Outlet Survey Republic of Benin 2009 Survey Report

Transcription

1 Evidence for Malaria Medicines Policy Outlet Survey Republic of Benin 2009 Survey Report Country Program Coordinator Cyprien Zinsou Association Béninoise pour le Marketing Social/PSI Lot 919 Immeuble Montcho Sikècodji Cotonou Republic of Benin Phone: /14 Fax: czinsou@abms bj.org Principal Investigator Dr. Kathryn O Connell ACTwatch, Malaria Control & Child Survival Department Population Services International Regional Technical Office Whitefield Place, School Lane, Westlands P.O. Box Nairobi, Kenya Phone: /6/7/8 koconnell@psi.org Copyright 2009 Population Services International (PSI). All rights reserved.

2 Copyright 2009 Population Services International (PSI). All rights reserved.

3 Acknowledgements ACTwatch is funded by the Bill and Melinda Gates Foundation. This study was implemented by Population Services International (PSI). ACTwatch s Advisory Committee: Mr. Suprotik Basu Mr. Rik Bosman Ms. Renia Coghlan Dr. Thom Eisele Mr. Louis Da Gama Dr. Paul Lalvani Dr. Ramanan Laxminarayan Dr. Matthew Lynch Dr. Bernard Nahlen Dr. Jayesh M. Pandit Dr. Melanie Renshaw Mr. Oliver Sabot Ms. Rima Shretta Dr. Rick Steketee Dr. Warren Stevens Dr. Gladys Tetteh Prof. Nick White, OBE Prof. Prashant Yadav Dr. Shunmay Yeung Advisor to the UN Secretary General's Special Envoy for Malaria Supply Chain Expert, Former Senior Vice President, Unilever Global Access Associate Director, Medicines for Malaria Venture (MMV) Assistant Professor, Tulane University Malaria Advocacy & Communications Director, Global Health Advocates Executive Director, RaPID Pharmacovigilance Program Senior Fellow, Resources for the Future Project Director, VOICES, Johns Hopkins University Centre for Communication Deputy Coordinator, President's Malaria Initiative (PMI) Head, Pharmacovigilance Department, Pharmacy and Poisons Board Kenya Advisor to the UN Secretary General's Special Envoy for Malaria Vice President, Vaccines Clinton Foundation Senior Program Associate, Strengthening Pharmaceutical Systems Program, Science Director, Malaria Control and Evaluation Partnership in Africa (MACEPA) Health Economist CDC Resident Advisor, President s Malaria Initiative Kenya Professor of Tropical Medicine, Mahidol and Oxford Universities Professor of Supply Chain Management, MIT Zaragoza International Logistics Paediatrician & Senior Lecturer, LSHTM Copyright 2009 Population Services International (PSI). All rights reserved.

4 The following individuals contributed as follows to the research study in Benin: Chérifatou Bello Adjibabi Cyprien Zinsou Esther Tassiba Ghyslain Guedegbe Njara Rakotonirina Hellen Gatakaa Sandra Le Fèvre Erik Munroe National Malaria Control Programme, MOH/Benin, (ACTwatch focal point within the Ministry of Health) assisted with advocacy. Monitoring and Evaluation Director, ABMS/PSI Benin, oversaw all aspects of implementation and management of the survey. ACTwatch Country Program Coordinator, ABMS/PSI Benin, was responsible for all aspects of implementation and management of the survey. Chef Service ACTwatch, ABMS/PSI Benin, assisted the Country Program Coordinator with the coordination and facilitation of trainings, data collection, and data entry. Maternal and Child Health Director, ABMS/PSI Benin, (PSI focal point for NMCP activity) assisted with advocacy and dissemination of results. Senior Research Associate, ACTwatch Central, provided overall guidance on the analysis and construction of indicators. Pfizer Research Fellow, ACTwatch Central, assisted the Country Program Coordinator with the coordination and facilitation of trainings, data collection, and data entry. Research Associate, ACTwatch Central, conducted analysis on the data. Stephen Poyer Dr. Kathryn O Connell Tanya Shewchuk Research Associate, ACTwatch Central, conducted analysis on the data and compiled the report. Principal Investigator, ACTwatch Central, provided overall technical guidance on the study. Project Director, ACTwatch Central, provided overall oversight and dissemination. Copyright 2009 Population Services International (PSI). All rights reserved.

5 The ACTwatch Group is comprised of the following individuals: PSI ACTwatch Central PSI ACTwatch Country Program Coordinators LSHTM Tanya Shewchuk, Project Director; Dr Kathryn O Connell, Principal Investigator; Hellen Gatakaa, Senior Research Associate; Stephen Poyer, Illah Evance, Julius Ngigi, Research Associates. Cyprien Zinsou, PSI/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. Dr. Kara Hanson, Principle Investigator; Edith Patouillard, Dr. Catherine Goodman, Benjamin Palafox, Sarah Tougher, Immo Kleinschmidt, co investigators. Suggested citation: ACTwatch Group and Association Béninoise pour le Marketing Social (ABMS)/Benin. (2009). Benin Outlet Survey Report Population Services International: DC. Available from: Copyright 2009 Population Services International (PSI). All rights reserved.

6 Table of Contents TABLE OF CONTENTS... I LIST OF ACTWATCH TABLES... II LIST OF FIGURES... II GENERAL DEFINITIONS... III CLASSIFICATION OF ACTS... V LIST OF ABBREVIATIONS... VIII EXECUTIVE SUMMARY... 1 Overview... 1 Key findings... 2 BACKGROUND... 7 Overview of the ACTwatch Research Project... 7 Country background... 8 METHODS RESULTS OUTLET SURVEY Characteristics of the sample Standard ACTwatch tables ADDITIONAL TABLES REFERENCES APPENDICES ACTs classified as quality assured Nationally registered ACTs Final sample Survey team Description of outlet types visited for this survey Questionnaire Page I

7 List of ACTwatch Tables Table A.1: Availability of antimalarials, by outlet type Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type Table A.3: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type Table A.4: Price of antimalarials, by outlet type Table A.5: Affordability of antimalarials, by outlet type Table A.6: Availability of diagnostic tests and cost to patients, by outlet type Table A.7: Market share, by outlet type Table A.8: Provider knowledge, by outlet type Table A.9: Provider perceptions, by outlet type Table B.1: Market share by antimalarial category within each outlet type List of Figures Figure 1. Availability of antimalarials by outlet type... 2 Figure 2. Outlet types stocking antimalarials... 3 Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock... 3 Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests... 4 Figure 5. Median price of a tablet AETD antimalarial treatment in the private sector... 5 Figure 6. Market share of AETDs sold/distributed in the past week (7 days)... 5 Figure 7. Provider knowledge of recommended first line treatment and dosing regimens... 6 Figure 8: Location of Benin... 8 Page II

8 General Definitions Term Adult Equivalent Treatment Dose (AETD) Antimalarial Antimalarial combination therapy Artemisinin based Combination Therapy (ACT) Artemisinin monotherapy Artemisinin and its derivatives Booster Sample Censused arrondissement Cluster Combination therapy Dosing/treatment regimen Definition An AETD is the number of milligrams (mg) of an antimalarial drug needed to treat a 60 kg adult. Any medicine recognized by the WHO for the treatment of malaria. Medicines used solely for the prevention of malaria were excluded from analysis in this report. The simultaneous use of two or more drugs with different modes of action to treat malaria. An antimalarial that combines artemisinin or one of its derivatives with an antimalarial or antimalarials of a different class. Refer to Combination Therapy (below). An antimalarial medicine that has a single active compound, where this active compound is artemisinin or one of 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. A booster sample is an extra sample of units (in this case, outlets) of a type not adequately represented in the main survey, but which are of special interest. In this survey public health facilities and pharmacies were targeted by a booster sample. The booster sample of public health facilities aimed to enumerate all PHFs in the commune in which a selected arrondissement fell. The booster sample of pharmacies comprised a simple random sample of a further two thirds of pharmacies in the department in which a selected arrondissement fell. An arrondissement where field teams conducted a full census of all outlets with the potential to sell antimalarials. The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit determined by the Ministry of Health (MOH) that host a population size of approximately 10,000 to 15,000 inhabitants. These units frequently are defined by geographical, health, or political boundaries, and are based around wards. In Benin, they were defined as Arrondissement. The use of two or more classes of antimalarial drugs/molecules in the treatment of malaria that have independent modes of action. The posology or timing and number of doses of an antimalarial used to treat malaria. This schedule often varies by patient weight. Page III

9 Enumerated Outlets First line treatment Monotherapy Nationally registered ACTs Non artemisinin therapy Outlet Oral artemisinin monotherapy Rapid Diagnostic Test (RDT) for malaria Screened Screening criteria Second line treatment Treatment/dosing regimen Outlets that were visited by a member of one of the field teams and for which, at minimum, basic descriptive information was collected. The government recommended treatment for uncomplicated malaria. Benin s first line treatment for malaria is artemether lumefantrine (AL) 20mg/120mg. An antimalarial medicine that has a single mode of action. This may be a medicine with a single active compound or a synergistic combination of two compounds with related mechanisms of action. 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. An antimalarial treatment that does not contain artemisinin or any of its derivatives. 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 the annex for a description of the outlet types visited for this survey. 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. A test used to confirm the presence of malaria parasites in a patient s bloodstream. An outlet that was administered the screening questions (S1 to S3) of the outlet survey questionnaire (see 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. The government recommended second line treatment for uncomplicated malaria. Benin s second line treatment for malaria is quinine. Second line treatment indicators include all dosage forms. The posology or timing and number of doses of an antimalarial used to treat malaria. This schedule often varies by patient weight. Page IV

10 Classification of ACTs Quality assured ACTs (QAACT) A quality assured product must be WHO pre qualified and/or authorized for marketing by a Stringent Drug Regulatory Authority. Products that have not yet been WHO pre qualified or approved by a Stringent Drug Regulatory Authority must be evaluated and recommended for use by an independent panel of technical experts hosted by World Health Organisation s Department for Essential Medicines and Pharmaceutical Policies (GFATM, 2010). Quality assured ACTs comply with the Quality Assurance Policy of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Brands included in this category and audited during data collection are: Artefan 20mg/120mg Coartem 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg Coarsucam (Adulte ; Enfant ; Nourisson) Winthrop (Adulte ; Nourisson) First line quality assured ACTs (FAACT): Government recommended first line treatments for uncomplicated malaria that appear on the WHO list of approved ACTs or the UNICEF procurement list. Brands included in this category and audited during data collection are: Artefan 20mg/120mg Coartem 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg Non first line quality assured ACTs (NAACT): ACTs that are not the government s recommended first line treatment for uncomplicated malaria, but which do appear on the WHO list of approved ACTs or the UNICEF procurement list. Brands included in this category and audited during data collection are: Coarsucam (Adulte ; Enfant ; Nourisson) Winthrop (Adulte ; Nourisson) Page V

