) (83.7, 95.3) (20.1, 66.6) (53.8, 85.8)

Chloroquine 63.2 95.0 22.7 86.3 43.0 94.0 47.1 84.1 11.8 95.1 52.8 93.7

(38.1, 82.7) (92.5, 96.7) (9.1, 46.3) (79.5, 91.0) (15.7, 75.3) (84.8, 97.8) (18.8, 77.4) (75.4, 90.1) (3.1, 35.7) (86.3, 98.3) (31.5, 73.1) (89.2, 96.4)

Oral Quinine 11.1 9.1 4.2 11.3 0.6 16.5 0.0 7.8 7.4 35.4 6.5 1.5

(2.0, 42.9) (3.5, 21.9) (0.5, 29.3) (8.6, 14.5) (0.1, 4.3) (6.8, 34.6) - (3.7, 15.6) (1.3, 33.0) (21.3, 52.6) (0.8, 36.5) (0.6, 3.7)

Quinine Injection (IM/IV)**

§

15.2 6.2 4.2 2.3 15.9 13.6 1.4 0.1 3.5 1.7 20.6 2.1

(4.1, 43.1) (2.4, 15.1) (0.5, 29.3) (0.4, 13.7) (2.4, 59.3) (6.0, 28.0) (0.2, 10.2) (<0.1, 0.6) (0.6, 18.4) (0.4, 6.6) (6.4, 49.9) (1.1, 4.0)

Amodiaquine 0.3 10.8 0.0 3.8 0.0 3.3 0.0 13.5 0.0 9.7 0.0 13.2

(<0.1, 2.8) (3.2, 30.5) - (2.4, 6.1) - (1.1, 9.6) - (7.0, 24.6) - (4.1, 21.2) - (8.6, 19.8)


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TOTAL


TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Any artemisinin monotherapy

22.6 31.5 15.0 34.7 46.5 60.5 14.2 40.8 30.7 47.3 50.2 37.6

(10.0, 43.6) (15.5, 53.5) (7.1, 29.2) (31.0, 38.6) (17.7, 77.9) (43.2, 75.5) (3.1, 46.2) (29.6, 53.0) (6.2, 74.6) (33.9, 61.0) (29.4, 71.0) (25.0, 52.1)


22.3 30.1 4.2 30.3 9.2 45.5 9.9 37.3 30.7 46.9 27.5 35.6

(9.7, 43.5) (14.1, 53.0) (0.5, 29.3) (27.0, 33.8) (2.0, 33.5) (32.8, 58.9) (1.4, 45.8) (25.2, 51.2) (6.2, 74.6) (33.6, 60.7) (10.5, 55.2) (24.0, 49.2)


20.0 7.5 15.0 9.8 43.6 44.7 4.3 5.1 0.0 3.7 50.2 4.4

(8.0, 41.8) (2.6, 20.0) (7.1, 29.2) (6.0, 15.6) (15.9, 76.0) (28.0, 62.7) (0.5, 27.0) (1.8, 13.7) - (1.0, 12.4) (29.4, 71.0) (2.4, 7.8)

Artesunate IV/IM*

§

0.0 0.0 9.0 0.2 0.6 0.3 0.0 <0.1 0.0 1.2 0.0 0.2

- - (2.7, 26.1) (<0.1, 2.5) (0.1, 4.3) (<0.1, 2.8) - (<0.1, 0.4) - (0.2, 7.4) - (<0.1, 1.4)

Rectal Artesunate*

§

-- -- -- -- -- -- -- -- -- -- -- --

Artemether IV/IM **

§

19.6 7.4 6.1 7.9 43.6 44.7 4.3 5.1 0.0 3.7 50.2 4.2

(7.7, 41.8) (2.5, 19.9) (1.1, 28.1) (3.9, 15.3) (15.9, 76.0) (27.9, 62.7) (0.5, 27.0) (1.8, 13.7) - (1.0, 12.4) (29.4, 71.0) (2.3, 7.5)

Artemotil IV/IM **

§

0.7 0.1 0.0 1.9 0.0 0.0 0.0 2.9 0.0 1.7 7.5 0.3

(0.1, 5.5) (<0.1, 1.2) - (1.2, 3.0) - - - (0.4, 18.3) - (0.4, 6.8) (1.7, 27.2) (<0.1, 2.1)


24.6 11.1 15.0 11.5 59.1 47.7 5.7 5.2 3.5 4.2 50.2 5.4

(11.7, 44.7) (4.1, 26.6) (7.1, 29.2) (6.1, 20.7) (25.6, 85.9) (28.6, 67.5) (1.1, 25.3) (1.8, 13.7) (0.6, 18.4) (1.3, 12.3) (29.4, 71.0) (3.3, 8.7)

*WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children [Guidelines for the treatment of malaria, 2nd

edition – revisions 1]. **Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available [Guidelines for the treatment of malaria, 2

nd edition – revisions 1].

§ If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The

following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.


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Table A.15: Availability of antimalarials among all public health facility, by geo-political zone

North-Central

North-Eastern

North-Western

South-Eastern

South-South South-

Western

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=19 N=15 N=25 N=19 N=12 N=18

Antimalarials in stock at the time of survey visit

85.9 98.4 71.7 75.0 99.2 82.3

(52.4, 97.1) (87.8, 99.8) (37.8, 91.4) (30.1, 95.5) (93.0, 99.9) (49.9, 95.6)

Any ACT 61.1 63.1 38.8 31.3 99.2 54.0

(32.7, 83.6) (37.3, 83.1) (15.7, 68.3) (11.2, 62.3) (93.0, 99.9) (26.4, 79.3)

Quality-assured ACT (QAACT) 42.6 63.1 38.8 30.8 92.7 51.7

(25.1, 62.1) (37.3, 83.1) (15.7, 68.3) (10.9, 61.8) (71.4, 98.5) (25.2, 77.2)

First-line (FAACT) 42.6 63.1 38.8 30.8 92.7 51.7

(25.1, 62.1) (37.3, 83.1) (15.7, 68.3) (10.9, 61.8) (71.4, 98.5) (25.2, 77.2)

Non-first-line (NAACT) -- -- -- -- -- --

Any child QAACT 32.1 19.4 19.4 18.1 17.6 26.2

(13.1, 59.7) (3.3, 62.8) (4.8, 53.3) (4.6, 50.0) (4.6, 48.8) (7.9, 59.3)

QAACTs with the AMFm logo 29.3 16.4 6.4 0.5 69.4 43.8

(15.5, 48.4) (5.8, 38.6) (1.7, 21.2) (0.1, 3.6) (31.2, 91.9) (19.5, 71.6)

Non-quality-assured ACT 29.3 0.6 14.6 0.5 51.4 39.3

(9.2, 63.1) (0.1, 4.7) (3.7, 43.3) (0.1, 3.6) (14.3, 87.0) (16.1, 68.6)

Nationally Registered ACT 43.0 46.7 33.4 31.3 91.6 54.0

(16.6, 74.2) (22.4, 72.8) (12.2, 64.2) (11.2, 62.3) (65.5, 98.4) (26.4, 79.3)

Any non-artemisinin therapy 85.9 59.7 45.6 36.0 99.2 58.7

(52.4, 97.1) (30.9, 83.1) (19.7, 74.1) (14.5, 65.2) (93.0, 99.9) (30.1, 82.4)

Sulfadoxine-Pyrimethamine (SP) 69.2 43.2 45.3 19.1 93.5 32.6

(41.0, 88.0) (13.4, 78.9) (19.5, 73.9) (6.9, 42.7) (72.4, 98.7) (12.1, 63.0)

Chloroquine 50.5 16.5 30.8 21.7 13.8 31.6

(26.5, 74.3) (6.1, 37.6) (11.3, 60.9) (6.0, 54.6) (2.8, 46.8) (13.0, 58.7)

Oral Quinine 10.3 5.1 0.4 0.0 12.1 7.0

(1.9, 41.0) (0.6, 31.8) (0.1, 3.1) - (2.0, 47.7) (0.9, 37.5)

Quinine Injection (IM/IV) 13.2 5.1 11.4 1.0 5.7 10.2

(3.3, 40.2) (0.6, 31.8) (1.7, 48.8) (0.1, 7.1) (0.9, 27.8) (1.4, 47.7)

Amodiaquine 0.0 0.0 0.0 0.0 0.0 0.0

- - - - - -

Any artemisinin monotherapy 21.4 7.3 33.4 14.4 49.9 28.8

(8.3, 45.2) (1.4, 30.0) (12.6, 63.5) (3.2, 46.6) (12.9, 87.0) (11.6, 55.6)

Oral artemisinin monotherapy 21.1 5.1 6.6 10.1 49.9 4.5

(8.0, 45.1) (0.6, 31.8) (1.5, 25.0) (1.4, 46.2) (12.9, 87.0) (1.1, 16.3)


18.8 7.3 31.3 4.3 0.0 28.8

(6.5, 43.8) (1.4, 30.0) (11.3, 62.0) (0.5, 27.2) - (11.6, 55.6)

ArtesunateIV/IM 0.0 0.0 0.4 0.0 0.0 0.0

- - (0.1, 3.1) - - -

Rectal Artesunate -- -- -- -- -- --

Artemether IV/IM 18.5 7.3 31.3 4.3 0.0 28.8

(6.2, 43.8) (1.4, 30.0) (11.3, 62.0) (0.5, 27.2) - (11.6, 55.6)

Artemotil IV/IM 0.3 0.0 0.0 0.0 0.0 8.0

(<0.1, 2.6) - - - - (1.9, 27.7)

Any treatment for severe malaria 22.2 7.3 42.4 5.3 5.7 28.8

(8.9, 45.5) (1.4, 30.0) (17.7, 71.6) (0.9, 25.5) (0.9, 27.8) (11.6, 55.6)


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Page 48

Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by geo-political zone



profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had:

N=22 N=291 N=17 N=180 N=22 N=173 N=24 N=136 N=17 N=183 N=19 N=463

No disruption in stock in the past 3 months

28.3 11.9 22.2 12.6 1.0 17.9 12.3 13.0 41.8 11.1 28.1 17.7

(8.3, 63.3) (7.2, 19.1) (7.6, 49.8) (8.9, 17.7) (0.2, 5.2) (13.2, 23.7) (2.7, 41.7) (5.5, 27.6) (11.0, 80.6) (6.2, 19.2) (9.5, 59.3) (13.8,22.4)

N=15 N=180 N=15 N=105 N=21 N=133 N=19 N=101 N=16 N=140 N=16 N=327

No disruption in stock of quality-assured ACT (QAACT) in the past 3 months, among outlets that have stocked QAACT in the past 3 months

19.1 29.3 39.0 27.2 1.7 28.7 38.4 31.7 43.7 25.4 31.1 39.4

(3.8, 58.5) (21.2,38.9) (20.3, 61.6) (19.0, 37.4) (0.5, 6.5) (19.3, 40.3) (20.1, 60.7) (19.6, 46.9) (11.5, 82.2) (18.5, 33.9) (10.0, 64.8) (28.9, 51.1)

N=15 N=180 N=15 N=105 N=21 N=133 N=19 N=101 N=16 N=140 N=16 N=327

No disruption in stock of first-line quality-assured ACT (FAACT) in the past 3 months, among outlets that have stocked FAACT in the past 3 months

19.1 29.3 39.0 27.2 1.7 28.7 38.4 31.7 43.7 25.4 31.1 39.4

(3.8, 58.5) (21.3, 8.9) (20.3, 61.6) (19.0,37.4) (0.5, 6.5) (19.3, 40.3) (20.1, 60.7) (19.6, 46.9) (11.5, 82.2) (18.5, 33.9) (10.0, 64.8) (28.9, 51.1)

N=20 N=283 N=16 N=170 N=20 N=163 N=19 N=131 N=17 N=180 N=18 N=452

Expired stock of any antimalarial

23

11.4 9.9 0.0 2.0 4.0 7.6 16.8 13.8 14.1 4.4 26.1 4.1

(2.2, 42.8) (4.6, 20.2) - (1.4, 2.9) (0.8, 18.2) (2.8, 18.8) (4.9, 44.1) (8.6, 21.4) (3.6, 41.5) (1.4, 12.9) (7.7, 59.8) (2.1, 7.8)

N=11 N=136 N=10 N=84 N=16 N=106 N=11 N=82 N=14 N=116 N=13 N=263

Expired stock of QAACT 18.6 8.7 0.0 0.1 0.5 2.6 23.6 4.3 11.5 1.1 27.4 3.9

(2.3, 68.8) (3.3, 20.6) - (0.0, 1.2) (0.1, 3.8) (1.0, 6.7) (4.8, 65.5) (1.7, 10.6) (2.8, 37.3) (0.3, 4.2) (6.0, 68.8) (1.9, 8.0)

N=11 N=136 N=10 N=84 N=16 N=106 N=11 N=82 N=14 N=116 N=13 N=263

Expired stock of FAACT 18.6 8.7 0.0 0.1 0.5 2.6 23.6 4.3 11.5 1.1 27.4 3.9

(2.3, 68.8) (3.3, 20.6) - (0.0, 1.2) (0.1, 3.8) (1.0, 6.7) (4.8, 65.5) (1.7, 10.6) (2.8, 37.3) (0.3, 4.2) (6.0, 68.8) (1.9, 8.0)

N=18 N=278 N=13 N=170 N=20 N=162 N=15 N=129 N=17 N=179 N=17 N=438

Acceptable storage conditions for medicines

24

100.0 98.5 99.3 85.4 82.2 89.4 100.0 97.8 100.0 92.4 100.0 97.7

- (94.3, 9.6) (94.8, 99.9) (82.0,88.3) (37.5, 97.3) (80.3, 94.6) - (90.8, 99.5) - (82.5, 96.9) - (95.3,98.9)


23 Information on expired stock was missing for 0.07% of cases [n=1,490]. The one missing value was for a drug store in South-Eastern. 24 Information on acceptable storage condition was unavailable or missing for 2.3% of cases [n=1,490]. Missing values were particularly common for South-Eastern (4.6%, n=151) and South-Western (3.2%, n=470).

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Page 49

Table A.17: Price of antimalarials, by geo-political zones


TOTAL


TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

% % % % % % % % % % % %

Proportion of first-line quality-assured ACT (FAACT) distributed free of cost (by volumes of AETDs)

69.1

n/a

64.4

<0.1

97.3

n/a

76.6

n/a

85.5

n/a

58.7

n/a

Median price of a tablet AETD:25 Median [IQR] (N of Antimalarials)


Median [IQR]

(N of Antimalarials)

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]




0.00 1.34 0.00 1.12 0.00 0.84 0.00 1.96 1.40 1.68 0.00 1.49

[0.00, 0.00] (25) [0.84, 2.24] (283) [0.00, 0.84](19) [0.84, 2.24] (147) [0.00, 0.00](39) [0.56,1.12](205) [0.00, 3.36](25) [1.40,3.36](180) [0.00, 2.24](29) [1.12,3.36](302) [0.00, 3.36](19) [1.12, 2.52](777)

First-line (FAACT) 0.00 1.34 0.00 1.12 0.00 0.84 0.00 1.96 1.40 1.68 0.00 1.49

[0.00, 0.00] (25) [0.84, 2.24] (283) [0.00, 0.84](19) [0.84,2.24](147) [0.00, 0.00](39) [0.56,1.12](205) [0.00, 3.36](25) [1.40,3.36](180) [0.00, 2.24](29) [1.12, 3.36] (302) [0.00, 3.36] (19) [1.12, 2.52](777)


0.00 1.12 2.80 1.12 0.00 0.73 0.00 1.79 1.40 1.68 0.00 1.49

[0.00, 0.00] (15) [0.84, 1.79] (221) [0.84, 2.80] (6) [0.84,1.68](118) [0.00, 0.42](21) [0.56,1.12](169) [0.00, 0.00] (5) [1.40,2.80](154) [0.00, 2.24](22) [1.01, 2.24] (252) [0.00, 1.12](14) [1.12, 2.24](723)

Non-quality-assured ACT 5.59 3.36 -- 3.36 0.00 0.78 2.52 3.08 0.00 3.64 0.00 3.15

[2.80, 5.59] (9) [2.80, 4.19] (194) [n/a] (0) [2.24, 4.19](91) [0.00, 0.00] (5) [0.56, 2.83](28) [n/a] (1) [2.52,3.92](122) [0.00, 3.64] (4) [2.52, 4.47] (197) [0.00, 0.00] (18) [2.52,3.92](412)


0.28 0.45 0.00 0.45 0.22 0.28 0.39 0.45 0.00 0.56 0.28 0.45

[0.00, 0.84] (18) [0.34, 0.56] (572) [0.00, 0.56](10) [0.28, 0.67] (287) [0.17, 0.28](15) [0.22, 0.39](207) [0.39, 0.56] (7) [0.39,0.67](399) [0.00, 0.45](15) [0.45, 0.84] (499) [0.00, 0.56](11) [0.34,0.67](1081)

Chloroquine 0.27 0.14 0.68 0.14 0.22 0.16 0.05 0.27 0.00 0.27 0.00 0.38

[0.11, 0.27] (5) [0.14, 0.27] (243) [0.23, 1.12] (2) [0.14, 0.27](94) [0.08, 0.22] (3) [0.14, 0.27](103) [n/a] (1) [0.14, 0.56](54) [0.00, 0.14] (2) [0.11, 0.84] (97) [n/a] (1) [0.27, 0.56] (219)


1.97 2.52 10.07 2.68 1.88 1.79 3.13 2.68 9.23 3.58 5.37 3.13

[0.45, 1.97] (4) [2.24, 8.39] (186) [n/a] (1) [1.96, 3.58] (70) [1.88, 2.68] (3) [0.89, 6.38](120) [2.68, 4.47] (3) [2.51,6.71](85) [9.23, 9.23] (5) [2.68,10.07](168) [5.37,23.49](5) [2.52, 8.95](325)


25 A total of 13,391 antimalarials were found in 1,490 outlets. Of these, 13,015 antimalarials are included in the pricing analysis; price indicators are based on tablet-formulation AETDs. Free antimalarials were found in 4.9% of outlets with

antimalarials, and 215 of the 13,015 antimalarials for which price information was recorded were available for free.

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Page 50

Table A.17: Price of antimalarials, by geo-political zones



profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private


profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

% % % % % % % % % % % %

Median price of a package: Median

[IQR] (N of Antimalarials)

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR] (N of

Antimalarials)

Median [IQR]


Median [IQR]



Pediatric QAACT (package appropriate for a two-year old child (10kg))

0.00 0.56 0.00 0.84 0.00 0.56 0.84 0.84 0.00 0.84 0.84 0.84

[0.00, 0.00] (6) [0.39, 0.67](79) [0.00, 0.00] (6) [0.56, 1.12](45) [0.00, 0.00](13) [0.34, 0.56](49) [0.00, 0.84] (8) [0.67, 1.12] (59) [0.00,1.68](8) [0.56, 1.40](85) [0.00, 1.12] (5) [0.56,1.12](173)

Median price of an AETD: Median

[IQR] (N of Antimalarials)

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR] (N of

Antimalarials)

Median [IQR]


Median [IQR]




8.28 8.05 0.89 9.47 5.37 5.92 0.00 23.49 5.92 18.79 10.07 14.20

[5.92, 8.39](12) [6.71,13.42](56) [0.89, 0.95] (6) [6.71,16.78](47) [4.03, 6.71](16) [5.37, 6.71](121) [0.00, 0.00] (4) [23.49,30.20](10) [5.92,5.92](2) [7.83,27.41](27) [5.92,20.13](11) [11.83,26.8](33)

ArtesunateIV/IM -- -- 0.89 0.75 0.00 0.45 -- 4.18 -- 0.67 -- --

[n/a] (0) [n/a] (0) [n/a](1) [0.60, 0.75] (4) [n/a](1) [0.45, 0.75] (5) [n/a] (0) [n/a](1) [n/a] (0) [n/a] (1) [n/a] (0) [n/a] (0)

Quinine Injection IV/IM

5.92 11.83 0.95 9.47 0.00 5.92 11.83 10.65 5.92 23.66 11.83 14.20

[0.00,5.92](7) [4.73,11.83](28) [n/a](1) [5.92, 9.47] (5) [0.00, 0.00] (3) [4.73, 5.92] (27) [11.83,18.93] (3) [n/a] (1) [5.92,5.92](2) [5.87,23.66] (3) [5.92, 11.83] (2) [11.83,14.20] (9)


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Page 51

Table A.18: Availability of diagnostic tests, by geo-political zones



profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had 26

: N=21 N=288 N=17 N=179 N=22 N=172 N=24 N=135 N=17 N=182 N=19 N=459

Any diagnostic test 43.6 5.5 37.5 2.8 6.0 0.3 1.6 2.7 52.9 0.7 51.6 3.9

(16.4, 75.4) (1.6, 17.1) (18.7, 61.0) (1.8, 4.3) (1.9, 17.3) (0.1, 1.6) (0.3, 7.5) (0.8, 9.4) (17.3, 85.8) (0.2, 3.2) (24.5, 77.8) (1.8, 8.4)

Microscopic blood tests 21.4 5.4 37.5 1.8 3.6 0.2 0.4 0.0 38.1 0.7 50.0 2.2

(5.4, 56.5) (1.6, 17.0) (18.7, 61.0) (1.1, 2.9) (1.2, 10.0) (<0.1, 1.5) (0.0, 2.8) (<0.1, 0.4) (8.8, 79.8) (0.2, 3.2) (23.1, 76.9) (1.1, 4.2)

Rapid diagnostic tests (RDTs) 33.1 0.2 0.0 1.9 4.3 0.2 1.3 2.7 19.3 <0.1 18.5 2.4

(14.9, 58.2) (<0.1, 1.0) - (1.2, 2.8) (1.1, 15.4) (<0.1, 1.2) (0.2, 6.6) (0.7, 9.4) (3.7, 60.1) (<0.1, 0.3) (6.4, 43.0) (0.7, 8.3)


N=21 N=288 N=17 N=179 N=22 N=172 N=24 N=135 N=17 N=182 N=19 N=459


12.8 0.1 0.0 0.9 3.5 0.2 0.9 2.6 15.2 0.0 11.9 1.3

(4.1, 33.6) (<0.1, 0.8) - (0.6, 1.4) (0.7, 15.3) (<0.1, 1.2) (0.1, 7.2) (0.7, 8.8) (2.2, 59.1) - (2.6, 40.2) (0.2, 7.8)


17.6 0.1 0.0 0.9 0.7 0.0 0.4 0.0 3.5 <0.1 4.9 1.1

(6.8, 38.5) (<0.1, 0.7) - (0.6, 1.4) (0.2, 3.5) - (<0.1, 2.8) - (0.6, 18.4) (<0.1, 0.3) (0.7, 27.4) (0.4, 2.9)

Proportion of outlets that provided diagnostic tests for free, among outlets providing diagnostic tests

N=12 N=21 N=6 N=4 N=11 N=3 N=2 N=2 N=6 N=4 N=7 N=14

Any diagnostic test 8.9 0.0 17 0.0 21.0 0.0 0.0 0.0 62.1 0.0 4.0 0.0

(0.9, 52.1) - (1.9, 68.7) - (4.5, 60.1) - - - (14.4, 94.1) - (0.4, 29.8) -

N=9 N=19 N=6 N=2 N=10 N=2 N=0 N=0 N=4 N=4 N=6 N=10

Microscopic blood tests 0.0 0.0 17.0 0.0 35.2 0.0 -- -- 0.0 0.0 0.0 0.0

- - (1.9, 68.7) - (10.2, 72.3) - - - - -

N=8 N=4 N=0 N=3 N=5 N=2 N=2 N=2 N=4 N=1 N=3 N=6

Rapid diagnostic tests 11.8 0.0 -- 0.0 37.6 0.0 0.0 0.0 75.6 0.0 9.6 0.0

(1.2, 59.1) - - (6.5, 83.9) - - - (21.7, 97.2) - (0.9, 56.2) -


26 Information on proportion of outlets that had diagnostic tests was missing for 2% of cases [n=1562]. 27 Excluding outlets with RDTs where the manufacturer could not be identified

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Page 52

Table A.19: Price of diagnostic tests, by geo-political zones



profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

Median price of: Median

US$ [IQR]

(N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$ [IQR]

(N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Microscopic blood tests 1.12 1.68 0.56 13.84 0.56 1.68 -- -- 1.68 2.24 1.12 3.92

[1.12, 6.71] (9) [1.12, 2.80] (19) [0.56, 1.12](6) [0.84, 26.85](2) [0.00, 0.56](10) [0.56, 2.80](2) [n/a] (0) [n/a] (0) [1.68, 2.80](4) [2.24, 2.24](4) [1.12, 1.68](6) [2.80,5.59](10)

Rapid diagnostic tests (RDTs) 1.12 0.84 -- 2.80 0.56 0.67 1.12 0.56 0.00 1.68 1.68 1.68

[1.12, 1.68] (8) [0.84, 1.687](4) [n/a] (0) [0.84, 26.85](3) [0.00, 0.56](5) [0.67, 2.80](3) [1.12, 1.12](2) [0.56, 0.56](2) [0.00, 0.00](4) [n/a](1) [1.68, 1.68](3) [0.28,2.24](6)


1.68 0.84 -- 0.84 0.56 0.67 1.12 0.56 0.00 -- 1.68 0.28

[0.00,1.68](4) [0.84,0.84](2) [n/a] (0) [n/a](1) [0.00,0.56](3) [0.67,2.80](3) [n/a](1) [0.56,0.56](2) [0.00,0.00](2) [n/a] (0) [1.68,1.68](2) [0.28,1.26](4)


1.12 1.03 -- 26.85 0.00 -- 1.12 -- 2.24 1.68 1.68 6.71

[1.12,1.12](4) [0.39,1.68](2) [n/a] (0) [26.85,26.85](2) [0.00,0.56](2) [n/a] (0) [n/a](1) [n/a] (0) [2.24,2.24](2) [n/a](1) [n/a](1) [1.68,6.71](2)


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Page 53

Table A.20: Availability of diagnostic tests in public health facility, by geo-political zones

North-Central

North-Eastern

North-Western

South-Eastern

South-South South-

Western

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had:28 N=18 N=14 N=22 N=19 N=11 N=17

Any diagnostic test 37.3 38.1 6.0 1.7 37.3 38.3

(14.4, 67.9) (16.2, 66.3) (1.9, 17.3) (0.3, 8.3) (8.8, 78.6) (16.5, 66.0)

Microscopic blood tests 12.6 38.1 3.6 0.5 13.1 36.2

(3.2, 39.1) (16.2, 66.3) (1.2, 10.0) (0.1, 3.6) (3.2, 41.0) (15.0, 64.7)

Rapid diagnostic tests (RDTs) 36.4 0.0 4.3 1.3 32.5 9.4

(13.7, 67.5) - (1.1, 15.4) (0.2, 9.2) (6.2, 77.7) (2.1, 33.3)


13.8 0.0 3.5 1.3 24.9 2.1

(3.7, 39.8) - (0.7, 15.3) (0.2, 9.2) (3.7, 74.4) (0.3, 14.5)


0.1 0.9 0.0 0.0 <0.1 1.1

(<0.1, 0.7) (0.6, 1.4) - - (<0.1, 0.3) (0.4, 2.9)


28Information on proportion of outlets that had diagnostic tests was missing for 1.9% of cases [n=103].

