Benin outlet report 2009
Data were collected in two tranches, between 28th April and 13th May, and 11th to 27th July, 2009. 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.
Outlet types stocking antimalarials
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.
Availability of different classes of 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.
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.
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]).
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.
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.
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 2009. 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).