Actwatch Study Reference Document Uganda Outlet Survey 2015

Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document Uganda Outlet Survey 2015

Released 29 July 2016

Suggested citation ACTwatch Group and PACE. (2015). ACTwatch Study Reference Document: The Republic of Uganda Outlet Survey 2015. Washington DC: PSI.

Contact Dr. Megan Littrell Peter Buyungo ACTwatch Principal Investigator Programme for Aaccessible Communication and Education (PACE) PSI | 1120 19th St NW Suit 600 Uganda Washington DC 20036 Plot # 2, Ibis Vale, Kololo – off Prince Charles Drive | Kampala, Uganda [email protected] [email protected]

Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation, UNITAID, and the UK Department for International Development. This study was implemented by Population Services International (PSI).

PACE Uganda SEDC (cont.) Fieldwork Team (cont.) Peter Buyungo Dr. Janestic Twikirize Christine Nagaba Henry Kaula Hadijah Mwenyango Denis Okello Doreen Nakimuli Sharlotte Tusasirwe Dianah Komugisha Aloysious Nyombi Dorcas Acheng Ministry of Health Jacob Mutazidwa Edward Kalyesubula Dr. Peter Okui Emmanuel Kiwendo Field Supervisors Godfrey Kusemererwa ACTwatch Team Alex Nduhukire Ibrahim Mandali Andrew Andrada Anne Adikini Jacqueline Namutaaya Erick Auko Bruce Orech Joan Bakanansa Dr. Katie Bates Denis Mitala Jobes Orombi Dr. Desmond Chavasse Jennifer Agwang John Robert Okello Kevin Duff Lawrence Magara Juliet Murungi Keith Esch Mariam Magezi Keneth Nyombi Anna Fulton Monica Dhabangi Linda Tusiime Tracy Tarryn Haslam Moses Okiror Longok Maximilian Koibe Catharine Hurley Olivia Nalwanga Lydia Gift Namuswa Beth Kangwana Marble Katushabe Gloria Kigo Field Quality Controllers Moreen Aliku Dr. Megan Littrell Archileo Kiwanuka Moses Aede Julius Ngigi Bashir Kawalya Musa Kabunga Dr. Kate O’Connell Christine Isunu Norah Nattimba Ricki Orford Jennifer Kobusingye Opio Kizito Stephen Poyer Julia Vera Nashuha Phiona Tumusiime Dr. Justin Rahariniaina Lameck Kawooya Kalule Richard Mugabi Christina Riley Moureen Naamara Rita Ochiba Dr. Andria Rusk Paul Tumuhairwe Samuel Kasoozi Julianna Smith Phionah Kamara Scovia Alinda Rachel Thompson Sarah Akullo Seera Leah Dianah Buke Cynthia Whitman Sira Egweu Stella Mudoola Fieldwork Team Stephen Adiga Socio-Economic Data Center LTD Aaron Kiwanuka Suzan Basalirwa (SEDC) Aisha Nanteza Vicent Otebata Prof. Asingwire Narathius Alice Nahabwe Wilberforce Ssebunya Joseph Kiwanuka Anthony Katende Dr. Denis Muhangi Brian Gilbert Kyomuhendo

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Table of Contents

List of Tables ...... 3 List of Figures ...... 5 Definitions ...... 8 Introduction ...... 10 Summary of Methods and Data Collection ...... 11 Summary of Key Findings ...... 13 Results Section A: Core Indicators ...... 43 Results Section B: Core Indicators across Urban/Rural Location ...... 61 Results Section C: Core Indicators across Survey Round: 2010, 2011, 2013, 2015 ...... 83 Annex 1: ACTwatch Background ...... 109 Annex 2: Country Background ...... 112 Annex 3: Outlet Survey Methods ...... 118 Annex 4: Sampled Sub-Counties ...... 123 Annex 5: Detailed Sample Description ...... 125 Annex 6: Questionnaire ...... 127 Annex 7: Antimalarial Reference ...... 149 Annex 8: RDT Reference ...... 154 Annex 9. Sampling Weights ...... 156 Annex 10: Indicator Definitions ...... 158 Annex 11. Adult Equivalent Treatment Dose (AETD) ...... 166 Annex 12: Antimalarial Volumes...... 168

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List of Tables

Results Core Indicators Table S1: Key results, by outlet type - 2015 ...... 13 Table A1: Availability of antimalarials, among all screened outlets, by outlet type ...... 43 Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type ...... 45 Table A3: Types of quality-assured and Non-Quality Assured ACTs audited in the public and private sector ...... 47 Table A4: Antimalarial market composition ...... 48 Table A5a: Price of tablet formulation antimalarials, by outlet type ...... 49 Table A5b: Price of pre-packaged antimalarials, by outlet type ...... 51 Table A6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type ...... 52 Table A7: Malaria blood testing market composition ...... 53 Table A8: Price of malaria blood testing for adults, by outlet type ...... 54 Table A9: Antimalarial market share ...... 55 Table A10: Antimalarial market share across outlet type ...... 56 Table A11: Malaria blood testing market share ...... 57 Table A12: Malaria blood testing market share, across outlet type ...... 58 Table A13: Provider case management knowledge and practices, by outlet type ...... 59 Table A14: Provider antimalarial treatment knowledge and practices, by outlet type ...... 60

Results Across Urban/Rural Location Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural sub-counties . 61 Table B2: Availability of antimalarials, among all outlets stocking at least one antimalarial, by outlet type, across urban/rural sub-counties ...... 65 Table B4: Antimalarial market composition, across urban/rural location ...... 69 Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location ...... 70 Table B5b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location ...... 72 Table B6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location ...... 73 Table B8: Price of malaria blood testing, by outlet type, across urban/rural location ...... 74 Table B9.1: Antimalarial market share, urban ...... 75 Table B9.2: Antimalarial market share, rural ...... 76 Table B10.1: Antimalarial market share across outlets, urban ...... 77 Table B10.2: Antimalarial market share across outlets, rural ...... 78 Table B13: Provider case management knowledge and practices, by outlet type, across urban/rural location ...... 79 Table B14: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location .... 81

Results Across Survey Round Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round ...... 83 Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round ...... 89

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Table C4: Antimalarial market composition, across survey round ...... 94 Table C5: Price of tablet formulation antimalarials, by outlet type, across survey round ...... 95 Table C6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round ...... 99 Table C8: Price of malaria blood testing for adults, by outlet type, across survey round ...... 101 Table C9: Antimalarial market share, across survey round ...... 103 Table C10: Antimalarial market share, across outlet type, across survey round ...... 105 Table C14: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round ...... 107

Annexes Table X1. Sampled Sub-Counties ...... 123 Table X2: Detailed sample description ...... 125 Table X3: Number of antimalarials audited ...... 149 Table X4: Quality Assured (QA ACT) and Non-Quality Assured ACTs ...... 150 Table X5: Nationally Registered ACTs ...... 152 Table X6: Severe Malaria Treatment ...... 153 Table X7: Number of RDTs audited ...... 154 Table X8: RDT Brand Names and Manufacturers* ...... 155 Table X9: Adult Equivalent Treatment Dose Definitions ...... 167 Table X10: Antimalarial volumes, by outlet type ...... 168

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List of Figures

Figure 1. Survey flow diagram, Uganda, 2015 ...... 12 Figure 2. Market composition: outlet type distribution, 2010-2015 ...... Error! Bookmark not defined. Figure 3. Market composition: outlet type distribution, 2015, urban/rural ...... Error! Bookmark not defined. Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2010-2015 ...... 16 Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2015, urban/rural... 16 Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2010-2015 ...... 17 Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2015, urban/rural 17 Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2010-2015 ...... 18 Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2015, urban/rural ...... 18 Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2010-2015 ...... 19 Figure 11. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2015, urban/rural...... 19 Figure 12. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2010-2015 ...... 20 Figure 13. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2015, urban/rural ...... 20 Figure 14. Types of quality-assured ACT and Non-Quality Assured ACT audited among public and private sector outlets, 2015 ...... 21 Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2010-2015 ...... 22 Figure 16. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2015, urban/rural ...... 22 Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2010-2015 ...... 23 Figure 18. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2015, urban/rural . 23 Figure 19. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2010-2015 ...... 24 Figure 20. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2015, urban/rural ...... 24 Figure 21. Percentage of antimalarial-stocking outlets with injectable artesunate in stock on the day of the survey, 2010-2015 ...... 25 Figure 22. Percentage of antimalarial-stocking outlets with injectable artesunate in stock on the day of the survey, 2015, urban/rural ...... 25 Figure 23. Percentage of antimalarial-stocking outlets with rectal artesunate in stock on the day of the survey, 2010- 2015 ...... 26 Figure 24. Percentage of antimalarial-stocking outlets with rectal artesunate in stock on the day of the survey, 2015, urban/rural ...... 26 Figure 25. Antimalarial market share, 2010-2015 ...... 27 Figure 26. Antimalarial market share within sector, 2010-2015 ...... 28 Figure 27. Antimalarial market share, 2015...... 29 www.ACTwatch.info Page 5

Figure 28. Antimalarial market share, 2015, urban/rural ...... 29 Figure 29. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2010-2015 ...... 30 Figure 30. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2015, urban/rural ...... 30 Figure 31. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2010-2015 ...... 31 Figure 32. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2015, urban/rural...... 31 Figure 33. Percentage of antimalarial-stocking outlets with malaria RDTs, 2010-2015 ...... 32 Figure 34. Percentage of antimalarial-stocking outlets with malaria RDTs, 2015, urban/rural ...... 32 Figure 35. Malaria blood testing market share, 2015 ...... 33 Figure 36. Malaria RDT market share by manufacturer, across sector, 2015 ...... 33 Figure 37. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2010-2015 ...... 34 Figure 38. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2015 ...... 35 Figure 39. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2015, urban/rural ...... 36 Figure 40. Private sector median price of QA ACT adult equivalent treatment dosages (AETD) with and ...... 37 without the ‘green leaf’ logo, 2010-2015 ...... 37 Figure 41. Median private sector consumer prices for malaria RDT testing for adults and children 2015 ...... 37 Figure 42. Median private sector prices for malaria RDT testing and QA ACT for adults and children 2015 ...... 38 Figure 43. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2010-2015 ...... 39 Figure 44. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2015, urban/rural ...... 40 Figure 45. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2010-2015 ...... 41 Figure 46. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2015, urban/rural ...... 42