11 Other ACTs ACTs that appear on neither the WHO list of approved ACTs or the UNICEF procurement list. This includes all audited brands of ACTs not included in the other two ACT categories: Alaxin Plus Alaxin SP Arco Artecom Artedar Artediam Artefan (40mg/240mg; 80mg/480mg) Artemether Lumefantrine (Tong Mei Laboratoire) Artequin Artesunate Amodiaquine (Tong Mei Laboratoire) AsunateDenk Plus Camoquin Plus Co Arinate Co Artesiane Cofantrine Combicure Darte Q Duo Cotexcin Larimal FD 400 Lonart Lufanter Lumet (Forte) Lumether Lumiter Mac Med Macsunate Plus Malacur Malmed P Alaxin Other ACT classifications Any first line ACT Government recommended first line treatments for uncomplicated malaria, artemether lumefantrine 20mg/120mg tablets. Brands included in this category and audited during data collection are: Artefan 20mg/120mg Artemether Lumefantrine 20mg/120mg (Tong Mei Laboratoire, Togo) Coartem 20mg/120mg Cofantrine 20mg/120mg Lufanter 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg Lumiter 20mg/120mg (MacLeods Pharmaceuticals, India) 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. (See Appendix B for a complete list of Benin s nationally registered ACTs.) Brands included in this category and audited during data collection are: Alaxin Plus Alaxin SP Arco Artecom Artedar Artediam Artefan Artequin Camoquin Plus Co Arinate Co Artesiane Coarsucam Coartem Cofantrine Darte Q Duo Cotecxin Lonart Lufanter Lumartem Lumether Macsunate Plus Malacur Malmed P Alaxin Page VI

12 AsunateDenk Plus Page VII

13 List of Abbreviations No data was available *** Undefined ratio as a non zero value is being divided by a value of zero ABMS ACT AETD AL AMFm ASAQ CFA CHW CI CQ DHS FAACT GFATM GPS IQR LLIN LSHTM MOH n/a NAACT NGO NMCP PMI PPS PSI QAACT RDT SP UN UNICEF WHO Association Béninoise pour le Marketing Social (PSI affiliate in Benin) Artemisinin based Combination Therapy Adult Equivalent Treatment Dose Artemether Lumefantrine Affordable Medicines Facility malaria Artesunate Amodiaquine (Franc) de la Communauté financière d Afrique Community Health Worker Confidence interval Chloroquine Demographic and Health Survey First line Quality Assured ACT Global Fund to Fight AIDS, Tuberculosis, and Malaria Global Positioning System Inter Quartile Range Long Lasting Insecticidal Net London School of Hygiene and Tropical Medicine Ministry of Health Not applicable: Indicates statistic cannot be calculated as the numerator is zero Non first line quality Assured ACT Non governmental Organization Programme National de Lutte contre le Paludisme (National Malaria Control Program) President s Malaria Initiative Probability Proportional to Size Population Services International Quality Assured ACT Rapid Diagnostic Test Sulfadoxine Pyrimethamine United Nations United Nations Children s Fund World Health Organization Page VIII

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15 Executive Summary Overview The ACTwatch Outlet Survey, one of the ACTwatch project components, 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 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 Benin from April to July 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 is also collected. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials. A nationally representative sample of all outlets with the potential to sell or provide antimalarials to a consumer was taken through a census approach in 19 clusters across Benin; clusters being defined as Arrondissements. Sampling was conducted using a one stage probability proportion to size (PPS) cluster design, with the measure of size being the relative cluster population. 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 are as follows: 1) public health facilities (government hospitals, health centres, dispensaries, village health units, and other government health facilities); 2) private not for profit health facilities (mission and NGO health facilities); 3) registered pharmacies; 4) private for profit health facilities (private clinics and hospitals); 5) stores and boutiques; 6) market stalls; and 7) itinerant drug vendors (hawkers). Refer to the annex for definitions and numbers of each type of outlet included in the analysis. Three questionnaire modules were administered to participating outlets: 1) screening module 2) audit sheet and 3) provider module. For all outlets, trained interviewers administered the screening module to collect information on the outlet type; location, including the outlet s longitude and latitude; and information on availability of antimalarials. Among those outlets that stocked antimalarials at the time of survey, the audit sheet was administered. For each antimalarial, information was recorded on the brand and generic names, strength, expiry, amount sold in the last week and price to the consumer. Among outlets that stocked antimalarials at the time of interview or in the past three months, the interviewer collected information on provider demographics, knowledge, perceptions, and medicine storage conditions. Several validation and data checking steps occurred during and after data collection. Double data entry was conducted using Microsoft Access (Microsoft Cooperation, Seattle, WA, USA). Data was analysed using Stata 11 (Stata Corp, College Station, TX). More information on the study design is available at Page 1

16 Key findings Data were collected in two tranches, between 28 th April and 13 th May, and 11 th to 27 th July, A total of 1,870 outlets were approached. Of these, 200 outlets were not screened for various reasons: 132 providers refused to be interviewed; 30 outlets were closed down permanently; 6 outlets were not open at the time of the survey visit; in 29 outlets, providers were not available for interview at the time of survey visit; and 3 providers were unable to be interviewed for other reasons. Overall, 1,670 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 1,061 outlets met our screening criteria and were interviewed. Of the 1,061 completed interviews, 217 reported having stocked antimalarials at any point in the three months prior to the interview and 844 outlets stocked antimalarials at the time of the interview. AVAILABILITY OF ANY ANTIMALARIAL: Stocking rates of any antimalarial varied by outlet type, with a clear distinction between formal and informal outlets. In the public/not for profit sector, 94 of outlets had at least one antimalarial in stock on the day of interview, with 95 of public health facilities stocking antimalarials. In the private (for profit) sector, 97 of pharmacies and 84 of private for profit health facilities stocked antimalarials on the day of interview. Stocking rates were lower among unregulated outlets in the private for profit sector: one third of boutiques and market stalls, and 43 of hawkers stocked antimalarials. Figure 1. Availability of antimalarials by outlet type Page 2

17 OUTLET TYPES STOCKING ANTIMALARIALS: Figure 2 shows the relative distribution of all outlets that had at least one antimalarial in stock. Market stalls were the most common type of outlet stocking antimalarials, followed by boutiques. Together with hawkers, the informal sector comprised three quarters of outlets stocking antimalarials. Figure 2. Outlet types stocking antimalarials AVAILABILITY OF DIFFERENT CLASSES ANTIMALARIALS: Among outlets stocking antimalarials, availability of FAACT and oral artemisinin monotherapy varied greatly by outlet type. While 86 of pharmacies and 84 of public health facilities stocked FAACTs, the proportions were much lower for mission/ngo and private health facilities (29 and 19). Less than 5 of informal outlets stocked FAACTs. Almost one in ten mission/ngo health facilities and four in ten pharmacies had oral artemisinin monotherapies in stock. Non artemisinin monotherapy was available in over 90 of outlets of all types. Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock Page 3

18 AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: Among outlets stocking antimalarials in the past three months, 75 of public/not for profit outlets had diagnostic testing available, compared to only 2 of outlets in the private (for profit) sector. RDTs were much more widely available than microscopy in public health facilities (85 and 16, respectively). In the private sector, 23 of for profit health facilities had tests available, compared to only 1 of pharmacies. No RDTs were available among the 618 informal providers interviewed. Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests No outlet type systematically provides FAACT free of charge in Benin, and the median price of FAACT in public health facilities was $1.30 [n=464]. The median FAACT price in the private sector was $3.24 [n=689], and pharmacies were substantially more expensive than other private outlets ($6.10 [n=191], compared to $2.59 [n=15] in for profit health facilities). By comparison the median price of SP, the most popular antimalarial, was 5 times cheaper than the median FAACT cost ($0.65 [n=577]). Page 4

19 Figure 5. Median price of a tablet AETD antimalarial treatment in the private sector VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: The private sector in Benin comprised over 70 of the antimalarial market. Pharmacies accounted for more than one third of total volumes sold/distributed. Three quarters of all treatments distributed were non artemisinin therapies, mainly SP (40) and CQ (25). 23 of treatments were ACTs, although only half of these were FAACT (12). Although available in 37 of pharmacies stocking antimalarials, oral artemisinin monotherapy comprised 0.1 of all volumes. Figure 6. Market share of AETDs sold/distributed in the past week (7 days) PROVIDER KNOWLEDGE: Overall, 22 of providers interviewed were able to correctly state AL as the recommended first line treatment for uncomplicated malaria in Benin. By sector, knowledge was significantly higher in the public/not for profit sector than the private sector (73 vs. 18). Knowledge was highest among providers in public health facilities (92), followed by those in pharmacies (67). Knowledge of adult and child dosing regimens for AL followed the same trends as first line knowledge: around 70 of public/not for profit providers described the correct regimens, compared to 13 of private sector providers. Page 5

20 Figure 7. Provider knowledge of recommended first line treatment and dosing regimens Page 6

21 Background Overview of the 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 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. In combination, the research components thread together 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, Democratic Republic of Congo, Madagascar, Nigeria, Uganda and Zambia between 2008 and Countries were selected with the aim of studying a diverse range of markets from which comparisons and contrasts could be made. The research in Benin is planned as follows: three outlet surveys (2008, 2009 and 2011); supply chain research (2009); and two household surveys (2009 and 2011). This report presents the results of a cross sectional survey of outlets conducted in Benin between April and July 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. Information on other ACTwatch studies can be found at Page 7

22 Country background Overview of the country Benin is located in the West Africa sub region and is bordered by Niger and Burkina Faso to the north, Nigeria to the east and Togo to the west (Figure 8). Figure 8: Location of Benin In 2009 the population was estimated at 8.6 million, with 1.5 million children under 5 years of age (World Population Prospects, 2011). Approximately 60 of people are live in rural areas (World Urbanization Prospects, 2010). There are over 40 ethnic groups in Benin, including Fon, Asja, Yoruba, Goun, Bariba and Fulani tribes. The official language is French; Fon, Goun and Yoruba are widely spoken in the south of the country, and Bariba and Fula are most common in the north. The south of Benin is characterized by low lying, marshy coastal plains which give way to flat plains and savanna in the north. The principal rainy season lasts from April to July and covers the whole country, while shorter rains also occur in the south during October and November. Between December and March Benin experiences the Harmattan, winds blowing south from the Sahara. Source: CIA, The World Factbook world factbook/index.html Description of health care system In the decade leading to 2009, GDP grew at an average annual rate of 4.4 while the population growth rate averaged 3.3. Over this decade GDP per capita more than doubled, from $370 in 1999 to $771 in 2008 (World Bank, 2010). However, by the end of this period more than one third of the population was living below the government defined poverty line (UNDP, 2008). One in eight children dies before reaching their fifth birthday (INSAE, 2007), and life expectancy at birth in 2009 was 54 years for men and 60 years for women (WHO, 2011). The total fertility rate remains high, at 5.4 per woman in 2009, while the contraceptive prevalence was estimated at 17.0 in 2006 (INSAE, 2007). Benin is divided into 12 departments, 77 communes or autonomous areas (the cities of Cotonou, Porto Novo, and Parakou), and 546 arrondissements. Arrondissements are sub divided into villages (more commonly called quartiers in urban areas). The public health system operates through three tiers, linked to the three levels of health care and their associated structures. At the highest level lies the Ministry of Health, and the National Referral Hospital in Cotonou. This is the Centre National Hospitalier et Universitaire which also serves as a teaching hospital. The second tier is at department Page 8

