Nigeria outlet report 2009
Data were collected between 14th September and 2nd November, 2009. A total of 6,089 outlets were approached. Of these, 633 outlets were not screened for various reasons: 168 providers refused to be interviewed; 108 outlets were closed down permanently; 165 outlets were not open at the time of the survey visit; in 158 outlets, providers were not available for interview at the time of survey visit; 34 providers were unable to be interviewed for other reasons. Overall, 5,456 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 2,210 outlets met our screening criteria; however, interviews could not be conducted for 4 outlets. Of the 2,206 interviews conducted, 93 reported having stocked antimalarials at any point in the three months prior to the interview and 2,113 outlets stocked antimalarials at the time of the interview.
Availability of any antimalarial
Stocking rates of any antimalarial varied by outlet type. In the public/not-for-profit sector, 89% of outlets had at least one antimalarial in stock on the day of interview. 92% of public health facilities stocked antimalarials. There was substantial variation in the private sector. More than 90% of private-for-profit facilities, pharmacies and drugs stores stocked antimalarials, in contrast to only 3.3% of general retailers. Almost one in three of itinerant drug vendors (70%) had at least one antimalarial in stock.
Outlet types stocking antimalarials
Drug stores, known also as proprietary patent medicine vendors (PPMVs), were the most common type of outlet stocking antimalarials (81%), followed by general retailers (9%).
Availability of different classes of antimalarials
First-line quality assured ACTs (FAACTs) were present in 46% of public health facilities and 27% of private sector outlets that stocked antimalarials on the day of interview. Non-artemisinin therapies were more commonly available than FAACTs in both the public/not-for-profit sector and the private sector (82% and 98% respectively). Availability of oral artemisinin monotherapy was greater than that of FAACTs for all private sector outlet types. 97% of pharmacies and 47% of PPMVs stocked oral artemisinin monotherapy.
Availability of diagnostic blood testing
Among outlets stocking antimalarials in the last three months, 28% of public health facilities reported offering microscopic diagnostic testing services on the day of interview. While 36% of private for-profit facilities offered microscopy, availability of any test was less than 3% across the other outlet types in the private sector. Availability of RDTs was less than 12% across all outlets.
Price of antimalarials
Almost all public health facilities (99%), distributed antimalarials free of cost. In the private sector, the median price of quality assured AL and ASAQ was $6.15 (IQR: $4.93-$6.57) and $3.15 (IQR: $1.84-$3.94) respectively. The median private-sector price of the most popular antimalarial, Sulfadoxine-Pyrimethamine (SP), was $0.53 (IQR: $0.39-$0.99). In the private sector, oral artemisinin monotherapy was cheaper than quality assured AL and priced similarly to ASAQ, at $3.15 (IQR: $2.63-$3.68).
Volumes of antimalarials sold/distributed
The private sector dominated the antimalarial market, representing 97% of antimalarials distributed. Drug stores (PPMVs) accounted for 90% of the total volumes sold/distributed. Over 80% of all treatments distributed were non-artemisinin therapies, mainly SP (48%) and chloroquine (CQ) (35%). QAACTs represented only 2.4% of the total market share, three times smaller than oral artemisinin monotherapy (8%). Most antimalarials distributed in the public sector were either CQ or SP.
Knowledge of the first-line treatment was recorded only for AL, not for the alternative first-line ASAQ. Overall, 15% of providers were able to correctly state AL as the recommended first-line treatment for uncomplicated malaria in Nigeria. By sector, knowledge was highest among providers at public/not-for-profit health facilities (38% and 14% in private for profit outlets). Across outlets, knowledge was highest for providers in pharmacies (72%). While knowledge was generally similar regarding adult and child dosing regimens, an exception was found for pharmacy respondents, who were less likely to know the correct child dosing regimen for AL.