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Acronyms

ACT Artemisinin combination therapy AETD Adult equivalent treatment dose AL Artemether lumefantrine AMFm Affordable Medicines Facility – malaria ASAQ Artesunate amodiaquine BMGF The Bill and Melinda Gates Foundation CHW Community Health Worker DHA PPQ Dihydroartemisinin piperaquine DHS The Demographic and Health Survey EMA European Medicines Agency GFATM Global Fund to Fight AIDS, TB, and Malaria IM Intramuscular injection ICCM Integrated community case management IV Intravenous injection MOH Ministry of Health NGO Non-governmental Organization NMCP National Malaria Control Program Oral AMT Oral artemisinin monotherapy PMI President’s Malaria Initiative Pf Plasmodium falciparum QA ACT Quality-assured artemisinin combination therapy QA RDT Quality-assured rapid diagnostic test RDT Rapid diagnostic test SP Sulfadoxine Pyrimethamine UK United Kingdom USAID United States Agency for International Development VHT Village Health Team

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Definitions

Survey Methods Definitions

Outlet Any service delivery point or point of sale for commodities. Outlets are not restricted to stationary points of sale and may include mobile units or individuals. Outlets eligible for Outlets were administered a full questionnaire if they met at least one of three inclusion inclusion in the criteria: (1) had one or more antimalarials in stock at the time of the survey visit; (2) study reportedly had one or more antimalarials in stock in the previous three months; or (3) provide malaria blood testing (microscopy or rapid diagnostic tests) but do not provide antimalarial treatment. Outlets not providing services to the general public (e.g. army and military clinics) were excluded from the study. Cluster The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit determined by the Ministry of Health (MOH) that hosts a population size of approximately 10,000 to 15,000 inhabitants. These units are defined by political boundaries. In Uganda, they were defined as sub-counties. Censused Cluster A sub-county where field teams conducted a full census of all outlets with the potential to sell antimalarials. Booster Sample A booster sample was collected by extending the primary sampling unit to a higher administrative unit for sampling certain outlet types. This extension achieves a larger sample size for specific outlets, allowing for estimates among key outlet types In this survey, a booster sample was collected for public health facilities and pharmacies. The administrative unit for sampling public health facilities was extended beyond sub-county to the county level in urban clusters. The administrative unit for sampling pharmacies was extended beyond sub-county to the county level in both urban and rural clusters. See Annex 9 for a detailed description of the booster sampling methods.

Malaria Product Indicator Definitions

Antimalarial Any medicine recognized by the WHO for the treatment of malaria. Medicines used solely for the prevention of malaria were excluded from analysis of key indicators in this report. Dosing/treatment The posology or timing and number of doses of an antimalarial used to treat malaria. This regimen schedule often varies by patient weight. Adult Equivalent An AETD is the number of milligrams (mg) of an antimalarial drug required to treat a 60 kg Treatment Dose adult (see Annex 11). (AETD) Monotherapy 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. Artemisinin and its Artemisinin is a plant extract or synthetic plant extract used in the treatment of malaria. The derivatives most common derivatives of artemisinin used to treat malaria are artemether, artesunate, and dihydroartemisinin. Artemisinin-based An antimalarial that combines artemisinin or one of its derivatives with an antimalarial or Combination antimalarials of a different class. Therapy (ACT)

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Artemisinin An antimalarial medicine that has a single active compound, where this active compound is monotherapy artemisinin or one of its derivatives. Oral artemisinin Artemisinin or one of its derivatives in a dosage form with an oral route of administration. monotherapy These include tablets, suspensions, and syrups and exclude suppositories and injections. Non-artemisinin An antimalarial medicine that does not contain artemisinin or any of its derivatives. therapy First-line The government recommended treatment for uncomplicated malaria. Uganda’s first-line treatment treatment for uncomplicated malaria is artemether lumefantrine (20mg / 120mg). The first- line treatment for uncomplicated malaria in pregnant women during the first trimester is quinine. Second-line The government recommended second-line treatment for uncomplicated malaria. Uganda’s treatment second-line treatment for uncomplicated malaria is dihydroartemisinin-piperaquine (40mg/320mg or 20mg/160mg pediatric). Nationally ACTs registered with Uganda’s national drug authority and permitted for sale or distribution in registered ACTs Uganda. Each country determines its own criteria for placing a drug on its nationally registered listing. Severe malaria WHO recommends intravenous or intramuscular artesunate as first-line treatment in the treatment management of severe falciparum malaria. If artesunate is not available, artemether in preference to quinine should be used for treating severe malaria cases. Rectal artesunate is 1 suitable for pre-referral treatment in children under 6 years of age.0F Quality-assured QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Artemisinin-Based Quality Assurance Policy. A QA ACT is any ACT that appeared on the Global Fund's indicative Combination list of antimalarials meeting the Global Fund's quality assurance policy prior to data collection Therapies (QA (see http://www.theglobalfund.org/en/healthproducts/qualityassurance/) or that previously ACTs) had C-status in an earlier Global Fund quality assurance policy. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®. Quality-assured The “green leaf” logo indicates that a quality-assured ACT was acquired through ACT with the a co-payment mechanism administered by the Global Fund (Affordable “green leaf” logo, Medicines Facility, malaria – or AMFm). These subsidized (co-paid) quality- or “co-paid ACTs” assured ACTs were available to first-line buyers in Uganda in the public sector between 2010-2011 and private sector from 2010-2015. Quality-assured QA RDTs are RDTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s RDT Quality Assurance Policy. A QA RDT is any RDT that appeared on the Global Fund's indicative list of RDTs meeting the Global Fund's quality assurance policy prior to data collection (see http://www.theglobalfund.org/en/healthproducts/qualityassurance/).

1 World Health Organization. (2015). Guidelines for the treatment of malaria, 3rd edition. Geneva: WHO.

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Introduction

This country reference document is a detailed presentation of the 2015 national ACTwatch outlet survey (OS) conducted in Uganda. The 2015 OS follows previous survey rounds conducted by ACTwatch in Uganda in 2008, 2009, 2010, 2011, 2013 and 2015.

ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence. The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through mid-2016 by the BMGF, UNITAID, and DFID. See Annex 1 for more information about the ACTwatch project.

ACTwatch antimalarial market monitoring in Uganda from 2008 to present has been implemented in the context of strategies designed and implemented to improve coverage of appropriate case management. This antimalarial market evidence monitored the health system readiness and performance for malaria case management in the context of recent strategies and investments to improve case management including:

 End of the AMFm ACT subsidy mechanism implemented from 2011-2013 and continuation of a similar Global Fund co-payment subsidy mechanism with a lower co-payment/subsidy available to first-line buyers from 2014. ACT procurement was also supported by PMI.  Scale up of Village Health Team volunteers equipped to manage malaria at community level as part of community case management for childhood illnesses. VHT trainings began in 2010 and scale up was supported by the Global Fund and PMI.  National Malaria Control Policy adopted in 2012 recommending that all suspected malaria cases received confirmatory testing using microscopy or a malaria RDT prior to treatment. Scale up of blood testing using RDTs or microscopy was supported by funding from PMI and the Global Fund.  Transition in severe malaria case management to pre-referral treatment at community level with rectal artesunate and treatment of severe malaria with IV artesunate (phasing out IV quinine). Procurement of IV artesunate was supported by PMI.  Efforts to support and improve supply chain management and prevent ACT and RDT stock outs at public health facilities.

The 2015 OS was the sixth round of ACTwatch outlet surveys conducted in Uganda. This report presents trend lines with four data points: 1) the 2010 AMFm baseline survey; 2) the 2011 AMFm pilot endline survey; 3) the 2013 outlet survey; and 4) the most recent 2015 survey. These surveys are designed to monitor key antimalarial market indicators at national level and within urban and rural research domains. ACTwatch outlet survey findings can inform ongoing monitoring, evaluation, and adjustment to policy, strategy, and funding decisions to strengthen malaria case management.

Report notes

 This document is a complete reference for the 2015 outlet survey. Please see annexes for information about the study context, design, implementation and data analysis.  Grey text for data appearing in report tables indicates that the estimate provided was derived from a small sample size. Specifically, grey text is used to indicate point estimates derived from an n of less than 50 and median prices derived from an n of less than 5.  Malaria testing and treatment prices are reported in US dollars. Price information is captured in local currency and converted to US dollars based on exchange rates available from www.oanda.com using the historical

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exchange rates tool. The average exchange rate over the entire data collection period is used for converting local currency captured during data collection to US dollars. Summary of Methods and Data Collection

A nationally-representative antimalarial outlet survey was conducted in Uganda between May 18, 2015 and July 2, 2015. A full description of research design and methods is provided in Annex 3. Briefly, a representative sample of sub-counties was selected from urban and rural domains (see sampled sub-counties in Annex 4). Within selected clusters, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was completed. Additional sub-counties were selected for oversampling of public health facilities and pharmacies. This booster sampling strategy was used to obtain a sufficient sample size for indicator estimates within these outlet types.

Outlets were screened to determine eligibility. Outlets eligible for the survey met at least one of three criteria: 1) one or more antimalarials were in stock on the day of the survey; 2) one or more antimalarials were in stock in the three months preceding the survey; and/or 3) malaria blood testing (microscopy or RDT) was available. Outlets that do not serve the general public (e.g. military facilities) were excluded from the study. The results of the census are summarized in Figure 1. A detailed sample summary is provided in Annex 5.

A structured questionnaire programmed into mobile phones using DroidDB software was used to complete an audit of all antimalarials and malaria rapid diagnostic tests (RDTs) as well as a provider interview (see Annex 6). See Annex 7 and Annex 8 for detailed summaries of antimalarials and RDTs audited. Key informant interviews were conducted with specific stakeholders to supplement information for the Uganda background.

All data cleaning and analysis was performed using Stata 13.1 (©StataCorp, College Station, TX). Data were weighted to account for variation in probability of outlet selection (see Annex 9), and standard error calculation reflected clustering of outlets at sub-county and county levels. Standard indicators were constructed according to definitions applied across ACTwatch project countries (see Annex 10).