23 level, whose main structures are the Departmental referral hospitals. Although there are 12 departments in Benin, in mid 2009 there were only 6 functional referral hospitals nationwide (PMI, 2009). The third tier comprises 34 health zones. Health zones are administratively separate from communes, with each zone containing between one and four communes. Health structures at this level are Zone level hospitals (Hopital de Zone); Commune level health centres (Centre de santé de commune); smaller, Arrondissement level health centres (Centre de santé d Arrondissement); and village health units. In addition to government run facilities, the health sector includes private forprofit facilities, NGO and faith based clinics and hospitals, licensed pharmacies, and unlicensed drug vendors selling from permanent sites or hawking their products from site to site. In 2006 there were an estimated 442 arrondissement level health centres and 75 commune level health centres across the whole country (PM, 2009). In 2009, approximately 180 private pharmacies were registered with the MOH. Healthcare consumers at government facilities are expected to pay for consultations, diagnostic tests, procedures and medicines. Fees are kept at the facility level and cover, on average, 43 of the operating costs of the facilities. In line with the general policy, treatment of uncomplicated malaria is provided at public facilities for a fee: blister packs of 6, 12, 18, and 24 AL tablets are sold for 150CFA, 300CFA, 450CFA, and 600CFA, respectively (PMI, 2009). In CFA was on average equivalent to $0.33. Epidemiology of malaria Malaria epidemiology in Benin can be characterized as stable endemic and, as such, the risk of an epidemic is considered to be low. The entire population is at risk of infection. Transmission is more intense in the (more populated) southern third of the country, while a single seasonal peak is observed in the north. The predominant parasite species is P.falciparum. Malaria is considered to be the leading cause of morbidity and mortality among children under five, accounting for 41 of outpatient visits and 29 of hospitalizations for this age group (INSAE, 2007). Government figures for 2009 report just under 900,000 confirmed malaria cases across all age groups, and a further 350,000 probable cases (reporting completeness for 2009 was estimated at 88) (WHO, 2010). Antimalarial Policies and Regulatory Environment Faced with growing resistance to chloroquine and SP, Benin adopted artemether lumefantrine (AL) as the first line treatment for uncomplicated malaria in March 2004 (PNLP, 2005). Artesunate+amodiaquine (ASAQ) is recommended as the alternative treatment, should AL not be available, for patients who cannot tolerate AL, and for children under six months of age. Parenteral quinine is recommended for the treatment of severe malaria and as pre referral treatment. Artesunate injection and suppositories are included in the national policy as a prereferral treatment for severe malaria. Oral artemisinin monotherapies have been banned in Benin since 2008 (WHO, 2010). Although the political policy change to ACT occurred in 2004, it was a further 4 years before this policy was truly active at the national level (PMI, 2009), and ACT only became widely available in the public sector in Prior to 2009 ACT was most commonly available through the private sector, Page 9

24 which has historically been an important distribution channel of antimalarials in Benin (Tougher et al, 2009). ACTs were first introduced in the public sector through a Global Fund supported pilot project and the Projet Intégré de Santé Familiale (PISAF), a mission funded integrated family health project. By late 2008, about one third of the country was covered (i.e., ACTs delivered to facilities and staff trained), including the Departments of Mono, Couffo, Zou, and Collines (PMI, 2008). Inefficiencies in the public sector supply management system have hindered initial distribution of ACTs to public health facilities, despite 2.7 million treatments being delivered to the government during 2009 (WHO, 2010). An assessment conducted by Management Sciences for Health identified both frequent stock outs of ACTs at public health facilities, and a large stock of AL warehoused by the Central Medical Stores (CAME) approaching expiration. Limited means of transportation from CAME s central and regional warehouses to public health facilities, insufficient space and inappropriate storage conditions, and an inadequate information management system to monitor consumption of antimalarials at public health facilities have all contributed to this situation (Ndoye et al, 2009). The NMCP strategic plan for views diagnosis and treatment of uncomplicated malaria by community agents using ACT as an important strategy in case management (PNLP, 2005). As of late 2009, this strategy had not been rolled out at scale across the country. As noted above, public health facilities charge a fee for treatment with AL. In 2009, the treatment policy for children under five was presumptive, while treatment for older patients was recommended only for those with a positive diagnostic test. With donor support rapid diagnostic tests (RDTs) have been extensively scaled up since In early 2009 the government had 586,000 RDTs for use in the public health system, divided between health zones and the central medical stores. The NCMP policy is that RDTs are to be provided free of charge in the public sector. Malaria control strategy The core interventions for malaria control in Benin include long lasting insecticide treated net (LLIN) distribution through antenatal care clinics (ANC) and immunization visits, universal campaigns, and subsidized and at cost sales in the private sector; intermittent preventive treatment for pregnant women (IPTp); case management (following diagnosis) at all levels of health care; and, to a morelimited extent, indoor residual spaying (IRS). Benin has removed import tariffs on mosquito nets, antimalarials and RDTs; as of August 2010 tariffs still apply to pumps and insecticides used for IRS (M Tap, 2010). In 2007 a national campaign distributed 1.4 million LLINs to households across Benin. This followed survey estimates that although 56 of households owned a mosquito net, only 25 of households reported owning an ITN, and only 20 of children under five had slept under an ITN the previous night (INSAE, 2007). The NMCP s universal coverage campaign envisions one net for every two people, and a second round of mass distribution was planned for LLINs are also available through ANC and immunization visits, where they form part of a kit that includes two doses of SP, one dose of mebendazole, folic acid and iron. These kits cost around $1, although the nets and SP is free and provided by funds from PMI, UNICEF and the World Bank. A partnership between PMI and PSI Benin also plans to sell highly subsidized, socially marketed LLINs in the private sector. The 2006 DHS found that 84 of pregnant women accessed an ANC clinic at least twice during their last pregnancy, but less than 1 of women received two doses of SP from ANC visits. IPTp was only introduced at a national level in 2005, and problems with the public sector supply chain described Page 10

25 above would doubtless have impacted the distribution of SP in the public sector. Recent research at selected maternity hospitals shows that coverage for two doses of IPTp has increased in some facilities from 3 in 2005 to 68 in 2009 (d Almeida et al, 2011). The results of the 2011 DHS will show whether this finding is generalisable. IRS has been recommended by the NMCP since 2006, and spraying rounds have been funded by PMI in 4 communes in Ouémé in 2008 and 2009, covering more than 520,000 people. LLINs were distributed to households following each round of spraying. Looking ahead, PMI intends to find other suitable locations in Benin for IRS, most likely in the north of the country where LLIN coverage is lower than the south and malaria transmission is seasonal (PMI, 2009). Malaria financing Financing for malaria control activities has increased dramatically in recent years, from less than $5 million annually between 2001 and 2005, to over $22 million in The main sources are the President s Malaria Initiative (PMI), World Bank, Government of Benin, and Global Fund. The NMCP received funding from the Global Fund Round 3 Grant ($2.14 million) which was channeled to a project providing 458 villages with ACTs, with the aim (among others) of improving case management of malaria in children under five through health facilities and community based management. The project was implemented in Mono and Couffo, two departments with high malaria transmission. A Round 3 Rolling Continuation Channel (RCC) to the implanting partner will provide $94 million to expand this project (as well as financing net distribution campaigns). A Round 7 ($22.6 million) grant launched in July 2008 aims to cover community level ACT distribution for 14 of the 34 health zones (approximately 40 of the population) not already covered by the RCC. Thus, together, these awards will finance community case management of malaria countrywide. In 2007 a four year grant ($31 million) from the World Bank Malaria Booster Programme commenced covering an important portion of ACT needs and the bulk of RDTs required. Benin also received $3.6 million in 2007 and $13.8 million in 2008 for malaria control activities from the PMI. Funds from 2008 were used to procure 900,000 LLINs; 250,000 ACT treatment doses for children under five; and kits for the treatment of severe malaria. In addition, PMI funds supported the training and supervision of laboratory staff, and public and private health workers. Of the $13.8 million allocated for 2009, approximately $2 million of this was for malaria treatment and diagnosis (PMI, 2009). Page 11

26 Methods Sampling approach The outlet survey was designed to allow reliable estimations of key indicators for the country as whole. Sample units The target sampling units were all outlets with the potential to sell or provide antimalarials, an outlet being defined as any point of sale or provision of a commodity to an individual. For this study outlets were not restricted to stationary points of sale and included mobile units or individuals. Determined on the basis of a pilot study prior to the main ACTwatch survey, the following outlet types were included in the sample: Public health facilities at all levels of the health system; NGO and Mission health facilities; Private health facilities; Part One pharmacies (registered pharmacies) and their rural outposts; General retail outlets: supermarkets, boutiques, market stalls; Hawkers. Outlets such as diagnostic centres; wholesale medical supply stores; eye, skin, dental and other similarly specialized clinics; and veterinary clinics were all excluded from the sample. In addition, at the time of data collection community health workers were not formally included in the MOH structure and were thus excluded from the survey. Sample size determination The proportion of outlets with any ACT, estimated to be 40 was used as a key indicator for sample size estimation. A minimum of 290 outlets with antimalarials in stock were needed to provide detectable changes in ACT availability for a single stratum and between sectors. With this number, 19 clusters per strata provided a representative sample to detect 20 increase at 80 power, setting the level of significance at 5 and adjusting for an estimated design effect of 3. Sampling frame Administratively, Benin is divided into 12 departments and subdivided into 77 communes. Communes are further divided into arrondissements. The desired cluster size for the outlet survey was approximately 10,000 to 15,000 inhabitants, which corresponds most closely arrondissements in Benin. The last census was conducted in 2002 and used as a sample frame for the 2009 outlet survey. In addition, a facility listing of 180 registered pharmacies was used to confirm the location of pharmacies in each department, and to inform the pharmacy booster sample. The list of pharmacies is grouped by commune within each department (except for Cotonou, where outlets are grouped by arrondissement) and gives the name of the proprietor, the address, and phone number. Page 12

27 Selection procedure of the sub districts Nineteen arrondissements were selected from the 2002 census frame using a one stage cluster design, with probability of selection proportional to arrondissement population size. All arrondissements in the country were included in the sampling frame. Selection procedure of the booster sample The main sample was supplemented by a booster sample. The inclusion of a booster sample helped ensure adequate representation of the relatively rare but important antimalarial outlet types: public health facilities and registered pharmacies. The booster sampling approach differed for the two types of outlets. For public health facilities, all facilities located in the commune in which a selected arrondissement fell were censused and invited to participate in the study. The booster sample of pharmacies comprised a simple random sample of two thirds of pharmacies in the department in which a selected arrondissement fell, excluding those outlets already enumerated in selected arrondissements. All departments were visited for the booster sample (that is, at least one selected arrondissement fell in each of the 12 departments). Questionnaire The outlet survey questionnaire comprised 3 modules: a screening module for all outlets; an audit module (the audit sheets) for outlets with antimalarials in stock on the day of interview; and a provider module for all eligible outlets, including those with no antimalarials in stock on the day of interview but had stocked antimalarials in the past three months. Audit sheets were based on the HAI Action International questionnaire for essential medicines, developed with the World Health Organization. In consultation with the ACTwatch advisory committee and National Malaria Control Program, the questionnaire was modified to reflect issues relevant to malaria in Benin. Paper questionnaires were administered during data collection. The questionnaires were written in French (the official language in Benin) and administered either in French or in a local language, most commonly Fon, Goun, or Bariba. Prior to finalisation, the questionnaire was pilot tested to assess the appropriateness of question wording as well as to verify the skip patterns and interviewer instructions. The Screening Module was used to record the type and location of all outlets, including GPS coordinates. In addition, basic information was collected on the items sold at the outlet. The main purpose of the screening module was to identify outlets that were eligible for the study, and the results of each interview. The Audit Module was used to collect data relating to each antimalarial product an eligible outlet had in stock on the day of interview. This information came from the antimalarial packaging: brand name, generic name and strengths, package type and size; and from provider recall: amount sold or distributed in the last 7 days, retail selling price, and the outlet s wholesale purchase price. The Provider Module was used to collect information from the main provider in all eligible outlets and covered the following topics: Outlet characteristics: number of staff, education level of staff, health related qualifications amongst staff, registration status, storage conditions; Knowledge: Benin s recommended first line treatment and its dosing regimen, health danger signs for children under five; Perceptions: beliefs about the most effective antimalarials; Provision of credit to customers. Page 13