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Page 54

Table A.21: Market share, by geo-political zones (relative to overall total)

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed in the past week:29 30



profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

% % % % % % % % % % % %

Any ACT 1.0 5.1 0.3 5.4 2.2 2.2 <0.1 1.8 0.2 1.8 0.7 7.7

Quality-assured ACT (QAACT) 0.8 4.1 0.3 2.9 2.1 2.0 <0.1 1.0 0.1 0.9 0.4 5.4

First-line (FAACT) 0.8 4.1 0.3 2.9 2.1 2.0 <0.1 1.0 0.1 0.9 0.4 5.4

Non-first-line (NAACT) -- -- -- -- -- -- -- -- -- -- -- --

QAACTs with the AMFm logo 0.7 3.7 0.1 2.8 0.2 1.6 <0.1 0.9 0.1 0.8 0.3 5.2

Non-quality-assured ACT 0.1 1.0 <0.1 2.5 0.1 0.2 <0.1 0.7 0.1 0.9 0.3 2.3

Nationally Registered ACT 0.5 3.4 0.2 4.2 1.2 0.6 <0.1 1.4 <0.1 1.5 0.6 5.8

Any non-artemisinin therapy 0.6 16.9 0.5 15.1 1.5 8.1 0.1 3.4 0.1 3.3 0.2 16.5

SP 0.4 9.3 0.4 8.9 0.9 3.9 <0.1 2.8 0.1 2.5 0.1 11.0

Chloroquine 0.2 7.4 0.1 6.0 0.5 4.0 <0.1 0.6 <0.1 0.7 0.1 5.3

Oral Quinine <0.1 0.1 <0.1 0.1 <0.1 0.1 -- <0.1 <0.1 <0.1 0.0 <0.1

Quinine Injection (IM/IV) <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 0.0 <0.1

Amodiaquine <0.1 0.1 -- 0.1 -- <0.1 -- <0.1 -- <0.1 -- <0.1

Oral artemisinin monotherapy <0.1 1.1 <0.1 0.6 <0.1 0.7 <0.1 0.2 <0.1 0.3 <0.1 1.2

Non-oral artemisinin monotherapy <0.1 <0.1 0.3 0.1 0.3 0.3 -- <0.1 -- 0.1 <0.1 0.1

ArtesunateIV/IM -- -- 0.3 <0.1 <0.1 <0.1 -- -- -- <0.1 -- <0.1

Rectal Artesunate -- -- -- -- -- -- -- -- -- -- -- --

Artemether IV/IM <0.1 <0.1 <0.1 <0.1 0.3 0.3 -- <0.1 -- <0.1 <0.1 <0.1

Artemotil IV/IM <0.1 <0.1 -- <0.1 -- -- -- <0.1 -- <0.1 <0.1 <0.1

Any treatment for severe malaria <0.1 0.1 0.3 0.1 0.3 0.3 <0.1 <0.1 <0.1 0.1 <0.1 <0.1


29There were a total of 71,984.7 AETDs (unweighted) sold or distributed in the past 7 days. 30 Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-quality-assured ACT; QAACT decompose fully into FAACT and NAACT. Row and column totals exhibit minor rounding errors.

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Page 55

Table A.22: Provider knowledge, by geo-political zones


TOTAL


TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private


profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can:

N=22 N=293 N=18 N=180 N=22 N=174 N=24 N=139 N=17 N=183 N=19 N=467


31

75.4 46.8 89.1 48.4 90.0 61.5 42.8 31.1 93.3 56.6 98.0 56.7

(45.6, 91.8) (31.5, 62.7) (59.4, 97.9) (43.4, 53.5) (55.3, 98.5) (48.7, 72.9) (15.2, 75.7) (17.2, 49.4) (73.0, 98.6) (42.6, 69.6) (86.9, 99.7) (44.2, 68.3)

N=2 N=288 N=3 N=178 N=0 N=174 N=5 N=138 N=6 N=183 N=2 N=463

State at least one health danger sign in a child that requires referral to a public health facility

32:

88.6 61.7 100.0 69.8 -- 78.6 75.5 47.5 90.4 71.5 0.0 67.8

(32.3, 99.2) (47.1, 74.6) - (62.9, 75.9) (68.1, 86.4) (18.0, 97.7) (35.1, 60.1) (40.3, 99.2) (63.2, 78.6) - (60.4, 74.3)

Convulsions 88.6 30.6 64.4 33.1 -- 51.0 75.5 21.1 3.2 37.2 0.0 34.7

(32.3, 99.2) (20.7, 42.8) (34.2, 86.4) (27.8, 38.9) (40.5, 61.4) (18.0, 97.7) (11.4, 35.9) (0.3, 28.6) (25.7, 50.4) - (26.3, 44.1)

Vomiting 88.6 36.7 64.4 44.8 -- 41.2 9.5 29.5 88.8 52.4 0.0 45.5

(32.3, 99.2) (25.9, 49.1) (34.2, 86.4) (38.5, 51.3) (32.6, 50.4) (0.8, 56.3) (20.3, 40.8) (40.5, 98.9) (36.3, 68.0) - (38.7, 52.4)

Unable to drink/breastfeed

0.0 1.9 0.0 10.4 -- 9.8 0.0 0.2 0.0 7.9 0.0 4.9

- (1.0, 3.6) - (7.4, 14.4) (2.1, 35.3) - (0.0, 1.3) - (3.9, 15.3) - (3.4, 7.0)

Excessive sleep/difficult to wake up

0.0 1.1 35.6 3.2 -- 4.0 0.0 0.6 77.2 2.8 0.0 4.8

- (0.2, 6.4) (13.6, 65.9) (2.5, 4.2) (1.7, 9.2) - (0.1, 3.3) (24.9, 97.2) (0.6, 12.0) - (3.3, 7.1)

Unconscious/coma 0.0 8.2 35.6 7.5 -- 29.2 0.0 4.2 77.2 8.9 0.0 19.2

- (4.1, 16.0) (13.6, 65.9) (3.6, 15.0) (22.3, 37.0) - (1.3, 12.3) (24.9, 97.2) (4.0, 18.9) - (12.8, 27.8)


31 Information on proportion of providers that correctly state the recommended first-line treatment for uncomplicated malaria was missing for 0.3% of cases [n=1,562]. 32 This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for 1.2% of cases [n=1,459]. Providers could state multiple responses and totals may

sum to more than 100%.

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Page 56

Table A.23: Provider perceptions, by geo-political zones


TOTAL


TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that: N=22 N=293 N=18 N=178 N=22 N=174 N=24 N=139 N=17 N=183 N=19 N=464

Agree with the statement, “Customers often request an antimalarial by name.”

33

10.5 39.4 18.2 31.0 25.9 45.0 30.8 58.9 7.1 67.8 13.4 63.4

(2.3, 37.2) (30.6, 48.9) (4.3, 52.7) (27.2, 35.1) (7.3, 60.9) (36.2, 54.2) (14.5, 53.9) (50.0, 67.2) (1.5, 27.1) (60.3, 74.6) (3.1, 42.6) (57.2, 69.2)

Agree with the statement, “I generally decide which antimalarial medicine customers receive.”

91.0 75.6 86.7 54.3 93.6 78.8 92.3 78.4 91.1 80.8 92.3 84.6

(68.4, 98.0) (70.0, 80.3) (52.8, 97.4) (44.0, 64.2) (73.2, 98.8) (70.1, 85.5) (66.3, 98.6) (71.8, 83.8) (72.3, 97.5) (70.7, 88.0) (72.2, 98.2) (75.4, 90.7)

Report that an ACT is the most effective antimalarial medicine for an adult

34

55.3 43.2 74.9 52.1 39.1 33.4 46.3 45.7 81.7 48.6 71.3 46.5

(37.1, 72.1) (30.5, 57.0) (54.7, 88.1) (46.5, 57.7) (14.6, 70.7) (21.4, 47.9) (30.3, 63.1) (31.2, 61.0) (52.8, 94.7) (36.2, 61.3) (38.4, 90.8) (32.8, 60.7)

Report that an ACT is the most effective antimalarial medicine for a child

69.6 38.3 70.8 46.7 85.5 40.9 75.0 63.0 92.3 53.9 77.0 52.0

(40.3, 88.6) (29.4, 48.1) (48.9, 86.0) (42.2, 51.3) (54.5, 96.7) (25.2, 58.7) (45.0, 91.7) (48.8, 75.2) (69.5, 98.4) (41.5, 65.8) (46.2, 92.9) (39.8, 63.9)


33 Information on this pair of indicators was missing for no more than 0.6% and 0.3% of cases [n=1,562]. 34 Information on this pair of indicators was missing for no more than 0.1% of cases [n=1,562].

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Table A.24: Provider knowledge in public health facility, by geo-political zones


%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=19 N=15 N=22 N=19 N=11 N=17


74.1 94.6 90.0 49.7 94.4 97.5

(43.8, 91.3) (69.2, 99.3) (55.3, 98.5) (21.1, 78.6) (64.2, 99.4) (84.2, 99.6)


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Page 58

Additional Tables Table B.1: Market share by antimalarial category within each outlet type

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed within a given outlet type in the past week:



Private not for-

profit HF

TOTAL Public / Not

for-profit

Private for-profit


General retailer


TOTAL Private

TOTAL Outlets

N=6581.2 N=37.3 N=386.7 N=6968.0 N=2047.0 N=6906.5 N=53929.1 N=1564.2 N=532.7 N=64979.4 N=71984.7

% % % % % % % % % % %

Any ACT 55.7 20.3 41.0 54.0 49.7 31.7 24.6 11.6 1.7 26.1 28.4

Quality-assured ACT (QAACT) 48.1 20.3 40.3 47.2 35.6 11.1 17.9 9.1 1.1 17.8 20.1

First-line (FAACT) 48.1 20.3 40.3 47.2 35.6 11.1 17.9 9.1 1.1 17.8 20.1


QAACTs with the AMFm logo 14.6 2.0 33.1 16.7 32.7 8.6 16.7 7.7 1.1 16.4 16.4

Non-quality-assured ACT 7.6 -- 0.7 6.8 14.1 20.6 6.7 2.5 0.6 8.4 8.2


Any non-artemisinin therapy 38.3 79.7 25.4 36.8 46.5 58.7 70.8 86.6 97.9 68.9 66.3

SP 26.1 55.4 14.5 24.8 28.7 37.7 42.6 52.4 91.8 41.9 40.5

Chloroquine 11.9 24.4 10.8 11.7 16.1 18.0 27.6 34.1 5.3 26.1 24.9

Oral Quinine 0.2 -- <0.1 0.2 1.1 0.8 0.2 -- 0.2 0.3 0.3

Quinine Injection (IM/IV) 0.1 -- <0.1 0.1 0.6 0.1 0.1 <0.1 <0.1 0.1 0.1

Amodiaquine -- -- 0.1 <0.1 0.1 1.2 0.3 0.1 0.6 0.4 0.4

Oral artemisinin monotherapy 0.8 -- 1.6 0.9 2.2 8.5 4.1 1.8 0.5 4.4 4.1


5.3 -- 32.0 8.3 1.6 1.1 0.4 -- -- 0.5 1.2

ArtesunateIV/IM 0.1 -- 31.6 3.7 0.5 0.5 <0.1 -- -- 0.1 0.4


Artemether IV/IM 4.9 -- 0.3 4.3 0.9 0.5 0.4 -- -- 0.4 0.8

Artemotil IV/IM 0.3 -- 0.1 0.3 0.2 0.1 <0.1 -- -- <0.1 <0.1

Any treatment for severe malaria 5.4 -- 32.0 8.5 2.2 1.1 0.5 <0.1 <0.1 0.6 1.2


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Page 59

Table B.2: Market share by antimalarial category within each geo-political zone

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed within a given outlet type in the past week:


TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

TOTAL Public / Not

for-profit

TOTAL Private

N= N= N= N= N= N= N= N= N= N= N= N=

% % % % % % % % % % % %

Any ACT 4.0 20.5 1.3 24.2 14.3 14.7 0.5 32.0 2.8 31.4 2.5 29.4

Quality-assured ACT (QAACT) 3.4 16.6 1.3 13.1 13.9 13.1 0.5 18.5 1.6 15.8 1.5 20.5

First-line (FAACT) 3.4 16.6 1.3 13.1 13.9 13.1 0.5 18.5 1.6 15.8 1.5 20.5

Non-first-line (NAACT) -- -- -- -- -- -- -- -- -- -- -- --

QAACTs with the AMFm logo 2.7 14.9 0.6 12.6 1.3 10.7 0.1 17.0 1.0 13.9 1.0 19.8

Non-quality-assured ACT 0.6 4.0 <0.1 11.1 0.4 1.6 <0.1 13.5 1.3 15.6 1.0 8.9

Nationally Registered ACT 1.9 13.8 0.8 18.6 7.8 4.2 0.4 25.6 0.5 25.4 2.1 21.9

Any non-artemisinin therapy 2.6 68.2 2.2 67.7 9.7 52.9 0.8 62.1 2.3 57.6 0.6 62.7

SP 1.7 37.6 1.6 39.9 6.1 25.7 0.8 51.0 2.1 43.7 0.3 41.9

Chloroquine 0.8 29.7 0.5 26.8 3.6 26.6 0.1 10.1 0.1 12.5 0.3 20.1

Oral Quinine <0.1 0.3 <0.1 0.4 <0.1 0.4 -- 0..2 <0.1 0.8 <0.1 <0.1

Quinine Injection (IM/IV) <0.1 0.1 <0.1 0.1 <0.1 0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1

Amodiaquine <0.1 0.4 -- 0.3 -- 0.1 -- 0.5 -- 0.4 -- 0.1

Oral artemisinin monotherapy 0.1 4.4 <0.1 2.9 0.2 4.3 <0.1 3.7 <0.1 4.9 <0.1 4.5

Non-oral artemisinin monotherapy 0.1 0.2 1.4 0.3 2.0 1.8 -- 0.1 -- 0.9 0.1 0.2

ArtesunateIV/IM -- -- 1.3 0.1 <0.1 <0.1 -- -- -- 0.4 -- 0.1

Rectal Artesunate -- -- -- -- -- -- -- -- -- -- -- --

Artemether IV/IM 0.1 0.2 0.1 0.2 1.9 1.8 -- 0.1 -- 0.3 <0.1 0.1

Artemotil IV/IM <0.1 <0.1 -- <0.1 -- -- -- <0.1 -- 0.1 0.1 <0.1

Any treatment for severe malaria 0.1 0.3 1.4 0.4 2.0 1.9 <0.1 0.1 <0.1 0.9 0.1 0.2


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AMFm Endline Phase 1 Indicators

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Page 61

Table 3.1.1: Outlets enumerated by location, drugs stocked and final interview status, [Nigeria], 2011

Urban n Rural n Total n

Number of outlets enumerated (Flow Diagram Reference A) 6063 2444 8507

Number of outlets stocking drugs at the time of the survey visit 1829 668 2497

Number of outlets meeting the screening criteria* (Flow Diagram Reference C) 1071 496 1567

Number of outlets stocking antimalarials at the time of the survey visit (Flow Diagram

Reference E) 1032 472 1504

Number of outlets without antimalarials in stock at the time of the survey visit, but who

had antimalarials in stock at some time in the 3 months previous to the survey 36 22 58

Final interview status

Outlet Not Screened 357 211 568 Interview interrupted 0 0 0 Eligible respondent not available 110 41 151 Outlet not open at the time 128 116 244 Outlet closed permanently 44 25 69 Refused 74 27 101 Other 1 2 3

Outlet did not meet screening criteria 4635 1737 6372 Outlet met screening criteria, but not interviewed (total) 3 2 5

Interview interrupted 1 2 3 Eligible respondent not available 2 0 2 Outlet not open at the time 0 0 0 Refused 0 0 0 Other 0 0 0

Completed interview 1048 490 1538 Partially completed interview 20 4 24

Interview interrupted 9 2 11 Eligible respondent not available 4 0 4 Outlet not open at the time 2 0 2 Refused 3 1 4 Other 2 1 3

Response rate (%) Proportion of outlets enumerated that were screened 94.1 91.4 93.3 Proportion of outlets meeting screening criteria that were interviewed** 99.7 99.6 99.7

* The number of outlets meeting the screening criteria is defined as the sum of the number of outlets stocking antimalarials at the time of the survey and the number of outlets without antimalarials in stock at the time of the survey, but who had antimalarials in stock at some time in the 3 months previous to the survey ** Response rate was calculated as outlets where final interview status was “Completed interview” or “Partially completed interview” as a percentage of all outlets meeting the screening criteria (i.e. flow diagram reference D divided by C).

Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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Table 3.1.2: Outlets enumerated [Nigeria], 2011

Number of outlets enumerated*, by location and type of outlet

Type of outlet

Urban Rural Total

Censused Localities

Booster sample Total

Censused Localities


Censused Localities


Public health facility 54 0 54 78 0 78 132 0 132 Private not for-profit health facility 9 0 9 4 0 4 13 0 13 Private for-profit outlet

Private for-profit health facility 88 0 88 41 0 41 129 0 129 Pharmacy 41 0 41 3 0 3 44 0 44 Drug Store 959 0 959 442 0 442 1401 0 1401 General retailer 4831 0 4831 1853 0 1853 6684 0 6684 Itinerant drug vendor 76 0 76 11 0 11 87 0 87 Total 5995 0 5995 2350 0 2350 8345 0 8345

Community health worker 4 0 4 12 0 12 16 0 16 Total 6062 0 6062 2444 0 2444 8507 0 8506

* Flow diagram reference A


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Table 3.1.3: Outlets with antimalarials in stock [Nigeria], 2011 Number of outlets with antimalarials in stock at the time of the survey where an interview was conducted*, by location and type of outlet **

Type of outlet

Urban Rural Total

Censused Localities


Censused Localities


Censused Localities


Public health facility 43 0 43 52 0 52 95 0 95 Private not for-profit health facility 6 0 6 3 0 3 9 0 9

Private for-profit outlet

Private for-profit health facility 63 0 63 30 0 30 93 0 93 Pharmacy 36 0 36 2 0 2 38 0 38 Drug Store 807 0 807 362 0 362 1169 0 1169 General retailer 52 0 52 13 0 13 65 0 65 Itinerant drug vendor 22 0 22 6 0 6 28 0 28 Total 980 0 980 413 0 413 1393 0 1393

Community health worker 3 0 3 4 0 4 7 0 7 Total 1032 0 1032 472 0 472 1504 0 1504

* Flow diagram reference E. An interview was conducted if final interview status for an outlet was “Completed interview” or “Partially completed”. ** These numbers form the denominator for all subsequent tables, unless specified otherwise. Any variation in the stated denominator in subsequent tables is due to missing data on specific variables.


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Table 3.1.4: Number of products audited [Nigeria], 2011

Number of products audited by outlet type, product type, and location Urban Rural Total

Number of

products audited

Number of

products audited

Number of

products audited

Quality-assured ACTs Public health facility 73 65 138 Private not for-profit health facility 10 6 16 Private for-profit outlet 1426 530 1956 Community health worker 6 3 9 Total 1515 604 2119

Non-quality- assured ACTs

Public health facility 30 32 62 Private not for-profit health facility 4 0 4 Private for-profit outlet 1282 262 1544 Community health worker 0 0 0 Total 1316 294 1610

Artemisinin monotherapy


Non-Artemisinin therapy


All antimalarials



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Page 65

Table 3.1.5: Outlets with at least one staff member who completed secondary school or primary school [Nigeria] 2011 Outlets with at least one staff member who completed secondary school or primary school* (n) as a percentage of all outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet.

Type of outlet

Urban Rural Total

Percentage (95% CI) N



At least one staff member completed primary school Public health facility 100.0 43 100.0 52 100.0 95 Private not for-profit health facility 100.0 6 100.0 3 100.0 9


Private for-profit health facility 100.0 63 100.0 30 100.0 93 Pharmacy 100.0 36 100.0 2 100.0 38 Drug Store 99.8 (98.5, 100.0) 807 100.0 361 99.9 (99.1, 100.0) 1168 General retailer 100.0 52 100.0 13 100.0 65 Itinerant drug vendor 91.4 (87.9, 94.0) 22 55.2 (9.2, 93.7) 6 85.8 (66.7, 94.8) 28 Total 99.6 (97.6, 99.9) 980 99.7 (97.5, 100.0) 412 99.6 (98.5, 99.9) 1392

Community health worker 100.0 3 100.0 4 100.0 7

Total 99.6 (97.7, 99.9) 1032 99.7 (97.9, 100.0) 471 99.7 (98.7, 99.9) 1503

At least one staff member completed secondary school Public health facility 100.0 43 100.0 52 100.0 95

Private not for-profit health facility 100.0 6 100.0 3 100.0 9


Private for-profit health facility 100.0 63 100.0 30 100.0 93 Pharmacy 100.0 36 100.0 2 100.0 38 Drug Store 95.1 (93.2, 96.5) 806 96.9 (93.5, 98.5) 362 95.8 (94.2, 97.0) 1168 General retailer 98.8 (94.2, 99.8) 52 47.8 (16.4, 81.0) 13 83.9 (57.9, 95.1) 65 Itinerant drug vendor 37.6 (29.4, 46.5) 22 55.2 (9.2, 93.7) 6 40.3 (29.6, 52.0) 28 Total 94.4 (90.4, 96.8) 979 95.3 (91.3, 97.5) 413 94.7 (92.0, 96.6) 1392

Community health worker 66.7 (66.7, 66.7) 3 100.0 4 98.7 (87.3, 99.9) 7

Total 94.6 (90.9, 96.9) 1031 95.9 (92.5, 97.8) 472 95.1 (92.6, 96.8) 1503

* The two groups are not mutually exclusive. Providers noted as having completed primary school include those who have completed secondary school and those who have not completed secondary school but who have completed primary school.


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Table 3.1.6: Outlets with a staff member with a health-related qualification [Nigeria], 2011 Outlets with at least one staff member with a health-related qualification* (n) as a percentage of all outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet.

Type of outlet

Urban Rural Total

Percentage (95% CI)

N Percentage

(95% CI) N

Percentage (95% CI)

N

Public health facility 66.0 (49.6, 79.2) 43 50.8 (32.0, 69.3) 52 55.7 (41.4, 69.0) 95 Private not for-profit health facility 79.7 (38.3, 96.1)

6 93.1 (53.6, 99.4)

3 84.8 (52.2, 96.6)

9


Private for-profit health facility 91.2 (76.9, 97.0)

63 74.2 (51.9, 88.5)

30 83.3 (70.4, 91.2)

93

Pharmacy 100.0 36 100.0 2 100.0 38 Drug Store 23.8 (18.9, 29.5) 796 24.0 (17.0, 32.7) 360 23.9 (19.8, 28.6) 1156 General retailer 18.4 (6.9, 40.8) 51 6.1 (1.0, 28.2) 13 14.8 (6.1, 31.7) 64 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 30.0 (23.5, 37.5) 968 28.2 (21.1, 36.5) 411 29.3 (24.5, 34.7) 1379

Community health worker 0.0 3 7.3 (0.6, 51.0) 4 7.0 (0.6, 48.5) 7

Total 31.7 (24.9, 39.4) 1020 31.1 (25.0, 38.0) 470 31.5 (26.7, 36.7) 1490

* A health-related qualification was defined as pharmacy, nurse or medical doctor related training. Pharmacy related training includes pharmacy studied to a certificate or diploma level; Nurse related training includes studying nursing to a certificate level (nurse aid) and diploma level; Medical doctor training includes clinical officers who studied medicine to a diploma level and fully qualified physicians.