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Figure 1. Survey flow diagram, Uganda, 2015

A Interview interrupted [4] Outlets enumerated* [9,919] Respondent not available [218] Outlets not screened Outlet closed at time of visit [122] [481] Outlet closed permanently [84] B Outlets screened** Other [8] [9,438]

Outlets that did not Refused [45] meet screening criteria C [4,658]

Outlets that met screening criteria [4,780] 1 = [4,381] Interview interrupted [2] 2 = [273] 3 = [126] Respondent not available [16] Outlets not interviewed Outlet closed at time of visit [4] [56] Other [4] D Outlets interviewed*** Refused [30] [4,724] 1 = [4,328] 2= [270] 3= [126]

1: Antimalarials in stock on day of visit 2: Antimalarials reportedly in stock during the previous 3 months but not on the day of the visit 3: Malaria blood testing available but no antimalarials in stock * Identified as outlets with potential to sell or distribute antimalarials and/or provide malaria blood testing during the census or booster sampling ** Administered questions to assess current or recent (previous 3 months) availability of antimalarials and malaria blood testing (microscopy or rapid diagnostic test) *** A partial or complete interview was conducted with an outlet representative

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Summary of Key Findings

Table S1: Key results, by outlet type - 2015

Public ALL Private Community ALL ALL Health Public / Not- For-Profit Pharmacy Drug Store Health Worker Private Outlets2 Facility For-Profit1 Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Readiness for malaria case management N=282 N=5,618 N=5,955 N=1,023 N=493 N=1,967 N=3,483 N=9,438 Proportion of all screened outlets outlets* with: Availability of malaria blood 95.2 10.2 11.7 67.7 50.2 20.5 32.0 16.5 testing (89.4, 97.9) (5.2, 19.1) (6.5, 20.1) (61.5, 73.4) (43.1, 57.3) (17.4, 23.9) (28.7, 35.5) (11.6, 22.9) 93.8 11.1 12.5 69.5 94.8 72.3 72.0 26.6 Availability of QA ACT (89.1, 96.5) (5.9, 20.0) (7.1, 21.0) (63.2, 75.1) (91.6, 96.8) (68.2, 76.0) (68.2, 75.4) (20.8, 33.4) Availability of QA ACT and 89.6 7.3 8.7 52.5 49.0 16.1 25.1 12.6 malaria blood testing (83.8, 93.5) (3.2, 15.8) (4.3, 16.6) (46.2, 58.6) (41.9, 56.1) (13.6, 19.0) (22.1, 28.4) (8.5, 18.2) Availability of QA ACT, blood 4.2 3.9 3.8 17.0 45.8 56.2 46.9 14.0 testing not available (1.6, 10.4) (2.0, 7.4) (2.0, 7.3) (13.3, 21.5) (38.8, 53.1) (52.6, 59.7) (43.8, 49.9) (11.4, 17.1) Availability of national first-line 53.1 0.0 0.8 20.0 63.8 2.3 7.3 2.4 severe malaria treatment (artesunate IV/IM) (42.8, 63.1) - (0.6, 1.1) (16.1, 24.6) (53.5, 72.9) (1.0, 5.1) (5.5, 9.8) (1.8, 3.1) Readiness for malaria case management N=275 N=719 N=1,047 N=956 N=467 N=1,849 N=3,281 N=4,328 Proportion of antimalarial- stocking outlets  with: Availability of malaria blood 95.3 65.2 69.2 71.0 51.4 21.4 33.5 44.3 testing (89.3, 98.0) (42.0, 82.9) (49.1, 83.9) (64.2, 77.1) (44.1, 58.6) (18.3, 24.9) (30.1, 37.1) (36.1, 52.9) 96.1 99.7 99.2 74.7 96.5 77.4 77.1 83.8 Availability of QA ACT (92.6, 98.0) (98.7, 99.9) (98.3, 99.6) (68.0, 80.3) (94.0, 97.9) (73.6, 80.9) (73.3, 80.4) (80.6, 86.6) Availability of QA ACT and 91.8 65.2 68.8 56.4 49.8 17.3 26.9 39.6 malaria blood testing (86.3, 95.2) (42.0, 82.9) (48.7, 83.6) (49.5, 63.0) (42.6, 57.0) (14.7, 20.2) (23.9, 30.2) (31.3, 48.5) Availability of QA ACT, blood 4.3 34.5 30.4 18.3 46.6 60.2 50.2 44.2 testing not available (1.7, 10.6) (16.9, 57.7) (15.8, 50.4) (14.4, 22.9) (39.5, 53.9) (56.3, 63.9) (46.8, 53.5) (37.2, 51.5) Availability of national first-line 54.4 0.0 6.5 21.5 64.9 2.4 7.8 7.4 severe malaria treatment - (artesunate IV/IM) (44.0, 64.5) (3.5, 11.7) (17.1, 26.6) (54.7, 73.8) (1.1, 5.5) (5.8, 10.4) (5.6, 9.7)

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Table S1: Key results, by outlet type - 2015

Public ALL Private Community ALL ALL Health Public / Not- For-Profit Pharmacy Drug Store Health Worker Private Outlets2 Facility For-Profit1 Facility Readiness for IPTp

Proportion of outlets with: Availability of SP, among all 81.4 0.0 1.3 48.5 82.5 45.9 47.1 12.1 screened outlets* (75.0, 86.5) (0.0, 0.1) (1.0, 1.7) (42.1, 54.8) (76.3, 87.3) (40.3, 51.7) (42.1, 52.1) (9.6, 15.3) Availability of SP, among 83.4 0.2 10.3 52.1 83.9 49.2 50.4 38.2 antimalarial-stocking outlets  (77.4, 88.1) (0.0, 1.2) (6.0, 17.0) (45.7, 58.4) (77.6, 88.7) (43.5, 54.9) (45.4, 55.4) (31.9, 45.0)

Antimalarial market share % % % % % % % % within outlet/sector type

% QA AL market share ^ 72.4 99.8 59.5 73.1 41.5 38.0 52.9 47.5

Median Median Median Median Median Private sector price [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) n/a n/a n/a $1.94 $1.29 $1.55 $1.62 n/a Median price for one QA ACT [1.29-3.23] [0.97-1.94] [1.13-1.94] AETD (tablets) [0.97-1.94] (2,446) (1,365) (1,467) (5,278) n/a n/a n/a $0.65 $0.48 $0.48 $0.48 n/a Median price for one SP AETD [[0.48-0.65] [0.48-0.65] (tablets) [0.48-0.81] (605) [0.48-0.65] (1,122) (587) (2,314) n/a n/a n/a $0.65 $0.48 $0.32 $0.39 n/a Median price for one pre- [0.32-0.97] packaged pediatric QA AL # [0.32-0.97] (84) [0.29-0.48] (173) [0.32-0.58] (391) (134) n/a n/a n/a $0.97 $0.97 $0.65 $0.81 n/a Median price for an RDT ## [[0.65-0.97] [0.32-0.97] [0.65-0.97] (391) [0.65-0.97] (949) (514) (44) 1 Inclusive of N=55 screened/53 antimalarial-stocking private not-for-profit health facilities 2 Inclusive of community health workers, private not-for-profit health facilities, and drug vendors. * The denominator includes 156 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).  Outlets with at least one antimalarial in stock on the day of the survey or reportedly in stock within the past 3 months. ^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by QA ACT sale/distribution within distribution by the outlet/sector. # Pre-packaged QA AL for a 10kg child ## Price inclusive of consultation / service fees for a child under age 5. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2010- 2015 Among all screened outlets, across survey round

100

40 Percentage of outlets

0 Public Community Private Not All Public Private For- Pharmacy Drug Store General All Private * Health Health For-Profit Profit Retailer Facility Worker Health Health Facility Facility 2010 2011 2013 2015

Antimalarial availability was high during each survey round and was greater than 90% in 2015 among all outlet types except CHWs (11%). *In 2010, 2011 and 2013, general retail outlets were screened for antimalarial availability. Thousands of retail outlets were included during each round, but very few were stocking antimalarials. As such in 2015, general retailers were not included in the study. For this reason, availability among all private outlets in 2015 is much higher than in previous years (due to exclusion of general retailers from the study).

Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2015, urban/rural Among all screened outlets

Antimalarial availability was similar across urban and rural locations for all outlet types.

www.ACTwatch.info Page 16

Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2010- 2015 Among all outlets with at least one antimalarial in stock, across survey round

100

Percentage of outlets 40

0 Public Health Community Private not-for- All Public Private for- Pharmacy Drug Store All Private Facility Health Worker Profit Health Profit Health Facility Facility

2010 2011 2013 2015

ACTs were available among nearly all antimalarial-stocking public health facilities (96%), CHWs (100%) and pharmacies (100%) in 2015. Availability was also high and had increased significantly in recent years among drug stores, from 50% in 2010 to 86% in 2015. Nearly 90% of antimalarial-stocking private sector outlets were stocking ACTs in 2015 (89%).

Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Availability of ACTs was similar across urban and rural locations for the public sector. In the private sector, ACT availability was higher in urban (93%) versus rural (83%) areas, including among private for-profit facilities (urban, 94%; rural, 79%) and drug stores (urban 92%; rural, 84%).

www.ACTwatch.info Page 17

Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey round

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Quality-assured ACTs were available among nearly all antimalarial-stocking public health facilities (96%), CHWs (100%) and pharmacies (97%) in 2015. Availability was also high and had increased significantly in recent years among drug stores, from 10% in 2010 to 77% in 2015. Three in four (77%) antimalarial-stocking private sector outlets were stocking QA ACTs in 2015, an increase from 11% in 2010.

Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Aavailability of QA ACTs was similar across urban and rural locations for the public sector. In the private sector, ACT availability was higher in urban (84%) versus rural (74%) areas, including among private for-profit facilities (urban, 80%; rural, 70%) and drug stores (urban 86%; rural, 75%).

www.ACTwatch.info Page 18

Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey round

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Following the implementation of the AMFm program in late 2010, ‘green leaf’ logo QA ACT availability among public health facilities hit its peak in 2011 at 83% of facilities, but decreased to 41% in 2013 and 11% in 2015. ‘Green leaf’ logo QA ACT availability has remained high among antimalarial-stocking private sector outlets since the end of the AMFm pilot period in 2011 (61%) and in 2015, more than 70% of private sector outlets were stocking these ACTs (73%). This includes 72% of private for- profit health facilities, 94% of pharmacies, and 73% of drug stores.

