Nigeria outlet report 2008
Data were collected from 2nd to 17th December 2008. A total of 607 outlets were sampled. 24 providers refused to be interviewed; 13 outlets were permanently closed; 50 outlets were closed at the time of the visits (up to three visits before exclusion); and in 52 outlets, providers were not available for interview at the time of data collection. These outlets were excluded from the analysis. Overall, 468 providers agreed to participate in the ACTwatch outlet survey. Of these, all 468 outlets stocked antimalarials at any point in the three months prior to the interview, and 444 outlets stocked antimalarials at the time of the interview.
Availability of antimalarials
The census of outlets found that 94.9% had antimalarials in stock. 16.7% of outlets stocked the recommended first-line treatment for uncomplicated malaria, artemether-lumefantrine (AL), 20mg/120mg. Less than one-third of public health facilities (30.0%) stocked the first-line treatment, compared to almost three-quarters (73.7%) of Part One pharmacies. The proportion of outlets stocking WHO-approved ACTs were similar to those stocking the first-line treatment. Across all outlet types, non-artemisinin therapies, such as chloroquine and SP, were more commonly stocked than the first-line treatment: 92.5% of all outlets surveyed had non-artemisinin therapies in stock. Oral artemisinin monotherapies were available at nearly half (47.0%) of outlets, including more than one-quarter (26.7%) of public health facilities.
Availability of diagnostic blood testing
Of outlets stocking antimalarials in the last three months, 9.8% offered diagnostic testing services of some kind. 9.1% of outlets had microscopic blood testing while 4.8% offered rapid diagnostic tests (RDTs). Diagnostic testing was available at 45.9% of public health facilities and at 32.6% of private health facilities, mostly through microscopy. Availability of diagnostic tests in Part One pharmacies and drug stores was very low (<1%).
Price of antimalarials
In public health facilities in Nigeria, the first-line treatment is mostly available free of cost. Among all outlets that sold ACTs for a price, the median price of the first-line treatment was $6.12. In comparison, the median price of the most popular antimalarial, SP, was $0.54, less than one-tenth the price of AL. Similarly, WHO approved and nationally registered ACTs were over 10 times more expensive than SP. The first-line treatment was also around 2.5 times more expensive than the international reference price for AL 20mg/120mg of $2.12. More than half of all outlets (59.3%) offered credit to consumers for the purchase of antimalarials.
Volumes of antimalarials sold/distributed
The most frequently sold or distributed class of antimalarials was non-artemisinin therapies (84.5%), the majority of which were distributed by drug stores. Overall, only 6.4% of all AM distribution was ACTs, and the first-line treatment accounted for only 2.1% of total AM distribution. Across all outlet types, oral artemisinin monotherapies accounted for larger relative volumes than the first-line treatment; in total oral artemisinin monotherapies comprised 9.1% of total AM distribution. The public sector accounted for only 5% of AM distribution in Nigeria. The private sector dominated the market, with Part One pharmacies and drug stores distributing nearly 90% of all antimalarials.
Overall, 17.0% of providers were able to correctly state that AL is the recommended first-line treatment for uncomplicated malaria in Nigeria. Knowledge was highest among providers at public health facilities, however less than half (43.5%) were able to correctly identify the first-line treatment. Knowledge at drug stores – the outlets responsible for over 60% of AM distribution – was only 10.2%. Figure 5. Provider Knowledge of Recommended First-line Treatment Among those providers who knew AL was the recommended first-line treatment for uncomplicated malaria, 74.7% were able to correctly state the dosing regimen of AL for an adult; 72.9% were able to correctly state the dosing regimen for a two-year old child. Similar levels of knowledge were found at public and private health facilities, while knowledge of first-line dosing regimens was lowest among drug store providers.
The outlet survey is one of the ACTwatch research components. The objective 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. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials. National trends are presented first, followed by indicators presented across outlet categories, geographical areas and urbanisation. Methods: A nationally representative sample of all outlets that could sell or provide antimalarials to a consumer was taken through a census approach in 76 sub-districts across four geographic strata in Nigeria. Sampling was conducted using a one-stage probability proportional to size (PPS) cluster design, with the measure of size being the relative sub-district population. Outlet inclusion criteria for this study included outlets which stocked an antimalarial at the time of survey or 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 (university and general hospitals, health centres, and community health extension workers); 2) Part One pharmacies (pharmacies registered by the Pharmacy Council of Nigeria and National Drug Authority and regulated by the National Agency for Food and Drug Administration and Control); 3) drug stores (Proprietary Patent Medicine Vendors [PPMVs]); and 4) private health facilities (private clinics) [see Appendix A for definitions and numbers of each type of outlet].
Among outlets, three questionnaires were administered: 1) Screening Questionnaire 2) Audit sheet and 3) Provider Questionnaire. For all outlets, trained interviewers administered the screening questionnaire 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, and perceptions. Interviewers observed outlet licensing and storage conditions of medicines using the provider questionnaire. 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 SPSS 17.0 (SPSS Inc., Chigaco, IL, USA).