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3.2 Availability of antimalarial drugs

3.2.1 Antimalarials in stock

Table 3.2.1: Outlets with antimalarials in stock in [Nigeria], 2011 Indicator 1.1 Outlets that had any antimalarials in stock at the time of the survey visit* (n) as a percentage of all outlets where screening questions were completed** (N), by location and type of outlet

Type of outlet

Urban Rural Total




Public health facility 98.6 (95.3, 99.6) 48 76.9 (58.6, 88.7) 61 82.8 (68.1, 91.5) 109 Private not for-profit health facility 60.7 (22.2, 89.3) 8 100.0 3 71.2 (29.8, 93.5) 11


Private for-profit health facility 92.2 (80.6, 97.1) 70 83.3 (65.8, 92.8) 36 87.9 (78.2, 93.6) 106

Pharmacy 100.0 37 100.0 2 100.0 39 Drug Store 98.1 (95.9, 99.1) 823 97.3 (90.9, 99.3) 370 97.8 (95.5, 98.9) 1193 General retailer 1.0 (0.5, 1.7) 4640 0.8 (0.4, 1.7) 1739 0.9 (0.6, 1.4) 6379 Itinerant drug vendor 25.2 (20.3, 30.8) 76 27.9 (7.0, 66.6) 11 25.6 (20.0, 32.1) 87 Total 17.3 (14.2, 20.9) 5646 19.8 (17.8, 21.9) 2158 18.1 (16.0, 20.5) 7804


Total 17.9 (14.9, 21.4) 5705 21.7 (19.6, 24.0) 2233 19.2 (17.1, 21.6) 7938

* Flow diagram reference E ** Flow diagram reference B. Screening questions asked whether outlets had any medicines in stock that day, or any antimalarials in stock that day, and if not whether they had had any medicines, or any antimalarials, in stock in the previous 3 months.


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3.2.2 Antimalarials in stock by type

Table 3.2.2: Outlets with non-artemisinin therapy in stock [Nigeria], 2011

Indicator 1.2Outlets that had non-artemisinin monotherapy or non-artemisinin combination therapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total

Percentage (95% CI)

N Percentage (95% CI)

N Percentage (95% CI)

N

Public health facility 78.2 (47.1, 93.6) 42 74.0 (55.2, 86.8) 52 75.4 (60.1, 86.2) 94 Private not for-profit health facility 100.0 6 53.2 (7.3, 94.3) 3 82.4 (34.2, 97.7) 9


Private for-profit health facility 84.1 (66.8, 93.3) 60 87.9 (66.9, 96.3) 28 85.9 (73.9, 92.9) 88 Pharmacy 100.0 35 100.0 2 100.0 37 Drug Store 99.2 (97.7, 99.7) 801 99.9 (99.1, 100.0) 362 99.5 (98.6, 99.8) 1163 General retailer 96.1 (76.6, 99.5) 51 100.0 13 97.3 (84.3, 99.6) 64 Itinerant drug vendor 82.2 (53.2, 95.0) 22 100.0 6 85.0 (63.1, 94.9) 28 Total 97.8 (95.5, 98.9) 969 98.8 (97.1, 99.5) 411 98.2 (96.8, 98.9) 1380

Community health worker 0.0 3 100.0 4 96.1 (67.6, 99.7) 7

Total 97.1 (94.4, 98.5) 1020 95.7 (93.2, 97.3) 470 96.6 (94.8, 97.8) 1490

* Flow diagram reference E


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Table 3.2.3.a: Outlets with artemisinin monotherapy in stock (ALL DOSAGE FORMS)[Nigeria], 2011

Indicator 1.3 Outlets that had artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total




Public health facility 33.0 (16.6, 54.8) 42 27.7 (14.7, 46.0) 52 29.4 (18.5, 43.3) 94

Private not for-profit health facility 46.7 (14.3, 82.2) 6 46.3 (5.6, 92.6) 3 46.5 (17.3, 78.3) 9

Private for-profit outlets

Private for-profit health facility 51.1 (39.0, 63.0) 60 20.2 (7.9, 42.9) 28 36.6 (25.5, 49.2) 88 Pharmacy 99.8 (98.0, 100.0) 35 100.0 2 99.8 (98.1, 100.0) 37 Drug Store 38.1 (24.6, 53.8) 801 38.2 (31.7, 45.2) 361 38.2 (29.2, 48.0) 1162 General retailer 22.8 (9.2, 46.1) 51 11.2 (2.2, 41.3) 13 19.2 (8.7, 37.2) 64 Itinerant drug vendor 0.0 22 6.2 (0.8, 35.8) 6 1.0 (0.1, 9.9) 28 Total 39.5 (26.6, 54.1) 969 35.6 (29.6, 42.2) 410 38.1 (29.8, 47.1) 1379


Total 39.4 (26.9, 53.3) 1020 34.6 (28.6, 41.2) 469 37.5 (29.8, 45.9) 1489



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Table 3.2. 3.b: Outlets with ORAL artemisinin monotherapy in stock [Nigeria], 2011

Outlets that had oral artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total







Private for-profit health facility 30.2 (14.5, 52.5) 60 3.6 (0.8, 14.4) 28 17.7 (8.5, 33.1) 88 Pharmacy 99.5 (97.1, 99.9) 35 100.0 2 99.5 (97.3, 99.9) 37 Drug Store 35.9 (23.1, 51.0) 801 36.6 (30.4, 43.4) 361 36.2 (27.7, 45.6) 1162 General retailer 22.8 (9.2, 46.1) 51 11.2 (2.2, 41.3) 13 19.2 (8.7, 37.2) 64 Itinerant drug vendor 0.0 22 6.2 (0.8, 35.8) 6 1.0 (0.1, 9.9) 28 Total 36.3 (24.4, 50.3) 969 32.8 (27.2, 38.8) 410 35.0 (27.3, 43.5) 1379


Total 35.9 (24.5, 49.1) 1020 30.2 (25.0, 36.0) 469 33.6 (26.7, 41.4) 1489



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Table 3.2.4: Outlets with non-quality-assured ACTs in stock [Nigeria], 2011 Indicator 1.4: Outlets that had non-quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total





Private not for-profit health facility 1.2 (0.1, 11.3) 6 0.0 3 0.7 (0.1, 6.2) 9


Private for-profit health facility 29.0 (13.1, 52.5) 60 18.9 (7.0, 41.9) 28 24.3 (13.5, 39.8) 88 Pharmacy 99.8 (98.2, 100.0) 35 100.0 2 99.8 (98.3, 100.0) 37 Drug Store 27.6 (16.7, 41.9) 801 23.3 (17.4, 30.4) 361 25.9 (18.9, 34.5) 1162 General retailer 24.0 (9.2, 49.5) 51 8.0 (1.0, 43.4) 13 19.1 (8.1, 38.7) 64 Itinerant drug vendor 17.8 (5.0, 46.8) 22 6.2 (0.8, 35.8) 6 16.0 (5.5, 38.3) 28 Total 29.8 (18.9, 43.6) 969 22.4 (16.6, 29.6) 410 27.1 (20.1, 35.4) 1379


Total 30.0 (19.4, 43.4) 1020 21.4 (15.8, 28.3) 469 26.6 (20.1, 34.4) 1489



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Table 3.2.5.a: Outlets with quality-assured ACTs in stock [Nigeria], 2011

Indicator 1.5: Outlets that had quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total





Private not for-profit health facility 79.7 (38.3, 96.1) 6 100.0 3 87.3 (51.2, 97.8) 9

Private for-profit outlets Private for-profit health facility 71.1 (55.2, 83.0) 60 28.8 (13.1, 52.1) 28 51.2 (36.0, 66.2) 88 Pharmacy 99.8 (98.0, 100.0) 35 100.0 2 99.8 (98.1, 100.0) 37 Drug Store 52.8 (37.4, 67.7) 801 56.5 (49.4, 63.3) 361 54.2 (44.1, 64.0) 1162 General retailer 29.4 (12.6, 54.6) 51 9.2 (2.3, 30.1) 13 23.2 (11.2, 42.0) 64 Itinerant drug vendor 1.3 (0.1, 11.6) 22 0.0 6 1.1 (0.1, 8.0) 28 Total 53.3 (38.6, 67.6) 969 52.2 (44.7, 59.5) 410 52.9 (43.4, 62.2) 1379 Community health worker 100.0 3 80.9 (29.3, 97.7) 4 81.6 (32.0, 97.7) 7

Total 53.7 (39.1, 67.8) 1020 53.2 (46.5, 59.8) 469 53.5 (44.4, 62.4) 1489



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Table 3.2.5.b: Outlets with quality-assured ACTs with and without the AMFm logo in stock [Nigeria], 2011 Indicator 1.5: Outlets that had quality-assured ACTs with and without the AMFm in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total




Stocked QAACTs with the AMFm logo Public health facility 45.0 (30.7, 60.2) 42 18.6 (9.2, 33.8) 52 27.1 (18.0, 38.6) 94


Private for-profit outlets Private for-profit health facility 64.8 (47.0, 79.3) 60 23.0 (9.9, 44.9) 28 45.1 (30.4, 60.8) 88 Pharmacy 80.3 (47.7, 94.8) 35 100.0 2 80.9 (50.0, 94.7) 37 Drug Store 49.7 (34.7, 64.8) 801 51.7 (44.0, 59.3) 361 50.5 (40.6, 60.3) 1162 General retailer 18.2 (6.7, 40.8) 51 9.2 (2.3, 30.1) 13 15.4 (6.6, 32.0) 64 Itinerant drug vendor 1.3 (0.1, 11.6) 22 0.0 6 1.1 (0.1, 8.0) 28 Total 49.2 (35.5, 62.9) 969 47.5 (39.4, 55.7) 410 48.5 (39.7, 57.5) 1379


Total 49.3 (35.9, 62.9) 1020 44.5 (36.9, 52.3) 469 47.4 (39.1, 55.9) 1489

Stocked QAACTs without the AMFm logo Public health facility 30.4 (14.6, 52.6) 42 41.8 (24.7, 61.1) 52 38.1 (25.1, 53.1) 94


Private for-profit outlets Private for-profit health facility 9.1 (3.2, 23.3) 60 9.3 (2.0, 33.3) 28 9.2 (3.8, 20.6) 88 Pharmacy 56.1 (28.5, 80.4) 35 100.0 2 57.5 (30.1, 80.9) 37 Drug Store 13.3 (7.8, 21.9) 801 13.2 (9.6, 18.0) 361 13.3 (9.4, 18.5) 1162 General retailer 12.9 (2.9, 42.2) 51 0.0 13 9.0 (2.3, 29.3) 64 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 14.3 (8.9, 22.1) 969 12.5 (9.2, 16.9) 410 13.6 (9.9, 18.4) 1379


Total 15.2 (9.8, 22.7) 1020 16.5 (12.9, 20.8) 469 15.7 (12.0, 20.3) 1489



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Table 3.2. 5.c: Public health facility outlets with quality-assured ACTs among ALL PUBLIC HEALTH FACILITIES screened in [Nigeria], 2011 Public health facilities that had quality-assured ACT in stock (n) as a percentage of ALL PUBLIC HEALTH FACILITIES screened (N), location

Type of outlet

Urban Rural Total

Percentage (95% CI) N Percentage (95% CI) N Percentage (95% CI) N



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3.2.3 Stockouts of quality-assured ACTs

Table 3.2.6: Outlets with stock-outs of quality- assured ACTs [Nigeria], 2011

Indicator 1.6: Outlets that were out of stock of all quality-assured ACTs for at least 1 day in the last 7 days (n) as a percentage of outlets with any quality-assured ACTs in stock at the time of the survey visit or in the 4 weeks preceding the survey visit (N), by location and type of outlet*

Type of outlet

Urban Rural Total




Public health facility 1.1 (0.2, 5.6) 36 2.4 (0.3, 15.9) 39 2.0 (0.4, 10.1) 75 Private not for-profit health facility 0.0 6 0.0 3 0.0 9


Private for-profit health facility 0.2 (0.0, 1.9) 49 0.0 24 0.1 (0.0, 1.0) 73 Pharmacy 1.6 (0.2, 10.0) 29 0.0 1 1.6 (0.2, 9.4) 30 Drug Store 5.6 (2.9, 10.4) 583 8.3 (4.4, 15.1) 251 6.7 (4.3, 10.2) 834 General retailer 9.9 (1.5, 43.7) 24 0.0 9 7.5 (1.2, 34.9) 33 Itinerant drug vendor 23.1 (9.5, 46.2) 9 0.0 3 20.1 (7.3, 44.3) 12 Total 5.4 (2.8, 10.0) 694 7.3 (3.9, 13.3) 288 6.1 (4.0, 9.4) 982


Total 5.1 (2.7, 9.4) 739 6.6 (3.6, 11.6) 334 5.7 (3.8, 8.6) 1073

*This indicator measures stockouts of quality-assured ACTs among outlets that have recently stocked these products. The denominator may include outlets which had no antimalarials in stock on the day of the survey but which had stocked them in the previous 3 months. A stock-out is defined as being out of stock of all quality-assured ACTs for at least 1 day in the last seven days. Outlets that have recently stocked QAACTs are defined as outlets with any QAACTs in stock at the time of the survey visit or in the 4 weeks preceding the survey visit.


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3.2.4 Population coverage of outlets with quality-assured ACTs

Table 3.2.7: Percentage of the population living in censused “localities” with outlets with quality-assured ACTs in stock at the time of survey [Nigeria], 2011

Indicator 1.7: Population living in a censused “locality” where there was at least one of a given type of outlet with a quality-assured ACT in stock at the time of the survey visit (n) as a percentage of the total population living in all the censused “localities” (N), by location.

Urban Rural Total




At least one public health facility stocking quality-assured ACTs

56.0 (39.2, 71.6) 607446 31.9 (22.5,43.0) 445914 36.6 (28.2, 45.9) 1053360

At least one private not for-profit health facility stocking quality-assured ACTs

16.1 (6.5, 34.5) 3.7 (1.1, 11.7) 6.1 (2.9, 12.4)

At least one private for-profit outlet stocking quality-assured ACTs

100.0 60.4 (49.2,70.6) 68.2 (59.0,76.1)

At least one community health worker stocking quality-assured ACTs

1.8 (0.2, 12.4) 2.0 (0.5, 7.9) 1.9 (0.6, 6.4)

At least one outlet of any type stocking quality-assured ACTs

100.0 65.6 (54.5,75.3) 72.4 (63.3,80.0)

Source of population data: National Population Commission (NPC) [Nigeria] Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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3.3 Pricing of antimalarials (Affordability)

3.3.1 Cost to patients of antimalarials

Table 3.3.1: Cost to patients of non-artemisinin therapy, in 2010 US dollars [Nigeria], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of non-artemisinin monotherapy or non-artemisinin combination therapy, by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost** [IQR]

Number of

products Median cost

[IQR]

Number of


[IQR]

Number of

products All dosage forms

Public health facility 0.92 [0.30, 2.21] 78 0.53 [0.00, 1.18] 79 0.71 [0.12, 1.48] 157 Private not for-profit health facility 1.48 [0.59, 1.77] 20 3.69 [1.14, 6.25] 2 1.48 [0.89, 1.77] 22 Private for-profit outlet 1.01 [0.41, 1.54] 5729 0.96 [0.47, 1.77] 2281 1.00 [0.47, 1.54] 8010 Community health workers -- 0 0.59 [0.41, 2.31] 9 0.59 [0.41, 2.31] 9 Total 1.01 [0.41, 1.54] 5827 0.89 [0.47, 1.77] 2371 1.00 [0.44, 1.54] 8198

Tablets Public health facility 0.30 [0.00, 1.18] 38 0.18 [0.00, 0.30] 44 0.23 [0.00, 0.47] 82 Private not for-profit health facility 0.59 [0.59, 1.18] 9 1.14 [n/a] 1 0.59 [0.59, 1.18] 10 Private for-profit outlet 0.46 [0.30, 0.71] 2899 0.47 [0.35, 0.89] 1206 0.47 [0.35, 0.77] 4105 Community health workers -- 0 0.41 [0.41, 0.41] 6 0.41 [0.41, 0.41] 6 Total 0.46 [0.30, 0.71] 2946 0.47 [0.35, 0.77] 1257 0.47 [0.35, 0.77] 4203

Oral Liquids Public health facility 0.74 [0.74, 1.48] 18 1.18 [0.59, 1.54] 14 1.03 [0.74, 1.54] 32 Private not for-profit health facility 1.48 [0.89, 1.48] 6 -- 0 1.48 [0.89, 1.48] 6 Private for-profit outlet 1.48 [1.18, 1.85] 2540 1.54 [1.23, 2.21] 997 1.54 [1.18, 1.85] 3537 Community health workers -- 0 2.31 [2.31, 2.31] 3 2.31 [2.31, 2.31] 3 Total 1.48 [1.18, 1.85] 2564 1.54 [1.23, 2.21] 1014 1.54 [1.18, 1.85] 3578

Injectables Public health facility 2.21 [1.11, 4.43] 22 1.18 [0.55, 1.77] 21 1.33 [0.89, 2.21] 43 Private not for-profit health facility 12.49 [1.85, 12.49] 5 6.25 [n/a] 1 6.25 [1.85, 12.49] 6 Private for-profit outlet 1.33 [0.55, 5.00] 290 1.11 [0.59, 2.21] 78 1.33 [0.59, 3.69] 368 Community health workers -- 0 -- 0 -- 0 Total 1.48 [0.59, 5.00] 317 1.14 [0.59, 1.83] 100 1.33 [0.59, 3.29] 417

Other

Public health facility -- 0 -- 0 -- 0

Private not for-profit health facility -- 0 -- 0 -- 0

Private for-profit outlet -- 0 -- 0 -- 0

Community health workers -- 0 -- 0 -- 0

Total -- 0 -- 0 -- 0

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial * * 1 USD = 152.803 NAIRA; An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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Table 3.3.2: Cost to patients of artemisinin monotherapy, in 2010 US dollars [Nigeria], 2011

Indicator 2.3: Median cost to patients of one adult equivalent treatment dose (AETD)* of artemisinin monotherapy, by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost** [IQR]

Number of


[IQR]

Number of


[IQR]

Number of


Public health facility 5.67 [2.08, 10.63] 23 5.67 [4.25, 9.74] 24 5.67 [2.08, 10.63] 47 Private not for-profit health facility 21.26 [0.94, 24.80] 6 5.67 [n/a] 1 21.26 [5.67, 24.80] 7 Private for-profit outlet 3.25 [2.36, 9.74] 929 3.31 [2.83, 9.74] 246 3.31 [2.36, 9.74] 1175 Community health workers -- 0 -- 0 -- 0 Total 3.25 [2.36, 9.74] 958 3.31 [2.83, 9.74] 271 3.31 [2.36, 9.74] 1229

All oral dosage forms Public health facility 1.98 [0.47, 2.08] 7 9.74 [2.83, 10.63] 11 2.08 [1.98, 9.74] 18 Private not for-profit health facility 24.80 [24.80, 24.80] 2 5.67 [n/a] 1 5.67 [5.67, 24.80] 3 Private for-profit outlet 2.83 [2.36, 8.86] 736 3.31 [2.65, 8.86] 218 2.83 [2.36, 8.86] 954 Community health workers -- 0 -- 0 -- 0 Total 2.83 [2.36, 8.86] 745 3.31 [2.66, 9.45] 230 2.83 [2.36, 8.86] 975

Tablets Public health facility 1.98 [0.47, 2.08] 5 2.83 [2.83, 4.72] 7 2.08 [0.47, 2.83] 12 Private not for-profit health facility 2.27 [n/a] 1 5.67 [n/a] 1 5.67 [5.67, 5.67] 2 Private for-profit outlet 2.65 [2.36, 2.83] 509 2.83 [2.36, 3.31] 155 2.66 [2.36, 2.83] 664 Community health workers -- 0 -- 0 -- 0 Total 2.65 [2.17, 2.83] 515 2.83 [2.36, 3.31] 163 2.66 [2.36, 2.83] 678

Oral liquids Public health facility 10.54 [9.74, 11.34] 2 10.63 [9.74, 17.36] 4 10.63 [9.74, 17.36] 6 Private not for-profit health facility 24.80 [n/a] 1 -- 0 24.80 [n/a] 1 Private for-profit outlet 14.17 [8.86, 15.94] 227 14.17 [9.74, 17.71] 63 14.17 [8.86, 15.94] 290 Community health workers -- 0 -- 0 -- 0 Total 14.17 [8.86, 15.94] 230 14.17 [9.74, 17.36] 67 14.17 [8.86, 15.94] 297

Injectables

Public health facility 10.63 [8.86, 10.63] 16 5.67 [4.25, 7.09] 13 7.09 [5.67, 10.63] 29 Private not for-profit health facility 21.26 [0.94, 21.26] 4 -- 0 21.26 [0.94, 21.26] 4 Private for-profit outlet 8.50 [6.38, 17.71] 193 7.09 [7.09, 14.17] 28 8.50 [7.09, 17.71] 221 Community health workers -- 0 -- 0 -- 0 Total 8.50 [6.38, 17.71] 213 7.09 [5.67, 14.17] 41 8.27 [6.38, 17.00] 254

Other Public health facility -- 0 -- 0 -- 0 Private not for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet -- 0 -- 0 -- 0 Community health workers -- 0 -- 0 -- 0 Total -- 0 -- 0 -- 0

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial * * 1USD = 152.803 NAIRA; An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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Table 3.3.3: Cost to patients of non-quality-assured ACTs, in 2010 US dollars [Nigeria], 2011 Indicator 2.2: Median cost to patients of one adult equivalent treatment dose (AETD)* of non-quality-assured ACTs by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost** [IQR]

Number of


[IQR]

Number of


[IQR]

Number of


Public health facility 6.30 [5.90, 11.81] 30 0.00 [0.00, 3.84] 32 4.72 [0.00, 9.45] 62 Private not for-profit health facility 3.19 [2.83, 5.31] 4 -- 0 3.19 [2.83, 5.31] 4 Private for-profit outlet 4.13 [2.95, 6.20] 1219 4.43 [2.95, 7.87] 253 4.13 [2.95, 6.49] 1472 Community health workers -- 0 -- 0 -- 0 Total 4.13 [2.95, 6.30] 1253 4.13 [2.36, 7.87] 285 4.13 [2.95, 6.49] 1538

Tablets Public health facility 5.90 [2.95, 5.90] 15 0.00 [0.00, 0.00] 19 2.95 [0.00, 5.90] 34 Private not for-profit health facility 2.83 [2.83, 3.54] 3 -- 0 2.83 [2.83, 3.54] 3 Private for-profit outlet 3.54 [2.66, 4.13] 863 3.54 [2.36, 4.43] 181 3.54 [2.66, 4.43] 1044 Community health workers -- 0 -- 0 -- 0 Total 3.54 [2.66, 4.13] 881 3.54 [2.07, 4.43] 200 3.54 [2.66, 4.43] 1081

Oral liquids Public health facility 10.63 [6.30, 13.28] 13 0.00 [0.00, 9.45] 11 6.30 [0.00, 10.23] 24 Private not for-profit health facility 7.09 [n/a] 1 -- 0 7.09 [n/a] 1 Private for-profit outlet 8.66 [7.09, 10.23] 309 8.86 [7.87, 11.02] 62 8.66 [7.09, 10.23] 371 Community health workers -- 0 -- 0 -- 0 Total 8.66 [6.49, 10.23] 323 8.66 [7.09, 11.02] 73 8.66 [7.09, 10.23] 396

Injectables Public health facility -- 0 -- 0 -- 0 Private not for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet -- 0 -- 0 -- 0 Community health workers -- 0 -- 0 -- 0 Total -- 0 -- 0 -- 0

Other Public health facility 9.45 [9.45, 11.81] 2 0.00 [0.00, 0.00] 2 9.45 [0.00, 11.81] 4 Private not for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet 7.09 [5.90, 10.39] 47 9.45 [7.09, 14.17] 10 8.27 [5.90, 11.81] 57 Community health workers -- 0 -- 0 -- 0 Total 8.27 [5.90, 11.81] 49 8.27 [3.54, 11.81] 12 8.27 [5.90, 11.81] 61

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial ** 1 USD = 152.803 NAIRA, An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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Table 3.3.4: Cost to patients of quality-assured ACTs, in 2010 US dollars [Nigeria], 2011

Indicator 2.1: Median cost to patients of one adult equivalent treatment dose (AETD)* of quality-assured ACTs, by presence of the AMFm logo, location and type of outlet

Type of outlet

Urban Rural Total

Median cost** [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Adult equivalent treatment dose (AETD)*

All QAACTs Public health facility 0.00 [0.00, 0.00] 70 0.00 [0.00, 0.00] 65 0.00 [0.00, 0.00] 135 Private not for-profit health facility 0.71 [0.71, 2.95] 10 1.48 [1.48, 4.72] 3 1.48 [0.71, 3.54] 13 Private for-profit outlet 1.48 [0.89, 2.66] 1378 1.57 [1.06, 2.36] 516 1.48 [0.89, 2.36] 1894 Community health worker 0.00 [0.00, 0.00] 6 3.54 [3.54, 3.54] 2 3.54 [3.54, 3.54] 8 Total 1.48 [0.89, 2.66] 1464 1.48 [0.89, 2.36] 586 1.48 [0.89, 2.36] 2050

QAACTs with the AMFm logo Public health facility 0.00 [0.00, 0.00] 45 0.00 [0.00, 0.00] 23 0.00 [0.00, 0.00] 68 Private not for-profit health facility 2.36 [0.71, 2.95] 7 1.48 [n/a] 1 1.48 [0.71, 2.95] 8 Private for-profit outlet 1.48 [0.89, 2.36] 1194 1.48 [0.89, 2.36] 443 1.48 [0.89, 2.36] 1637 Community health worker 0.00 [0.00, 0.00] 6 7.09 [n/a] 1 0.00 [0.00, 7.09] 7 Total 1.42 [0.89, 2.36] 1252 1.48 [0.89, 2.36] 468 1.48 [0.89, 2.36] 1720

QAACTs without the AMFm logo Public health facility 0.00 [0.00, 0.00] 25 0.00 [0.00, 0.00] 42 0.00 [0.00, 0.00] 67 Private not for-profit health facility 0.71 [0.71, 0.71] 3 4.72 [4.72, 4.72] 2 0.71 [0.71, 4.72] 5 Private for-profit outlet 2.95 [1.48, 5.02] 184 2.76 [1.18, 5.90] 73 2.95 [1.42, 5.31] 257 Community health worker -- 0 3.54 [n/a] 1 3.54 [n/a] 1 Total 2.83 [0.94, 5.02] 212 1.18 [0.00, 3.84] 118 2.36 [0.71, 4.72] 330

Pediatric formulation -Pack for a two-year old child (10kg)***

All QAACTs

Public health facility 0.00 [0.00, 0.00] 21 0.00 [0.00, 0.00] 15 0.00 [0.00, 0.00] 36 Private not for-profit health facility 0.89 [0.18, 2.36] 4 1.18 [n/a] 1 0.89 [0.18, 1.18] 5 Private for-profit outlet 0.71 [0.59, 1.18] 343 0.89 [0.59, 1.18] 147 0.89 [0.59, 1.18] 490 Community health worker 0.00 [0.00, 0.00] 3 0.89 [0.89, 0.89] 2 0.89 [0.89, 0.89] 5 Total 0.71 [0.59, 1.18] 371 0.71 [0.59, 1.18] 165 0.71 [0.59, 1.18] 536

QAACTs with the AMFm logo Public health facility 0.00 [0.00, 0.00] 11 0.00 [0.00, 0.00] 4 0.00 [0.00, 0.00] 15 Private not for-profit health facility 0.18 [0.18, 0.89] 3 -- 0 0.18 [0.18, 0.89] 3 Private for-profit outlet 0.71 [0.59, 1.18] 282 0.89 [0.59, 1.18] 120 0.71 [0.59, 1.18] 402 Community health worker 0.00 [0.00, 0.00] 3 1.77 [n/a] 1 1.77 [0.00, 1.77] 4 Total 0.71 [0.59, 0.89] 299 0.71 [0.59, 1.18] 125 0.71 [0.59, 1.18] 424

QAACTs without the AMFm logo Public health facility 0.00 [0.00, 0.00] 10 0.00 [0.00, 0.00] 11 0.00 [0.00, 0.00] 21 Private not for-profit health facility 2.36 [n/a] 1 1.18 [n/a] 1 1.18 [1.18, 2.36] 2 Private for-profit outlet 0.89 [0.59, 1.48] 61 0.89 [0.59, 1.18] 27 0.89 [0.59, 1.48] 88 Community health worker -- 0 0.89 [n/a] 1 0.89 [n/a] 1 Total 0.89 [0.59, 1.48] 72 0.59 [0.00, 1.06] 40 0.89 [0.35, 1.18] 112

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial ** 1 USD = 152.803 NAIRA; An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial. ***Pediatric formulations (PFs) are packages intended for children. In the calculation of median cost we include only packages whose age (weight) range includes a 2 year old (10kg) child.