Figure 11. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

‘Green leaf’ logo QA ACTs were more commonly available among private sector urban (80%) versus rural outlets (70%). This includes higher availability among drug stores in urban (81%) versus rural areas (70%).

www.ACTwatch.info Page 19

Figure 12. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey round

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Availability of non-QA ACTs remained below 10% among public health facilities across all survey rounds. In the private sector, non-QA ACT availability decreased from 52% in 2010 to 34% in 2011 and was 38% in 2015. Private sector availability was particularly high among pharmacies; nearly all pharmacies were stocking non-QA ACT across survey rounds. Half of private for- profit health facilities and one-third of drug stores were stocking non-QA ACT in 2015.

Figure 13. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Availability of non-QA ACTs was higher in urban versus rural areas. Within the private sector, more than half (56%) of antimalarial-stocking outlets in urban areas had non-QA ACTs in stock as compared with 29% in rural areas.

www.ACTwatch.info Page 20

Figure 14. Types of quality-assured ACT and Non-Quality Assured ACT audited among public and private sector outlets, 2015 Among all ACT medicines audited, across sector, 2015

Quality-assured Private Sector AL tablet Quality-assured Public Sector Non-quality assured Private Sector Non-quality assured Public Sector N=5,369 N=2,011 N=7,179 N=59 A NAP tablet

A PPQ tablet

DHA PPQ tablet

DHA SP tablet

AL non-tablet

DHA PPQ non-tablet

The majority of QA ACTs audited in both the public (100%) and private sector (76%) were Al tablets. Nearly one-quarter of QA ACTs audited in the private sector were ASAQ tablets. Non- quality assured ACTs audited in the private sector included AL tablets (35%) and DHA-PPQ tablets (31%) as well as AL non-tablets (17%) such as suspensions and DHQ-PPQ non-tablets (8%).

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Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey round

100

60 Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

The majority of antimalarial-stocking outlets in Uganda were stocking non-artemisinin therapy during each survey round, with the exception of CHWs. These include SP and quinine.

Figure 16. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Non-artemisinin therapy availability was higher among public health facilities in urban (97%) versus rural areas (87%).

www.ACTwatch.info Page 22

Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2010- 2015 Among all outlets with at least one antimalarial in stock, across survey round

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Although SP is no longer indicated for malaria case management, it is used for intermittent preventive therapy during pregnancy (IPTp). Readiness for IPTp remains high among public health facilities, with more than 80% stocking SP in 2015 (83%). SP has also been commonly found in the private sector, where about half of all antimalarial-stocking outlets have SP in stock.

Figure 18. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

SP availability was higher among public health facilities in urban (90%) versus rural areas (75%). SP availability was also higher in in the private sector in urban (58%) versus rural areas (46%).

www.ACTwatch.info Page 23

Figure 19. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey rounds

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Oral quinine is one of two second-line treatments for malaria in Uganda. Availability of oral quinine among antimalarial-stocking public health facilities was 61% in 2015. Oral quinine availability remained high in the private sector over time, although availability has decreased from 90% in 2010 to 78% in 2015.

Figure 20. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Availability of oral quinine was higher among public health facilities in urban (74%) versus rural areas (45%). Private sector availability was similar in urban versus rural areas.

www.ACTwatch.info Page 24

Figure 21. Percentage of antimalarial-stocking outlets with injectable artesunate in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey rounds

100

Percentage of outlets 40

0 Public Health Facility Private not-for-Profit Private for-Profit Health Drug Store All Private Health Facility Facility

2010 2011 2013 2015

Availability of injectable artesunate, the first line recommended treatment for severe malaria since 2014, increased considerably in 2015 compared to prior years. Over 50% of antimalarial-stocking public health facilities had injectable artesunate available in the last survey round. Availability has also increased in 2015 among pharmacies to 64%, and among private for-profit health facilities to 20%.

Figure 22. Percentage of antimalarial-stocking outlets with injectable artesunate in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Availability of injectable artesunate was higher among public health facilities in urban (64%) versus rural areas (39%). Data trends suggest higher availability in urban versus rural private for-profit health facilities (urban, 27%; rural, 13%) and pharmacies (urban, 65%; rural, 57%).

www.ACTwatch.info Page 25

Figure 23. Percentage of antimalarial-stocking outlets with rectal artesunate in stock on the day of the survey, 2010-2015 Among all outlets with at least one antimalarial in stock, across survey rounds

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store General All Private Facility Health For-Profit Profit Health Retailer Worker Health Facility Facility 2010 2011 2013 2015

Rectal artesunate is recommended for pre-referral treatment of severe malaria. Availability in public health facilities increased from 1% in 2013 to 31% in 2015, but remained low in all other outlet types.

Figure 24. Percentage of antimalarial-stocking outlets with rectal artesunate in stock on the day of the survey, 2015, urban/rural Among all outlets with at least one antimalarial in stock

Availability of rectal artesunate was higher among public health facilities in rural (43%) versus urban areas (21%).

www.ACTwatch.info Page 26

Figure 25. Antimalarial market share, 2010-2015 Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class, across survey round

100 90 80 70 60 50 40 30 20 10 0

Public Private Public Private Public Private Public Private Percentage of total market volume 2010 2011 2013 2015

QA ACT green leaf QA ACT without green leaf Non QA ACT SP Other non-artemisinin therapy Non-oral artemisinin monotherapy

The private sector has accounted for more than half of the antimalarial market share at national level in 2011 (53%), 2013 (56%) and 2015 (54%). Market share for QA ACT increased from 40% in 2010 to 57% in 2011 during the AMFm pilot period and remained high in 2013 (55%) and 2015 (59%). The market share for QA ACT with the ‘green leaf’ logo was 43% in 2011 and decreased with continuation of the mechanism in the private sector only, to 26% in 2013 and 34% in 2015. Market share for non-QA ACT has remained around 10% over time. Market share for non-artemisinin therapies including SP has declined over time to 29% in 2015 and SP accounted for 20% of the antimalarial market share.

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Figure 26. Antimalarial market share within sector, 2010-2015 Relative market volume (sale/distribution) of antimalarial AETDs, within sector, by antimalarial class, across survey round

100 90 80 70 60 50 40 30 20 10 0

Public Private Public Private Public Private Public Private Percentage of sector market volume 2010 2011 2013 2015

QA ACT green leaf QA ACT without green leaf Non QA ACT SP Other non-artemisinin therapy Non-oral artemisinin monotherapy

Within the public sector, QA ACTs have accounted for the majority of antimalarials distributed during each survey round. QA ACT market share increased from 68% in 2010 to 78% in 2011, and declined to 72% in 2013 and 73% in 2015. A decline in QA ACT market share relative to SP, which may be used for IPTp, may be due to increased rational ACT use with scale-up of confirmatory testing prior to treatment. However, it is noted that market share for other non-artemisinin therapy, namely oral quinine, has increased in 2015 to 8% from 2% in 2013.

Within the private sector, QA ACT market share increased during the AMFm pilot period from 5% in 2010 to 39% in 2011, and continued to increase in 2013 (44%) and 2015 (48%). Nearly all of these QA ACTs distributed in the private sector have the ‘green leaf’ logo indicating subsidized product from the Global Fund. Within the private sector, market share for non-QA ACT was 19% in 2015 and SP accounted for 20% of the antimalarial market share.

www.ACTwatch.info Page 28

Figure 27. Antimalarial market share, 2015 Relative market volume (sale/distribution) of antimalarial AETDs, by outlet type and antimalarial class

100

Percentage Percentage market of total volume 0 Public Private Private For-Profit Pharmacy Drug Store Facility QA ACT green leaf QA ACT without green leaf Non QA ACT SP Other non-artemisinin therapy Non-oral artemisinin monotherapy

Private sector market share in 2015 (54%) is comprised of relative market share for drug stores (31%), private for‐profit health facilities (14%), and pharmacies (9%).

Figure 28. Antimalarial market share, 2015, urban/rural Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class

100

0 Public Private Public Private Urban Rural

Percentage of sector market volume QA ACT green leaf QA ACT without green leaf Non QA ACT SP Other non-artemisinin therapy Non-oral artemisinin monotherapy

The private sector distributed 72% of the antimalarials in urban areas, and 43% of the antimalarials in rural areas. QA ACT market share was higher in rural (63%) versus urban areas (54%) and non-QA ACT market share was higher in urban (17%) versus rural areas (6%). SP market share was about nearly 20% in both urban and rural areas, with more of the SP distribution occurring in the public sector in rural areas (10%) as compared to urban areas (5%).

www.ACTwatch.info Page 29

Figure 29. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2010-2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store All Private Facility Health Worker For-Profit Profit Health Health Facility Facility

2010 2011 2013 2015

Availability of malaria blood testing increased in all outlet types in 2015, compared to baseline. Availability was highest among private not for-profit facilities (96%) and public health facilities (95%). Availability was above 50% in all other outlet types in 2015 except drug stores, where availability of blood testing was 21%.

Figure 30. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2015, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

Data trends suggest higher availability of malaria blood testing among antimalarial stocking outlets in urban versus rural areas. Among private sector outlets, availability was 44% in urban areas as compared with 27% in rural areas. www.ACTwatch.info Page 30

Figure 31. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2010-2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store All Private Facility Health Worker For-Profit Profit Health Health Facility Facility

2010 2011 2013 2015

Availability of malaria microscopy increased in public health facilities, from 32% in 2010 to 54% in 2015. Microscopy testing was available in roughly 40% of private for-profit health facilities across all survey rounds.

Figure 32. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2015, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

Availability of malaria microscopy was higher among public health facilities in urban (72%) versus rural locations (35%). Data trends also suggest higher availability among private for-profit facilities in urban (51%) versus rural areas (31%).