28 Data collection Recruitment of Field Team Experienced research assistants from the ABMS/PSI Benin pool of consultants were recruited to be trained as interviewers and team leaders for this study. Trainees were over recruited by 20 and final selection of study personnel was made after a rigorous six day training, which included a practical fieldwork exercise. Training Interview training followed a 6 day structured agenda, including fieldwork practice on day 5 and formal tests to examine participants understanding of the material presented. Standardised training materials developed by ACTwatch were adapted to the national setting, and sessions were facilitated by staff from ABMS/PSI Benin and the ACTwatch core team. Training consisted of a review of how to fill out the screening, audit, and provider modules; mock interviews; and sessions covering tips on interviewing, how to conduct a census, and how to identify different outlet types. A key element of the training focused on the identification of antimalarial medicines, including the differences between ACTs and non ACTs; the difference between brand names and generic names; how to correctly record medicine strengths; how to record packaged and loose tablets; and the various formulations in which medicines are available. Role plays and exercises using antimalarial packages occurred throughout the sessions. Interviewers were also trained how to introduce the study, answer questions a respondent may have; and seek informed verbal consent for participation. During the fieldwork practice, interviewers followed the full survey methodology in one arrondissement not included in the sample. Trainees were local to the region in which they would work and travelled to Cotonou for the training. Fieldwork Fieldwork was conducted by 25 staff, divided into 7 teams of differing sizes depending on the departments they were assigned. Generally, teams in the south of Benin comprised more interviewers than those in the northern departments. The best performing member of each team was further assigned the role of team leader. Quality control and oversight was provided by ABMS/PSI Benin staff and ACTwatch core team staff. These individuals monitored data collection to ensure procedures were employed properly and were on hand to troubleshoot any issues that were encountered. Initial data collection started on the 28 th April and terminated on the 13 th May. During this time all 19 selected arrondissements were censused, and the public health facility booster sample conducted. The pharmacy booster sample was conducted from the 11 th to the 27 th July. Upon arrival in a study area, team leaders and ABMS/PSI Benin staff (if present) first met with local leaders to introduce themselves and seek permission to carry out the study. Arrondissement boundaries were identified in consultation with local leaders and guides; team leaders then assigned data collectors to a particular area. During fieldwork, data collectors systematically canvassed the arrondissement, approaching every outlet with the potential to sell antimalarials, according to the outlet type definitions designated for this study. Some of these outlets had been signalled in advance through discussions with local authorities and guides. In addition a snowball technique was used, with visited outlets asked to identify other outlets in the locality with the potential to stock medicine. Page 14

29 For each outlet that was identified during the census, the outlet type and location were noted, along with its GPS coordinates. At the start of the interview fieldworkers recorded the outlet s basic details and then asked the following screening question about the availability of antimalarials: Do you have any antimalarial medicines in stock today? If the outlet did not currently have any antimalarials in stock the interviewer asked: Are there any antimalarials that are out of stock today, but that you stocked in the past 3 months? If the interviewee answered no to both questions, the interview was terminated at that point. If the interviewee answered yes to either screening question, the fieldworker proceeded to identify the senior staff member currently present at the outlet. Once presented to the most senior member of staff, the interviewer read the information sheet; answered any questions the respondent may have; obtained informed verbal consent; and then proceeded with the interview. A copy of the questionnaire is included in the annex. During the audit, interviewers requested to see one example of each antimalarial product that was in stock on that day. This included different formulations and age/weight categories of the same brand, as these were all considered different products and required separate entries in the audit. Due to the high volume of antimalarials in many urban pharmacies, data collectors worked in pairs when necessary to complete the work in good time and reduce disruption to the outlet. Pilot tests conducted prior to starting the survey indentified hawkers as a potential source of medicines in Benin. Hawkers were screened and administered the questionnaire in the same manner as any stationary point of sale. Longitude and latitude coordinates were taken from the point where the interview was conducted. A memorandum of understanding was obtained from the Ministry of Health to conduct the survey. Quality control During data collection, experienced ABMS/PSI Benin research staff and ACTwatch core staff accompanied teams to the field and acted as supervisors, monitoring the progress of data collection and resolving queries referred by team leaders. Two reviews of questionnaires were performed during data collection. The team leader performed the first review, scrutinizing for verbal consent; completion; filter errors; and consistency between questions. Second reviews were conducted by an ABMS/PSI Benin supervisor. Queries were followed up with the interviewer and, as required, a callback was performed. In addition to reviewing questionnaires, ABMS/PSI Benin and ACTwatch core staff also provided monitoring and supervision during data. Staff travelled from team to team and conducted spotchecks to ensure team leaders and interviewers were performing their responsibilities adequately. Control of questionnaires Team leaders followed data safeguarding procedures during data collection, collecting questionnaires from interviewers at the end of each day and ensuring their safe storage. During monitoring visits, ABMS/PSI Benin and ACTwatch core staff collected field questionnaires and returned them to Cotonou. Data processing Double data entry was performed using Microsoft Access by experienced data entry clerks. A trained ABMS/PSI Benin research staff member was 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. Page 15

30 A final Access database file was sent to ACTwatch central. Staff reviewed this data, and any entries requiring clarification were documented and raised with ABMS/PSI Benin. ABMS/PSI Benin 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 ABMS/PSI Benin and at ACTwatch central. Data analysis Data were analyzed by the ACTwatch Central team in Nairobi. The ACTwatch analysis plan was followed to analyze the data. These plans outline the steps to take in summarizing and analyzing the data, and contain detailed guidance on data cleaning, weighting, numerators and denominators for calculation of key indicators, definition and calculation of AETDs, and a set of blank tables (a tabulation plan). Indicators were calculated as specified in the indicator table, and presented by outlet type and nationally. Price, availability and volumes are derived from the audit sheets and screening questions. Additional analyses, derived from provider data, examine outlet characteristics, provider knowledge, and availability of microscopic testing for malaria and RDTs. Research associates cleaned data in SPSS and generated statistical tests and means, medians and proportions, using Stata. Survey settings were used to account for the clustered design. Data analysis included descriptive summaries, presented with 95 confidence intervals (CIs). All analysis was reviewed by the senior research associate. A summary of the analysis is presented in this section. Availability and stock outs The availability of any antimalarial was measured as the proportion of surveyed outlets that had at least one antimalarial in stock among all surveyed outlets. Only outlets with at least one antimalarial (of any type and dose) were considered to have antimalarials available. Drugs intended solely for malaria chemoprophylaxis were not included. Cotrimoxazole was also excluded, as it is very rarely used as an antimalarial. Stock out information was collected through both the drug audit and provider interviews. For each drug found in stock, providers were asked if the drug, specific to the brand, and dose, had been out of stock at any point over the past three months. Providers were also asked to list all drugs that were not currently in stock, but had been in stock during the previous 3 months. These two measures were combined to calculate the proportion of outlets with a reported stock out of at least one drug, amongst those that had recently stocked such drugs (defined as stocking today or in the last 3 months). This information measures the ability of outlets to maintain supply rather than provide a particular treatment at a given point in time. Volumes and price The volume and price of the antimalarial recorded in the drug audit were standardized using the adult equivalent treatment dose (AETD) to allow meaningful comparisons between antimalarials with different treatment courses. One AETD is defined as the amount of the drug, in milligrams (mg), that a 60kg adult would need in order to receive a full course of treatment, based upon WHO, peer reviewed, or/and manufacturer guidelines, in that order. The price per package was scaled to be equivalent to one full AETD course, while the number of packages distributed (volumes) was scaled to the equivalent number of AETD courses sold in the previous week. For combination antimalarials, one drug in the combination was selected for these calculations. For ACTs, this was always the artemisinin derivative component (e.g. the artesunate component of artesunate amodiaquine). Page 16

31 To improve understanding of the state of the antimalarial market and aid comparison between and within countries, pricing information for antimalarials were grouped into the three categories that are believed to be most pertinent to policy level decisions: quality assured ACT (including first line quality assured ACT), the most popular non ACT (based on volumes), and oral artemisinin monotherapy. The median price per AETD was calculated for each of these categories. Price measures include only tablet formulations in order to ensure meaningful comparisons. We have elected to exclude the price of non tablet formulations from the price analysis as these formulations (powders for reconstitution, suspensions, suppositories and syrups) tend to be far more expensive per AETD than their tablet equivalents and this would skew the price results and make interpretation difficult. The most popular non ACT was defined as the generic antimalarial that comprised the greatest fraction of AETD volumes across all outlets. 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$ = franc CFA, source: Price data are reported using median and inter quartile range, which are appropriate for describing distributions likely to be skewed. Weighting Weighting outlet survey data was done to allow for the difference in sampling probabilities due to: 1) the sampling strategy which involved a full census of outlets in clusters of varying sizes selected by PPS, and 2) the oversampling for the booster sample. Weights were calculated specific to outlet and analysis type but generally involved the inverse of selection probability and corresponding population size. An exception to this last point is the method used for weighting pharmacies in analysis involving the booster sample (availability and median price or antimalarials), where a sampling fraction was used to mirror the booster sampling approach. For other outlet types we used Arrondissement population sizes for non PHFs, and for analysis involving only the non booster sample (i.e. estimation of volumes); Commune populations were used for PHF outlet types where analysis included the booster sample (availability and price). Page 17

32 Results Outlet survey Characteristics of the sample Figure 3.1.1: Survey flow diagram, [Benin], 2009 A Outlets enumerated* [1,870] Interview interrupted : [0] Eligible respondent not available/time not convenient for interview : [29] Outlets not screened [200] Outlet not open at the time : [6] Outlet closed permanently : [30] B Outlets screened [1,670] Other : [3] Refused : [132] Outlets which did not meet screening criteria [609] C Outlets which met screening criteria 1=[844] or 2=[217] Eligible respondent not available/time not convenient for interview : [0] D Outlets interviewed** [1,061] Outlets not interviewed [0] Outlet not open at the time : [0] Other : [0] Refused : [0] E Outlets with antimalarials in stock on day of visit [844] Outlets with no antimalarials in stock on day of visit*** [217] 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 *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 stock in previous 3 months Page 18