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Table 3.3.5.a: Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales volumes (SP) for ALL DOSAGE TYPES, in 2010 US dollars [Nigeria], 2011 Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national private for-profit sales volumes in [Nigeria] that is not a quality-assured ACT, for ALL DOSAGE TYPES (SP), by location and type of outlet

Urban Rural Total

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Private for-profit outlet 0.47 [0.35, 0.89] 2296 0.47 [0.41, 0.89] 1004 0.47 [0.35, 0.89] 3300

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


Table 3.3.5.b: Cost to patients of the most popular antimalarial in terms of national private for-for-profit outlet sales volumes (SP) for TABLETS, in 2010 US dollars [Nigeria], 2011 Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national private for-profit sales volumes in [Nigeria] that is not a quality-assured ACT, for TABLETS (SP), by location and type of outlet

Urban Rural Total

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Private for-profit outlet 0.47 [0.35, 0.71] 2098 0.47 [0.41, 0.71] 947 0.47 [0.35, 0.71] 3045



Table 3.3.5.c: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for ALL DOSAGE TYPES, in 2010 US dollars [Nigeria], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national sales volumes for all outlet types in [Nigeria] that is not a quality-assured ACT, for ALL DOSAGE TYPES (SP), by location and type of outlet

Urban Rural Total

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

All outlets 0.47 [0.35, 0.89] 2339 0.47 [0.41, 0.89] 1045 0.47 [0.35, 0.89] 3384



Table 3.3. 5.d: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for TABLETS, in 2010 US dollars [Nigeria], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national sales volumes for all outlet types in [Nigeria] that is not a quality-assured ACT, for TABLETS (SP), by location and type of outlet

Urban Rural Total

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

Median cost [IQR]

Number of products

All outlets 0.47 [0.35, 0.71] 2133 0.47 [0.41, 0.71] 988 0.47 [0.35, 0.71] 3121



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3.3.2 Gross percentage markup between purchase price and retail selling price

Table 3.3.6: Gross percentage markup between purchase price and retail selling price of non-artemisinin therapy [Nigeria], 2011

Median percentage markup between purchase price and retail selling price of non-artemisinin monotherapy or non-artemisinin combination therapy by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of

products Median markup

[IQR]

Number of


[IQR]

Number of

products

Public health facility 0.0 [0.0, 31.6] 65 33.3 [0.0, 100.0] 71 25.0 [0.0, 80.0] 136 Private not for-profit health facility 66.7 [33.3, 100.0] 15

225.0 [150.0, 300.0] 2 66.7 [33.3, 100.0] 17


Private for-profit health facility 40.0 [29.0, 50.0] 95 66.7 [42.9, 114.3] 35 42.9 [33.3, 100.0] 130 Pharmacy 37.3 [25.0, 53.8] 306 50.0 [33.3, 66.7] 13 37.3 [25.0, 53.8] 319 Drug Store 41.2 [25.0, 66.7] 4673 42.9 [25.0, 60.0] 2062 41.2 [25.0, 66.7] 6735 General retailer 40.0 [25.0, 66.7] 158 40.0 [33.3, 66.7] 35 40.0 [25.0, 66.7] 193 Itinerant drug vendor 66.7 [66.7, 100.0] 32 42.9 [40.0, 66.7] 21 66.7 [42.9, 100.0] 53 Total 40.0 [25.0, 66.7] 5264 42.9 [25.0, 62.8] 2166 41.2 [25.0, 66.7] 7430

Community health worker -- 0 40.0 [25.0, 40.0] 6 40.0 [25.0, 40.0] 6 Total 40.0 [25.0, 66.7] 5344 42.9 [25.0, 66.7] 2245 41.2 [25.0, 66.7] 7589

Note: 6 markups were treated as missing, because the purchase price was zero and the selling price was non-zero.


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Table 3.3.7: Gross percentage markup between purchase price and retail selling price of artemisinin monotherapy [Nigeria], 2011

Median percentage markup between purchase price and retail selling price of artemisinin monotherapy by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility 15.4 [0.0, 20.0] 18 20.0 [10.0, 42.9] 20 20.0 [2.1, 33.3] 38 Private not for-profit health facility 71.4 [71.4, 71.4] 4 50.0 [n/a] 1 50.0 [50.0, 71.4] 5 Private for-profit outlet

Private for-profit health facility 35.1 [17.6, 50.0] 32 42.9 [20.0, 42.9] 6 35.1 [17.6, 50.0] 38 Pharmacy 25.0 [19.4, 40.0] 94 57.8 [50.4, 92.9] 4 25.0 [19.4, 41.7] 98 Drug Store 25.0 [20.0, 38.9] 675 25.0 [16.7, 36.4] 213 25.0 [18.6, 38.9] 888 General retailer 21.6 [20.0, 44.4] 17 20.0 [20.0, 36.4] 2 20.0 [20.0, 36.4] 19 Itinerant drug vendor -- 0 75.0 [n/a] 1 75.0 [n/a] 1 Total 25.6 [19.4, 38.9] 818 25.0 [16.7, 40.0] 226 25.0 [18.6, 38.9] 1044

Community health worker -- 0 -- 0 -- 0 Total 25.0 [19.0, 38.9] 840 25.0 [16.7, 40.0] 247 25.0 [18.4, 40.0] 1087

Note: 0 markup was treated as missing, because the purchase price was zero and the selling price was non-zero.


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Table 3.3.8: Gross percentage markup between purchase price and retail selling price of non-quality-assured ACTs [Nigeria], 2011

Median percentage markup between purchase price and retail selling price of non-quality-assured ACTs by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility 14.3 [0.0, 25.0] 24 0.0 [0.0, 1.2] 30 0.0 [0.0, 14.3] 54 Private not for-profit health facility 63.3 [55.0, 83.3] 4 -- 0 63.3 [55.0, 83.3] 4 Private for-profit outlet:

Private for-profit health facility 37.5 [18.2, 53.8] 37 12.5 [5.3, 20.0] 6 31.6 [16.7, 53.8] 43 Pharmacy 25.0 [20.0, 31.0] 200 33.3 [29.4, 42.9] 9 25.0 [20.0, 31.0] 209 Drug Store 21.2 [13.3, 31.6] 754 20.0 [14.0, 32.4] 187 20.0 [13.6, 31.6] 941 General retailer 38.9 [16.7, 44.4] 23 20.0 [n/a] 1 33.3 [16.7, 44.4] 24

Itinerant drug vendor 170.0 [n/a] 1 130.3 [127.3,

133.3] 2 170.0 [170.0,

170.0] 3 Total 23.1 [15.4, 33.3] 1015 20.0 [14.0, 32.4] 205 22.2 [14.6, 32.4] 1220


Note: 0 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. Refer to section 2.1.5.4.


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Table 3.3.9.a: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs [Nigeria], 2011

Indicator 2.5:Median percentage markup between purchase price and retail selling price of quality-assured ACTs by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility 0.0 [0.0, 0.0] 70 0.0 [0.0, 0.0] 63 0.0 [0.0, 0.0] 133 Private not for-profit health facility 500.0 [66.7, 500.0] 9

100.0 [100.0, 100.0] 2

500.0 [66.7, 500.0] 11


Private for-profit health facility 36.4 [20.0, 50.0] 33

66.7 [34.6, 100.0] 7 36.4 [25.0, 50.0] 40

Pharmacy 87.5 [33.3, 150.0] 92 62.2 [44.5, 71.1] 4 87.5 [33.3,

150.0] 96 Drug Store 50.0 [25.0, 76.5] 1038 50.0 [25.0, 75.0] 474 50.0 [25.0, 75.0] 1512 General retailer 50.0 [38.9, 66.7] 34 25.0 [10.0, 50.0] 3 50.0 [36.4, 66.7] 37

Itinerant drug vendor 100.0 [47.1, 100.0] 2 -- 0 100.0 [47.1,

100.0] 2 Total 50.0 [25.0, 87.5] 1199 50.0 [25.0, 75.0] 488 50.0 [25.0, 76.5] 1687

Community health worker 0.0 [0.0, 0.0] 6 15.4 [n/a] 1 15.4 [15.4, 15.4] 7 Total 50.0 [25.0, 87.5] 1284 42.9 [20.0, 66.7] 554 50.0 [25.0, 75.0] 1838



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Table 3.3. 9.b: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs, by presence of the AMFm logo, [Nigeria], 2011

Indicator 2.5: Median percentage markup between purchase price and retail selling price of quality-assured ACTs by presence of the AMFm logo by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products


Public health facility 0.0 [0.0, 0.0] 45 0.0 [0.0, 0.0] 21 0.0 [0.0, 0.0] 66

Private not for-profit health facility 500.0 [66.7, 500.0] 6 -- 0

500.0 [66.7, 500.0] 6



66.7 [66.7, 100.0] 4 36.4 [25.0, 50.0] 32

Pharmacy 87.5 [50.0, 212.5] 78 62.2 [62.2, 62.2] 2 87.5 [50.0,

150.0] 80 Drug Store 50.0 [25.0, 87.5] 906 50.0 [25.0, 76.5] 412 50.0 [25.0, 84.6] 1318 General retailer 50.0 [38.9, 78.6] 29 25.0 [10.0, 50.0] 3 50.0 [33.3, 66.7] 32

Itinerant drug vendor 100.0 [47.1, 100.0] 2 -- 0 100.0 [47.1,

100.0] 2 Total 50.0 [26.3, 87.5] 1043 50.0 [25.0, 76.5] 421 50.0 [25.0, 87.5] 1464

Community health worker 0.0 [0.0, 0.0] 6 -- 0 0.0 [0.0, 0.0] 6 Total 50.0 [25.0, 87.5] 1100 50.0 [25.0, 75.0] 442 50.0 [25.0, 87.5] 1542

QAACTs without the AMFm logo


Private not for-profit health facility 500.0 [500.0, 500.0] 3

100.0 [100.0, 100.0] 2

500.0 [100.0, 500.0] 5



34.6 [15.4, 150.0] 3 33.3 [33.3, 50.0] 8

Pharmacy 9.5 [9.5, 12.5] 14 53.4 [26.8, 80.0] 2 12.0 [9.5, 17.6] 16 Drug Store 25.0 [15.4, 50.0] 132 42.9 [20.0, 60.0] 62 26.3 [16.7, 53.8] 194 General retailer 50.0 [38.9, 50.0] 5 -- 0 50.0 [38.9, 50.0] 5

Itinerant drug vendor -- 0 -- 0 -- 0 Total 25.0 [14.3, 50.0] 156 42.9 [20.0, 60.0] 67 26.3 [15.4, 50.0] 223

Community health worker -- 0 15.4 [n/a] 1 15.4 [n/a] 1 Total 25.0 [12.5, 50.0] 184 15.4 [0.0, 50.0] 112 25.0 [5.9, 50.0] 296



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Table 3.3.10: Median total gross markup between first-line buyer price and retail selling price of quality-assured ACTs bearing the AMFm logo, in US dollars, [Nigeria], 2011

Indicator 2.6: Median total gross markup* between first-line buyer price** and retail selling price per adult equivalent treatment dose (AETD)*** of quality-assured ACTs bearing the AMFm logo, by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility -0.06 [-0.10, -0.06] 45 -0.10 [-0.15, -0.06] 23 -0.06 [-0.15, -0.06] 68 Private not for-profit health facility 2.26 [0.58, 2.81] 7 1.33 [n/a] 1 1.33 [0.58, 2.81] 8 Private for-profit outlet

Private for-profit health facility 1.92 [0.73, 3.38] 30 2.19 [1.02, 8.70] 5 1.92 [0.73, 3.40] 35 Pharmacy 0.73 [0.58, 2.19] 108 2.22 [1.45, 3.41] 3 0.73 [0.58, 2.19] 111 Drug Store 1.32 [0.74, 2.26] 1016 1.35 [0.84, 2.26] 431 1.33 [0.74, 2.26] 1447 General retailer 1.64 [1.30, 2.25] 37 1.79 [1.64, 5.03] 4 1.64 [1.32, 2.25] 41 Itinerant drug vendor 1.61 [1.33, 1.61] 2 -- 0 1.61 [1.33, 1.61] 2 Total 1.32 [0.74, 2.26] 1193 1.37 [0.87, 2.26] 443 1.33 [0.74, 2.26] 1636

Community health worker -0.08 [-0.10, -0.06] 6 6.92 [n/a] 1 -0.06 [-0.10, 6.92] 7 Total 1.32 [0.73, 2.26] 1251 1.35 [0.75, 2.23] 468 1.33 [0.74, 2.25] 1719

*Median total gross markup is the median of the difference between the retail selling price and the mean first-line buyer price for each QAACT. **First-Line Buyer (FLB) price data were provided by The Global Fund. *** An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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3.3. 3 Availability and cost to patients of diagnostic tests (RDT/microscopy)

3.3.3.1 Any Diagnostic test

Table 3.3.11: Availability of any diagnostic test for malaria, [Nigeria], 2011

Outlets where any diagnostic tests (microscopy or RDT) were available* (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit** (N), by location and type of outlet.

Type of outlet

Urban Rural Total






Private for-profit health facility 47.2 (25.0, 70.5) 61 32.2 (12.1, 62.2) 29 40.0 (24.2, 58.3) 90 Pharmacy 6.3 (0.8, 35.9) 33 0.0 2 6.0 (0.8, 33.8) 35 Drug Store 0.7 (0.2, 2.1) 794 1.1 (0.2, 6.6) 359 0.8 (0.3, 2.5) 1153 General retailer 0.0 49 0.0 13 0.0 62 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 3.7 (1.9, 7.1) 959 3.9 (1.5, 10.0) 409 3.7 (2.1, 6.5) 1368


Total 6.2 (3.3, 11.2) 1010 5.9 (3.4, 10.2) 467 6.1 (4.0, 9.2) 1477

* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the day of the survey visit ** Flow diagram reference E


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3.3.3.2 Malaria microscopy

Table 3.3.12: Availability of malaria microscopy, [Nigeria], 2011

Outlets where malaria microscopic tests were available* (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit** (N), by location and type of outlet

Type of outlet

Urban Rural Total






Private for-profit health facility 41.0 (19.9, 66.1) 61 28.9 (9.7, 60.6) 29 35.2 (19.7, 54.6) 90 Pharmacy 6.3 (0.8, 35.9) 33 0.0 2 6.0 (0.8, 33.8) 35 Drug Store <0.02 794 0.0 359 0.0 1153 General retailer 0.0 49 0.0 13 0.0 62 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 2.7 (1.2, 6.0) 959 2.7 (0.9, 8.0) 409 2.7 (1.4, 5.1) 1368


Total 4.5 (2.1, 9.5) 1010 4.3 (2.3, 8.1) 467 4.5 (2.7, 7.4) 1477

* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the day of the survey visit ** Flow diagram reference E


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Table 3.3.13: Cost to patients of malaria microscopy in 2010 US dollars [Nigeria], 2011

Median cost to patients of one malaria diagnostic test with microscopy, by outlet type and patient age

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of outlets

reporting price of malaria

microscopy Median cost

[IQR]

Number of outlets


microscopy Median cost

[IQR]

Number of outlets


microscopy

Adults

Public health facility 1.18 [1.18, 7.09] 21 0.59 [0.30, 1.48] 8 1.18 [0.59, 1.77] 29 Private not for-profit health facility 1.77 [1.18, 1.77] 4 1.18 [1.18, 1.18] 2 1.18 [1.18, 1.77] 6 Private for-profit outlet

Private for-profit health facility 1.77 [1.18, 4.13] 28 1.77 [0.89, 3.54] 7 1.77 [1.18, 3.54] 35 Pharmacy 28.34 [n/a] 1 -- 0 28.34 [n/a] 1 Drug Store 2.36 [n/a] 1 -- 0 2.36 [n/a] 1 General retailer -- 0 -- 0 -- 0 Itinerant drug vendor -- 0 -- 0 -- 0 Total 1.77 [1.18, 4.13] 30 1.77 [0.89, 3.54] 7 1.77 [1.18, 3.54] 37


Children

Public health facility 1.18 [1.18, 7.09] 21 0.00 [0.00, 0.30] 8 1.18 [0.00, 1.77] 29 Private not for-profit health facility 1.77 [1.18, 1.77] 4 1.18 [1.18, 1.18] 2 1.18 [1.18, 1.77] 6 Private for-profit outlet

Private for-profit health facility 1.77 [1.18, 4.13] 28 1.18 [0.89, 3.54] 7 1.77 [1.18, 3.54] 35 Pharmacy 22.44 [n/a] 1 -- 0 22.44 [n/a] 1 Drug Store 2.36 [n/a] 1 -- 0 2.36 [n/a] 1 General retailer -- 0 -- 0 -- 0 Itinerant drug vendor -- 0 -- 0 -- 0 Total 1.77 [1.18, 4.13] 30 1.18 [0.89, 3.54] 7 1.77 [1.18, 3.54] 37



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3.3.3.3 Diagnostic test with rapid diagnostic tests

Table 3.3.14: Availability of rapid diagnostic tests for malaria, [Nigeria], 2011

Outlets where rapid diagnostic tests were available (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet

Urban Rural Total






Private for-profit health facility 10.3 (3.4, 27.6) 61 7.4 (1.3, 31.8) 29 8.9 (3.5, 20.7) 90 Pharmacy 6.3 (0.8, 35.9) 33 0.0 2 6.0 (0.8, 33.8) 35 Drug Store 0.7 (0.2, 2.1) 795 1.1 (0.2, 6.6) 359 0.8 (0.3, 2.5) 1154 General retailer 0.0 49 0.0 13 0.0 62 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 1.4 (0.6, 3.1) 960 1.6 (0.3, 9.0) 409 1.5 (0.6, 3.5) 1369


Total 2.7 (1.7, 4.5) 1011 2.2 (0.7, 6.8) 467 2.5 (1.5, 4.2) 1478

* Flow diagram reference E Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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Table 3.3.15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in US dollars [Nigeria], 2011

Median cost to patients of one rapid diagnostic test for malaria, by location, outlet type and patient age

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of

RDT products Median cost

[IQR]

Number of

RDT products Median cost

[IQR]

Number of

RDT products Adults


Private not for-profit health facility 1.77 [1.77, 1.77] 3 -- 0 1.77 [1.77, 1.77] 3


Private for-profit health facility 7.09 [7.09, 7.09] 7 1.77 [1.77, 2.36] 3 2.36 [1.77, 7.09] 10

Pharmacy 28.34 [n/a] 1 -- 0 28.34 [n/a] 1

Drug Store 0.59 [0.59, 0.89] 5 0.30 [0.30, 0.30] 3 0.30 [0.30, 0.59] 8

General retailer -- 0 -- 0 -- 0

Itinerant drug vendor -- 0 -- 0 -- 0

Total 1.77 [0.59, 7.09] 13 0.30 [0.30, 1.77] 6 0.89 [0.30, 2.36] 19

Community health worker -- 0 -- 0 -- 0

Total 1.18 [1.18, 1.77] 29 0.30 [0.30, 1.77] 12 1.18 [0.59, 1.77] 41

Children


Private not for-profit health facility 1.77 [1.77, 1.77] 3 -- 0 1.77 [1.77, 1.77] 3


Private for-profit health facility 7.09 [7.09, 7.09] 7 1.77 [1.77, 2.36] 3 2.36 [1.77, 7.09] 10

Pharmacy 22.44 [n/a] 1 -- 0 22.44 [n/a] 1

Drug Store 0.89 [0.89, 0.89] 4 0.30 [0.30, 0.30] 2 0.30 [0.30, 0.89] 6

General retailer -- 0 -- 0 -- 0

Itinerant drug vendor -- 0 -- 0 -- 0

Total 7.09 [0.89, 22.44] 12 0.89 [0.30, 1.77] 5 1.77 [0.41, 7.09] 17

Community health worker -- 0 -- 0 -- 0

Total 1.18 [1.18, 1.77] 28 0.30 [0.00, 1.77] 11 1.18 [0.30, 1.77] 39


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3.4 Quality-assured ACTs market share

Table 3.4.1: Percentage breakdown of antimalarial sales volumes by antimalarial type, [Nigeria], 2011

Indicator 4.1: Total number of AETDs of each antimalarial type sold or distributed in the week preceding the survey visit (n), as a percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Urban Rural Total

Percentage N Percentage N Percentage N

Public health facility Quality-assured ACTs 60.6 40.1 48.1 Non-quality-assured ACTs 8.1 7.2 7.6 Oral artemisinin monotherapy 1.5 0.3 0.8 Non-oral artemisinin monotherapy 1.9 7.4 5.3 Non-artemisinin therapy 27.8 45.0 38.3 Total 100.0 4700.3 100.0 1881.0 100.0 6581.2

Private not for-profit health facility

Quality-assured ACTs 39.2 49.4 40.3 Non-quality-assured ACTs 0.8 0.0 0.7 Oral artemisinin monotherapy 0.1 14.0 1.6 Non-oral artemisinin monotherapy 35.7 0.7 32.0 Non-artemisinin therapy 24.2 35.8 25.4 Total 100.0 350.8 100.0 35.9 100.0 386.7



Community health worker


All outlets

Quality-assured ACTs 19.0 22.9 20.1 Non-quality-assured ACTs 9.6 4.7 8.2 Oral artemisinin monotherapy 4.7 2.8 4.1 Non-oral artemisinin monotherapy 1.1 1.4 1.2 Non-artemisinin therapy 65.6 68.3 66.3

Total 100.0 58701.3 100.0 13283.4 100.0 71984.7


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Table 3.4.2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, [Nigeria], 2011

Indicator 4.1:Total number of AETDs of QAACTs sold or distributed in the week preceding the survey visit (n), as a percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any antimalarials in stock at the time of the survey visit (N), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, by location and type of outlet