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Figure 33. Percentage of antimalarial-stocking outlets with malaria RDTs, 2010-2015 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store All Private Facility Health Worker For-Profit Profit Health Health Facility Facility

2010 2011 2013 2015

Availability of malaria RDTs increased considerably from 2010 to 2015 in all outlet types. Availability in public health facilities increased from 4% in 2010 to 82% in 2015, in community health workers from 12% in 2010 to 58% in 2015, and in private not- for-profit facilities from 9% in 2010 to 87% in 2015. Although availability remained lower in the private sector compared to the public sector, increases were also seen: from 10% to 48% in private for-profit facilities, from 22% to 51% in pharmacies, and from 2% to 20% in drug stores.

Figure 34. Percentage of antimalarial-stocking outlets with malaria RDTs, 2015, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban and rural zones

Availability of malaria RDTs was similar across urban and rural areas in 2015.

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Figure 35. Malaria blood testing market share, 2015 Relative market volume (sale/distribution) of malaria blood testing using RDTs and microscopy, by outlet type and type of test

100 90 80 70 60 50 40 30 20

10 Percentage of total market volume 0 Public Private Private For-Profit Pharmacy Drug Store Facility Microscopy RDT

Nearly three quarters of all malaria blood tests were performed by public sector outlets (71%) and the majority of these were performed using RDTs (70%). Private for-profit facilities accounted for the majority of malaria blood testing performed by the private sector (22% of all tests performed, 76% of all tests performed in the private sector).

Figure 36. Malaria RDT market share by manufacturer, across sector, 2015 Relative market volume (sale/distribution) of malaria RDTs by manufacturer, within the public sector, private sector, and total market

100 90 80 70 60 50 40 30 20 10

Percentage of within outlet market volume 0 Public Private ACCESS BIO STANDARD DIAGNOSTICS INC ASTEL DIAGNOSTICS Other RDT manufacturer Manufacturer not specified

Among RDTs performed within the public sector, the majority (82%) were manufactured by Access Bio Inc, followed by Astel Diagnostics (9%) and Standard Diagnostics, Inc (8%). In the private sector, Access Bio Inc accounted for 74% of the RDT market share, followed by Standard Diagnostics at 6%.

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Figure 37. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2010- 2015 Among all SP and quality-assured ACT (tablet formulation only) available in the private sector, in 2010 US dollars to account for inflation, across survey round

The median private sector price for one adult equivalent treatment dose (AETD) of QA ACT has decreased steadily over time. However, even the lowest price of QA ACT, at $1.48 in 2015 was still more than three times as expensive as a full course of SP at $0.44. The price of SP also decreased over time, from $0.70 in 2010 to $0.44 in 2015.

www.ACTwatch.info Page 34

Figure 38. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2015 Among all SP, QA ACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2015 US Dollars

$2.50

$2.00 $1.62 $1.62$1.62 $1.50 $1.29

2015USD $1.00 $0.65 $0.65 $0.48$0.48$0.48 $0.48 $0.39 $0.50 $0.32

$0.00 SP AETD QA ACT AETD Pre-packaged pediatric QA AL

Private For-Profit Facility Pharmacy Drug Store All Private

The price of one QA ACT AETD in the private sector in 2015 USD was $1.62 compared with $0.48 for one SP AETD. Pre-packaged AL for a 10kg child (6-tablets) was $0.39 in the private sector.

Private for-profit facilities had the highest prices for all drug types compared to other private outlets. The cost of one SP AETD was $0.65 in these outlets in 2015, compared to $0.48 in all other outlet types. One QA ACT AETD was $1.94 in 2015 in private for-profit facilities, $1.55 in drug stores, and $1.29 in pharmacies.

www.ACTwatch.info Page 35

Figure 39. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2015, urban/rural Among all SP, QA ACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2015 US Dollars, across survey round

$2.50

$2.00 $1.62 $1.62 $1.50

2015USD $1.00

$0.48 $0.48 $0.48 $0.50 $0.39

$0.00 Urban Rural Urban Rural Urban Rural SP AETD QA ACT AETD Pre-packaged pediatric QA AL

All Private

The private sector price of QA ACT and SP was similar in urban and rural areas. Pre-packaged AL for a 10kg child was $0.48 in urban areas as compared with $0.39 in rural areas.

www.ACTwatch.info Page 36

Figure 40. Private sector median price of QA ACT adult equivalent treatment dosages (AETD) with and without the ‘green leaf’ logo, 2010-2015 Among all quality-assured ACT (tablet formulation only) available in the private sector, in 2010 US dollars to account for inflation, across survey rounds

The private sector median price for QA ACT with the ‘green leaf’ logo has matched that of QA ACT without the ‘green leaf’ logo at each survey round until 2015, when the price of QA ACT without the logo was $0.15 cheaper than QA ACT with the logo.

Figure 41. Median private sector consumer prices for malaria RDT testing for adults and children 2015 Among all RDTs available within private for-profit health facilities, pharmacies and drug stores, in 2015 US dollars

The median private sector price for adult RDTs was equal to the price for child RDTs in each outlet type. Prices for RDTs in private for-profit facilities and pharmacies were the same: $0.97. RDTs in drug stores were cheaper by one-third at $0.65. www.ACTwatch.info Page 37

Figure 42. Median private sector prices for malaria RDT testing and QA ACT for adults and children 2015 Among antimalarial-stocking outlets, in 2015 US dollars

The median private sector price for malaria RDT testing for a child was two times more expensive than the cost of pre-packaged QA AL treatment (RDT, $0.65; QA AL, $0.32). However, for adults, the median price for malaria RDT testing was considerable cheaper ($0.65) as compared with the price of pre-packaged QA AL treatment ($1.62).

www.ACTwatch.info Page 38

Figure 43. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2010-2015 Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store All Private Facility Health Worker For-Profit Profit Health Health Facility Facility 2010 2011 2013 2015

Across survey rounds, more than 90% of providers among antimalarial‐stocking public health facilities correctly stated the first‐line treatment for uncomplicated malaria (AL). Knowledge of first-line treatment increased over time among providers at private for-profit health facilities (85% in 2015) and drug stores (84% in 2015). Slight decreases were seen in antimalarial drug knowledge among community health workers (from 97% in 2010 to 82% in 2015), and private not for-profit facilities (from 93% in 2010 to 89% in 2015).

www.ACTwatch.info Page 39

Figure 44. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2015, urban/rural Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months

First-line treatment knowledge was similar among providers in urban versus rural areas across outlet type.

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Figure 45. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2010-2015 Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

100

Percentage of outlets 40

0 Public Health Community Private Not All Public Private For- Pharmacy Drug Store All Private Facility Health Worker For-Profit Profit Health Health Facility Facility

2010 2011 2013 2015

The percentage of providers who correctly stated the first-line dosing regimen for uncomplicated malaria in a two-year old child increased among private sector outlet types compared to baseline, and decreased among public sector outlet types compared to baseline. Proportion of retailers in private for-profit health facilities who correctly stated the treatment rose from 59% in 2010 to 76% in 2015, in pharmacies from 72% to 84%, and in drug stores from 65% to 75%. The proportion of community health workers who correctly stated the dosing regimen declined from 91% in 2010 to 66% in 2015, in private not for-profit facilities from 78% to 76%, and data trends showed only a slight decline in public health facilities from 92% to 91%.

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Figure 46. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2015, urban/rural Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months

Knowledge of the dosing regimen for a two-year old child using the first-line treatment for uncomplicated malaria was similar among providers in urban versus rural areas across outlet type, apart from pharmacies which showed higher percentages of respondents reporting accurate dosing knowledge in urban areas (86%) compared to rural areas (68%).

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Results Section A: Core Indicators

Table A1: Availability of antimalarials, among all screened outlets, by outlet type Public ALL Private Community Private Not For- ALL ALL Health Public / Not- For-Profit Pharmacy Drug Store Health Worker Profit Facility Private Outlets Facility For-Profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=282 N=5618 N=55 N=5955 N=1023 N=493 N=1967 N=3483 N=9438 stocking: Any antimalarial at the time 97.6 11.2 97.8 12.6 93.1 98.3 93.4 93.4 31.7 of survey visit (93.0, 99.2) (5.9, 20.1) (87.6, 99.6) (7.2, 21.1) (90.4, 95.1) (96.4, 99.2) (91.3, 95.0) (91.8, 94.7) (25.1, 39.2) 93.8 11.1 96.7 12.5 80.3 97.9 80.4 80.7 28.7 Any ACT (89.1, 96.5) (5.9, 20.0) (88.0, 99.1) (7.1, 21.1) (74.2, 85.3) (96.1, 98.9) (76.9, 83.5) (77.3, 83.6) (22.4, 35.9) 93.8 11.1 96.7 12.5 75.1 97.8 79.1 78.4 28.2 AL (89.1, 96.5) (5.9, 20.0) (88.0, 99.1) (7.1, 21.1) (68.5, 80.7) (96.0, 98.8) (75.5, 82.3) (75.0, 81.6) (22.0, 35.3) 1.4 0.0 8.3 0.1 26.4 59.1 15.2 18.5 4.4 ASAQ (0.5, 3.6) - (3.2, 19.7) (0.0, 0.2) (21.6, 32.0) (47.9, 69.5) (12.5, 18.3) (15.7, 21.6) (3.5, 5.6) 1.5 0.0 10.9 0.1 30.6 96.9 13.7 18.9 4.5 DHA-PPQ (0.7, 3.3) - (4.6, 23.5) (0.0, 0.2) (25.2, 36.5) (94.4, 98.3) (10.6, 17.6) (15.3, 23.0) (3.3, 6.2) Quality Assured ACT (QA 93.8 11.1 93.6 12.5 69.5 94.8 72.3 72.0 26.6 ACT) (89.1, 96.5) (5.9, 20.0) (84.2, 97.5) (7.1, 21.0) (63.2, 75.1) (91.6, 96.8) (68.2, 76.0) (68.2, 75.4) (20.8, 33.4) QA ACT with the “green 10.8 2.4 40.1 2.7 67.3 92.3 68.2 68.3 18.3 leaf” logo (6.5, 17.3) (1.1, 5.2) (25.5, 56.5) (1.4, 5.3) (61.2, 72.9) (87.3, 95.5) (63.6, 72.5) (64.1, 72.3) (15.0, 22.1) QA ACT without the “green 92.8 8.8 64.5 10.0 6.9 20.6 5.8 6.3 9.1 leaf” logo (88.0, 95.8) (4.1, 18.1) (46.8, 78.9) (5.1, 18.7) (5.0, 9.5) (12.8, 31.5) (4.6, 7.3) (5.1, 7.7) (5.2, 15.6) 93.8 11.1 92.2 12.5 63.8 93.1 70.1 69.0 25.9 QA AL  (89.1, 96.5) (5.9, 20.0) (82.7, 96.7) (7.1, 21.0) (57.2, 70.0) (88.8, 95.9) (66.0, 74.0) (65.1, 72.6) (20.2, 32.5) Non-Quality Assured ACT 6.0 0.0 17.3 0.2 46.0 97.7 30.8 35.3 8.5 (non-QA ACT) (2.5, 13.6) (0.0, 0.1) (9.3, 30.1) (0.1, 0.3) (39.8, 52.3) (95.6, 98.8) (26.4, 35.6) (30.7, 40.2) (6.5, 11.1) 93.8 4.1 95.6 5.6 75.3 97.9 69.7 71.4 21.2 Nationally Registered ACT (89.1, 96.5) (1.8, 9.3) (84.9, 98.8) (3.1, 10.2) (69.0, 80.6) (96.0, 98.9) (65.7, 73.5) (67.6, 75.0) (17.0, 26.2) 90.0 0.0 91.0 1.5 87.1 97.2 82.7 83.9 21.1 Any non-artemisinin therapy (84.8, 93.6) (0.0, 0.1) (80.1, 96.2) (1.2, 1.9) (83.0, 90.4) (94.7, 98.5) (78.7, 86.0) (80.7, 86.7) (17.4, 25.3) 81.4 0.0 67.6 1.3 48.5 82.5 45.9 47.1 12.1 Sulfadoxine-Pyrimethamine (75.0, 86.5) (0.0, 0.1) (53.1, 79.3) (1.0, 1.7) (42.1, 54.8) (76.3, 87.3) (40.3, 51.7) (42.0, 52.1) (9.6, 15.3) 59.9 0.0 85.2 1.2 65.9 94.1 75.0 73.2 18.2 Oral Quinine (50.1, 69.1) - (73.1, 92.4) (0.9, 1.5) (60.7, 70.8) (89.1, 96.8) (70.8, 78.9) (69.5, 76.6) (15.0, 22.0) Other non-artemisinin 0.6 0.0 1.3 0.0 9.1 53.5 10.5 10.8 2.6 therapy ^ (0.2, 1.9) - (0.2, 8.6) - (6.2, 13.2) (43.1, 63.6) (8.4, 13.1) (9.1, 12.8) (2.0, 3.4) www.ACTwatch.info Page 43

