Nigeria outlet report 2011
Data were collected between 7th October and November 30th, 2011. A total of 8,507 outlets were approached. Of these, 568 outlets were not screened for various reasons: 101 providers refused to be interviewed; 69 outlets were closed down permanently; 244 outlets were not open at the time of the survey visit; in 151 outlets, providers were not available for interview at the time of survey visit; 3 providers were unable to be interviewed for other reasons. Overall, 7,939 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 1,567 outlets met our screening criteria; however, interviews could not be conducted for 5 outlets. Of the 1,562 interviews conducted, 58 reported having stocked antimalarials at any point in the three months prior to the interview and 1,504 outlets stocked antimalarials at the time of the interview.
Availability of any antimalarial
Stocking rates of any antimalarial varied by outlet type. In the public/not for-profit sector, 83% of public health facilities and 71% of private not for-profit facilities had at least one antimalarial in stock on the day of interview. Of community health workers, who according to government policy may treat using antimalarials, 34% stocked an antimalarial. There was substantial variation in the private sector. 87% of private for-profit facilities, 100% of pharmacies and 98% of drugs stores, stocked antimalarials. This is in contrast to 1% of general retailers and 26% of itinerant drug vendors.
Outlet types stocking antimalarials
Drug stores/PPMVs were the most common type of outlet stocking antimalarials, followed by private health facilities and public health facilities.
Availability of different classes of antimalarials
Among facilities that stocked antimalarials at any time in the three months preceding the survey, overall QA ACT availability in 2011 was 54%. There was no difference in availability between urban and rural areas at endline. However, there was considerable variation within the private for-profit sector, in which availability was 53%. QA ACT availability was much higher in pharmacies (99%) than in drug stores (54%) or private for-profit facilities (51%) or general retailers (23%). In public health facilities that stocked antimalarials at any time in the three months preceding the survey, QA ACT availability was 57%. QA ACT availability was higher among community health workers (CHWs) (82%). Forty-seven percent of all outlets stocked QA ACTs with the AMFm logo at endline. In public health facilities, 27% of outlets stocked QA ACTs with the logo, as compared with the private sector, where 49% of outlets stocked QA ACTs with the logo. A relatively high proportion of outlets stocked QA ACTs without the logo (38% of public health facilities and 14% of private for-profit health facilities [data not shown]). It should be noted that Nigeria has several nationally-approved ACTs that are included in the non-quality-assured category. Availability of nAT remained very high at endline (97% in all outlets). Oral AMT was available in 99.5% of pharmacies, 18% of private for-profit outlets, 19% of general retailers and 15% of public health facilities.
Availability of diagnostic blood testing
Of outlets stocking antimalarials in the last three months, 87% of private not for-profit facilities offered any test services. Among other outlet types, availability of any testing services was less than 10% across all outlet types in the private sector, with the exception of private for profit facilities (37%) and public health facilities (26%). Microscopic testing was generally more available than rapid diagnostic tests.
Price of antimalarials
Among all outlets, the median price QA ACTs per AETD is USD 1.48. In public health facilities, the median price of QA ACTs is USD 0.00, indicating the policy of free ACTs in those facilities. In private for-profit outlets, the median price of QA ACTs is USD 1.48. The median price of QA ACTs with the AMFm logo is USD 1.48, where as the median price of QA ACTs without the AMFm logo is USD 2.95 (data not shown). The ratio of the median price of QA ACTs with the AMFm logo to that of the most popular antimalarial is 3.1 times. QA ACTs with the AMFm logo were being sold on average for 2.4 times more than the recommended retail price for an adult dose, which was set at USD 0.59. In private for-profit outlets, the median price of oral AMT is USD 2.83.
Volumes of antimalarials sold/distributed
Measured across all outlets, the market share of QA ACTs is 20%. The QA ACT share is largest in public health facilities (48%), followed by private not for profit facilities (40%). QA ACT market share in the private for profit sector is 18%. The share of non-quality-assured QA ACTs is 8% in all outlets. Market share of nATs in all outlets is 66.3%, and is highest among community health workers (80%) followed by the private for-profit sector (69%). Measured across all outlets, the market share of oral AMT is 4.1%, and greatest in pharmacies (9%) and the private sector generally (4.4%). The private sector accounted for over 90% of all antimalarials distributed.
Overall, 53% of providers were able to correctly state ASAQ or AL as the recommended first-line treatment for uncomplicated malaria in Nigeria. Knowledge was higher among providers at public/not-for-profit sector outlets, compared to the private sector (82% vs. 51% respectively). There was substantial variability across outlet types as well. For example, while knowledge was relatively high for public health facilities (83%), private not for-profit outlets (97%) and pharmacies (83%), it was lower among drug stores (51%) general retailers (27%) and community health workers (22%).