Urban Rural Total


Public health facility All QAACTs 60.6 40.1 48.1 QAACTs with logo 24.6 8.2 14.6

QAACTs without logo 36.0 31.9 33.5

Total number of AETD sold 4700.3 1881.0 6581.2 Private not for-profit health facility

All QAACTs 39.2 49.4 40.3 QAACTs with logo 32.2 40.5 33.1 QAACTs without logo 7.0 9.0 7.2 Total number of AETD sold 350.8 35.9 386.7 Private for-profit outlet All QAACTs 17.1 19.7 17.8 QAACTs with logo 15.8 18.1 16.4 QAACTs without logo 1.3 1.6 1.4 Total number of AETD sold 53646.7 11332.8 64979.4 Community health worker All QAACTs 100.0 19.7 20.3 QAACTs with logo 100.0 1.3 2.0 QAACTs without logo 0.0 18.4 18.3 Total number of AETD sold 3.5 33.8 37.3 All outlets All QAACTs 19.0 22.9 20.1 QAACTs with logo 16.3 16.7 16.4 QAACTs without logo 2.7 6.3 3.7 Total number of AETD sold 58701.3 13283.4 71984.7


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Table 3.4.3: Percentage breakdown of antimalarial sales volumes by outlet type, [Nigeria], 2011

Total number of AETDs sold or distributed in the week preceding the survey visit by each outlet type (n), as a percentage of all antimalarial AETDs sold or distributed in the week preceding the survey visit by all outlets with any antimalarials in stock at the time of the survey visit (N), by location and antimalarial type

Urban Rural Total


Quality-assured ACTs Public health facilities 12.2 26.7 16.9 Private not for-profit health facilities 2.3 0.8 1.8 Private for-profit outlets 85.4 72.4 81.3 Community health workers 0.0 0.1 0.0 Total 100.0 11889.1 100.0 2901.8 100.0 14790.9


Public health facilities 3.2 23.6 6.5 Private not for-profit health facilities 0.1 0.0 0.1 Private for-profit outlets 96.7 76.4 93.4 Community health workers 0.0 0.0 0.0 Total 100.0 4589.7 100.0 896.1 100.0 5485.8

Oral artemisinin therapies Public health facilities 1.2 1.6 1.3 Private not for-profit health facilities 0.0 1.8 0.4 Private for-profit outlets 98.7 96.6 98.3 Community health workers 0.0 0.0 0.0 Total 100.0 2564.9 100.0 366.7 100.0 2931.6

Non-oral artemisinin therapies Public health facilities 6.9 82.7 32.1 Private not for-profit health facilities 37.6 0.2 25.2 Private for-profit outlets 55.4 17.1 42.7 Community health workers 0.0 0.0 0.0 Total 100.0 853.6 100.0 130.3 100.0 983.9

Non-artemisinin therapies Public health facilities 1.6 10.1 4.1 Private not for-profit health facilities 0.4 0.2 0.4 Private for-profit outlets 97.9 89.5 95.5 Community health workers 0.0 0.2 0.1 Total 100.0 38803.9 100.0 8988.5 100.0 47792.4

All antimalarials Public health facilities 3.8 15.3 7.1 Private not for-profit health facilities 1.1 0.4 0.9 Private for-profit outlets 95.0 84.2 92.0 Community health workers 0.0 0.2 0.0 Total 100.0 58701.3 100.0 13283.4 100.0 71984.7


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3.5 Provider knowledge of first-line antimalarial treatment and ACT regimen

Table 3.5.1: Provider knowledge of first-line antimalarial treatment, [Nigeria], 2011

Providers able to correctly identify the antimalarial for first-line treatment** (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit* (N), by location and type of outlet

Type of outlet

Urban Rural Total




Public health facility 99.0 (96.1, 99.8) 43 80.8 (64.9, 90.5) 52 86.7 (74.6, 93.5) 95 Private not for-profit health facility 100.0 6 93.1 (53.6, 99.4) 3 97.4 (81.1, 99.7) 9


Private for-profit health facility 74.3 (55.5, 87.1) 63 47.5 (31.8, 63.7) 29 61.9 (49.9, 72.5) 92

Pharmacy 84.5 (52.1, 96.5) 36 50.0 (50.0, 50.0) 2 83.4 (53.3, 95.7) 38 Drug Store 51.4 (39.6, 63.1) 804 50.7 (39.9, 61.5) 362 51.2 (42.9, 59.4) 1166 General retailer 39.0 (25.5, 54.5) 52 17.7 (4.1, 51.9) 13 32.8 (21.2, 46.9) 65 Itinerant drug vendor 0.8 (0.1, 10.5) 22 49.0 (8.6, 90.8) 6 8.2 (1.1, 42.9) 28 Total 52.3 (41.8, 62.5) 977 49.4 (39.4, 59.4) 412 51.2 (43.9, 58.4) 1389


Total 54.3 (43.8, 64.4) 1029 53.0 (43.2, 62.6) 471 53.8 (46.5, 60.9) 1500

* Flow diagram reference E ** The first-line treatment in Nigeria includes Artemether Lumefantrine and Artesunate Amodiaquine


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Table 3.5.2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult. [Nigeria], 2011 Providers able to correctly describe the dosing regimen for quality-assured ACTs for an adult (n) as a percentage of the number of outlets with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*

Type of outlet

Urban Rural Total




Public health facility 97.0 (90.0, 99.2) 32 74.9 (46.4, 91.2) 27 82.4 (60.7, 93.4) 59 Private not for-profit health facility 67.9 (14.7, 96.3) 4 93.1 (53.2, 99.4) 3 78.8 (33.4, 96.5) 7


Private for-profit health facility 92.3 (72.5, 98.2) 34 94.0 (72.1, 98.9) 11 92.8 (79.1, 97.7) 45 Pharmacy 100.0 31 50.0 (50.0, 50.0) 2 98.2 (86.5, 99.8) 33 Drug Store 82.1 (76.0, 87.0) 466 73.0 (60.0, 83.0) 193 78.6 (72.1, 83.9) 659 General retailer 60.0 (18.0, 91.1) 17 0.0 3 52.7 (17.6, 85.4) 20 Itinerant Health Worker 6.7 (0.9, 36.2) 4 -- 0 6.7 (0.9, 36.2) 4 Total 82.8 (77.7, 87.0) 552 73.6 (61.4, 83.0) 209 79.5 (73.8, 84.2) 761

Community health worker 33.3 (33.3, 33.3) 3 9.0 (0.6, 63.4) 2 10.2 (0.9, 59.9) 5

Total 83.1 (77.8, 87.4) 591 73.5 (62.0, 82.5) 241 79.4 (73.6, 84.2) 832

* “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number of times the medicine should be taken per day and the duration of the dose in number of days for a 60kg adult for a specific product which they selected from the QAACTs that they stocked.


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Table 3.5.3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child, [Nigeria], 2011

Providers able to correctly describe the dosing regimen for quality-assured ACT for a child (n) as a percentage of the number of outlets with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*

Type of outlet

Urban Rural Total





Private not for-profit health facility 100.0 5 93.1 (53.2, 99.4) 3 97.0 (78.7, 99.7) 8


Private for-profit health facility 38.7 (17.8, 64.8) 32 66.9 (34.7, 88.6) 11 46.2 (27.4, 66.3) 43 Pharmacy 78.4 (41.7, 94.8) 30 50.0 (50.0, 50.0) 2 77.4 (42.8, 94.0) 32 Drug Store 48.0 (37.1, 59.1) 460 61.2 (49.7, 71.5) 189 53.2 (44.3, 61.9) 649 General retailer 67.1 (20.7, 94.1) 16 100.0 3 71.2 (26.7, 94.4) 19 Itinerant drug vendor 2.6 (0.2, 24.1) 4 -- 0 2.6 (0.2, 24.1) 4 Total 49.0 (38.1, 60.0) 542 61.7 (50.7, 71.6) 205 53.6 (45.0, 62.1) 747


Total 50.5 (39.7, 61.2) 581 61.8 (51.3, 71.2) 239 54.9 (46.6, 62.9) 820

* “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number of times the medicine should be taken per day and the duration of the dose in number of days for child under 2 years (10kg) for a specific product which they selected from the QAACTs that they stocked.


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Table 3.5.4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Nigeria], 2011

Private for-profit providers stating a specific reason for why they were not stocking QAACTs (n) as a percentage of all private for-profit outlets* not stocking QAACTs at the time of the survey visit** (N), by location

Urban Rural Total

Reason Percentage

(95% CI) N Percentage


(95% CI) N

Too expensive 33.3 (27.1, 40.3) 402 36.9 (27.5, 47.4) 202 34.7 (29.5, 40.4) 604 Not profitable 4.8 (3.2, 7.2) 402 2.4 (0.9, 6.3) 202 3.9 (2.4, 6.1) 604 The outlet is not allowed to sell them 6.2 (3.5, 10.8) 402 3.0 (1.1, 8.0) 201 4.9 (3.1, 7.7) 603 They have too many side effects 1.5 (0.5, 4.1) 401 0.5 (0.1, 3.5) 202 1.1 (0.4, 2.8) 603 They do not work well 0.5 (0.1, 2.5) 402 0.1 (0.0, 0.8) 202 0.3 (0.1, 1.4) 604 They are not available/my suppliers do not have it in stock 15.5 (8.4, 26.8) 402 20.4 (14.3, 28.3) 201 17.4 (11.8, 24.9) 603 My customers do not ask for them 46.4 (40.0, 52.9) 401 29.0 (22.1, 37.0) 202 39.7 (33.7, 45.9) 603 I don’t know about these drugs 17.0 (10.0, 27.3) 402 15.0 (9.1, 23.7) 202 16.2 (11.3, 22.8) 604 I am temporarily out of stock 17.6 (9.7, 29.9) 402 17.1 (10.9, 25.9) 202 17.4 (11.7, 25.2) 604 Other 16.5 (10.3, 25.4) 400 16.5 (11.4, 23.2) 202 16.5 (12.0, 22.1) 602

* This indicator excludes responses from public-health facilities and CHW. ** Note that a provider could give more than one response to this question. Percentage may add to more than 100


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3.6 AMFm logo

Table 3.6.1: Provider recognition of AMFm logo, [Nigeria], 2011

Providers able to recognize the AMFm logo* (n) as a percentage of the number of outlets with antimalarials in stock at the time of the survey visit** (N), by location and type of outlet

Type of outlet

Urban Rural Total





Private not for-profit health facility 100.0 6 53.2 (7.3, 94.3) 3 82.4 (34.2, 97.7) 9


Private for-profit health facility 65.4 (47.0, 80.2) 63 58.7 (43.4, 72.6) 30 62.3 (50.5, 72.8) 93 Pharmacy 99.8 (98.0, 100.0) 36 100.0 2 99.8 (98.1, 100.0) 38 Drug Store 52.0 (38.4, 65.2) 807 52.0 (43.0, 61.0) 362 52.0 (43.0, 60.9) 1169 General retailer 43.3 (27.2, 61.0) 52 14.7 (4.2, 40.8) 13 35.0 (20.5, 52.8) 65 Itinerant drug vendor 19.9 (5.6, 51.2) 22 18.3 (3.1, 61.4) 6 19.7 (6.7, 45.4) 28 Total 53.3 (41.6, 64.7) 980 51.3 (42.7, 59.9) 413 52.6 (44.8, 60.3) 1393

Community health worker 33.3 (33.3, 33.3) 3 73.6 (21.4, 96.6) 4 72.0 (21.7, 96.0) 7

Total 54.1 (42.5, 65.2) 1032 50.8 (43.0, 58.5) 472 52.8 (45.4, 60.0) 1504

* All respondents were shown a visual aid depicting the AMFm logo and were asked whether they have seen the symbol before. A provider is “able to recognize the AMFm logo” if they answer that they have seen the symbol before. ** Flow diagram reference E.


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Table 3.6.2: Provider knowledge of the AMFm logo [Nigeria], 2011

Providers stating a specific meaning of the AMFm logo (n) as a percentage of outlets that recognized the AMFm logo (N), by location*

Meaning of AMFm logo

Urban Rural Total




Effective/quality antimalarial 20.8 (15.2, 27.7) 589 26.7 (19.4, 35.6) 234 23.0 (18.3, 28.6) 823 Affordable antimalarial 5.5 (3.7, 8.1) 589 3.4 (1.4, 7.7) 233 4.7 (3.3, 6.8) 822 An antimalarial in high demand 3.1 (1.6, 5.9) 589 2.8 (1.0, 7.2) 234 3.0 (1.7, 5.1) 823 Effective/quality medicine 4.3 (2.5, 7.2) 589 6.7 (4.0, 10.9) 234 5.2 (3.6, 7.5) 823 Affordable medicine 1.8 (0.6, 5.6) 589 1.3 (0.4, 3.6) 234 1.6 (0.7, 3.7) 823 A medicine in high demand 1.8 (0.8, 4.2) 589 0.1 (0.0, 1.0) 234 1.2 (0.5, 2.6) 823 It means nothing 3.1 (1.3, 7.1) 589 2.4 (0.9, 6.8) 234 2.9 (1.5, 5.4) 823 Artemisinin Combination Therapy (ACT) 33.3 (25.4, 42.4) 589 22.6 (15.4, 31.8) 233 29.3 (23.3, 36.0) 822 Recommended treatment 2.3 (0.8, 6.4) 588 4.6 (2.0, 10.2) 234 3.2 (1.6, 6.0) 822 Subsidized medicine 2.7 (1.1, 6.6) 589 1.2 (0.2, 5.8) 234 2.1 (1.0, 4.6) 823 I don’t know what it means -- 0 -- 0 -- 0 Other: Antimalarial 7.1 (2.4, 19.6) 589 3.9 (1.9, 8.1) 234 5.9 (2.6, 13.1) 823 Other: Herbal Medicine 3.0 (1.5, 5.6) 589 1.4 (0.4, 4.5) 234 2.4 (1.3, 4.2) 823 Other: Logo or Trademark 3.7 (2.2, 6.3) 589 2.2 (0.9, 5.0) 234 3.1 (2.0, 4.9) 823

* Note that providers could give more than one response to this question. Percentage may add to more than 100


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Table 3.6.3: Sources from which providers have seen or heard of the AMFm logo, [Nigeria], 2011

Providers stating a specific source where they have seen or heard of the AMFm logo (n) as a percentage of providers that recognized the AMFm logo (N), by location*

Urban Rural Total

Source Percentage



(95% CI) N

On malaria medicine packaging 57.7 (47.9, 67.0) 591 52.0 (45.6, 58.3) 234 55.6 (49.3, 61.7) 825 On medicine packaging 22.0 (15.0, 31.1) 591 23.1 (15.8, 32.5) 234 22.4 (17.1, 28.9) 825 On posters 12.0 (9.6, 14.8) 591 4.6 (2.1, 9.9) 234 9.2 (7.0, 12.1) 825 On billboards 3.6 (1.7, 7.5) 591 1.2 (0.5, 2.9) 234 2.7 (1.5, 5.0) 825 On TV/radio 23.7 (16.6, 32.7) 591 23.2 (15.7, 32.9) 234 23.5 (18.2, 29.9) 825 On a prescription 4.7 (2.2, 9.6) 591 2.5 (0.7, 8.0) 234 3.9 (2.1, 7.1) 825 In newspapers/magazines 4.8 (2.8, 8.3) 590 0.9 (0.2, 3.1) 234 3.3 (2.0, 5.6) 824 In pharmacies/ drug shops 15.1 (9.9, 22.5) 591 15.2 (10.1, 22.3) 234 15.2 (11.3, 20.1) 825 In private clinics 2.1 (0.9, 4.9) 590 3.4 (1.2, 9.3) 234 2.6 (1.4, 4.9) 824 In public health facilities 5.9 (4.1, 8.5) 591 11.6 (6.4, 20.2) 234 8.1 (5.6, 11.5) 825 In training 15.8 (12.4, 20.0) 591 14.9 (9.7, 22.4) 234 15.5 (12.4, 19.1) 825 From a supplier 1.0 (0.4, 2.6) 591 8.3 (5.1, 13.2) 234 3.7 (2.2, 6.1) 825 From a public event 1.5 (0.5, 4.0) 591 1.5 (0.4, 4.8) 234 1.5 (0.7, 3.1) 825 From a local leader 0.1 (0.0, 0.5) 591 0.0 234 0.0 825 From a friend/family member 1.9 (0.6, 6.4) 591 0.0 234 1.2 (0.3, 4.1) 825 On the internet 0.0 590 0.0 234 0.0 824 Don’t know 3.1 (1.5, 6.1) 591 1.2 (0.3, 5.1) 234 2.4 (1.2, 4.5) 825 Other: Meeting 0.2 (0.1, 0.5) 591 0.5 (0.1, 4.0) 234 0.3 (0.1, 1.2) 825 Other: T shirt 2.8 (1.2, 6.5) 591 1.3 (0.4, 3.8) 234 2.3 (1.1, 4.6) 825 Other: Other 0.6 (0.1, 3.8) 591 1.6 (0.3, 7.7) 234 1.0 (0.3, 3.3) 825



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Table 3.6.4: Percentage of antimalarials bearing the AMFm logo, [Nigeria], 2011

Antimalarials bearing the AMFm logo (n) as a percentage of all QAACTs and of all antimalarials audited (N), by location and type of outlet

Type of antimalarial

Urban Rural Total





Public health facility 70.7 (44.0, 88.1) 73 32.2 (12.4, 61.3) 65 43.8 (24.4, 65.2) 138 Private not for-profit health facility 60.9 (43.8, 75.7) 10 39.0 (14.0, 71.5) 6 52.2 (32.8, 70.9) 16 Private for-profit outlet 85.7 (80.5, 89.6) 1425 87.3 (80.6, 92.0) 530 86.3 (82.3, 89.5) 1955 Community health worker 100.0 6 16.6 (1.2, 77.2) 3 23.7 (2.6, 78.6) 9 Total 84.8 (79.7, 88.8) 1514 80.6 (71.5, 87.3) 604 83.1 (78.8, 86.7) 2118

All other antimalarials

Public health facility 0.0 133 0.0 138 0.0 271 Private not for-profit health facility 0.0 30 0.0 7 0.0 37 Private for-profit outlet 0.1 (0.0, 0.4) 8107 0.3 (0.1, 0.9) 2845 0.2 (0.1, 0.4) 10952 Community health worker -- 0 0.0 9 0.0 9 Total 0.1 (0.0, 0.4) 8270 0.2 (0.1, 0.8) 2999 0.2 (0.1, 0.4) 11269

Total 12.8 (10.7, 15.3) 9784 14.6 (11.3, 18.8) 3603 13.4 (11.5, 15.7) 13387


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Table 3.6.5: Provider knowledge of the AMFm program, [Nigeria], 2011

Providers who have heard of “a program that reduces the prices of antimalarial medicines known as ACTs” (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet

Urban Rural Total







Private for-profit health facility 51.7 (34.8, 68.1) 61 56.0 (31.7, 77.8) 29 53.8 (38.9, 68.0) 90 Pharmacy 59.1 (37.0, 78.0) 33 50.0 (50.0, 50.0) 2 58.8 (37.8, 77.0) 35 Drug Store 35.1 (24.1, 48.0) 793 33.6 (23.1, 46.0) 358 34.5 (26.5, 43.5) 1151 General retailer 20.1 (12.8, 30.2) 49 17.8 (4.9, 48.0) 13 19.4 (12.0, 30.0) 62 Itinerant drug vendor 18.8 (14.9, 23.5) 22 24.5 (6.3, 61.0) 6 19.7 (14.8, 25.8) 28 Total 35.8 (26.2, 46.8) 958 35.1 (24.4, 47.5) 408 35.6 (28.3, 43.6) 1366


Total 36.1 (26.8, 46.5) 1009 36.4 (26.1, 48.1) 465 36.2 (29.2, 43.8) 1474


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Table 3.6.6: Sources from which providers have seen or heard of AMFm [Nigeria], 2011

Providers stating a specific source where they have seen or heard of “a program that reduces the prices of antimalarial medicines known as ACTs” (n) as a percentage of providers that have heard of “a program that reduces the prices of antimalarial medicines known as ACTs” (N), by location*

Urban Rural Total

Source Percentage



(95% CI) N

On malaria medicine packaging 14.0 (7.7, 23.9) 397 21.3 (12.7, 33.5) 167 16.9 (11.6, 24.0) 564 On medicine packaging 3.0 (1.1, 8.0) 394 2.7 (1.1, 6.5) 164 2.9 (1.4, 5.7) 558 On posters 5.1 (3.1, 8.5) 394 4.1 (1.6, 10.3) 164 4.7 (3.0, 7.5) 558 On billboards 1.6 (0.5, 4.7) 394 0.2 (0.0, 1.3) 163 1.0 (0.4, 2.6) 557 On TV/radio 48.9 (37.4, 60.5) 394 67.8 (56.5, 77.3) 164 56.4 (47.8, 64.6) 558 On a prescription 2.3 (1.0, 5.4) 394 0.2 (0.0, 1.3) 164 1.5 (0.7, 3.2) 558 In newspapers/magazines 7.2 (4.7, 10.9) 394 1.0 (0.2, 4.3) 164 4.8 (2.9, 7.7) 558 In pharmacies/ drug shops 6.4 (4.1, 9.7) 394 4.3 (1.7, 10.4) 164 5.5 (3.7, 8.2) 558 In private clinics 4.0 (1.4, 10.5) 392 2.6 (0.6, 9.7) 163 3.4 (1.5, 7.5) 555 In public health facilities 10.2 (5.3, 18.5) 394 12.1 (7.4, 19.2) 164 10.9 (7.2, 16.2) 558 In training 37.6 (30.3, 45.5) 393 29.6 (21.8, 38.8) 164 34.4 (28.8, 40.5) 557 From a supplier 4.8 (2.2, 10.2) 394 5.5 (2.1, 13.6) 164 5.1 (2.8, 9.1) 558 From a public event 6.4 (3.2, 12.6) 393 4.1 (1.7, 9.7) 163 5.5 (3.2, 9.2) 556 From a local leader 1.0 (0.3, 3.4) 393 1.0 (0.3, 3.6) 164 1.0 (0.4, 2.5) 557 From a friend/family member 5.1 (3.1, 8.2) 393 3.2 (1.2, 8.4) 164 4.4 (2.8, 6.8) 557 SMS messages 0.0 393 0.0 164 0.0 557 On the internet 1.1 (0.3, 3.2) 392 0.0 162 0.6 (0.2, 2.1) 554 Don’t Know 2.0 (0.7, 6.0) 394 0.0 164 1.2 (0.4, 3.6) 558 Other: Meetings 16.6 (8.1, 31.0) 393 4.7 (1.9, 11.1) 163 11.9 (6.4, 21.0) 556 Other: Other 12.3 (4.8, 28.0) 394 3.4 (1.1, 10.0) 164 8.7 (3.9, 18.6) 558 Total



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Table 3.6.7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Nigeria], 2011

Providers stated that there is a RRP for antimalarials with the AMFm logo (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet

Urban Rural Total







Private for-profit health facility 9.3 (2.4, 29.8) 61 18.7 (7.7, 38.6) 29 13.8 (6.6, 26.8) 90 Pharmacy 45.1 (23.4, 68.8) 33 50.0 (50.0, 50.0) 2 45.3 (24.5, 67.9) 35 Drug Store 16.1 (12.0, 21.3) 797 15.0 (11.3, 19.7) 360 15.7 (12.8, 19.2) 1157 General retailer 1.5 (0.5, 5.0) 50 6.1 (1.0, 28.2) 13 2.9 (0.9, 9.2) 63 Itinerant drug vendor 0.5 (0.0, 6.9) 22 18.3 (3.1, 61.4) 6 3.2 (0.4, 24.2) 28 Total 15.7 (12.3, 19.7) 963 15.2 (11.5, 19.8) 410 15.5 (13.0, 18.4) 1373


Total 15.8 (12.3, 20.0) 1014 13.7 (10.5, 17.8) 469 15.0 (12.5, 17.9) 1483


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Table 3.6.8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Nigeria], 2011 Providers stated the correct RRP* for antimalarials with the AMFm logo (n) as a percentage of providers who responded that there was a RRP for antimalarials with the AMFm logo (N), by location and type of outlet

Type of outlet

Urban Rural Total




Public health facility 0.0 6 0.0 4 0.0 10

Private not for-profit health facility 0.0 2 0.0 1 0.0 3


Private for-profit health facility 0.0 8 17.9 (3.5, 57.0) 6 11.6 (2.0, 46.2) 14 Pharmacy 25.7 (3.8, 75.2) 15 0.0 1 24.7 (3.8, 73.0) 16 Drug Store 10.4 (4.9, 20.8) 160 11.6 (3.6, 31.6) 58 10.8 (5.7, 19.5) 218 General retailer 0.0 5 0.0 2 0.0 7 Itinerant drug vendor 0.0 1 0.0 1 0.0 2 Total 11.4 (5.1, 23.4) 189 12.0 (4.5, 28.4) 68 11.6 (6.4, 20.3) 257

Community health worker 0.0 1 -- 0 0.0 1

Total 10.8 (4.8, 22.7) 198 11.6 (4.3, 27.5) 73 11.1 (6.0, 19.6) 271

*Responses were considered correct if respondents stated 100 Naira or 75 Naira due to change in the RRP during data collection. 61 providers mentioned 120 Naira as the maximum RRP reflecting the use of this RRP by a previous ACT social marketing project. A response of 120 Naira was not counted as correct.