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=282 N=5618 N=55 N=5955 N=1023 N=493 N=1967 N=3483 N=9438 stocking: Oral artemisinin 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 monotherapy ------Non-oral artemisinin 71.4 0.3 61.4 1.4 47.7 84.0 10.9 20.6 5.9 monotherapy (62.7, 78.7) (0.1, 0.6) (44.0, 76.3) (1.0, 1.9) (42.2, 53.3) (77.0, 89.2) (8.2, 14.4) (17.5, 24.1) (4.7, 7.5) Any treatment for severe 74.5 0.3 79.9 1.5 78.6 89.6 24.8 38.4 10.3 malaria (66.0, 81.5) (0.1, 0.6) (64.0, 89.9) (1.1, 2.1) (74.2, 82.5) (84.0, 93.4) (21.0, 29.1) (34.7, 42.2) (8.3, 12.6) 53.1 0.0 42.3 0.8 20.0 63.8 2.3 7.3 2.3 Artesunate IV/IM # (42.8, 63.1) - (26.4, 59.9) (0.6, 1.1) (16.1, 24.6) (53.65 72.9) (1.0, 5.1) (5.5, 9.8) (1.8, 3.1) 30.6 0.3 8.5 0.6 1.6 5.1 0.4 0.7 0.7 Artesunate Rectal (22.7, 39.9) (0.1, 0.6) (3.3, 20.2) (0.4, 1.0) (0.9, 2.6) (3.1, 8.4) (0.2, 1.0) (0.5, 1.2) (0.5, 0.9) 3.1 0.0 25.5 0.2 38.4 72.9 10.0 17.6 4.3 Artemether IV/IM (1.0, 9.2) - (14.6, 40.6) (0.1, 0.3) (33.1, 44.1) (63.3, 80.7) (7.6, 13.1) (14.8, 20.8) (3.3, 5.6) 24.3 0.0 71.1 0.7 67.1 79.5 20.0 31.9 8.1 Quinine IV/IM (14.7, 37.4) - (55.6, 82.8) (0.5, 1.0) (60.2, 73.4) (70.1, 86.5) (16.5, 24.0) (28.4, 35.6) (6.5, 10.1) * The denominator includes 156 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other types of non-artemisinin therapy – other than SP: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine. # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria.

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type Public Private Not ALL Private Community ALL ALL Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Private Outlets Facility Facility For-Profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=275 N=719 N=53 N=1047 N=956 N=476 N=1849 N=3281 N=4328 96.1 99.7 98.9 99.4 86.3 99.7 86.1 86.4 90.3 Any ACT (92.6, 98.0) (98.7, 99.9) (92.6, 99.8) (98.6, 99.7) (79.6, 91.0) (98.3, 99.9) (83.2, 88.6) (83.3, 89.0) (87.8, 92.3) 96.1 99.7 98.9 99.4 80.7 99.5 84.7 84.0 88.7 AL  (92.6, 98.0) (98.7, 99.9) (92.6, 99.8) (98.6, 99.7) (73.9, 86.0) (98.3, 99.9) (81.8, 87.3) (80.8, 86.7) (85.9, 90.9) 1.4 0.0 8.5 0.5 28.4 60.2 16.2 19.8 13.9 ASAQ (0.6, 3.7) - (3.3, 20.0) (0.2, 1.4) (23.0, 34.5) (48.8, 70.5) (13.4, 19.5) (16.8, 23.1) (11.1, 17.3) 1.5 0.0 11.1 0.7 32.8 98.6 14.7 20.2 14.3 DHA PPQ (0.7, 3.4) (0.0, 0.2) (4.7, 24.0) (0.3, 1.6) (27.0, 39.2) (97.0, 99.3) (11.4, 18.7) (16.4, 24.6) (10.9, 18.6) Quality Assured ACT (QA 96.1 99.7 95.7 99.2 74.7 96.5 77.4 77.1 83.8 ACT) (92.6, 98.0) (98.7, 99.9) (87.2, 98.7) (98.3, 99.6) (68.0, 80.3) (94.0, 97.9) (73.6, 80.9) (73.3, 80.4) (80.6, 86.6) QA ACT with the “green leaf” 11.0 21.4 41.0 21.6 72.3 93.9 73.0 73.2 57.6 logo (6.7, 17.7) (8.4, 44.6) (25.9, 57.9) (9.6, 41.4) (65.8, 78.0) (89.7, 96.5) (68.6, 77.0) (69.0, 77.0) (47.2, 67.3) QA ACT without the “green leaf” 95.1 78.8 65.9 79.5 7.4 21.0 6.2 6.7 28.8 logo (91.5, 97.2) (55.6, 91.7) (48.4, 79.9) (59.6, 91.0) (5.4, 10.2) (12.9, 32.2) (4.9, 7.9) (5.5, 8.2) (18.9, 41.1) 96.1 99.7 94.3 99.1 68.6 94.8 75.1 73.9 81.5 QA AL  (92.5, 98.0) (98.7, 99.9) (85.5, 97.9) (98.2, 99.6) (61.8, 74.6) (91.2, 96.9) (71.2, 78.6) (70.0, 77.4) (78.1, 84.5) Non-Quality Assured ACT (non- 6.1 0.1 17.7 1.5 49.4 99.4 33.0 37.8 26.8 QA ACT) (2.6, 13.9) (0.0, 0.6) (9.5, 30.7) (0.8, 2.8) (42.8, 56.1) (98.2, 99.8) (28.4, 37.9) (33.0, 42.9) (21.6, 32.8) 96.1 37.0 97.8 44.7 80.8 99.6 74.6 76.5 66.8 Nationally Registered ACT (92.6, 98.0) (19.3, 58.9) (85.8, 99.7) (27.7, 63.0) (73.8, 86.4) (98.3, 99.9) (70.9, 78.0) (72.6, 79.9) (58.4, 74.4) 92.3 0.2 93.0 12.2 93.6 98.9 88.5 89.9 66.3 Any non-artemisinin therapy (88.4, 94.9) (0.0, 1.2) (82.3, 97.5) (7.0, 20.0) (90.7, 95.6) (97.5, 99.5) (85.0, 91.3) (87.2, 92.1) (55.4, 75.8) 83.4 0.2 69.1 10.3 52.1 83.9 49.2 50.4 38.2 Sulfadoxine-Pyrimethamine (77.4, 88.1) (0.0, 1.2) (54.2, 80.9) (6.0, 17.0) (45.7, 58.4) (77.6, 88.7) (43.5, 54.9) (45.4, 55.4) (31.9, 45.0) 61.4 0.0 87.1 9.3 70.8 95.7 80.4 78.4 57.4 Oral Quinine (51.4, 70.5) (0.0, 0.2) (74.8, 93.9) (5.3, 15.8) (65.9, 75.3) (91.8, 97.8) (76.3, 83.8) (74.9, 81.5) (48.4, 66.0) 0.6 0.0 1.3 0.1 9.8 54.4 11.3 11.5 8.1 Other non-artemisinin therapy ^ (0.2, 1.9) - (0.2, 8.8) (0.0, 0.4) (6.6, 14.1) (43.8, 64.7) (9.0, 14.0) (9.7, 13.7) (6.4, 10.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Oral artemisinin monotherapy ------73.2 2.3 62.8 11.0 51.3 85.5 11.7 22.1 18.7 Non-oral artemisinin monotherapy (64.7, 80.2) (1.0, 5.6) (44.7, 77.9) (6.4, 18.3) (45.1, 57.4) (78.9, 90.3) (8.9, 15.3) (18.8, 25.7) (15.3, 22.8) 76.3 2.3 81.7 12.2 84.5 91.1 26.6 41.1 32.4 Any treatment for severe malaria (68.0, 83.0) (1.0, 5.6) (65.1, 91.5) (7.1, 20.2) (79.9, 88.2) (86.0, 94.5) (22.5, 31.1) (37.3, 45.0) (27.1, 38.1) www.ACTwatch.info Page 45