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34 Standard ACTwatch tables Table A.1: Availability of antimalarials, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor Proportion of outlets that had: N=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 Antimalarials in stock at the time of survey visit (87.8, 98.4) (67.5, 98.1) (86.7, 97.4) (70.2, 92.3) (92.0, 98.7) (23.9, 38) (23.9, 46.8) (19.9, 69.2) (27.1, 46.6) (30.1, 48.7) Any ACT (71.6, 88.9) (12.8, 72.3) (51.8, 79.5) (7.4, 39.8) (92.0, 98.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (1.0, 5.1) (3.8, 7.5) Quality Assured ACT (QAACT) (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (5.4, 39.5) (83.7, 92.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.9) (3.5, 7.1) First line (FAACT) (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (4.9, 39.8) (79.2, 86.2) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.8) (3.4, 7.0) Non first line (NAACT) (6.3, 27.7) (3.9, 20.1) (0.1, 3.1) (60.2, 74.2) (0.2, 1.4) (0.5, 1.6) (95 CI) Private (95 CI) Outlets (95 CI) Non quality Assured ACT Other ACT Classifications Any first line ACT Nationally Registered ACT Any non artemisinin therapy Chloroquine Sulfadoxine pyrimethamine (SP) Second line treatment (Quinine) Continued on following page (2.7, 10.0) (12.8, 72.3) (6.5, 35.5) (1.5, 9.3) (92.0, 98.7) (<0.1, 0.8) (0.4, 2.3) (0.8, 3.3) (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (5.4, 39.5) (82.1, 90.5) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.9) (3.5, 7.0) (71.6, 88.9) (12.8, 72.3) (51.8, 79.5) (6.7, 39.6) (92.0, 98.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (1.0, 5.0) (3.8, 7.4) (82.2, 95.5) (67.5, 98.1) (82.3, 95.6) (68.9, 92.1) (79.3, 96.2) (23.9, 37.8) (23.9, 46.8) (19.9, 69.2) (27.0, 46.5) (29.9, 48.4) (0.5, 4.3) (8.3, 50.1) (3.6, 19.6) (7.5, 25.5) (10.9, 17.7) (21.3, 35.5) (21.5, 43.0) (15.1, 65.7) (21.9, 38.9) (21.4, 37.4) (32.9, 66.5) (19.3, 73.8) (31.5, 65.1) (14.5, 50.2) (75.6, 86.4) (0.9, 7.7) (1.8, 7.5) (6.2, 31.1) (2.9, 10.8) (4.7, 12.3) (78.6, 91.0) (67.2, 97.0) (79.6, 91.9) (58.6, 83.7) (52.0, 67.7) (2.6, 13.4) (1.9, 10.2) (2.0, 44.7) (4.3, 16.7) (7.7, 19.4) Page 20

35 Table A.1: Availability of antimalarials, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor Proportion of outlets that had: N=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 Any artemisinin monotherapy (2.7, 10.8) (9.6, 72.1) (5.5, 35.6) (0.5, 4.7) (63.1, 80.7) (0.2, 1.5) (0.6, 2.6) Oral artemisinin monotherapy (0.3, 4.4) (1.2, 40.7) (0.8, 14.7) (27.4, 45.4) (0.1, 0.7) (0.2, 0.9) Non oral artemisinin monotherapy (1.8, 10.2) (4.6, 71.9) (3.2, 34.5) (0.5, 4.7) (54.5, 68.8) (0.2, 1.3) (0.5, 2.3) (95 CI) Private (95 CI) Outlets (95 CI) Page 21

36 Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor Proportion of outlets that had: N=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 Antimalarials in stock at the time of survey visit (87.8, 98.4) (67.5, 98.1) (86.7, 97.4) (70.2, 92.3) (92.0, 98.7) (23.9, 38.0) (23.9, 46.8) (19.9, 69.2) (27.1, 46.6) (30.1, 48.7) Among outlets with an antimalarial in stock, proportion of outlets that had: N=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N=844 Any ACT (78.3, 90.9) (14.3, 75.7) (55.6, 83.3) (7.9, 48.5) (1.9, 11.1) (0.3, 10.7) (0.1, 12.0) (3.1, 12.9) (10.0, 18.8) Quality Assured ACT (QAACT) (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.9, 47.4) (87.4, 95.1) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.7, 12.3) (9.1, 17.7) First line (FAACT) (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.4, 47.5) (82.0, 89.0) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.6, 12.1) (8.9, 17.6) Non first line (NAACT) (6.7, 28.6) (4.2, 21.3) (0.1, 3.9) (62.5, 76.4) (0.6, 3.8) (1.3, 4.5) (95 CI) Private (95 CI) Outlets (95 CI) Non quality Assured ACT Other ACT Classifications Any first line ACT Nationally Registered ACT Any non artemisinin therapy Chloroquine Sulfadoxine pyrimethamine (SP) Second line treatment (Quinine) (2.8, 10.5) (14.3, 75.7) (6.9, 37.4) (1.6, 12.0) (0.0, 2.5) (1.0, 6.3) (2.2, 7.9) (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.9, 47.4) (85.0, 93.2) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.7, 12.3) (9.0, 17.7) (78.3, 90.9) (14.3, 75.7) (55.6, 83.3) (7.2, 48.2) (1.9, 11.1) (0.3, 10.7) (0.1, 12.0) (3.0, 12.8) (9.9, 18.7) (83.5, 98.7) (87.7, 99.2) (95.8, 99.9) (82.0, 98.1) (97.7, 100) (99.3, 99.9) (98.4, 99.8) (0.5, 4.6) (9.0, 54.0) (3.9, 20.6) (8.1, 32.2) (11.2, 18.4) (77.6, 97.1) (82.0, 95.7) (53.5, 97.2) (70.9, 89.6) (63.9, 81.8) (35.3, 68.4) (20.5, 78.7) (34.0, 68.1) (18.7, 55.3) (79.0, 88.7) (3.0, 23.5) (5.2, 20.7) (17.4, 56.9) (8.6, 27.2) (12.4, 30.1) (81.8, 94.8) (90.0, 99.5) (86.3, 96.0) (58.6, 96.8) (53.0, 70.6) (7.9, 41.7) (5.9, 26.7) (3.7, 77.9) (12.3, 41.7) (20.0, 46.4) Continued on following page Page 22

37 Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor (95 CI) Private (95 CI) Outlets (95 CI) Among outlets with an antimalarial in stock, proportion of outlets that had: Any artemisinin monotherapy Oral artemisinin monotherapy Non oral artemisinin monotherapy N=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N= (2.9, 11.2) (10.7, 75.3) (5.8, 37.3) (0.5, 5.8) (64.9, 83.4) (0.7, 4.0) (1.8, 6.2) (0.3, 4.6) (1.3, 43.1) (0.8, 15.4) (28.2, 47.1) (0.3, 1.8) (0.5, 2.4) (1.9, 10.5) (5.1, 74.9) (3.4, 36.3) (0.5, 5.8) (55.9, 71.5) (0.6, 3.4) (1.3, 5.5) Page 23

38 Table A.3: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy General retailer (Boutique) (95 CI) Market stall Itinerant drug vendor Proportion of outlets that had: N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 No disruption in stock in the past months 1 (23.1, 44.4) (6.4, 42.3) (19.0, 39.4) (16.7, 53.4) (23.1, 38.0) (14.9, 32.1) (18.7, 34.7) (12.6, 19.8) (18.6, 31.9) (19.0, 32.0) 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 No disruption in stock of any first line treatment in the past 3 months, among outlets that have stocked the first line treatment in the past 3 months (95 CI) (95 CI) (95 CI) Private (95 CI) Outlets (95 CI) N=154 N=9 N=163 N=19 N=100 N=10 N=7 N=1 N=137 N= (43.8, 69.0) (9.4, 94.5) (38.9, 73.2) (7.7, 83.8) (79.5, 92.6) (44.1, 94.3) (6.8, 27.8) (24.7, 66.9) (41.0, 60.1) N=155 N=12 N=167 N=26 N=105 N=10 N=7 N=1 N=149 N= (43.2, 68.6) (9.4, 93.5) (38.3, 72.3) (8.0, 81.1) (77.6, 89.2) (43.2, 94.2) (6.8, 27.8) (24.4, 64.9) (40.2, 58.7) N=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N=844 Expired stock of any antimalarial (1.6, 11.9) (0.2, 9.4) (1.4, 9.0) (2.2, 45.4) (0.9, 19.5) (0.1, 2.8) (0.6, 6.6) (1.0, 6.7) (1.2, 6.2) Expired stock of first line quality assured ACT (FAACT) Expired stock of any first line treatment N=143 N=5 N=148 N=11 N=98 N=7 N=2 N=1 N=119 N= (0.6, 7.3) (0.5, 6.5) (0.3, 4.4) N=143 N=5 N=148 N=12 N=103 N=7 N=2 N=1 N=125 N= (0.6, 7.1) (0.5, 6.4) (0.3, 4.3) N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Acceptable storage conditions for medicines 3 (93.9, 99.0) (89.0, 99.7) (94.5, 99.1) (48.8, 96.5) (90.9, 99.5) (85.5, 94.5) (71.0, 93.9) (69.1, 80.8) (78.9, 92.0) (80.9, 92.5) 1 Information on stock disruptions was missing for 4 of cases [n=1,021] 2 Information on expired stock was missing for 10 of cases [n=756]. Missing values were particularly common for boutiques (15, n=117) and stalls/kiosks (17, n=195). 3 Information on acceptable storage condition was missing for 16 of cases [n=895]. Missing values were particularly common for boutiques (25, n=163) and stalls/kiosks (23, n=261). Page 24