The ACTwatch Outlet Survey involves quantitative research at the outlet level in ACTwatch countries (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo). Other elements of ACTwatch research include Household Surveys led by Population Services International (PSI) and Supply Chain Research led by the London School of Hygiene & Tropical Medicine (LSHTM). This report presents the results of a cross-sectional survey of outlets conducted in Nigeria from August to September 2009 and also serves as the baseline for the Affordable Medicines Facilities –malaria (AMFm) Phase 1 Independent Evaluation.
Overview of the AMFm independent evaluation process
The independent evaluation is part of a multi-faceted monitoring and evaluation framework developed for Phase 1 of the Affordable Medicines Facility – malaria (AMFm). It is intended to assess whether, and to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent evaluation will be summarized in a report to be considered by the Global Fund Board at the end of Phase 1. The four main objectives of AMFm are: (i) to increase ACT affordability, (ii) to increase ACT availability, (iii) to increase ACT use, including among vulnerable groups, and (iv) to “crowd out” other oral antimalarials by gaining market share. Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene and Tropical Medicine (LSHTM) to carry out the Independent Evaluation (IE) in all of the currently operational Phase 1 countries (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda, and Zanzibar). The baseline of the AMFm assessment relied on primary data collected from outlet surveys. In addition, with the exception of Nigeria, in-depth interviews with key stakeholders involved in the drug supply chain in the country, and a review of documents was also collected. ACTwatch provided data for Kenya, Madagascar, Nigeria, Tanzania mainland, Uganda, and Zanzibar. Baseline outlet surveys were carried out in 8 pilots in 7 countries with the objectives of assessing availability, affordability, and market share of co-paid ACTs in rural and urban areas in each of the seven participating countries. The Independent Evaluation uses outlet survey data from two groups: 1) those in which nationally representative outlet surveys have been conducted under the ACTwatch program (Madagascar and Nigeria), and 2) those in which new outlet surveys were conducted under the AMFm Phase 1 IE (Ghana, Kenya, Niger, Tanzania mainland, Uganda and Zanzibar). The surveys were conducted in all the countries between August 2009 and December 2010.
Nigeria Outlet Survey Methods
A nationally representative sample of all outlets that could sell or provide antimalarials to a consumer was taken through a census approach in 114 clusters across six geo-political strata in Nigeria. A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were localities, with an average of 10,000 to 15,000 inhabitants. Clusters were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular commune is selected is proportional to its population size. For all localities (i.e. regardless of the locality population size) a full census of public health facilities, private health facilities, and pharmacies was conducted. For localities with fewer than 50,000 inhabitants, a full census of drug stores (known as Proprietary Patent Medicine Vendors [PPMVs]), grocery stores (general retailers), Community Health Workers (CHWs), and hawkers was conducted. For localities with more than 50,000 inhabitants, the census of PPMVs, general retailers, CHWs, and hawkers was restricted to 3 randomly selected Enumeration Areas of that locality. The sample size was powered to detect a change of 20% percentage points in availability of ACTs over time. 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 (government hospitals, health centres and CHWs); 2) pharmacies; 3) private health facilities (private clinics, private practices, NGO health centres and dispensaries); 4) drug stores (PPMVs); 5) grocery stores (general retailers); and 6) hawkers (itinerant drug vendors).
Three paper based 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, and perceptions. Interviewers also observed outlet licensing and storage conditions of medicines using the provider module. Double data entry was conducted using Microsoft Access (Microsoft Cooperation, Seattle, WA, USA). To ensure a high level of data quality, ACTwatch performed cleaning using standard ACTwatch guidelines, and cleaning was performed in SPSS version 14. For the analysis, the Independent Evaluators provided a tabulation plan for all tables presented in this report for the IE indicators, and analysis do-files in STATA, which produced all the required indicators and automatically generated the tables. ACTwatch adapted these analysis files to the country setting and ran the analysis using STATA version 11, recording results in a log file. Additional analysis for other ACTwatch specific indicators was conducted by ACTwatch following standard guidelines in STATA.