54.4 0.0 43.3 6.5 21.5 64.9 2.4 7.8 7.4 Artesunate IV/IM # (44.0, 64.5) - (26.8, 61.3) (3.5, 11.7) (17.1, 26.6) (54.7, 73.8) (1.1, 5.5) (5.8, 10.4) (5.6, 9.7) 31.4 2.3 8.6 5.0 1.7 5.2 0.4 0.8 2.1 Rectal Artesunate (23.3, 40.8) (1.0, 5.6) (3.3, 20.6) (2.8, 8.7) (1.0, 2.8) (3.1, 8.6) (0.2, 1.1) (0.5, 1.3) (1.5, 2.9) 3.1 0.0 26.1 1.6 41.3 74.1 10.7 18.8 13.6 Artemether IV/IM (1.0, 9.4) - (15.0, 41.3) (0.8, 3.2) (35.6, 47.2) (64.8, 81.7) (8.1, 14.0) (15.9, 22.2) (10.7, 17.1) 24.9 0.0 72.7 5.6 72.1 80.9 21.4 34.2 25.5 Quinine IV/IM (15.1, 38.2) - (56.7, 84.4) (3.0, 10.3) (64.9, 78.3) (71.6, 87.6) (17.7, 25.7) (30.6, 38.0) (21.0, 30.6) *Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 68 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other types of non-artemisinin therapy – other than SP: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine. # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria.

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A3: Types of quality-assured and Non-Quality Assured ACTs audited in the public and private sector Quality-assured ACT Non-Quality Assured ACT ACT generic name and formulation Public sector Private sector Public Sector Private Sector % (95% CI) % (95% CI) % (95% CI) % (95% CI) Proportion of all audited antimalarials: N audited=2,011 N audited=5,369 N audited=59 N audited=7,179

Tablet formulation: 99.66 75.64 25.19 35.24 Artemether lumefantrine 99.16-99.87 72.24-78.75 11.59-46.37 30.47-40.32 0 0 0 1.02 Artesunate mefloquine - - - 0.68-1.51 0.34 24.36 0 0.27 Artesunate amodiaquine 0.13-0.84 21.25-27.76 - 0.08-0.98 0 0 42.63 31.18 Dihydroartemisinin piperaquine - - 25.85-61.3 28.71-33.75 0 0 0.49 0.28 Arterolene piperaquine - - 0.06-2.63 1.15-0.54 0 0 19.04 6.74 Artemisinin napthoquine - - 7.74-39.72 5.44-8.32

Non-tablet formulation*: 0 0 12.42 17.26 Artemether lumefantrine - - 5.67-25.07 15.08-19.68 0 0 0.32 7.89 Dihydroartemisinin piperaquine - - 0.05-2.31 6.54-9.49 0 0 0 0.12 Artesunate mefloquine - - - 0.06-0.27 * Non-tablet ACTs were most commonly suspensions but also included granules and suppositories. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A4: Antimalarial market composition Public Community Private Not ALL Private ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Private antimalarial in stock on the day of the survey:* Facility Worker Facility For-Profit Facility sition % % % % % % % % 6.3 25.0 1.4 32.8 15.5 2.0 49.7 67.2 (5.1, 7.8) (15.6, 37.6) (1.0, 2.0) (23.5, 43.7) (12.4, 19.2) (1.3, 3.1) (41.7, 57.7) (56.3, 76.5) N=3,907 outlets

* Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A5a: Price of tablet formulation antimalarials, by outlet type Private ALL For-Profit Pharmacy Drug Store Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD*: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $2.59 $2.91 $1.62 $1.94 Any ACT [1.62-4.20] (2,352) [1.62-4.85] (4,158) [1.29-2.59] (3,714) [1.29-3.23] (10,224) $1.94 $1.62 $1.55 $1.62 AL [1.45-3.10] (1,392) [1.29-2.59] (1,828) [1.13-1.94] ((2,623) [1.29-1.94] (5,843) $2.15 $1.29 $1.94 $1.94 ASAQ [1.29-4.85] (437) [0.81-2.59] (415) [0.97-3.56] (504) [0.97-3.88] (1,356) $4.85 $3.88 $4.85 $4.85 DHA PPQ [3.88-5.17] (458) [3.23-4.85] (1,190) [3.23-4.85] (478) [3.23-4.85] (2,126) $1.94 $1.29 $1.55 $1.62 Quality Assured ACT (QA ACT) [1.29-3.23] (1,365) [0.97-1.94] (1,467) [0.97-1.94] (2,446) [1.13-1.94] (5,278) $1.94 $1.29 $1.55 $1.62 QA ACT with the “green leaf” logo [1.29-3.23] (1,280) [0.97-1.94] (1,229) [0.97-1.94] (2,302) [1.13-1.94] (4,811) $1.62 $6.46 $1.29 $1.45 QA ACT without the “green leaf” logo [1.29-3.23] (84) [2.59-8.08] (237) [0.97-1.62] (133) [1.08-1.94] (454) $1.62 $1.29 $1.55 $1.55 QA AL  [1.29-2.59] (931) [0.97-1.94] (1,053) [0.97-1.94] (1,942) [1.13-1.94] (3,926) $3.88 $3.88 $3.23 $3.23 Non-Quality Assured ACT (Non-QA ACT) [2.59-4.85] (987) [2.91-6.46-] (2,691) [1.62-4.85] (1,268) [1.94-4.85] (4,946) $0.65 $0.48 $0.48 $0.48 SP [0.48-0.81] (605) [[0.48-0.65] (587) [0.48-0.65] (1,122) [0.48-0.65] (2,314) $3.39 $2.72 $3.39 $3.39 Oral Quinine [2.72-4.07] (454) [2.72-4.07] (384) [2.72-4.07] (1,116) [2.72-4.07] (1,954)

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Table A5a: Price of tablet formulation antimalarials, by outlet type Private ALL For-Profit Pharmacy Drug Store Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD*: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price and/ or product information are as follows: 219 any ACT tablet, 102 artemether lumefantrine tablet, 96 QA ACT tablet, 84 QA ACT with the 'green leaf' logo tablet, 11 QA ACT without the 'green leaf' logo tablet, 123 non-Quality Assured ACT tablet, 40 SP tablet.

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A5b: Price of pre-packaged antimalarials, by outlet type

Private ALL For-Profit Pharmacy Drug Store Private Facility Median price of one pre- Median [IQR] Median [IQR] Median [IQR] Median [IQR] packaged therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $1.62 $1.29 $1.62 $1.62 Adult QA AL [1.29-2.26] (664) [0.97-1.62] (670) [1.29-1.62] (1,269) [1.29-1.94] (2,603) $0.65 $0.48 $0.32 $0.39 Pediatric QA AL * [0.32-0.97] (84) [0.32-0.97] (134) [0.29-0.48] (173) [0.32-0.58] (391) * Pediatric AL is the pre-packaged regimen appropriate for a 2 year old child. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 45 adult AL, 8 child AL Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type

Public Private Not ALL Private Community ALL ALL Health For-Profit Public / Not- For- For-Profit Pharmacy Drug Store Health Worker Private Outlets Facility Facility Profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets** N=280 N=900 N=53 N=1233 N=966 N=467 N=1914 N=3347 N=4580 stocking Any malaria blood 95.4 58.2 96.1 62.3 70.1 51.4 20.9 32.6 42.6 testing (89.5, 98.1) (35.5, 77.9) (87.6, 98.9) (41.8, 79.1) (63.1, 76.3) (44.1, 58.6) (17.8, 24.4) (29.2, 36.3) (34.2, 51.4) N=279 N=900 N=53 N=1232 N=966 N=467 N=1914 N=3347 N=4579 55.7 0.0 64.4 6.4 41.1 0.6 1.2 10.3 9.0 Microscopic blood tests (47.6, 63.5) - (47.0, 78.7) (3.8, 10.5) (34.3, 48.1) (0.2, 1.4) (0.6, 2.3) (8.2, 12.8) (7.1, 11.3) N=280 N=900 N=53 N=1233 N=965 N=467 N=1914 N=3346 N=4579 Rapid diagnostic tests 81.7 58.2 86.5 61.0 47.7 51.4 20.1 26.8 38.3 (RDTs) (71.2, 89.0) (35.5, 77.9) (69.5, 94.7) (40.6, 78.1) (41.7, 53.8) (44.1, 58.6) (17.1, 23.4) (23.9, 30.0) (29.7, 47.7) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. 19 antimalarial-stocking outlet was missing information about both availability of microscopy and availability of RDTs. 20 antimalarial-stocking outlet had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.”

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A7: Malaria blood testing market composition Public ALL Private Community Private Not For- ALL Health Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with malaria blood Health Worker Profit Facility Private testing available on the day of the survey:* Facility For-Profit Facility % % % % % % % % 11.3 43.0 2.6 56.9 21.1 1.7 20.4 43.1 N=2,082 outlets (8.3, 15.2) (28.9, 58.3) (1.7, 4.0) (44.9, 68.1) (15.2, 28.4) (1.0, 2.8) (15.1, 26.9) (31.9, 55.1)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. 19 antimalarial-stocking outlet was missing information about both availability of microscopy and availability of RDTs. 20 antimalarial-stocking outlet had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.”