39 Table A.4: Price of antimalarials, by outlet type Proportion of first line quality assured ACT distributed free of cost (by volumes of AETDs) Median price of a tablet AETD: 4 Any ACT Quality Assured ACT (QAACT) First line (FAACT) Non first line (NAACT) Non quality Assured ACT Other ACT Classifications Any first line ACT Nationally Registered ACT Public Health Facility Private not for profit HF Public / Not for profit Private for profit HF Pharmacy General retailer (Boutique) Market stall Itinerant drug vendor Private Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Median [IQR] (N of Antimalarials) Outlets Median [IQR] (N of Antimalarials) $1.30 [ ] (503) $6.49 [ ] (19) $1.30 [ ] (522) $2.59 [ ] (28) $8.63 [ ] (1,443) $1.73 [ ] (9) $3.03 [n/a] (2) $3.24 [n/a] (1) $8.30 [ ] (1,483) $3.03 [ ] (2,005) $1.30 $1.30 $1.30 $2.59 $8.83 $1.73 $3.03 $3.24 $5.75 $1.30 [ ] (489) [ ] (9) [ ] (498) [ ] (16) [ ] (327) [ ] (7) [n/a] (2) [n/a] (1) [ ] (353) [ ] (851) $1.30 $1.30 $1.30 $2.59 $6.10 $1.73 $3.03 $3.24 $3.24 $1.30 [ ] (464) [ ] (9) [ ] (473) [ ] (15) [ ] (191) [ ] (7) [n/a] (2) [n/a] (1) [ ] (216) [ ] (689) $1.73 (0) $1.73 $2.59 $16.82 (25) [ ] [ ] (25) [n/a] (1) [ ] (136) (0) (0) (0) $16.82 $16.82 [ ] (137) [ ] (162) $7.78 $8.65 $8.65 $6.49 $8.52 $8.05 [ ] (14) [ ] (10) [ ] (24) [ ] (12) [ ] (1,116) [n/a] (2) (0) (0) $8.52 $8.52 [ ] (1,130) [ ] (1.154) $1.30 [ ] (464) $1.30 [ ] (9) $1.30 [ ] (473) $2.59 [ ] (16) $6.69 [ ] (290) $1.73 [ ] (7) $3.03 [n/a] (2) $3.24 [n/a] (1) $5.40 [ ] (316) $1.30 [ ] (789) $1.30 $6.49 $1.30 $2.59 $8.83 $1.73 $3.03 $3.24 $8.52 $2.59 [ ] (478) [ ] (18) [ ] (496) [ ] (25) [ ] (1,229) [ ] (9) [n/a] (2) [n/a] (1) [ ] (1,266) [ ] (1,762) Any non artemisinin therapy $3.63 $2.27 $2.72 $3.63 $1.15 $0.41 $0.41 $0.54 $0.41 $0.43 [ ] (286) [ ] (84) [ ] (370) [ ] (183) [ ] (456) [ ] (234) [ ] (325) [ ] (112) [ ] (1,310) [ ] (1,680) Chloroquine $0.22 $0.24 $0.24 $0.32 $0.58 $0.27 $0.32 $0.27 $0.32 $0.32 [ ] (5) [ ] (8) [ ] (13) [ ] (20) [ ] (4) [ ] (112) [ ] (182) [ ] (28) [ ] (346) [ ] (359) Sulfadoxine pyrimethamine (SP), the most popular antimalarial 5 $0.32 [ ] (94) $0.43 [ ] (21) $0.32 [ ] (115) $0.43 [ ] (34) $1.04 [ ] (284) $0.54 [ ] (46) $0.43 [ ] (62) $1.08 [ ] (36) $0.65 [ ] (462) $0.65 [ ] (577) Second line treatment (Quinine) $3.78 $3.03 $3.68 $4.54 $12.61 $4.54 $4.54 $4.54 $4.54 $4.09 [ ] (186) [ ] (55) [ ] (241) [ ] (129) [ ] (111) [ ] (75) [ ] (78) [ ] (48) [ ] (441) [ ] (682) Any artemisinin monotherapy Oral artemisinin monotherapy $6.30 $17.29 $17.29 [n/a] (1) [n/a] (1) (0) $8.11 (2) [n/a] [ ] (56) (0) (0) (0) $8.11 [ ] (56) $9.86 [ ] (58) 4 A total of 5,233 antimalarials were found in 844 outlets. Of these, 3,743 antimalarials are included in the pricing analysis; price indicators are based on tablet formulation AETDs. Free antimalarials were found in 3.1 of outlets with antimalarials, and 35 of the 5,115 antimalarials for which price information was recorded were available for free. 5 Sulfadoxine pyrimethamine was the most popular antimalarial by volume sold/distributed in the past week. Page 25

40 Table A.5: Affordability of antimalarials, by outlet type Median price of a tablet AETD relative to SP, the most popular antimalarial treatment in Benin: Public Health Facility Private not for profit HF Public / Not for profit Private for profit HF Pharmacy General retailer (Boutique) Market stall Itinerant drug vendor Private Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Outlets Any ACT First line quality assured ACT (FAACT) Any first line ACT Median price of a tablet AETD relative to the minimum legal daily wage ($2.13) 6 : Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Any ACT First line quality assured ACT (FAACT) Any first line ACT Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Median price of a first line quality assured tablet AETD relative to the international reference price ($1.45) Proportion of outlets that: N=43 N=43 N=105 N=118 N=218 N=338 N=62 N=841 N=884 Offer credit to consumers for antimalarials 8 (21.8, 86.1) (21.8, 86.1) (23.0, 60.8) (29.0, 51.5) (26.9, 54.5) (38.1, 65.9) (33.7, 71.1) (37.2, 58.2) (37.5, 58.3) 6 Minimum daily wage information taken from United States Department of State, Country Reports on Human Rights Practices. Available at: 7 International reference price taken from Management Sciences for Health, International drug price indicator guide. Available at: $1.45 is the median listed supplier price for 24 tablets of AL 20mg/120mg. 8 This question was not asked in Public Health Facilities. Information on proportion of outlets that offer credit to consumers for antimalarials was missing for 13 of cases [n=766]. Missing values were particularly common for boutiques (18, n=179); stalls/kiosks (17, n=281); and hawkers (15, n=53). Page 26

41 Table A.6: Availability of diagnostic tests and cost to patients, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor Proportion of outlets that had: 9 N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Any diagnostic test (95 CI) Private (95 CI) Outlets (95 CI) (77.0, 92.2) (19.2, 83.3) (58.8, 86.5) (10.5, 42.0) (0.3, 3.3) (0.6, 4.4) (5.0, 11.8) Microscopic blood tests (9.7, 24.2) (7.2, 73.6) (9.7, 39.4) (4.2, 31.6) (0.3, 3.0) (1.4, 4.4) Rapid diagnostic tests (74.1, 91.3) (13.4, 82.1) (53.5, 85.0) (1.8, 42.4) (0.3, 3.3) (0.1, 4.5) (3.9, 11.0) Proportion of outlets that provided diagnostic tests for free, among outlets N=142 N=13 N=155 N=24 N=1 N=0 N=0 N=0 N=25 N=180 providing diagnostic tests 10 Any diagnostic test Microscopic blood tests Rapid diagnostic tests Median price of: Microscopic blood tests (88.3, 99.0) (15.6, 96.5) (81.1, 97.3) (53.4, 93.4) N=30 N=9 N=39 N=22 N=0 N=0 N=0 N=0 N=22 N= (29.2, 88.3) (20.1, 79.3) (5.9, 65.7) N=135 N=6 N=141 N=3 N=1 N=0 N=0 N=0 N=4 N= (88.3, 99.1) (4.1, 91.7) (51.7, 96.4) (49.9, 96.4) 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) $0.00 $2.16 $1.08 $3.24 [ ] (22) [ ] (8) [ ] (30) [ ] (20) (0) (0) (0) (0) $3.24 $2.16 [ ] (20) [ ] (50) Rapid diagnostic tests $0.00 $0.22 $0.00 $2.70 [ ] (129) [ ] (5) [ ] (134) [ ] (2) (0) (0) (0) (0) $2.70 $0.00 [ ] (2) [ ] (136) 9 Information on proportion of outlets that had diagnostic tests was missing for 3 of cases [n=1,031]. 10 Information on diagnostic test pricing was missing for 7 of cases where the outlet was known to provide testing [n=167]. Page 27

42 Table A.7: Market share, by outlet type Public Health Facility Private not for profit HF Public / Not for profit Private for profit HF Pharmacy General retailer (Boutique) Market stall Itinerant drug vendor Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed in the past week: 11 Any ACT < Quality Assured ACT (QAACT) < First line (FAACT) < Non first line (NAACT) <0.1 0 < Private Outlets Non quality Assured ACT < < Other ACT Classifications Any first line ACT < Nationally Registered ACT < Any non artemisinin therapy Chloroquine Sulfadoxine pyrimethamine (SP) Second line treatment (Quinine) Any artemisinin monotherapy <0.1 <0.1 <0.1 < Oral artemisinin monotherapy 0 <0.1 < Non oral artemisinin monotherapy <0.1 <0.1 <0.1 < There were a total of 87,451 AETDs (unweighted) sold or distributed in the past 7 days. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACTs and Non quality Assured ACT; QAACTs decompose fully into FAACTs and NAACTs; nationally registered ACTs are either QAACTs or non QAACTs. Row and column totals exhibit minor rounding errors. Page 28

43 Table A.8: Provider knowledge, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy General retailer (Boutique) (95 CI) Market stall Itinerant drug vendor Proportion of providers that: N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Correctly state the recommended firstline treatment for uncomplicated malaria 12 (84.9, 95.4) (8.0, 69.8) (54.2, 86.1) (42.0, 69.3) (55.4, 76.6) (5.1, 33.2) (6.0, 27.9) (7.1, 21.4) (10.1, 29.1) (14.7, 32.5) Correctly state the dosing regimen of the first line treatment for an adult Correctly state the dosing regimen of the first line treatment for a two year old Can list at least one health danger sign in a child that requires referral to a public health facility 13 : Convulsions Vomiting Unable to drink / breastfeed Excessive sleep / difficult to wake up Unconscious / coma (95 CI) (95 CI) (95 CI) Private (95 CI) Outlets (95 CI) (81.6, 93.0) (7.4, 69.0) (51.9, 84.1) (33.3, 62.3) (48.8, 73.8) (2.8, 14.7) (0.9, 10.7) (0.3, 13.0) (4.4, 15.2) (8.8, 20.5) (81.1, 92.4) (6.7, 68.5) (51.1, 83.5) (32.9, 63.0) (44.0, 70.3) (2.4, 11.5) (0.6, 10.8) (0.3, 13.0) (4.0, 14.1) (8.4, 19.3) N=43 N=43 N=105 N=118 N=218 N=338 N=62 N=841 N= (23.5, 82.0) (23.5, 82.0) (41.6, 91.2) (63.8, 78.2) (45.5, 76.9) (39.0, 79.4) (39.2, 70.1) (44.8, 76.9) (44.9, 76.4) (8.0, 67.0) (8.0, 67.0) (18.0, 63.6) (28.9, 52.5) (14.6, 40.4) (10.6, 46.5) (15.2, 53.7) (15.0, 42.0) (15.4, 41.7) (18.6, 76.5) (18.6, 76.5) (25.7, 65.4) (32.5, 60.9) (23.3, 41.6) (27.3, 49.1) (19.7, 35.6) (29.6, 42.6) (30.3, 42.5) (0.6, 20.5) (0.6, 20.5) (4.0, 59.9) (13.6, 33.0) (8.4, 44.5) (10.9, 26.5) (9.8, 29.3) (10.6, 30.9) (10.3, 30.4) (1.9, 11.6) (5.0, 24.4) (0.9, 7.1) (0.8, 6.1) (0.3, 12.4) (1.4, 5.1) (1.3, 5.0) (1.4, 33.5) (1.4, 33.5) (8.3, 47.4) (16.8, 40.9) (2.4, 23.5) (2.6, 19.3) (1.3, 49.7) (3.3, 23.1) (3.2, 23.1) 12 Information on proportion of providers that correctly state the recommended first line treatment for uncomplicated malaria was missing for 10 of cases [n=953]. Missing values were particularly common for boutiques (15, n=186); stalls/kiosks (16, n=285); and hawkers (13, n=54). 13 Information on proportion of providers that correctly state at least one health danger sign was missing for 18 of cases [n=728]. Missing values were particularly common for boutiques (24, n=165); stalls/kiosks (22, n=264); and hawkers (16, n=52). Page 29