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Table 3.6.9: Providers who have received training on antimalarials with the AMFm logo, [Nigeria], 2011

Outlet where at least one staff member has received training on antimalarials with the AMFm logo (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet

Urban Rural Total







Private for-profit health facility 29.4 (13.9, 51.9) 61 12.9 (2.8, 43.1) 29 21.5 (10.9, 38.0) 90 Pharmacy 19.6 (4.4, 56.0) 33 50.0 (50.0, 50.0) 2 20.6 (5.3, 54.5) 35 Drug Store 15.5 (11.8, 20.1) 796 9.6 (6.3, 14.3) 360 13.2 (10.3, 16.8) 1156 General retailer 5.2 (1.3, 18.9) 50 11.0 (2.6, 36.2) 13 7.0 (2.7, 17.1) 63 Itinerant drug vendor 0.0 22 0.0 6 0.0 28 Total 15.7 (12.3, 19.8) 962 9.9 (6.3, 15.3) 410 13.5 (10.7, 16.9) 1372


Total 15.8 (12.1, 20.2) 1014 11.4 (7.8, 16.3) 468 14.0 (11.2, 17.4) 1482


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AMFm implementation: process and key contextual factors

4.1 Introduction

In order to document the implementation process of AMFm (supply of copaid ACTs and supporting

interventions) and contextual factors that may influence the effectiveness of AMFm, the

Independent Evaluation team collected data in each AMFm pilot, using key informant interviews

(KII), a structured questionnaire on supporting interventions, and document review. These data

were collected to facilitate an assessment of (1) whether any improvement observed in AMFm

indicators between baseline and endline is likely to be due to AMFm and (2) whether a lack of

improvement in indicators can be reasonably attributed to a failure of AMFm. The methods and

findings for this activity in Nigeria are summarised below.

4.2 Methods

Three types of key informants were included in interviews: those centrally involved in AMFm

implementation, antimalarial importers, and other stakeholders who were knowledgeable about the

AMFm process or other key contextual factors. A total of 40 interviews were conducted from

November 2011 to January 2012. Oral consent was obtained for all interviews, and participants were

assured of confidentiality and given the option of whether they wanted their interviews to be

recorded. Notes were taken during all interviews. Interviewers used a semi-structured interview

guide that covered AMFm governance, registration of first-line buyers, ordering and distribution of

copaid drugs, supporting interventions (e.g., communications, training, regulation and

recommended retail prices), diagnostics, and key contextual events (e.g., weather anomalies,

economic and political factors, changes in other malaria control activities and changes in the health

system more broadly). Using the agreed template, the information from each interview was then

broken into the appropriate reporting categories, and findings across interviews were synthesized. In

addition, a form for quantifying supporting interventions was sent to the relevant authorities for

completion. Finally, key documents were reviewed such as policy documents, briefing documents

and reports prepared by CHAI, Global Fund grant documents, preliminary findings of research

studies, data on first-line buyer orders, and communication materials.

4.3 Findings

4.3.1 AMFm intervention process

4.3.1.1 Governance structure for AMFm

The main governance structure established for AMFm in Nigeria is the AMFm Task Force. The

activities of the Task Force are operationalized through the administrative functions of the AMFm

Secretariat. The AMFm Task Force was set up by the Country Coordinating Mechanism (CCM) and

has 15 members from the public sector, the private sector, national and international non-

governmental organizations (NGO), and the United Nations (UN). The Task Force was originally

chaired by the Clinton Health Access Initiative (CHAI) and was later chaired by the National Malaria

Control Program (NMCP). The AMFm Secretariat is the desk office for the hands-on administration of

AMFm. Presently, the AMFm focal persons from the two Principal Recipients are jointly

administering the Secretariat, which is domiciled within the NMCP, with technical assistance from

CHAI.

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4.3.1.2 AMFm copaid ACT supply mechanism

The increasing availability of ACTs in the national supply chain in the public and private sectors in

Nigeria was facilitated by the rapid expansion of the number of importers of quality-assured ACTs.

Timely advocacy surrounding the launching of AMFm has helped to secure buy-in and mobilization

of the private sector for AMFm (especially among local manufacturers) and has helped to reduce

resistance from importers and manufacturers. Following the development of criteria and structures

for the engagement of AMFm First-Line Buyers (FLBs), Nigeria registered 54 FLBs (one in the public

sector, two in the private not-for-profit sector, and 51 in the private-for-profit sector), of whom 28

had placed orders at the time the case study was being conducted. The participation of a large

number of FLBs in Nigeria has resulted in a sizeable importation drive, such that Nigeria accounts for

about 40% of global copaid ACTs delivered. Six pre-qualified international manufacturers have

supplied copaid ACTs to Nigeria, since Nigeria does not have any domestic manufacturers that are

pre-qualified. Despite the substantial participation of the private sector, the non-qualification of

domestic manufacturers for AMFm, which was the fulcrum for concerted agitation against AMFm at

its onset, makes it difficult to guarantee their sustained acquiescence.

Ordering and delivery of AMFm copaid ACTs

The National Malaria Control Program places orders through the Voluntary Pooled Procurement

(VPP) system, whereas the private sector Sub-Recipient (SFH) and FLBs place individual orders

directly with the manufacturers. Through the end of December 2011, a total of 78 million treatments

had been ordered in Nigeria, out of which about 39 million had been delivered.

A key challenge for product ordering in the public sector was the late approval of Procurement

Supply Management (PSM) plans, arising from unfulfilled Condition Precedent (CP) requirements, as

well as training delays in rolling out the Logistics Management Information System (LMIS). The

termination of the Global Fund Round 8 malaria grant to the Yakubu Gowon Centre (YGC) and the

subsequent delay of the release of funds contributed to a delay in the procurement of ACTs, which

had an adverse effect on the supply of copaid ACTs to the public sector. The challenges in the private

sector have mainly been linked to delays in the approval of orders. The long lead times and

uncertain processes for final approval of copaid ACT orders have led to a sluggish national ACT

supply chain and back orders, creating difficulties for achieving increases in the availability and

market share of copaid ACTs. This problem was sometimes aggravated by the skewed distribution of

the limited available stock to the major urban hubs, contributing to sub-optimal access to ACTs in

rural areas.

Clearing customs of AMFm Phase 1 copaid ACTs

Clearing of goods through customs for all players (the NMCP, private not-for-profit (SFH), and private

FLBs) was facilitated through waivers from the Federal Ministry of Finance and the National Agency

for Food and Drug Administration and Control (NAFDAC). While the clearing of copaid ACTs for

public-sector consignees has always been expedited, the private-for-profit sector FLBs have

sometimes experienced bottlenecks in the customs clearing process at the ports. Some FLBs have

had to pay demurrage costs, with a few opting to pay tax on the subsidized import price to avoid the

eventuality of demurrage. Demurrage payments and unexpected/unofficial clearing costs have

resulted in some affected importers increasing the price of copaid ACTs to cut their losses, which

makes it more difficult to achieve the goal of affordability.

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Distribution of AMFm Phase 1 copaid ACTs

The distribution mechanism for copaid ACTs varies by the type of outlet. In the public sector, the

manufacturer delivers copaid ACTs directly to the State Stores (through the 3rd Party Logistics

Providers) for further distribution to the health facilities by the Sub-Recipients (SRs) to the NMCP.

Proprietary Patent Medicine Vendors (PPMVs) are the cornerstone of the private sector distribution

system through the private sector SR (SFH). From SFH warehouses, copaid ACTs are distributed to

wholesalers or SRs, who deliver the drugs to the facilities. In the private for-profit sector, distribution

of copaid ACTs by private sector first-line buyers is based on existing distribution networks and

mechanisms since this was a condition of registration as an importer (First-Line Buyer). Copaid ACTs

are distributed through wholesalers/distributors who sell to pharmacists, PPMVs and finally

consumers, as well as through medical representatives, who sell copaid ACTs directly, along with

their normal consignments sold to hospitals, pharmacists and PPMVs. However, the tardy and

inadequate supply of copaid ACT orders has led to complications in the supply chain, whereby

distribution and availability become inadequate and retail costs are sometimes subject to increase

by the retailers, with possible decreased affordability.

4.3.2 Implementation of AMFm supporting intervention

4.3.2.1 Communication

The AMFm Task Force has spearheaded the buy-in and mobilization of the private sector for

participation in AMFm, as well as clarifying implementation modalities. The strong support of the

AMFm Task Force and the AMFm Secretariat has sustained public and private sector interest, while

strong advocacy and interventions in the public and private sectors have created an enabling

environment for the FLBs and have been an asset on which to build sustained imports of ACTs into

the country. The AMFm Secretariat has organized stakeholders’ meetings with the public and private

sectors, and has maintained a functional interface with AMFm stakeholders, particularly with First-

Line Buyers. The Clinton Health Access Initiative (CHAI) has supported AMFm with technical

expertise, starting even before the grant signing.

There was a successful national launch of AMFm on March 31, 2011, which sensitized the public and

private sectors alike to AMFm. However, the country has not yet carried out any sub-national

launches, although sectoral launches have been organized for the public sector, professional

associations and faith-based organizations (FBO).

The official rollout of major information, education and communication (IEC) and behavior change

communication (BCC) activities was delayed until June 2011. However, some key IEC/BCC activities

were started in both the public and private sectors. These activities included advocacy visits to

policymakers at the State and Local Government Area (LGA) levels, community dramas, road shows,

television advertisements, radio jingles, the erection of billboards and other activities. The road

shows, especially by the key AMFm implementers (the PRs, along with their SRs), have likely

contributed to increased use of copaid ACTs through key messages that emphasize the use of quality

ACTs for malaria treatment. Community mobilization has promoted community uptake of copaid

ACTs, as well as their proper use and price, thus creating a demand for ACTs and likely increasing

their market share. Contributions by development partners working in the field of malaria have

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helped to promote a unitary message against monotherapy use, which could have led to an increase

in the use of copaid ACTs and their market share. However, delays in rolling out the BCC supporting

intervention may have limited the demand for copaid ACTs and might also have contributed to

sustained high prices, particularly in the private sector.

4.3.2.2 Recommended Retail Price

Pricing of AMFm ACTs has been regulated by a participatory process to set the recommended

maximum national retail prices and to create a good environment for lowering the price of ACTs. The

setting up of a national pricing structure for the recommended maximum retail prices was seen as

key to achieving a steep decrease in the price of ACTs across all sectors and levels of care (even for

ACTs that are not copaid), as well as increased use of ACTs. The participatory and methodical setting

of prices for each level of the distribution chain has contributed to the increased affordability of

ACTs. The recommended retail price was initially 75 naira (USD 0.44) and then raised to 100 naira

(USD 0.59) and was not shown on the drug packaging at the time of the case study. Price

enforcement plans are in motion, and consultations are ongoing with regulatory bodies in Nigeria

such as the Consumer Protection Council (CPC) and the Pharmacists Council of Nigeria (PCN).

However, there have been some pockets of resistance to the approved price, leading to some

measure of non-compliance. In addition, the frequent stockouts of some weight bands of ACTs

sometimes results in the sale of multiple packs of a smaller weight band in lieu of the unavailable

drugs for the correct weight band.

Furthermore, decreasing motivation of PPMVs and other retailers to stock and sell copaid ACTs due

to low price margin and low volume of stock available for sale may have presented a challenge to

achieving increases in the market share, affordability and use. The preference for operators of high-

end facilities not to stock copaid ACTs because of the low approved price in relation to the high

overheads may have led to limited availability of copaid ACTs in those facilities and a concomitant

higher market share of non-subsidized ACTs and monotherapies.

4.3.2.3 Training

Diverse training activities have been held in both the public and private sectors across various cadres

and levels of health staff to improve the knowledge of providers and to ensure the correct use of the

medicines and commodities distributed. The rollout of the LMIS system has commenced, but the

Health Facility (HF) training did not start as planned, except in the seven World Bank supported

states. The training plan for health facilities was designed as On the Job Training (OJT), but it was

discovered that OJT would take considerably more time and incur more expense than originally

planned. John Snow, Inc. (JSI) and the Support to Nigeria Malaria Program (SuNMaP) subsequently

conducted training in 7 states each. Without the training in all states, the LMIS system cannot be

fully rolled out.

4.3.2.4 Other AMFm supporting interventions

Regulatory interventions

NAFDAC has demonstrated its regulatory readiness for AMFm by granting over-the-counter (OTC)

status to ACTs, which enabled increased availability of ACTs, and by providing multiple waivers for

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AMFm, including the liberalization of the 1:1 import franchise policy and reductions in the cost of

analysis of AMFm products. The 1:1 policy had stipulated that only the company that registers a

medicine has the permission to import it to the country (that is, One Product – One Company). The

liberalization of the policy permitted other FLBs to import the medicine. These regulatory actions

may have helped promote availability, market share and affordability of copaid ACTs through the

combined import volume of about 28 importing FLBs and a reduction in clearing costs. However, the

impact of the OTC status of copaid ACTs has been limited by gaps in the supply of orders. Prior to

AMFm, NAFDAC had reclassified chloroquine as a treatment for conditions other than malaria. The

reclassification of chloroquine could have provided the supply sector with the leeway to

continuously manufacture and import chloroquine, thus contributing to maintaining a high level of

stock of chloroquine in circulation and possibly leading to a limited market share for copaid ACTs.

Malaria diagnosis

In 2011, the malaria treatment guidelines were revised to stipulate that malaria should be diagnosed

with a laboratory test or with a rapid diagnostic test (RDT) before providing antimalarial treatment

for persons of all ages, including children. A pilot program to introduce RDTs has commenced in 12

states—six in the north (implemented by the NMCP) and six in the south (implemented by SFH).

Activities to train primary health workers and private health providers on the use of RDTs and to

increase the supply of RDTs (although limited in scope and quantity) should lead to greater rational

use of ACTs.

Pharmacovigilance

Pharmacovigilance training and sensitization has commenced, with an explicit structure set for

national cross-sectoral interventions, as the feedback system is being strengthened for reporting and

processing Adverse Drug Reactions (ADRs). Capacity building for pharmacovigilance and the

development of Cohort Event Monitoring (CEM) aimed to give health care providers the necessary

tools to advance the use of ACTs, thus potentially increasing confidence in their rational use and

minimizing the possibility of widespread disenchantment with ACTs in the event of suspected

adverse reactions. However, the system for collecting pharmacovigilance feedback (through ADR

forms) is still developing, so the maximum benefits have yet to be realized.

Research

The AMFm program, within the context of malaria control programming, and in consonance with

other RBM stakeholders, is keeping pace with relevant research of a wide scope as well as focused

Operational Research (OR). However, there is a need for research projects to be more widely

disseminated and archived, especially as research activities related to the objectives of AMFm are

ongoing in the public and private sector and across different line agencies and development

partners.

Interventions focused on poor and vulnerable populations

There is a renewed drive to train Role Model Care Givers (RMCG) on the management of malaria

(including using RDTs for malaria diagnosis and dispensing ACTs) for poor and vulnerable populations

(children under five years and pregnant women). This strategy is aimed at increasing access to ACTs,

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use of ACTs, and ACT affordability in settings where RMCGs are operating. However, the supply gap

of ACTs has prevented the program from reaching its full potential and thus from having the

expected impact. Interventions from partners such as the World Bank, community directed

distribution by PPMVs, and community directed information by organizations such as NIFAA are

jumpstarting ACT access for poor and vulnerable populations.

Monitoring and evaluation

The monitoring of public and private sector implementation by the AMFm PRs and SRs is ongoing

and covering key areas. However, information obtained on implementation has not yet been

optimally coordinated between the public and private sectors into one national system.

4.3.2.5 Implementation of non-AMFm supporting interventions

Various malaria control interventions have been carried out in Nigeria from October 2010 to

December 2011. The Nigerian government, through allocations to the health sector from the

Millennium Development Goals Fund provided LLINs for five states at a cost of $46.7 million and

RDTs worth $1.9 million. Interventions carried out with funds from the Global Fund and other

malaria control partners include the procurement and distribution of ACTs with Rd 8 Global Fund

funds in both the public and private sector, as well as by the World Bank, USAID, UNICEF, SuNMaP,

and other partners. These interventions include the procurement and distribution of RDTs, LLINs,

indoor residual spraying (IRS), and larviciding in two states (Lagos and Rivers), as well as ongoing BCC

activities in both the public and private sectors.

Others interventions include training and implementation of Home Management of Malaria (HMM),

general health system strengthening (including laboratory services for diagnosis) and the training of

lower health care cadres in the use of rapid diagnostic test kits.

ACTs have been included in the Essential Medicine List (5th Revision, 2010), while chloroquine

tablets, syrups and injections have been expunged, providing a basis for providers to use and claim

ACTs for primary care and initiatives to mop-up chloroquine formulations from health facilities.

4.3.3 Key events and context

There are promising developments in the health care delivery system, such as the Midwives Service

Scheme, the National Strategic Development Health Plan, and the Community Insurance trust of the

National Health Insurance Scheme (NHIS). However, the impact of these programs on health care,

and ACT availability, access and use, are yet to be evaluated.

The termination of the Global Fund Round 8 grant with PR Yakubu Gowon Centre (YGC) in October

2011, preceded by months of non-disbursement, is a major contextual influence in the availability,

access, and use of ACTs in the public sector. There have also been specific strikes in the health

sector, which could decrease the use of ACTs because of the likely resort to self medication with any

medicine, including monotherapies. The increased threat to national security caused by activities of

the Boko Haram movement could have indirect effects on the transporting and availability of copaid

ACTs to affected areas, particularly rural areas, resulting in general blockages to program

implementation.

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4.3.4 Conclusion

Table 4.5.1 summarizes key factors likely to have supported or hindered achievement of AMFm goals

in Nigeria and Figure 4.5.1 presents a timeline of all key events related to AMFm implementation

and context.

The signing of the AMFm grant agreement with the Global Fund and the commencement of its

implementation has heralded new hope for Nigeria’s populace, whose national malaria burden

influences a large proportion of the global burden of malaria. The commitment to the AMFm project

has been demonstrated by the achievements made ahead of the signing of the grant agreement,

such as major regulatory changes and advocacy aimed at critical public and private sector

stakeholders. The implementation timeline (from inception in October 2010 to the present)

demonstrates notable achievements as well as substantial program and contextual challenges.

The reactions to AMFm have evolved from initial skepticism, to cautious embrace, and ultimately to

vigorous involvement by the private sector in particular. There has been participation from a diverse

group of stakeholders in the public and private sectors, as well as development partners, civil society

and faith-based organizations. Communities have also felt the impact of BCC activities to support the

greater use of ACTs, albeit to a limited extent. Despite the less than adequate delivery and

distribution of ACTs as per orders made, key informants observe that AMFm has triggered a

substantial decrease in prices, with attendant gains in affordability, market share, and use, as the

supply of copaid ACTs has increased.

An added benefit of the AMFm program is that the National Malaria Control Program and

development partners in Nigeria have expanded the original scope of their malaria interventions

through savings made on ACT purchases through AMFm, and they have been able to add

opportunities across all tiers of health care through the supporting interventions, which include

capacity development, BCC, malaria diagnosis and pharmacovigilance.

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Table 4.3.1: Summary of key factors likely to have supported or hindered achievement of AMFm goals in Nigeria Factors likely to have supported achievement of AMFm

goals

Factors likely to have hindered achievement of AMFm

goals

Procurement of ACTs with Global Fund Round 8,

AMFm, World Bank, and DFID/SuNMaP Funds

Liberalization of 1:1 Marketing Franchise Policy:

there are now 54 FLBs on AMFm

National AMFm pricing structure

Reduction of costs of NAFDAC analysis

Waiver of ports’ duties

Facilitation of clearing customs by AMFm

AMFm Launch - national and sectoral

Effects of NAFDAC regulation of ACTs as OTC

PPMVs well sensitized

Procurement of ACTs by funding streams

IEC/BCC on the ACT policy and AMFm

“WHO Bans Monotherapies” media parley

Wide distribution networks for ACTs

Inclusion of ACTs in 2010 EDL (Health Facilities and

National Health Insurance Scheme)

Buy-in of health professionals into AMFm

Training of health care providers across cadres and

sectors

Sensitization/training of CSOs and FBOs

BCC activities by PRs, public and private sectors

BCC activities by CSOs, FBOs

Media report on ban on monotherapies and on

inclusion of ACTs in 2010 EDL 5th

version

Home Management of Malaria activities

Implementation of the National Strategic Health

Development Plan (NSHDP)

Introduction of Social Health Insurance Programs

(SHIP)

Termination of Global Fund Round 8 grant to

YGC

Delayed approval of ACT orders to FLBs

Inadequate supply of ACTs

Unstable supply of ACTs

Demurrages with customs clearing

High transport costs to rural areas

High overheads in urban/ secondary care

settings

MOU on price ONLY with FLBs

Inadequate ACT supply pipelines

Inadequate distribution of ACTs to rural areas

Re-indication of chloroquine

Interrupted ACT supplies nationally

Availability of chloroquine in market

Late/inadequate rollout of BCC

Occasional strikes by health workers

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Figure 4.3.1: Timeline of key events related to the AMFm implementation process and context in Nigeria

2009 2010 2011 2012

Activity Aug Sep Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan

Baseline outlet survey – ACTwatch

CHAI: Radio hypes on AMFm

NAFDAC: Approval to bring in Coartem under AMFm for 2 Principal

Recipients: SFH/YGC

NMCP: No Objection Letter obtained for AMFm FLBs

AMFm Grant signed

GF funds accessed

FMoH: Inclusion of ACTs on the EDL

FMoH: Exclusion of chloroquine from EDL

Acquisition of an all duty/taxes waiver from FMoF

Media launch of AMFm

Development and airing of PV jingles targeting public

CHAI: Soft launch/media parley/mass media campaign/National Tease

Campaign

SFH: Malaria case mgt training for PPMVs/senior HCP-private for-

profit/CSOs-private for-profit/quant/forecasting training for PPMVs/TOT

workshop on PV for doctors/pharm/record keeping (M&E) for PPMVs

Ongoing Task Force meetings with FLBs

SFH: Review of training manual and raining content / training of senior HCP

on PV ADRs/reporting

AMFm national launch

NMCP: Advocacy to policymakers at state/LGAS, community

opinion//traditional/religious leaders

NMCP: TV Advertisements/radio jingles/spots/community drama/road

shows - North and South Nigeria

National sensitization meeting with women groups

AMFm Secretariat: advocacy to FMoF/agencies on custom clearance

Meeting with FLBs on PSM reporting tool

NMCP: Training on malaria management for senior HCP

NMCP: Malaria quant/forecasting for states

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2009 2010 2011 2012


SFH: Development and printing of training manual, training on PV for

Community Health Extension Workers and Community Health Officers,

training on PV for doctors, pharmacists, nurses, lab techs

NMCP: RDTs store assessment in 6 states/repairs

SFH: BCC rolled out

NMCP: Training of PHC H/HWs on RDTs refresher training for HW on RDTs

AMFm public sector sensitization

NAFDAC: Capacity building on research

AMFm Presentations at ACPN conference

NMCP: Distribution of RDTs to HFs -Kaduna/Nasarawa

Pharmacovigilance: Development and printing of posters, fliers/handbills

on ADRs

Pharmacovigilance: Distribution of posters, fliers/ handbills on ADRs

NMCP: Malaria case management. Training for senior HCP

NMCP: Lab diagnosis/RDTs-CNOs, lab techs CHEWS

NMCP: Supervision/retrieval of RDT data from HFs

NAFDAC: PV: Development, printing of CEM materials/refresher training for

13 institutions

AMFm Presentations at NMA conference

NMCP: Erection of billboards

NAFDAC: Training of NAFDAC - minilab test kits

PV: Development of PV pins and distribution

NMCP: Training of CSOs on case management

Endline IE outlet survey data collection

SFH: TOT on PV for HCs - public and private

AMFm Secretariat: Pricing consultations with CPC and PCN

SFH: Review/finalization of PPMV manual with PCN

NMCP: National refresher TOT for RMCGs

Pharmacovigilance: Development/printing of Cohort Event (CEM)program

materials for 18 institutions

PV-Development and airing of PV jingles - general public

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2009 2010 2011 2012


Advocacy to the Hon. Minister of Health and DG NAFDAC to

postpone/waive the policy on Text Message Authentification System

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Summary of findings

5.1 Quality of data collected

During data collection quality control (QC) persons travelled with the field teams and visited a

sample of the outlets visited by the data collectors. The QCs went to 5%of outlets which met the

screening criteria and 5% which did not. They asked basic background questions to the outlet

attendants, and audited a selection of drugs present. Data were reviewed with supervisors on a daily

basis. Completed questionnaires were also reviewed by the supervisors, by exporting data to Excel at

the end of the day. Any issues were fed back to field teams, which minimised problems that arose in

the field. In addition, regular communication with ACTWatch Central ensured that problems could

be resolved quickly when issues arose in the field.

No major issues appeared during data cleaning or analysis.

5.2 Availability of quality-assured ACTs

Among facilities that stocked antimalarials at any time in the three months preceding the survey,

overall QAACT availability in 2011 was 54%. There was no difference in availability between urban

and rural areas at endline. However, there was considerable variation within the private for-profit

sector, in which availability was 53%. QAACT availability was much higher in pharmacies (99%) than

in drug stores (54%) or private for-profit facilities (51%). In public health facilities that stocked

antimalarials at any time in the three months preceding the survey, QAACT availability was 57%.

QAACT availability was higher among community health workers (CHWs) (82%).