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 between October14thand November 30th, 2011 and also serves as the endline for the Affordable Medicines Facility – malaria (AMFm) Phase I Independent Evaluation.
The objective of the outlet survey is to monitor levels and trends in the availability, price and volumes of antimalarials, and providers’ perceptions and knowledge of antimalarial medicines at different outlets. Price and availability data on diagnostic testing services are also collected. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials.
Overview of the independent evaluation process
The independent evaluation (IE) is part of a multi-faceted monitoring and evaluation (M&E) framework developed for Phase 1 of the Affordable Medicines Facility – malaria (AMFm). It is intended to assess whether, and to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent evaluation will be summarized in a report to be considered by the Global Fund Board at the end of Phase 1.The four main objectives of AMFm are: (i) to increase ACT affordability, (ii) to increase ACT availability, (iii) to increase ACT use, including among vulnerable groups, and (iv) to “crowd out” other oral antimalarials by gaining market share.
Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene and Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda, and Zanzibar). In addition, the Global Fund contracted with Data Contributors (DCs) that were responsible for in-country fieldwork, data analysis and country reports. These institutions are Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de Recherche pour le Développement Humain (CRDH).
The ACTwatch Project (www.actwatch.info), which is part of PSI, was responsible for the work in Kenya, Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health Institute) and Zanzibar, through funding from both the Bill and Melinda gates Foundation and the Global Fund. This work was carried out as part of their existing portfolio and funding stream provided by the Bill and Melinda Gates Foundation for work in Nigeria, Madagascar, and Uganda. DNDi subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, to undertake the work in Ghana. CRDH subcontracted with the Centre International d'Etudes et de Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.
The IE is based on a non-experimental design with a pre- and post-test intervention assessment in which each participating country is treated independently as a case study. In addition to measuring the changes in key indicators pre- and post-intervention, the evaluation includes an assessment of the implementation process and a comprehensive documentation of the context both to inform assessments about causality and to aid in generalizability to other contexts. The current report is based on the endline assessment in Nigeria conducted by PSI/ACTwatch and Society of Family Health, Nigeria. The results of the baseline survey can be found in the Nigeria baseline report (ACTwatch, SFH/Nigeria and the Independent Evaluation Team, 2009), and for all pilots in the Multi-Country Baseline Report (Independent Evaluation Team, 2011). Analysis of changes between baseline and endline outlet surveys will be presented in the Multi-Country Endline Report (forthcoming), together with the data the IE team has compiled from national household surveys. In addition, country case studies on context/process were conducted by the IE, and these case studies are summarized in the present report.
Endline outlet survey methods
A cluster sampling approach was used because there were no reliable lists of all outlets stocking antimalarials. Clusters were sub-districts/communes, with an average of 10,000 to 15,000 inhabitants. In Nigeria, 114 clusters were selected with probability proportional to size (PPS)—a sampling technique in which the probability that a particular sub-district is selected is proportional to its population size. The sample size was powered to detect a change of 20% percentage points in availability of quality-assured ACTs (QA ACTs) between baseline and endline in rural and urban areas.
The inclusion criteria for this study were outlets that stocked an antimalarial at the time of survey or had stocked antimalarials in the previous three months. An outlet is defined as any point of sale or provision of commodities for individuals. Outlets included in the survey were: 1) public health facilities (government hospitals, health centres and CHWs); 2) pharmacies; 3) private health facilities (private clinics, private practices, NGO health centres and dispensaries); 4) drug stores (PPMVs); 5) grocery stores (general retailers); and 6) hawkers (itinerant drug vendors).
A structured endline questionnaire was developed, which included questions to measure indicators for the Independent Evaluation. Fieldworkers recorded the outlets’ basic details and then asked a screening question about the availability of antimalarials to decide whether to proceed with the full interview or not. The questionnaire was administered to a senior person at the outlet to collect data on outlet identification, outlet characteristics, provider knowledge, antimalarials and rapid diagnostic tests (RDTs) stocked, and stockouts of quality-assured ACTs. They recorded information on “audit sheets” on all antimalarials and RDT products stocked in terms of their price and volume sold in the past week. Data quality control tools used in the field were based on those implemented by ACTwatch for the baseline survey.
An Access data entry program was developed by ACTwatch, and all data were double entered and verified. To ensure a high level of data quality, ACTwatch undertook data cleaning using a detailed guideline provided by the IE team and also followed structured ACTwatch guidelines.
For the analysis, the ACTwatch team used a standardized tabulation plan for all ACTwatch tables presented in this report and analysis do files in STATA, which produced all the required ACTwatch indicators. In addition, the IE team provided a tabulation plan for all IE tables presented in this report, and analysis do-files in STATA, which produced all the required indicators and automatically generated the IE tables. All analysis was run using STATA version 11, recording results in a log file.