44 Table A.9: Provider perceptions, by outlet type Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy General retailer (Boutique) Market stall Itinerant drug vendor Proportion of providers that: N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Agree with the statement, Customers often request an antimalarial by name. 14 (8.7, 25.1) (2.9, 41.8) (8.3, 23.8) (13.0, 59.3) (13.2, 36.8) (72.0, 88.3) (66.9, 87.3) (61.7, 98.8) (65.8, 83.7) (60.1, 78.9) Agree with the statement, I generally decide which antimalarial medicine customers receive. (95 CI) (95 CI) (95 CI) (95 CI) Private (95 CI) Outlets (95 CI) (34.7, 57.9) (24.4, 83.8) (34.7, 64.3) (71.7, 95.8) (33.0, 51.4) (15.6, 32.9) (21.5, 48.0) (17.6, 44.9) (24.6, 46.4) (26.3, 47.1) Report that an ACT is the most effective antimalarial medicine 15 (58.0, 78.0) (5.0, 74.2) (38.0, 71.8) (14.8, 69.1) (57.3, 67.5) (2.1, 11.5) (0.5, 19.2) (0.1, 9.5) (3.3, 15.6) (7.0, 18.6) Proportion of providers than state the following reasons for stocking antimalarials: 16 N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Most profitable Recommended by government Lowest priced Consumer demand Easily available Drug company Brand reputation Dosage form Frequently prescribed (0.6, 4.4) (0.4, 2.8) (3.3, 39.7) (10.6, 21.0) (14.9, 58.1) (12.4, 30.3) (1.4, 25.7) (12.7, 35.7) (11.5, 33.3) (32.9, 71.8) (12.1, 68.5) (29.0, 66.1) (11.4, 47.9) (19.9, 38.4) (0.3, 5.1) (<0.1, 1.3) (0.1, 6.0) (1.3, 6.0) (3.9, 11.2) (4.6, 17.4) (0.4, 14.2) (3.5, 13.3) (2.3, 23.2) (5.7, 16.7) (12.7, 34.7) (14.3, 44.2) (2.8, 47.5) (12.5, 37.4) (11.7, 35.5) (11.7, 36.0) (16.0, 79.5) (15.4, 49.1) (25.8, 77.8) (61.4, 79.1) (71.8, 89.1) (70.8, 95.9) (60.7, 99.0) (71.9, 91.2) (67.6, 87.3) (3.7, 16.2) (6.2, 41.3) (6.0, 19.7) (4.3, 29.6) (5.6, 21.8) (2.1, 12.2) (1.7, 15.6) (10.8, 24.8) (3.3, 13.3) (3.7, 13.3) (1.9, 39.9) (0.6, 16.1) (0.1, 5.0) (0.4, 6.2) (0.4, 6.3) (<0.1, 2.4) (0.2, 2.1) (0.4, 2.4) (2.6, 16.2) (4.4, 38.4) (4.4, 18.3) (4.8, 24.7) (2.9, 9.6) (2.3, 13.5) (8.8, 28.9) (0.9, 34.7) (6.8, 20.5) (6.8, 19.8) (0.7, 11.4) (0.8, 26.3) (1.2, 10.5) (0.5, 21.0) (0.9, 10.2) (<0.1, 0.5) (0.1, 4.4) (0.1, 6.0) (0.2, 2.5) (0.3, 3.0) (20.3, 57.9) (6.0, 40.6) (17.3, 48.4) (14.4, 48.7) (18.9, 45.9) (1.6, 13.2) (0.6, 6.2) (0.8, 32.3) (2.4, 11.9) (4.5, 12.9) 14 Information on this pair of indicators was missing for 12 of cases [n=932, and n=929]. 15 Information on the most effective antimalarial was missing for 9 of cases [n=961]. Missing values were particularly common for General retailers (14, n=187) and Market stalls (15, n=289). 16 Information on this indicator was missing for 9 of cases [n=964]. Providers could state multiple responses and totals may sum to more than 100. Page 30

45 Table A.9: Provider perceptions, by outlet type Continued on following page Public Health Facility (95 CI) Private not for profit HF (95 CI) Public / Not for profit (95 CI) Private for profit HF (95 CI) Pharmacy (95 CI) General retailer (Boutique) (95 CI) Market stall (95 CI) Itinerant drug vendor (95 CI) Private (95 CI) Outlets (95 CI) Proportion of providers than state the following reasons for stocking antimalarials: Effectiveness Other reasons Don t know N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1, (1.5, 11.4) (1.7, 24.9) (2.2, 11.8) (6.0, 45.9) (4.8, 29.6) (1.5, 16.5) (1.4, 9.4) (0.7, 43.5) (1.9, 15.8) (1.9, 15.2) (0.8, 5.4) (0.6, 3.3) (0.1, 9.0) (0.1, 6.9) (0.2, 7.3) (<0.1, 0.7) (0.1, 1.9) (0.2, 1.8) (0.2, 3.9) (4.4, 74.6) (1.7, 38.3) (0.4, 3.7) (0.1, 5.3) (0.2, 5.2) (0.3, 14.4) (0.1, 5.2) (0.3, 7.2) (0.7, 6.9) Page 31

46 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: 17 Public Health Facility Private not for profit HF Public / Not for profit Private for profit HF Pharmacy General retailer (Boutique) Market stall Itinerant drug vendor Private Any ACT Quality Assured ACT (QAACT) First line (FAACT) Non first line (NAACT) Outlets Non quality Assured ACT < Other ACT Classifications Any first line ACT Nationally Registered ACT Any non artemisinin therapy Chloroquine Sulfadoxine pyrimethamine (SP) Second line treatment (Quinine) Any artemisinin monotherapy < Oral artemisinin monotherapy < Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACTs and Non quality Assured ACT; QAACTs decompose fully into FAACTs and NAACTs; nationally registered ACTs are either QAACTs or non QAACTs. Row and column totals exhibit minor rounding errors. Page 32

47 Non oral artemisinin monotherapy <0.1 <0.1 < Page 33

48 References Malaria Taxes and Tariffs Advocacy Project, Current Status of Tariffs on Antimalarial Commodities, February [online] Available at: tap.org [Accessed 12 August 2011]. Institut National de la Statistique et de l Analyse Economique (INSAE) Benin et Macro International Inc., Demographic and Health Survey (EDSB III) Benin Calverton, Maryland: INSAE et Macro. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision. [online] Available at: [Accessed 12 August 2011]. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Urbanization Prospects: The 2009 Revision. [online] Available at: [Accessed 15 March 2011]. President s Malaria Initiative (PMI), FY 2009 Malaria Operation Plan: Benin. President s Malaria Initiative (PMI), FY 2010 Malaria Operation Plan: Benin. World Bank, World databank. [online] Available at: [Accessed 12 Agust 2011]. Values given in current US$. World Health Organisation (WHO), World Malaria Report Geneva: WHO Press. World Health Organisation (WHO), Global Health Observatory. [online] Available at: [Accessed 12 August 2011]. Tougher S, et al., (2009). The private commercial sector distribution chain for antimalarial drugs in Benin. [online] London: LSHTM. Available at [Accessed 12 August 2011]. Ndoye T, et al., Évaluation de la gouvernance, de la transparence et des opérations de la Centrale d Achats des Médicaments Essentiels du Bénin, décembre Présenté à l Agence des États Unis pour le Développement International par le Programme Strengthening Pharmaceutical Systems (SPS). Arlington, VA: Management Sciences for Health. Programme National de Lutte contre le Paludisme (PNLP), Ministère de la Sante Publique, Politique nationale de lutte contre le paludisme et cadre stratégique de mise en œuvre. Cotonou : Les presses d Afrique. d Almeida T. et al., Field evaluation of the intermittent preventive treatment of malaria during pregnancy (IPTp) in Benin: evolution of the coverage rates since its implementation, Parasites & Vectors, [online] Available at: [Accessed: 12 August 2011]. Page 34

49 Appendices ACTs classified as quality assured Active ingredients Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artesunate + Amodiaquine Artemether + Lumefantrine Artemether + Lumefantrine Artemether + Lumefantrine Artemether + Lumefantrine Artemether + Lumefantrine Artemether + Lumefantrine Artesunate + Sulfadoxine / Pyrimethamine Formulation and strength Tablets 50mg + 150mg Tablets 50mg + 153mg Tablets 50mg + 153mg Tablets 25mg mg Tablets 50mg + 135mg Tablets 100mg + 270mg Tablets 25mg mg Tablets 50mg + 135mg Tablets 100mg + 270mg Tablets 50mg + 153mg Tablets 50mg + 153mg (200mg salt) Tablets 20mg + 120mg Tablets 20 gm+ 120mg Dispersible Tablets 20mg + 120mg Tablets 20mg + 120mg Tablets 20mg + 120mg Tablets 20mg + 120mg Tablets 50mg + 500mg/25mg Manufacturer Manufacture site Brand name Package size Guilin Pharmaceutical Co. Ltd Ipca Laboratories Limited Ipca Laboratories Limited Sanofi Aventis Group Sanofi Aventis Group Sanofi Aventis Group Sanofi Aventis Group Sanofi Aventis Group Sanofi Aventis Group Strides Arcolab Limited Cipla Ltd Novartis Pharma Ajanta Pharma Ltd Novartis Pharma AG Cipla Ltd Ipca Laboratories Ltd Ipca Laboratories Ltd Guilin Pharmaceutical Co. Ltd Guilin, Guangxi, China Dadra and Nagar Haveli (U.T.), India Dadra and Nagar Haveli (U.T.), India MAPHAR Laboratories, Casablanca, Morocco MAPHAR Laboratories, Casablanca, Morocco MAPHAR Laboratories, Casablanca, Morocco MAPHAR Laboratories, Casablanca, Morocco MAPHAR Laboratories, Casablanca, Morocco MAPHAR Laboratories, Casablanca, Morocco Arsuamoon (1 6yrs;7 13yrs; Adults) AS AQ Generic (Child; Junior; Adult) Larimal (Child; Junior; Adult) Coarsucam 25mg/67.5mg (Infant) Coarsucam 50mg/135mg (Toddler) Coarsucam 100mg/270mg (Child; Adult) Winthrop 25mg/67.5mg (Infant) Winthrop 50mg/135mg (Toddler) Winthrop 100mg/270mg (Child; Adult) 6;12;24 6;12;24 6;12;24 Bangalore, India ACTipal (Madagascar) 3, 6, 12 Patalganga, India; Goa, India Beijing, China; Suffern, USA Paithan, Aurangabad, Maharashtra, India Novartis Pharmaceuticals Corporation, Suffern, USA Patalganga, India; Himachal Pradesh, India Dadra and Nagar Haveli (U.T.), India Dadra and Nagar Haveli (U.T.), India 3 3 3; ;6 Falcimon Kit & 6;12;24 Serenadose (DRC) (Young children up to 6yrs; Children 7 13yrs; Adults) Coartem 20/120 6;12;18;24 Artefan 20/120 6;12;18;24 Coartem D 6;12 Lumartem (5 15kg; 15 3;6;12;18;24 25kg; 25 35kg; >=35kg); Lumartem Forte & Lumet Forte Lumerax 20/120 6;12;24 AL Generic 6;12; 18;24 Guilin, Guangxi, China Artecospe Co blistered 6+2 Page 35