Forty-seven percent of all outlets stocked QAACTs with the AMFm logo at endline, but a relatively

high proportion of outlets stocked QAACTs without the logo (38% of public health facilities and 14%

of private for-profit health facilities). It should be noted that Nigeria has several nationally-approved

ACTs that are included in the non-quality-assured category.

Availability of nAT remained very high at endline (97% in all outlets). Oral AMT was available in

99.5% of pharmacies, 18% of private for-profit outlets, 19% of general retailers and 15% of public

health facilities.

5.3 Pricing/affordability of quality-assured ACTs

Among all outlets, the median QAACT price per AETD is USD 1.48. In public health facilities, the

median price of QAACTs is USD 0.00, indicating the policy of free ACTs in those facilities.

In private for-profit outlets, the median price of QAACTs is USD 1.48. The median price of QAACTs

with the AMFm logo is USD 1.48, where as the median price of QAACTs without the AMFm logo is

USD 2.95 (data not shown).

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The ratio of the median price of QAACTs with the AMFm logo to that of the most popular

antimalarial is 3.1. QAACTs with the AMFm logo were being sold on average for 2.4 times more than

the recommended retail price for an adult dose, which was set at USD 0.59.

In private for-profit outlets, the median price of oral AMT is USD 2.83.

5.4 Market share of quality-assured ACTs

Measured across all outlets, the market share of QAACTs is 20%. The QAACT share is largest in public

health facilities (48%), followed by private not for profit facilities (40%). QAACT market share in the

private for profit sector is 18%.

The share of non-quality-assured QAACTs is 8% in all outlets.

Market share of nATs in all outlets is 66.3%, and is highest among community health workers (80%)

followed by the private for-profit sector (69%).

Measured across all outlets, the market share of oral AMT is 4.1%, and greatest in pharmacies (9%)

and the private sector generally (8.4%).

The private sector accounted for over 90% of all antimalarials distributed.

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Page 122

References ACTwatch Group, SFH/Nigeria and the Independent Evaluation Team. (2009). Outlet Survey

Report 2009 for the Baseline Independent Evaluation of the Affordable Medicines

Facility (AMFm), Nigeria, ACTwatch/SFH/PSI. www.actwatch.info

Adeyi, O. and Atun, R. (2010). "Universal access to malaria medicines: innovation in

financing and delivery," Lancet 376 (9755): 1869-1871.

Arrow, K., Panosian, C.B. and Gellband H. (2004). Saving Lives, Buying Time: Economics

of malaria drugs in an age of resistance, National Academies Press, Washington, DC.

Craig, P., Dieppe P. et al. (2008). Developing and evaluating complex interventions: new

guidance, Medical Research Council,<www.mrc.ac.uk/complexinterventionsguidance>. de

Savigny, D. and

Adam T., eds. (2009). Systems thinking for health systems strengthening, Alliance for Health

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Federal Ministry of Health, (2004a). Revised national health policy, Abuja.

Federal Ministry of Health, National Malaria Control Program, (2004b). National

Antimalarial Treatment Policy, Abuja.

Federal Ministry of Healtha, National Malaria Control Program, (2005). National

Antimalarial Treatment Guidelines, Abuja.

Federal Ministry of Healthb, , (2006). National child health policy (draft), Abuja.

Federal Ministry of Health, , (2008). Monitoring and Evaluation plan for Malaria control

in Nigeria,Abuja.

Federal Ministry of Health, , (2009). National Malaria Control Program Strategic Plan

2009-2013, Abuja.

Federal Ministry of Health(2009). Malaria Strategic Plan 2009-2013: A Road Map for

Malaria Control in Nigeria. Federal Ministry of Health, National Malaria Control

Program. Abuja.

Global Fund to Fight AIDS, Tuberculosis and Malaria (2010). Global Fund Quality

Assurance Policy for Pharmaceutical

Products<http://www.theglobalfund.org/documents/psm/PSM_QAPharm_Policy_en.p

df>, Geneva.

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Habicht, J.P., Victora C.G., et al. (1999). "Evaluation designs for adequacy, plausibility

and probability of public health program performance and impact," International

Journal of Epidemiology 28: 10-18.

Independent Evaluation Team (2011). Independent Evaluation of Phase 1 of the

Affordable Medicines Facility - malaria (AMFm) Multi-Country Independent

Evaluation Report.

International Monetary Fund, (2011). World Economic Outlook Database,

<http://www.imf.org/external/pubs/ft/weo/2011/01/weodata/index.aspx>.

Kleinschmidt, I., et al., (2001). "An empirical malaria distribution map for West Africa,"

Tropical Medicine and International Health 6: 779-786. Map available online at

<http://www.mara.org.za>.

Malaria Taxes and Tariffs Advocacy Project, (2010). Current Status of Tariffs on

Antimalarial Commodities, accessed 16 March 2011, <http://www.m-tap.org>.

National Population Commission, and ICF Macro, (2004). Nigeria Demographic and

Health Survey 2003, Abuja, Nigeria.

National Population Commission, Nigeria and ICF Macro, (2009). Nigeria Demographic

and Health Survey 2008, Abuja, Nigeria.

National Primary Healthcare Development Agency, Nigeria, (2007). Health Facilities

Survey.

Okeke, T.A., Uzochukwu, B.S.C., Okafor, H.U., (2006). : An in-depth study of patent

medicine sellers’ perspectives on malaria in a rural Nigerian community," Malaria

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Oladepo, O., et al., (2008). "Malaria treatment in Nigeria: the role of patent medicine

vendors, “Future Health Systems Nigeria, Policy Brief 1,

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Onwujekwe, O., Chima, R., Okonkwo, P., (2000). "Economic burden of malaria illness

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Onwujekwe, O., Ojukwu, J., Uzochukwu, B., Dike, N., Shu, E., (2005). "Where do people

from different socio-economic groups receive diagnosis and treatment for malaria in

southeast Nigeria, Annals of Tropical Medicine and Parasitology, 99(5): 473–81.

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President’s Malaria Initiative, (2010). FY 2011 Malaria Operation Plan: Nigeria,

accessed 16 March 2011, <www.pmi.gov/countries/mops/fy11/nigeria_mop-fy11.pdf>.

Roll Back Malaria, (2008). The Global Malaria Action Plan,

<http://www.rollbackmalaria.org/gmap/>.

Ross-Degnan, D., et al.,(1996). "The impact of face-to-face educational outreach on

diarrhea treatment in pharmacies," Health Policy Planning11:308-318.

Sabot, O.J., et al.,(2009). "Piloting the global subsidy: The impact of subsidized

artemisinin-based combination therapies distributed through private drug shops in

rural Tanzania," PLoS ONE 4(9): e6857.

Shewchuk, T., O'Connell, K. A. et al. (2011). "The ACTwatch project: methods to describe

anti-malarial markets in seven countries," Malar J10: 325.

Uzochukwu, B.S.C. and Onwujekwe, O.E., (2004). "Socio-economic differences and health

seeking behaviour for the diagnosis and treatment of malaria: a case study of four

local government areas operating the Bamako initiative program in south-east

Nigeria,"International Journal of Equity in Health,3:6.

Uzochukwu, B.S.C., Onwujekwe E.O., Onoka C.A., Ughasoro M.D., (2008). "Rural-urban

differences in maternal responses to childhood fever in south east Nigeria,"PLoS

ONE3:e1788.

UN Population Division, Department of Economic and Social Affairs, (2009). World

Urbanization Prospects: The 2009 Revision, <http://esa.un.org/wup2009/unup>.

UN Population Division, Department of Economic and Social Affairs, (2010). World

Population Prospects: The 2010 Revision, <http://esa.un.org/unpd/wpp/index.htm>.

World Bank, (2010). World databank, <http://databank.worldbank.org>.

Values given in constant 2005 international PPP US$ for comparison over time.

World Health Organization, , (2008). World Malaria Report 2008, WHO Press: Geneva.

World Health Organization (2009). Systems thinking for health systems strengthening,

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http://esa.un.org/wup2009/unup

http://databank.worldbank.org/

www.ACTwatch.info

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Acknowledgements This report presents the results of the 2011 Nigerian Outlet Survey. It is a comprehensive, nationally

representative outlet survey designed for the evaluation of the Affordable Medicines Facility for

malaria.

This report would not have been possible without the efforts of a large number of people who

assisted with the data analysis, data processing, and preparation of the report, as well as those who

worked tirelessly to collect the endline survey data and analyze the results. We particularly

appreciate the efforts of the National Malaria Control Program for providing overall support for the

survey. Additional thanks are expressed to Society for Family Health for providing project

management support and implementing the survey and to the Bill and Melinda Gates Foundation for

their financial support.

We would like to express our thanks to the field teams and individuals involved in the survey. Their

names are presented in the Appendix 9.4.

Finally, we would like to thank the thousands of providers who took time to complete the interview.

Without them, it would not be possible to provide these results.

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Appendices

8.1 Questionnaire

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8.2 ACTs classified as quality-assured

Key indicators for the Independent Evaluation of AMFm measure the price, availability and market

share of quality-assured ACTs (QAACT). A QAACT is defined as any ACT that meets the Global Fund

to Fight AIDS, Tuberculosis and Malaria’s (The Global Fund) quality-assurance policy. According to

this policy, a quality-assured product are ACTs that comply with the Global Fund to Fight AIDS,

Tuberculosis and Malaria’s Quality Assurance Policy. For the purpose of the Independent Evaluation,

a QAACT is any ACT which appeared on the Global Fund's indicative list of antimalarials meeting the

Global Fund's quality assurance policy prior to baseline or endline data collection (see

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General), or which

previously had C-status in an earlier Global Fund quality assurance policy and was used in a program

supplying subsidized ACTs. At endline, QAACTs were defined as any ACT which appeared on the

Global Fund’s indicative list of antimalarials meeting its quality assurance policy as at September

2011, or which previously had C-status in an earlier Global Fund quality assurance policy and was

used in a program supplying subsidized ACTs. A

The list of antimalarials that complies with the quality-assurance policy varies over time.

Consequently, an operational definition that would establish a fixed list of QAACTs was adopted for

the purpose of the Independent Evaluation endline outlet survey as follows: a QAACT is any ACT

which appeared on the Global Fund's Indicative List of antimalarials meeting the Global Fund's

quality assurance policy as at September 201135, or which previously had C-status in an earlier

Global Fund quality assurance policy and was used in a program supplying subsidised ACTs.

In September 2011, the Global Fund provided the Independent Evaluator with the indicative list of

antimalarials that met the quality-assurance policy. Since brand names are not pre-qualified by the

WHO or registered when recommended by the Expert Review Panel, the Independent Evaluator

contacted each manufacturer on the list to get details on all of the brand names used for each

product appearing on the list and produced at the approved manufacturing site. In addition, quality-

assured products are also often re-packaged and re-branded for the use in domestic social

marketing or subsidy programs. Details on the brand names used in in-country marketing programs

were compiled by contacting national authorities, or the organization involved in the marketing

campaign (e.g., PSI and MENTOR).

For the availability, price, markup and market-share indicators, products were classified as quality-

assured ACTs if the brand name, generic name, strength, manufacturer and country of manufacturer

matched one of the entries in Table 8.2.1.

For the stockout indicator, a prompt card showing photographs of the ACTs classified as quality-

assured was used so the interviewer and respondent could identify QAACTs in stock during the

survey visit or in stock in the previous 4 weeks. Photographs of QAACTs used for social

marketing/subsidy program were not included in the prompt card, unless the country in which data

collection took place had a social marketing or subsidy program which used a QAACT.

35Refer to http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General for the most up-to-date list.



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Table 8.2.1: List of Quality-Assured ACTs for availability, price and market share indicators

Brand Name Generic Name Strength Manufacturer Country of

manufacture

Package Size

(tablets per

pack)

FDC Notes

ACT WITH A LEAF 4

MONTHS TO <3

YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg NOVARTIS PHARMA

AG

China or USA 6 or 30 Yes Repackaged by PSI

for distribution in

Uganda

ACT WITH A LEAF 3

YEARS TO <7 YEARS

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACT WITH A LEAF 7

YEARS TO <12 YEARS

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACT WITH A LEAF 12

YEARS AND ABOVE

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACTIPAL ARTESUNATE +

AMODIAQUINE

25mg + 67.5mg SANOFI AVENTIS or

MAPHAR

Morocco 3 Yes C-status product.

Repackaged by PSI

for distribution in

Madagascar


AMODIAQUINE

50mg + 135mg SANOFI AVENTIS or

MAPHAR

Morocco 3 Yes C-status product.

Repackaged by PSI

for distribution in

Madagascar


AMODIAQUINE

50mg + 153mg STRIDES ARCO LABS India 6 No C-status product.

Repackaged by PSI

for distribution in

Madagascar

ARTEMEF 4 MONTHS

UP TO 3 YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD India 6 Yes QAACT – over

branded for Nigeria

ARTEMEF 3 YEARS UP

TO 7 YEARS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

ARTEMEF 7 YEARS UP

TO 12 YEARS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

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ARTEMEF 12 YEARS

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

ARTEQUIN 600/1500 ARTESUNATE +

MEFLOQUINE

200mg + 250mg MEPHA Switzerland 9 No Not included on the

prompt card used for

the stockout

indicator

ARSUAMOON 1-6

YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 6 or 150 No

ARSUAMOON 7-13

YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 12 or 300 No

ARSUAMOON

ADULTS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 24 or 600 No

ARTEFAN 20/120 5-

14KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg AJANTA PHARMA LTD India 6 or 180 Yes

ARTEFAN 20/120 15-

24KG

ARTEMETHER +

LUMEFANTRINE


ARTEFAN 20/120 25-

34KG

ARTEMETHER +

LUMEFANTRINE


ARTEFAN 20/120 35+

KG ADULTS

ARTEMETHER +

LUMEFANTRINE


ARTEMETHER +

LUMEFANTRINE

<3 YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg IPCA LABORATORIES

LTD

India 6, 60 or 180 Yes

ARTEMETHER +

LUMEFANTRINE

3-8 YEARS

ARTEMETHER +

LUMEFANTRINE


LTD

India 12,120, or 360 Yes

ARTEMETHER +

LUMEFANTRINE

9-14 YEARS

ARTEMETHER +

LUMEFANTRINE


LTD

India 18, 180, or 540 Yes

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ARTEMETHER +

LUMEFANTRINE

>14 YEARs

ARTEMETHER +

LUMEFANTRINE


LTD

India 24, 240, or 720 Yes

ARTESUNATE +

AMODIAQUINE CHILD

1-6 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 or 60 No

ARTESUNATE +

AMODIAQUINE

JUNIOR 7-13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 or 120 No

ARTESUNATE +

AMODIAQUINE

ADULT

ARTESUNATE +

AMODIAQUINE


LTD

India 24 or 240 No

ARTESUNATE +

AMODIAQUINE CHILD

1-6 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153.1 mg IPCA LABORATORIES

LTD

India 6 or 60 No

ARTESUNATE +

AMODIAQUINE

JUNIOR 7-13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 or 120 No

ARTESUNATE +

AMODIAQUINE

ADULT

ARTESUNATE +

AMODIAQUINE


LTD

India 24 or 240 No

COARSUCAM INFANT

2-11 MONTHS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

COARSUCAM

TODDLER 1-5 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

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COARSUCAM CHILD

6-13 YEARS

ARTESUNATE +

AMODIAQUINE

100mg + 270mg SANOFI AVENTI or

MAPHAR

Morocco 3 or 75 Yes

COARSUCAM ADULT

+14 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 6 or 150 Yes

COARTEM 20/120 5-

15 KG

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 30 or 180 Yes

COARTEM 20/120 15-

25 KG

ARTEMETHER +

LUMEFANTRINE


AG


COARTEM 20/120 25-

35 KG

ARTEMETHER +

LUMEFANTRINE


AG


COARTEM 20/120 ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 24, 216, 720 Yes

COARTEM

DISPERSIBLE 5-15KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 6 or 180 Yes

COARTEM

DISPERSIBLE 15-25KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 12 or 360 Yes

COARTEM

DISPERSIBLE 25-35KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 18 or 540 Yes

COARTEM

DISPERSIBLE

ARTEMETHER +

LUMEFANTRINE


AG

USA 6 or 216 Yes

COARTEM E FIXE 5-

15KG

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6 Yes Distributed by

MENTOR in Angola

COARTEM E FIXE 15-

25KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

COARTEM E FIXE

DISPERSIBLE 5-15KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

COARTEM E FIXE

DISPERSIBLE 15-25KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

CO-FALCINUM 5-14

KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

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CO-FALCINUM 15-

24KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

CO-FALCINUM 25-

34KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

CO-FALCINUM 35KG

AND ADULTS

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

COMBISUNATE

20/120 5-14KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg AJANTA PHARMA LTD India 6 Yes QAACT – over

branded for Nigeria

COMBISUNATE

20/120 15-24KG

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

COMBISUNATE

20/120 25-34KG

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

COMBISUNATE

20/120 35+ KG

ADULTS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

DAWA MSETO YA

MALARIA ALU

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12, 18, 24 Yes Repackaged by PSI

for distribution in TZ

FALCIMON KIT

YOUNG CHILDREN UP

TO 6 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153mg CIPLA PHARMA LTD India 6 No

FALCIMON KIT

CHILDREN 7-13

YEARS

ARTESUNATE +

AMODIAQUINE


FALCIMON KIT

ADULTS

ARTESUNATE +

AMODIAQUINE


LA COARTEM ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12 Yes Repackaged by PSI

for distribution in

Malawi

LARIMAL CHILD 1-6

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 No

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LARIMAL JUNIOR 7-

13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 No

LARIMAL ADULT 14+

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 24 No

LARIMAL CHILD 1-6

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 No

LARIMAL JUNIOR 7-

13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 No

LARIMAL ADULT 14+

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 24 No

LUMERAX ARTEMETHER +

LUMEFANTRINE


LTD

India 24 Yes

LUMARTEM 5KG TO

<15KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD India 6 or 180 Yes

LUMARTEM 15 TO

<25KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 25 TO

<35KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 35KG

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 5KG TO

<15KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD Uganda 6 or 180 Yes

LUMARTEM 15 TO

<25KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 25 TO

<35KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 35KG

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


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MALARIAKIT ARTESUNATE +

AMODIAQUINE


LTD

India 6 No Repackaged by PSI

for distribution in

Sudan

MALARPACK

COARTEM

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12 Yes Repackaged by PSI

for distribution in

Myanmar

PRIMO ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Rwanda

SERENA DOSE

ENFANTS 1-5 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153mg CIPLA PHARMA LTD India 6 Yes Repackaged by

PSI/Manufacturer for

distribution in DRC

TIBAMAL ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6 or 12 Yes Repackaged by

manufacturer for

distribution in Kenya

WINTHROP INFANT

2-11 MONTHS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP TODDLER

1-5 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP CHILD 6-

13 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP ADULT

+14 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 6 or 150 Yes

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8.3 Final sample

Table 8.3.1: List of clusters/sub-districts sampled and their population, Nigeria, 2011

State LGA Locality Population Locality (urban/rural)

ABIA

ABA SOUTH ABA 427,421 Urban

BENDE OKOKO 7,327 Rural

OBIOMA-NGWA UMUKALIKA-AHIABA 1,750 Rural

UMUAHIA NORTH OSSAH 7,635 Rural

ADAMAWA

SONG SONG 26,818 Urban

GIREI GIREI 17,713 Rural

MUBI SOUTH GELLA 3,826 Rural

AKWA AIBOM

ESSIEN-UDIM ADIASIM IKOT EKON 1,898 Rural

IKONO IBIAKU ATA 2,392 Rural

NSIT IBOM MBIOKPORO II 4,538 Rural

UKANAFUNUN IKOT AKPAN AFAHA 2,124 Rural

ANAMBRA

EKWUSIGO ORAIFITE 45,638 Urban

NNEWI SOUTH EZINIFITE 24,897 Urban

DUNUKOFA UMUDIOKA 11,951 Rural

BAUCHI

DARAZO KARITASHA 5,413 Rural

JAMARE DOGONJEJI 5,683 Rural

TAFAWABALEWA LIM 1,808 Rural

BAYELSA

NEMBE NEMBE 35,967 Urban

EKEREMOR OBIRIGBENE I 3,113 Rural

SOUTHERN IJAW OPOROMA 12,775 Rural

BENUE

GBOKO MBADEDA (MBATIER 1,043 Rural

OTURKPO OTUKPO 132,798 Urban

OKPOKWU EFFOYO 2,730 Rural

USHONGO MBAINGIJOR 1,890 Rural

CROSS-RIVER

AKPABUYO IKOT EKPO 3,104 Rural

BOKI KAKWAGOM CENTRAL 1,452 Rural

UGEP NORTH EBOM 9,902 Rural

DELTA

OSHIMILI SOUTH IBUSA 42,959 Urban

BURUTU SOKE BOLOU 2,078 Rural

ISOKO SOUTH OWODOKPOKPO 12,822 Rural

UGHELI SOUTH EWU URHOBO 15,291 Rural

EBONYI

OHAOZARA OKPOSI UKWU 23,527 Urban

AFIKPO SOUTH AMOSO 4,879 Rural

OHAUKWU UMUEZEAKA 8,287 Rural

EDO

OREDO BENIN CITY 364,000 Urban

ESAN CENTRAL EBULEN 1,774 Rural

ORHIONMWON UMOGHUNMWUN 1,834 Rural

EKITI

ADO EKITI ADO-EKITI 256,338 Urban

EKITI EAST ARAROMI OMUO EKITI 4,947 Rural

OYE OYE EKITI 18,545 Rural

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ENUGU

ENUGU NORTH ENUGU NORTH 121,070 Urban

NKANU EAST AMAGUNZE 17,466 Urban

IGBO-EZE NORTH UDA 9,217 Rural

NKANU EAST ORUKU 6,359 Rural

GOMBE BALANGA LOBWARE 1,736 Rural

KWAMI TAPPI 3,307 Rural

IMO

ABOH-MBAISE UMUKOHIE UVURU 2,958 Rural

IDEATO SOUTH NKAHU 3,599 Rural

MBAITOLI AZARA OBIATO 2,440 Rural

NKWERRE UMUEGBE AMAOKPARA 4,166 Rural

ORLU OKWUABALA II IHIOMA 6,245 Rural

JIGAWA

BIRNIN-KUDU BIRNIN KUDU 33,213 Urban

DUTSE MALAMAWA C/GARI 4,903 Rural

KAUGAMA DABUWARAN CIKIN GARI 1,392 Rural

KADUNA

KADUNA NOR UNG GWARI 10,291 Urban

ZANGON-KATAF ZANGO 15,917 Urban

BIRNIN GWARI SAMINAKA (DOGON DAWA) 2,303 Rural

KAURA ANTURUNG I & II 930 Rural

ZANGON-KATAF GORA BAFAI 3,208 Rural

KANO

GAYA GAYA 58,458 Urban

MINJIBIR KUNYA 15,578 Urban

DAMBATTA UNG ALI C/GARI 3,033 Rural

GARUN MALLAM YADAKWARI C/GARI 5,314 Rural

KIRU RANGAS 3,215 Rural

RIMIN-GADO UNGUWAR RIGA 1,962 Rural

TSANYAWA UNGUWAR MAIGARI KABAGIW 2,542 Rural

KATSINA

DANDUME DANDUME 23,521 Urban

ZANGO ZANGO 23,565 Urban

BAKORI UNG DANJATAU 1,860 Rural

DANMUSA DAN-ALI A 1,496 Rural

KAFUR UNGWAR JANGE 1,718 Rural

MASHI DOKAWA B 1,677 Rural

KEBBI ARGUNGU SAUSA 8,770 Rural

JEGA JIGA MAGORAWA 3,325 Rural

KOGI

DEKINA AYANGBA 41,947 Urban

BASSA KPANCHE 3,117 Rural

OFU AGOJEJU I 5,265 Rural

KWARA ILORIN WEST ILORIN 359,217 Urban

EDU EDOGI DUKUN 3,428 Rural

LAGOS

AGEGE OYEWOLE 13,257 Urban

ALIMOSHO MEIRAN 7,411 Urban

APAPA IJORA BADIA 110,059 Urban

IKORODU IKORODU 269,593 Urban

LAGOS-MAIN LAND MAKOKO 31,818 Urban

OSHODI/ISHOLO OSHODI 36,497 Urban

SURULERE ORILE IGANMU 78,838 Urban

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NASARAWA AWE TSOHO WUSE 1,994 Rural