50 Artesunate + Sulfadoxine / Pyrimethamine Tablets 100mg + 500mg/25mg Guilin Pharmaceutical Co. Ltd Guilin, Guangxi, China Artecospe Co blistered 6+3 Page 36

51 Nationally registered ACTs Benin s nationally registered ACTs as of September Active ingredients Formulation Strength Manufacturer Manufacture Site Brand Name Artesunate / Amodiaquine Tablet 200mg / 200mg Dafra Belgium Amonate Artesunate / Amodiaquine Tablet 50mg / 153mg Ajanta India Apoxin Artesunate / Amodiaquine Tablet 50mg / 150mg Guilin pharma China Arsuamoon Artesunate / Amodiaquine Tablet 50mg / 153mg Sanofi Aventis Morocco Arsucam Artesunate / Amodiaquine Tablet 100mg / 153mg Odypharm England Artediam Artesunate / Amodiaquine Tablet 100mg / 300mg Pfizer USA Camoquin Plus Artesunate / Amodiaquine Tablet 200mg / 600mg Pfizer USA Camoquin Plus Artesunate / Amodiaquine Tablet 25mg / 67.5mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 50mg / 135mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 100mg / 270mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 50mg / 153mg Ipca India Larimal Artesunate / Amodiaquine Tablet 50mg / 200mg Macleods India Macsunate Plus Artesunate / Amodiaquine Tablet 25mg / 75mg Medinomics India Malmed Artemether / Lumefantrine Tablet 20mg / 120mg Ajanta India Artefan Artemether / Lumefantrine Tablet 40mg / 240mg Ajanta India Artefan Artemether / Lumefantrine Tablet 80mg / 480mg Ajanta India Artefan Artemether / Lumefantrine Tablet 20mg / 120mg Novartis Switzerland Coartem Artemether / Lumefantrine Powder 15mg / 90mg Dafra Belgium Co Artesiane Artemether / Lumefantrine Suspension 360mg / 2160mg / Dafra Belgium Co Artesiane 120ml Artemether / Lumefantrine Suspension 360mg / 2160mg / Dafra Belgium Co Artesiane 120ml Artemether / Lumefantrine Suppository 20mg / 120 mg Bliss Gvs India Lonart Artemether / Lumefantrine Tablet 20mg / 120mg Bliss Gvs India Lonart Artemether / Lumefantrine Suspension 180mg / 1080mg / Bliss Gvs India Lonart 60ml Artemether / Lumefantrine Tablet 40mg / 240mg Imex Health India Lufanter Artemether / Lumefantrine Tablet 20mg / 120mg Cipla India Lumartem Artemether / Lumefantrine Tablet 20mg / 120mg Macleods India Lumether Artesunate / Mefloquine Granules 50mg / 125mg Mepha Switzerland Artequin Paediatric Artesunate / Mefloquine Tablet 100mg / 125mg Mepha Switzerland Artequin Artesunate / Mefloquine Tablet 100mg / 250mg Mepha Switzerland Artequin Artesunate / Mefloquine Tablet 200mg / 250mg Mepha Switzerland Artequin Artemisinine / Naphthoquine Tablet 125mg / 50mg Kunming China Arco Artesunate / Sulfamethoxypyrazine / Tablet Stallion India Artecure 18 Nationally registered ACTs were compiled through the Ministry of Health in Benin. Page 37

52 Active ingredients Formulation Strength Manufacturer Pyrimethamine Manufacture Site Brand Name Continued on following page Artesunate / Sulfadoxine / Pyrimethamine Artesunate / Sulfamethoxypyrazine / Pyrimethamine Artesunate / Sulfamethoxypyrazine / Pyrimethamine Artesunate / Sulfamethoxypyrazine / Pyrimethamine Artesunate / Sulfamethoxypyrazine / Pyrimethamine Dihydroartemisinin / Piperaquine Dihydroartemisinin / Piperaquine Dihydroartemisinin / Piperaquine Dihydroartemisinin / Piperaquine Dihydroartemisinin / Piperaquine Dihydroartemisinin / Piperaquine / Trimethoprim Dihydroartemisinin / Sulfadoxine / Pyrimethamine Tablet 100mg / 500mg / 25mg Tablet 100mg / 250mg / 12.5mg Tablet 200mg / 500mg / 25mg Tablet 100mg / 250mg / 12.5mg Tablet 200mg / 500mg / 25mg Plethico India Artedar Denk pharma Germany AsunateDenk 100 Plus Denk pharma Germany AsunateDenk 200 Plus Dafra Belgium Co Arinate Dafra Belgium Co Arinate Granules 15mg / 120mg Steyuan pharm China Darte q Capsule 40mg / 320mg Steyuan pharm China Darte q Tablet 40mg / 320mg Holleypharm China Duo cotecxin Tablet 40mg / 320mg Laboratoire Salvat India Malacur Suspension 80mg / 640mg / 80ml Bliss Gvs India P Alaxin Tablet 32mg / 320mg / 90mg Tonghe Pharma China Artecom Tablet 160mg / 500mg / 25mg Bliss Gvs India Alaxin Page 38

53 Final sample List of clusters/arrondissements sampled, Benin, Refer to page 12 for an explanation of the booster sample approach for this survey. Department Commune Arrondissement Censused cluster or booster sample? Alibori Banikoara Toura Census Alibori Banikoara Booster sample of PHFs Alibori Karimama Birni Lafia Census Alibori Karimama Booster sample of PHFs Alibori Booster sample (SRS) of Pharmacies Atacora Boukoumbe Tabota Census Atacora Boukoumbe Booster sample of PHFs Atacora Booster sample (SRS) of Pharmacies Atlantique Abomey Calavi Godomey Census Atlantique Abomey Calavi Booster sample of PHFs Atlantique Toffo Ague Census Atlantique Toffo Booster sample of PHFs Atlantique Booster sample (SRS) of Pharmacies Borgou Bembereke Gomia Census Borgou Bembereke Booster sample of PHFs Borgou Perere Sontou Census Borgou Perere Booster sample of PHFs Borgou Booster sample (SRS) of Pharmacies Collines Dassa Zoume Kpingni Census Collines Dassa Zoume Booster sample of PHFs Collines Ouesse Kilibo Census Collines Ouesse Booster sample of PHFs Collines Save Kaboua Census Collines Save Booster sample of PHFs Collines Booster sample (SRS) of Pharmacies Couffo Djakotome Djakotomey I Census Couffo Djakotome Booster sample of PHFs Couffo Booster sample (SRS) of Pharmacies Donga Bassila Penessoulou Census Donga Bassila Booster sample of PHFs Donga Booster sample (SRS) of Pharmacies Littoral Cotonou 1st Arrondissement Census Littoral Cotonou 9th Arrondissement Census Littoral Cotonou Booster sample of PHFs and Pharamcies Mono Grand Popo Sazoue Census Mono Grand Popo Booster sample of PHFs Mono Booster sample (SRS) of Pharmacies Continued on following page Page 39

54 Department Commune Arrondissement Censused cluster or booster sample? Oueme Bonou Bonou Census Oueme Bonou Booster sample of PHFs Oueme Porto Novo 2nd Arrondissement Census Oueme Porto Novo Booster sample of PHFs Oueme Booster sample (SRS) of Pharmacies Plateau Pobe Pobe Census Plateau Pobe Booster sample of PHFs Plateau Booster sample (SRS) of Pharmacies Zou Bohicon Lissezoun Census Zou Bohicon Booster sample of PHFs Zou Booster sample (SRS) of Pharmacies Page 40

55 Survey team List of staff members involved in the survey, Benin, Team Leaders Moudachirou BIAOU Abdoul Ramane CHABI Marcellin ODOULAMI Roland AGBESSI Francois DADEDJI Prudencio NOUGLOKOU Epiphane ABOGOURIN Interviewers Laminou ASHANTI Rachidatou CHABI GADO Habib BIO YIRO Ben Youssouf BIO BANGANA Rafatou KOKOKO Ghyslaine BALOGOUN Tayewo CHACON Remy EKON Kike PADONOU Renaud ACCOMBESSY Armelle DAHOUNLINTON Augustine KPOTON Nellie AGUIDI Baudoin ADINAKOU Gynette GINDEHOU Maryse OGOULOLA Harence FAGNIBO Marc ADJERAN Page 41

56 Description of outlet types visited for this survey Public Health Facilities N Description Referral hospital (Hôpital de zone, or larger) 9 Government run health facilities that provide prescription medicine following medical consultation or diagnosis. Fees are usually charged for consultations and medicines. Commune health centre 21 Arrondissement health centre 116 Dispensary 15 Maternity 10 Village health unit (and smaller) 11 Arrondissement health centres are the first level of facilitybased public health care, and are usually staffed by nurses, a midwife, and auxiliary staff. They usually include a dispensary and maternity, although these facilities may also exist on their own. Commune health centres the next level are usually staffed by a doctor, nurses, and midwives. Across Benin s 34 health zones, there is an average of 2 communes per zone. Health zone level hospitals and the national referral hospital in Cotonou receive first level referral services and typically staffed with a surgeon and offer specialist health practitioners. Village health units are staffed by voluntary community health workers and are linked to an arrondissement or communal health centre. Private, not for profit facilities N Description Non Governmental Organization (NGO) hospital / health centre Missionary hospital / clinic 5 42 These facilities provide prescription medicine following medical consultation or diagnosis. They are usually staffed with qualified health practitioners, though some smaller clinics run by NGOs have less well qualified staff. Private for profit facilities N Description Private hospital / clinic 118 These are non governmental health facilities. Private clinics are smaller than hospitals and many of them are not registered with the Ministry of Health. They provide consultations and examinations, and sell prescription medicines at commercial prices. Pharmacies N Description Pharmacy 115 Registered pharmacies are licensed by the Ministry of Health and sell prescription medicine at commercial prices. They outlets are staffed by qualified health practitioners, with oversight/supervision provided by a pharmacist. They sell all classes of drugs and are highly regulated. Page 42

57 Rural outpost pharmacy (Dépôt pharmaceutique) 3 Rural outpost pharmacies are smaller pharmacies that are affiliated with and supplied by larger pharmacies in towns and urban areas. These small "sister" pharmacies are located in remote and rural areas and act as extensions of the larger pharmacies. Page 43

58 General Retailers N Description Boutique (outside a market) 396 Boutique (in a market) 37 Businesses/points of sale which sell fast moving consumer goods (e.g. food, household products), in addition to some medicines (most often antipyretics). Drugs sold at these locations are not regulated. Boutiques are more formal structures than stalls, ranging from lockable steel structures in markets, to outlets located in an arcade of shops, or occupying the ground floor of a house. Stalls N Description Stall (outside a market) 526 Stall (in a market) 165 Stalls sell a variety of products that are displayed on tables (for example, on the roadside or in populated areas). They sell fast moving consumer goods and sometimes medicines, which are usually antipyretics. Drugs sold at these locations are not regulated. Itinerant drug vendors N Description Hawkers 81 Itinerant salesmen who often sell products of unknown origin, including medicines. Pharmacy Rural outpost pharmacy Boutique (in a market) Stall (outside a market) Page 44

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