OBI DADDARE 12,067 Rural

NIGER

CHANCHAGA MINNA 171,434 Urban

MAGAMA TUNGAN KADE 2,006 Rural

RIJAU WARARI UNG.HAUSAWA 1,499 Rural

OGUN

IJEBU-NORTH IJEBU IGBO 122,774 Urban

ADO-ODO/OTA OKE PADRE 3,092 Rural

ODEDA OBANTOKO 4,747 Rural

ONDO

AKURE SOUTH AKURE 340,017 Urban

IDANRE ALADE IDANRE 7,117 Rural

OSE IDOANI 17,715 Rural

OSUN IFE EAST ILE-IFE 107,861 Urban

IFEDAYO ORA 14,670 Rural

OYO

ATIBA OYO 75,493 Urban

IBADAN SOUTH EAST ODINJO 24,905 Urban

OLORUNSOGO IGBETI 55,609 Urban

IBARAPA CENTRAL ERUWA/ANKO 5,172 Rural

ONA-ARA OLOBA 4,427 Rural

PLATEAU

SHENDAM YELWA 27,103 Urban

KANAM YIPMONG DIST DENGI 1,564 Rural

SHENDAM DILORI 1,381 Rural

RIVERS

ELEME NONWA KAGBARA I TAI 20,415 Urban

ABUAL/ODUA OKOBOH TOWN ABUA 9,038 Rural

ANDONI ATABA 11,619 Rural

EMUOHA EGBEDA 15,361 Rural

GOKANA GAAGA-YEGHE 6,135 Rural

OBIO/AKPOR RUMUOCHIOLU II RUMUOKWU 7,218 Rural

OPOBO\NKORO KALAIBIAMA 13,251 Rural

SOKOTO

ISA ISA 38,685 Urban

BINJI BINKARI 5,098 Rural

ILLELA RUNJIN KWARE 1,327 Rural

TAMBUWAL BAGIDA 2,215 Rural

TARABA

JALINGO JALINGO 108,433 Urban

DONGA SUNTAI 2,965 Rural

USSA LISSAM SAMBO 2,971 Rural YOBE JAKUSKO BUDUWA 6,908 Rural

ZAMFARA BUKKUYUM RAFIN MAIKI 2,285 Rural

MARU DAN GODABE 2,063 Rural Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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8.4 Survey team

Table 8.4.1: List of staff members involved in the survey, [Nigeria], 2011

Name Responsibility/role Nike ojo Interviewer Dung Christana Interviewer Comfort Agwu Interviewer Edadoghwaye Jennifer Interviewer Gaadi Iveren Interviewer Gunguma Nguevese Interviewer Olajide Olayemi Interviewer Fatima Jaafar Sambo Interviewer Wulnan Shedrack Interviewer Deborah Samaila Interviewer Blessing Paul Davo Interviewer Adejimi Kunle Interviewer Lukman Abubakar Interviewer Isa Shehu-Usman Interviewer Turman theophilus Interviewer Yusuf Hassan Interviewer Musa Abubakar Interviewer Yarima Abdoolmumin Interviewer Evans Unachukwu Interviewer Valentine Nwobu Interviewer Abubakar Abdullahi Interviewer Shafiu Husseni Interviewer Samson Aliyu Interviewer Dawuda Kognet Interviewer Lilian Ehyeate Interviewer Shamir Mohammed Interviewer Matthew Katung Interviewer Ademujimi Olakunle Interviewer Ugwu Ifeoma Interviewer Bisi Bello Interviewer Akilo Olalekan Interviewer Ogunleye Olabimpe Interviewer Antonia Afolekmia Interviewer Faniyan Adedokun Interviewer Osofisan Olayinka Interviewer Awe Elizabeth Interviewer Akinade Joy Interviewer Yetunde Agbayewa Interviewer Omotoso Omotola Interviewer Obinna Eze Interviewer Philip Odoemelem Interviewer Frank Hussani Interviewer Adiele Ikechi Interviewer Onyeagoziri Sophia Interviewer Chigozie Anaemeji Interviewer Ijeoma Chukwumeze Interviewer Samuel Nwoke Interviewer Maraizu Ikechukwu Interviewer Nwabueze Thankgod Interviewer Ogwuche Jacob Interviewer Ability Emmanuel Interviewer Nseabasi Onwioduokit Interviewer Aanu Rotimi Interviewer Orji Victor Interviewer Keme Opia Interviewer

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Igbinedion Samuel Interviewer Didi Womene Interviewer Tolu Ariyo Interviewer Oluchi Nwachukwu Interviewer Faith Yakubu Quality Controller Funke Majedokunmi Quality Controller Idemoh Barbara Quality Controller Omale Isaac Adejoh Quality Controller Mutallab Musa Ahmed Quality Controller Danlami Nakoto Quality Controller Folakemi Adebiyi Quality Controller Sanni Olusiji Quality Controller Eyara Ofonime Quality Controller Jibola Raji Quality Controller Adeike Adetoye Quality Controller Ani Ugochi Quality Controller Anuoluwapo Sanni Supervisor Esther Nakoto Supervisor Millicent Shaset Supervisor Mohammed kassim Supervisor Esien Esiere Supervisor Kwalkwap Emmanuel C. Supervisor Yemisi Ogundare Supervisor Imoh Akpan Emmanuel Supervisor Tonye Ayanmah Supervisor Ifeyinwa Egwaoje Supervisor Nnene Orji Supervisor Oluwaseun Adedokun Supervisor Obiageri Ogubata Lilian Assistant project coordinator Omowumi Idowu Ali Assistant project coordinator

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8.5 Description of outlet types visited for this survey

Outlet Type Description

Public health facilities

University teaching hospital / Federal Medical Centre

These tertiary level public health facilities are designated as referral hospitals for the State. They have specialized clinics with qualified personnel.

Federal Medical Centres (FMCs) are headed by a Chief Medical Director, appointed by Federal Government, funded by and reporting to the Federal Government. They conduct postgraduate training of health providers including doctors and nurses. Unlike university teaching hospitals, FMCs are not attached to any specific university or medical school.

By definition, university teaching hospitals are linked to a university ormedical school. They are headed by a Chief Medical Director, and regulated by the Medical and Dental Council. Some teaching hospitals are privately owned and the distinction between government-owned and private-owned facilities has been made during the survey.

General / Specialist hospital These secondary public health facilities are funded by and report to State governments.

General hospitals typically serve urban or peri-urban areas with a catchment area covering 200,000 to 300,000 people. They are headed by a Medical Superintendant, and have facilities for diagnosis, in-patient admission, and surgery. They include pharmacy section(s), dispensary unit(s), an ambulance, and a few residential houses for staff on emergency duties. General hospitals may host internships for doctors under supervision, but do not perform postgraduate training.

Primary Health Care Centre (PHCC) These primary health facilities are managed and operated at the local government area level.

They are the smallest of all government-owned health facilities and offer fewer services than those found at tertiary and secondary level facilities. Health centres are located in both urban and rural settings, and have a typical catchment area covering 10,000 to 30,000 people. They are usually staffedby one or two nurses with some community health extension workers and a few auxiliary staff. However, some are operated by doctors, while others have doctors that periodically visit to make major decisions or run specialist clinics. Services provided include community Integrated Management of Childood Illness (IMCI); family planning; focusef ANC; routine immunization; and Prevention of Mother-to-Child Transimission (PMTCT).

Private not for-profit facilities

Non-Governmental Organization (NGO) Hospital / Health Centre

These health facilities operate at different levels of the health system, depending on their size. They are funded and supported by non-governmental organizations and provide medical consultations, diagnoses, and prescription medicines at a nominal cost.

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Pharmacy These outlets are registered by the Pharmacy Council of Nigeria and are authorized to sell all classes of medicines, including prescription medicines. They usually employ nurses and intern pharmacists. Pharmacies are highly regulated by the National Agency for Food and Drug Administration and Control (NAFDAC). They are privately owned, either by registered pharmacists or individuals who employ the services of a registered pharmacist. In Nigeria, pharmacies are overwhelmingly located in urban areas in commercial zones.

Propriety patent medicine vendors / Drug Store

These are small- to medium-sized outlets, equivalent to drug shops in other ACTwatch countries. PPMVs may be registered by the Directorate of Pharmaceutical Services (DPS), but the majority of them are not registered. They are legally allowed to sell over-the-counter (OTC) medicines, however a number of them also illegally stock prescription medicines. (In 2006, NAFDAC de-classified ACTs from prescription-only to OTC; hence ACTs are legally available at PPMVs.) Some operate without a license, especially at the village level or remote areas. PPMVs are ubiquitous across Nigeria and, given the lack of pharmacies in rural settings, serve as accessible medicine outlets for consumers. Staff typically have little or no training in health service delivery, although a small proportion of PPMVs are owned by nurses or other health workers, such as community health extension workers.

Private hospitals / clinics These are non-governmental health facilities. Just as with public health facilities, private hospitals and clinics are classified in terms of their capacity— tertiary, secondary, or primary. For this study, all three levels have been grouped into one category. Hence, they can range from offering comprehensive health services to being limited in scope. Likewise, staff range in qualification and number. There is usually a dispensing section, but in some cases, the doctors may dispense medications themselves.

Supermarket / Minimarket / Provision store/Kiosk

Small businesses which sell household products, food, and beverages. These stores may also sell medicines, usually antipyretics. They are unlicensed.

Community Health Workers

Community Health Extension Worker/Role Model Mothers/Village Health Worker

This cadre of trained health worker is found mostly at the primary health care level and provides services directly to the communities in which they work. While most of them are attached to government facilities, some of them operate at privately owned outlets, such as PPMVs, or from their residential homes.

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8.6 Sampling weights

Sampling weights are needed to analyze the survey data if PPS cluster sampling is applied.

Otherwise, bias may be introduced in the calculated statistics if the sub-districts/communes are very

different in size. If a complete sampling frame is available for applying PPS sampling, with the

measure of size being the population, sampling weights are easy to calculate. Assuming that the

distribution of the outlets is proportional to the population within each sampling stratum and that a

booster sample is applied, then for all the outlets enumerated in the selected sub-district, not

including the public health facilities and the part one pharmacies (POP), (there is a separate

weighting procedure for these weights shown later), sampling weight is the inverse of the selection

probability of the selected sub-district, calculated as:

M n

M =W

hih

hi

hi

where

hiW = the sampling weight for the ith selected sub-district/commune of stratum h,

M hi = the total number of population (or total number of households) in the stratum h

hn = the number of sub-districts/communes selected in stratum h, and

M hi = the number of population (or number of households) in the ith selected sub-district/commune

of stratum h

If no explicit stratification is used in the sample selection, then h=1.

The sampling weight for all the public health facilities and part one pharmacies, which are included

in the sample from the entire district including the ones in the selected sub-district, is calculated

similarly but with the above parameters replaced by district level characteristics:

**

*

*

hjh

hj

hj Mn

M =W

where *

hjW = the sampling weight for the jth selected district (a district is selected if one or more of its sub-

districts are selected in the sample) of stratum h, *

hj M = the total number of population (or total number of households) in stratum h

*

hn = the number of districts selected in stratum h, and

*

hjM = the number of population (or number of households) in the jth selected district of stratum h

With the above calculated district level weights (posterior weights because there is no direct

selection of districts in the sampling procedure), a booster sample outlet should be counted only

once in the data analysis even if two or more sub-districts/communes are selected from the same

district.

The above calculated sampling weights are cluster-wide weights. This means that all the outlets

interviewed in the same sub-district/commune share the same sampling weight, for both public

health facilitiesand part onepharmacies and all other facilities.

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8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs)

Introduction

Antimalarial medicines are manufactured usinga variety of active pharmaceutical ingredients,

dosage forms, strengths and package sizes. To analyze prices and volumes across products with

different characteristics, they are standardized using the AETD. Indicators based on price and

volume data, namely market share and antimalarial prices, are presented in terms of AETDs.

Assumptions for calculating AETDs One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat a 60

kilogram (kg) adult. For each antimalarial medicine category, the number of mg in one AETD is set to

what was recommended in the treatment guidelines for uncomplicated malaria in areas of low drug

resistance issued by the WHO. Where WHO treatment guidelines did not exist, AETDs were based on

peer reviewed research, or the product manufacturer’s recommended treatment course for a 60kg

adult. A list of AETDs by antimalarial category prepared by PSI for the ACTwatch project (Shewchuk,

O'Connell et al. 2011)was reviewed and updated by the Independent Evaluator in April 2010. Refer

to Table 8.7.1 for the list used for the endline report.

Additional assumptions

1) For combination therapies, which have two or more active antimalarial ingredient packaged

together (either co-formulated or co-blistered) the AETD is based on the total amount of one

of the active ingredients. For ACTs, the artemisinin derivative was used as the basis of the

AETD.

2) Co-blistered combinations are assumed to be in a 1:1 ratio of tablets, with the following

exceptions:

Amodiaquine + Sulfadoxine + Pyrimethamine manufactured under the brand name

Dualkin;

Artesunate + Amodiaquine manufactured under the brand names Amonate Junior

and Amonate Adult;

Artesunate + Mefloquine manufactured under the brand names Artequin 600/1500,

Artequn 300/750, A + M1, A + M2, A + M3, A + M4, A + M5, Malarine for Adults,

Malarine for Teenagers, and Malarine for Children;

Artesunate + Sulfadoxine + Pyrimethamine manufactured under the brand names

SulamonPlus 500, Malosunat, Amalar, Artescope, Farenax, Artidox, Artedar,

Asunatedenk 100, Asunatedenk 200, Co-arinate, Arte-Plus.

3) Sulfamethoxypyrazine-pyrimethamine is assumed to have the same full adult treatment

dose as Sulfadoxine-Pyrimethamine.

4) Artequick lacking strength information is assumed to contain Artemisinin 62.4mg and

Piperaquine phosphate 375mg.

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Methods for calculating price and market share indicators Information collected on the medicine’s strength and unit size, as listed on the product packaging,

was used to calculate the total amount of each active ingredient found in the package. Next, the

number of AETDs in a unit was calculated.36 For monotherapies, the number of AETDs in the unit

was calculated by dividing the total amount of the active ingredient contained in the unit, by the

AETD (i.e. by the total number of mg required to treat a 60kg adult). For combination therapies, the

number of AETDS in the unit was calculated by dividing the total amount of the active ingredient

that was used as the basis for the AETD by the AETD.

Calculating price indicators

Pricing indicators (Indicators 2.1-2.4) are presented in terms of the cost to patients for one AETD. For

each antimalarial audited, the cost to patients for one unit was computed based on the retail selling

price reported by the respondent for that product. This was then divided by the number of AETDs in

the unit to get the cost to patients for one AETD. (An exception is the pediatric price indicator for

quality-assured ACT (Indicator 2.1) where AETDs were not used. Rather, the price for a 2 year-old

child was calculated including only pediatric formulations whose age (weight) range includes a 2

year-old (10kg) child.)

Calculating market share

For each antimalarial audited, the number of AETDs sold over the past 7 days was calculated by

multiplying the number of units sold as reported by the respondent by the number of AETDs in the

unit.

Market share was then calculated by summing this for all antimalarials audited belonging to a

particular category, which was then divided by the sum of AETDs of all antimalarials sold.

Market share was calculated by dividing the number of AETDs of a particular antimalarial category

sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked

antimalarials, but some or all sales volumes were missing, we did not impute for missing values.

36The unit depends on the antimalarial medicine’s dosage form. For antimalarials in tablet, suppository or granule dosage form, the unit is the package. For antimalarials in injectable dosage form, the unit is the ampoule. For antimalarials in syrup or suspension dosage form, the unit is the bottle.

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Table 8.7.1: AETD Calculation details by antimalarial type

Antimalarial Category

Dose used for

calculating

1 AETD

(mg required to treat

a

60kg adult)

Generic product used

for AETD mg

dose value

Notes Source

Amodiaquine 1800mg WHO Model Formulary, 2008

Amodiaquine-Sulfadoxine-

Pyrimethamine 1800mg Amodiaquine

Info available only for Amodiaquine (not the

combination) WHO Model Formulary, 2008

Atovaquone-Proguanil 3000mg Atovaquone WHO Guidelines for the treatment of malaria 2

nd

edition, 2010

Chloroquine 1500mg Info available for P.vivax malaria WHO Guidelines for the treatment of malaria 2

nd

edition, 2010

Chloroquine-Sulfadoxine-

Pyrimethamine 1500mg Chloroquine

Info available for P.vivax malaria

Info only available for Chloroquine (not the

combination)

WHO Guidelines for the treatment of malaria 2nd

edition, 2010

Chlorproguanil-Dapsone 360mg Chlorproguanil Manufacturer Guidelines

(LapDap – GSK)

Halofantrine 1500mg or 1398mg

1500mg is for halofantrine hydrochloride, as the

strength is normally reported in this manner. The total

dose for halofantrine base is 1398 mg.

Manufacturer Guidelines

(Halfan – GSK)

Hydroxychloroquine

1500mg

One tablet of 200mg hydroxychloroquine sulfate is

equivalent to 155mg base.


(Plaquenil – Sanofi Aventis)

Mefloquine 900mg

WHO Model Formulary, 2008

Mefloquine-Sulfadoxine-

Pyrimethamine 900mg Mefloquine Info only available for Mefloquine (not the combination) WHO Model Formulary, 2008

Primaquine 45mg This dose is for the gametocytocidal treatment of P.

falciparum.


edition, 2010

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Quinacrine 2100mg

Recommendations for malaria treatment are very dated.

This value is the treatment regimen for giardiasis, which

has also been used in the treatment for malaria.

The Gardner & Hill article specifies dosing is usually 100

mg three times a day over 5 to 7 days for adults.

Gardner, T. B. and Hill, D. R. 2001. Treatment of

Giardiasis. Clinical Microbiology Reviews. 14(1):

114-128

http://cmr.asm.org/cgi/content/full/14/1/114#T2

Quinimax 10500mg Manufacturer Guidelines

(Quinimax – Sanofi Aventis)

Quinine 12600mg or

10408mg

12600mg is for quinine sulfate, a salt, as quinine

strengths are normally reported for salts.

The total dose for quinine base based on 24mg/kg is

10408mg for a 60kg adult.

Both dosages are based on treatment lasting 7 days.


Quinine-Sulfadoxine-

Pyrimethamine

12600mg or

10408mg Quinine

12600mg is for quinine sulfate, a salt, as quinine

strengths are normally reported for salts.

The total dose for quinine base based on 24mg/kg is

10408mg for a 60kg adult.

Both dosages are based on treatment lasting 7 days.

Info available only for Quinine (not the combination)


Sulfadoxine-

Pyrimethamine 1500mg Sulfadoxine WHO Model Formulary, 2008

Arteether 1050mg 1050mg is for 7 days of treatment WHO Use of Antimalarials, 2001

Artemether 960mg WHO Use of Antimalarials, 2001

Artesunate 960mg WHO Use of Antimalarials, 2001

Dihydroartemisinin 480mg Manufacturer Guidelines

(Cotecxin – Holleypharm; MALUether – Euromedi)

Artemether-Lumefantrine 480mg Artemether WHO Guidelines for the treatment of malaria 2

nd

edition, 2010

http://cmr.asm.org/cgi/content/full/14/1/114#T2

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Artemisinin-Naphthoquine 2400mg Artemisinin

Manufacturer Guidelines for this product are 1000mg

Artemisinin in a single dose. According to WHO

Guidelines for the treatment of malaria 2nd

edition, a

three day course for ACTs is recommended.

This treatment dose used is based upon the WHO

Artemisinin-MQ recommendation 20 mg/kg in a divided

loading dose on the first day, followed by 10mg/kg once

a day for two more days, plus mefloquine (15-25 mg of

base per kg) as a single or split dose on the second

and/or third day.

WHO Use of Antimalarials, 2001

Artemisinin-Piperaquine 576mg Artemisinin

Krudsood, S. et al. 2007. Dose ranging studies of

new artemisinin-piperaquine fixed combinations

compared to standard regimens of artemisinin

combination therapies for acute uncomplicated

falciparum malaria.The Southeast Asian Journal of

Tropical Medicine and Public Health. 38(6): 971-8.

http://www.ncbi.nlm.nih.gov/pubmed/18613536

Artemisinin-Piperaquine-

Primaquine 576mg Artemisinin

Tangpukdee, N. et al. 2008. Efficacy of Artequick

versus artesunate-mefloquine in the treatment of

acute uncomplicated falciparum malaria in

Thailand. The Southeast Asian Journal of Tropical

Medicine and Public Health. 39(1): 1-8

http://imsear.hellis.org/handle/123456789/33676

Artesunate-Amodiaquine 600mg Artesunate WHO Guidelines for the treatment of malaria 2

nd

edition, 2010

Artesunate-Halofantrine 600mg Artesunate

Relatively uncommon combination; dosing information

is difficult to find and the value here is based on the

Artesunate-Amodiaquine, Artesunate-SP, and

Artesunate-Mefloquine values.

-

http://www.ncbi.nlm.nih.gov/pubmed/18613536

http://imsear.hellis.org/handle/123456789/33676

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Artesunate-Lumefantrine 600mg Artesunate





-

Artesunate-Mefloquine 600mg Artesunate WHO Guidelines for the treatment of malaria 2

nd

edition, 2010

Artesunate-Piperaquine 600mg Artesunate





-

Artesunate-Pyronaridine 600mg Artesunate





-

Artesunate-Sulfadoxine-

Pyrimethamine 600mg Artesunate


edition, 2010

Dihydroartemisinin-

Amodiaquine 360mg Dihydroartemisinin



most common Dihydroartemisinin-combinations

(Dihydroartemisinin+Piperaquine,Dihydroartemisinin+SP

and Dihydroarteminn+Mefloquine) with sources listed in

the entries for those products.

-

Dihydroartemisinin-

Halofantrine 360mg Dihydroartemisinin







-

www.ACTwatch.info

Page 160

Dihydroartemisinin-

Lumefantrine 360mg Dihydroartemisinin







-

Dihydroartemsinin-

Mefloquine 360mg Dihydroartemisinin


(Meflodisin – Adams Pharma)

Dihydroartemisinin-

Piperaquine 360mg Dihydroartemisinin


edition, 2010

Dihydroartemisinin-

Piperaquine-Trimethoprim 256mg Dihydroartemisinin


(Artecxin – Medicare Pharma; Artecom – Ctonghe)

Dihydroartemisinin-

Pyronaridine 360mg Dihydroartemisinin







-

Dihydroartemisinin-

Sulfadoxine-

Pyrimethamine

360mg Dihydroartemisinin Manufacturer Guidelines

(Dalasin – Adams Pharma)

www.ACTwatch.info

Page 161

8.8 Child QAACTs

The following products are considered as Child QAACTs for the purpose of ACTwatch:

Artemether Lumefantrine ACT with a leaf 4 months to <3 years (Novartis)

ACT with a leaf 3 years to <7 years (Novartis)

Artemef 4 months up to 3 years (Cipla)

Artemef 3 years up to 7 years (Cipla)

Artefan 20/120 5-14kg (Ajanta)

Artefan 20/120 15-24kg (Ajanta)

Artemether + Lumefantrine <3 years (Ipca Laboratories)

Artemether + Lumefantrine 3-8 years (Ipca Laboratories)

Coartem 20/120 5-15kg (Novartis)

Coartem 20/120 15-25kg (Novartis)

Coartem Dispersible 5-15kg (Novartis)

Coartem Dispersible 15-25kg (Novartis)

Coartem E Fixe 5-15kg (Novartis)

Coartem E Fixe 15-25kg (Novartis)

Coartem E Fixe Dispersible 5-15kg (Novartis)

Coartem E Fixe Dispersible 15-25kg (Novartis)

Co-Falcinum 5-14kg (Cipla)

Co-Falcinum 15-24kg (Cipla)

Combisunate 20/120 5-14kg (Ajanta)

Combisunate 20/120 15-24kg (Ajanta)

Dawa Mseto Ya Malaria Alu (6 and 12 tablet packs, Novartis)

La Coartem (6 and 12 tablet packs, Novartis)

Lumartem 5kg to <15kg (Cipla)

Lumartem 15kg to <25kg (Cipla)

Malarpack Coartem (6 and 12 tablet packs, Novartis)

Primo (6 and 12 tablet packs, Novartis)

Tibamal (6 and 12 tablet packs, Novartis)

Artesunate Amodiaquine

ACTipal 25mg/67.5mg (Sanofi Aventis)

ACTipal 50mg/135mg (Sanofi Aventis)

ACTipal 50mg/153mg (Strides Arco Labs)

Arsuamoon 1-6 years (Guilin Pharmaceutical)

Artesunate + Amodiaquine Child 1-6 years (Ipca Laboratories)

Coarsucam Infant 2-11 months (Sanofi Aventis)

Coarsucam Toddler 1-5 years (Sanofi Aventis)

Falcimon Kit Young Children up to 6 years (Cipla)

Larimal Child 1-6 years (Ipca Laboratories)

Malariakit (Ipca Laboratories)

Serenadose Enfants 50mg/153mg 1-5 years (Cipla)

Winthrop Infant 2-11 months (Sanofi Aventis)

Winthrop Toddler 1-5 years (Sanofi Aventis)

www.ACTwatch.info

Page 162

8.9 RDT manufacturers submitting to WHO for product testing

The following manufacturers have submitted at least one RDT for testing during rounds 1-3 of the

WHO Malaria RDT Product Testing cycle (2008-2011).

Access bio, Inc.

ACON Laboratories, Inc.

Amgenix International, Inc.

AZOG, Inc.

Bhat Bio-Tech India (P) Ltd.

Biosynex

Blue Cross Bio-Medical (Beijing) Co., Ltd.

CTK Biotech, Inc.

Diagnostics Automation/Cortez Diagnostics, Inc.

DiaMed AG

Guangzhou Wonfo Biotech Co., Ltd

HBI Co., Ltd.

Human GmbH

ICT Diagnostics

IND Diagnostic Inc.

Innovatek Medical Inc.

InTec Products, Inc.

Inverness Medical Innovations, Inc.

J. Mitra & Co. Pvt. Ltd.

Orchid Biomedical Systems

Premier Medical Corporation Ltd.

Span Diagnostics Ltd

SSA Diagnostics & Biotech Systems

Standard Diagnostics, Inc.(now Alere Healthcare (Pty) Ltd)

Unimed International Inc.

Vision Biotech (Pty) Ltd.(now Alere Healthcare (Pty) Ltd)

Zephyr Biomedicals

www.ACTwatch.info

Evidence for Malaria Medicines Policy

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