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A8: Price of malaria blood testing for adults, by outlet type Private ALL For-Profit Pharmacy Drug Store Private Facility Total median price to Median [IQR] Median [IQR] Median [IQR] Median [IQR] consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Microscopic blood tests $0.97 $1.62 $0.65 $0.97 Adult [0.65-0.97] (409) [0.97-1.62] (8) [0.48-0.97] (19) [0.65-0.97] (436) $0.97 $1.62 $0.65 $0.81 Child under age five [0.65-0.97] (410) [0.97-1.62] (8) [0.48-0.97] (18) [0.65-0.97] (436)

Rapid diagnostic tests (RDTs)

$0.97 $0.97 $0.65 $0.81 Adult [[0.65-0.97] (513) [0.32-0.97] (44) [0.65-0.97] (390) [0.65-0.97] (947) $0.97 $0.97 $0.65 $0.81 Child under five [[0.65-0.97] (514) [0.32-0.97] (44) [0.65-0.97] (391) [0.65-0.97] (949) * Total price to the consumer including consultation and/or service fees. Microscopic blood testing price information was not available (missing or “don’t know” response) for: 257 adult RDTs, 7 child RDTs, 5 adult microscopy tests, 5 child microscopy tests Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A9: Antimalarial market share Public Community Private Not TOTAL Private ANTI- TOTAL AETDs sold or distributed in the previous week Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL Private by outlet type and antimalarial type as a Facility Worker Facility For-Profit Facility TOTAL** percentage of all AETDs sold / distributed:* % % % % % % % % % 1. Any ACT 29.1 2.5 2.1 33.6 9.0 6.0 20.9 35.9 69.6 AL  29.0 2.5 1.9 33.4 6.5 3.5 17.9 27.9 61.3 ASAQ 0.0 0.0 0.0 0.0 1.1 0.7 1.7 3.5 3.6 DHA PPQ 0.0 0.0 0.1 0.2 1.3 1.6 1.2 4.1 4.3 Quality Assured ACT (QA ACT) 29.0 2.5 1.9 33.4 5.9 3.3 16.6 25.8 59.2 QA ACT with the “green leaf” logo 0.9 0.5 0.5 2.0 5.2 3.3 15.2 23.7 25.7 QA ACT without the “green leaf” logo 28.1 2.0 1.3 31.4 0.6 0.1 1.4 2.1 33.5 Non-Quality Assured ACT 0.1 0.0 0.2 0.3 3.2 2.7 4.3 10.1 10.4 Nationally Registered ACT 29.0 1.0 2.0 31.9 7.7 5.1 16.6 29.5 61.4 2. Any non-artemisinin therapy 10.5 0.0 1.0 11.5 4.7 2.5 10.3 17.5 29.0 Sulfadoxine-Pyrimethamine 7.1 0.0 0.8 7.9 3.2 1.6 6.9 11.6 19.5 Oral Quinine 3.4 0.0 0.2 3.5 0.9 0.3 2.3 3.5 7.1 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.3 0.4 0.7 1.4 1.4 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.5 0.0 0.1 0.5 0.4 0.3 0.2 0.9 1.4 Artesunate IV/IM # 0.3 0.0 0.0 0.3 0.1 0.1 0.0 0.2 0.6 OUTLET TYPE TOTAL*** 40.0 2.5 3.1 45.7 14.1 8.8 31.4 54.3 100.0 * A total of 74749.61 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type.  At the time of the 2015 Country ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine # At the time of the 2015 Country ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 20,137 antimalarials (in the census sample) were audited. Of these, 565 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A10: Antimalarial market share across outlet type AETDs sold or distributed in the previous Public Community Private Not TOTAL Private TOTAL week by antimalarial type as a percentage of Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Private all AETDs sold / distributed within each outlet Facility Worker Facility For-Profit Facility type:* % % % % % % % %

1. Any ACT 72.7 99.8 65.3 73.6 63.9 68.2 66.6 66.1 AL  72.6 99.8 59.6 73.2 45.8 40.2 57.0 51.4 ASAQ 0.0 0.0 1.1 0.1 8.1 7.9 5.4 6.5

DHA PPQ 0.1 0.0 4.3 0.3 9.5 17.9 3.8 7.6 Quality Assured ACT (QA ACT) 72.4 99.8 59.5 73.1 41.5 38.0 52.9 47.5 QA ACT with the “green leaf” logo 2.3 21.1 16.8 4.3 36.9 37.1 48.4 43.6

QA ACT without the “green leaf” logo 70.2 78.7 42.7 68.8 4.6 0.8 4.3 3.8 Non-Quality Assured ACT 0.2 0.0 5.8 0.6 22.4 30.3 13.7 18.6 Nationally Registered ACT 72.4 39.6 63.2 70.0 54.8 58.4 52.9 54.3

2. Any non-artemisinin therapy 26.2 0.2 33.0 25.2 33.3 28.4 32.8 32.2

Sulfadoxine-Pyrimethamine 17.6 0.2 26.4 17.3 22.3 18.1 21.8 21.3

Oral Quinine 8.4 0.0 5.5 7.8 6.1 3.8 7.4 6.5

Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 2.2 5.0 2.2 2.6

3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 1.2 0.0 1.6 1.1 2.9 3.4 0.7 1.7

Artesunate IV/IM # 0.8 0.0 0.6 0.7 0.8 0.8 0.1 0.4

* AETDs reportedly sold or distributed in the previous seven days: 21739.042 public health facilities; 1553.3854 community health workers; 2198.3319 private not for-profit health facilities; 16760.319 private for-profit health facilities; 10032.617 pharmacies; 22465.919 drug stores. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% within each column. A total of 20,137 antimalarials were audited. Of these, 565 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 42 public health facilities; 2 community health workers; 34 private not for-profit health facilities; 164 private for-profit health facilities; 191 pharmacies; 132 drug stores. Source: ACTwatch Outlet Survey, Uganda, 2015. www.ACTwatch.info Page 56

Table A11: Malaria blood testing market share Public Community Private Not TOTAL Private Number of malaria blood tests provided in the TOTAL BLOOD TEST Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store previous week by outlet type and blood test Private TOTAL** type as a percentage of all blood tests Facility Worker Facility For-Profit Facility provided:* % % % % % % % % % 1. Malaria microscopy 14.0 0.0 1.9 15.9 13.4 0.0 0.8 14.2 30.1 2. RDT 45.2 4.9 4.8 55.0 8.7 0.4 5.7 14.9 69.9 OUTLET TYPE TOTAL*** 59.2 4.9 6.7 70.9 22.2 0.5 6.5 29.1 100.0 * A total of 52356 malaria blood tests were reportedly administered in the previous seven days. ** Row sum – market share for the specified type of blood testing medicine. *** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 2,588 malaria blood tests were audited. Of these, 108 audited tests were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A12: Malaria blood testing market share, across outlet type TOTAL Public Community Private Not Private Number of malaria blood tests provided in the Public / TOTAL BLOOD TEST Health Health For-Profit For-Profit Pharmacy Drug Store previous week by blood test type as a Not-For- Private TOTAL** Facility Worker Facility Facility percentage of all blood tests provided within Profit each outlet type:* % % % % % % % % % Total blood testing market 1. Malaria microscopy 23.6 0.0 28.4 22.4 60.7 3.1 11.7 48.9 30.1 2. RDT 76.4 100.0 71.6 77.6 39.3 96.9 88.3 51.1 69.9

Malaria RDT market Manufacturer  Access Bio Inc. 88.5 12.7 95.9 82.4 77.0 37.4 72.7 74.2 80.6 Standard Diagnostics Inc. 0.5 87.1 0.0 8.2 5.1 2.5 8.5 6.3 7.8 Astel Diagnostics 11.0 0.0 1.3 9.1 0.7 0.7 1.0 0.8 7.4 Other 0.0 0.1 2.4 0.2 15.5 33.6 15.9 16.2 3.6 Unknown 0.0 0.1 0.4 0.0 1.7 25.8 1.9 2.5 0.6 * Malaria blood tests reportedly administered in the previous seven days: 268 public health facilities; 679 community health workers; 83 private not for-profit health facilities; 929 private for-profit health facilities; 84 pharmacies; 437 drug stores Categories 1 through 2 sum to 100% in within each column. A total of 2,588 malaria blood tests were audited. Of these, 108 audited tests were not included in market share calculations due to incomplete or inconsistent information.  Manufacturer was not captured for 45 RDTs audited. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A13: Provider case management knowledge and practices, by outlet type Public Community Private Not ALL Private ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2 year old child with symptoms of severe malaria to a - N=899 - N=899 - N=463 N=1904 N=2367 N=3266 health facility Yes, would refer to health n/a 97.0 n/a 97.0 n/a 91.7 77.5 77.8 84.9 facility (93.0, 98.7) (93.0, 98.7) (84.2, 95.8) (73.6, 81.0) (73.9, 81.2) (80.5, 88.4) Would recommend that a client with a negative malaria blood N=280 N=852 N=52 N=1184 N=948 N=445 N=1809 N=3202 N=4386 test take an antimalarial 58.9 8.8 55.8 14.4 54.0 65.7 38.0 42.2 32.9 Yes – sometimes (48.5, 68.6) (4.9, 15.4) (39.6, 70.9) (9.3, 21.6) (48.5, 59.5) (53.3, 76.4) (34.2, 42.0) (38.6, 46.0) (28.0, 38.2) 4.5 0.5 5.1 1.0 6.6 3.2 4.2 4.7 3.5 Yes – always (1.6, 11.8) (0.2, 1.7) (1.3, 18.4) (0.5, 2.2) (4.4, 9.7) (1.6, 6.4) (3.1, 5.7) (3.6, 6.1) (2.6, 4.6) Circumstances cited for recommending antimalarial N=164 N=81 N=31 N=276 N=602 N=265 N=788 N=1655 N=1931 treatment to a client who tested negative for malaria:* Patient has signs and 93.9 98.6 100.0 97.5 95.9 94.7 93.6 94.3 94.8 symptoms of malaria. (80.7, 98.3) (91.8, 99.8) - (93.0, 99.1) (93.5, 97.5) (88.3, 97.7) (90.4, 95.8) (92.1, 96.0) (92.8, 96.2) When the patient asks for 23.7 4.6 24.4 13.5 25.5 26.8 16.4 19.4 18.6 antimalarial treatment. (14.9, 35.5) (1.3, 15.2) (10.2, 48.1) (7.8, 22.4) (18.5, 34.0) (14.4, 44.4) (13.1, 20.5) (15.8, 23.7) (15.2, 22.5) Provider doesn't trust the test 3.3 9.3 0.0 5.9 4.9 8.8 6.5 6.1 6.1 results. (0.9, 10.9) (4.5, 17.9) - (3.1, 11.0) (2.8, 8.5) (3.4, 20.6) (4.7, 9.0) (4.5, 8.2) (4.6, 8.1) 13.9 35.4 25.3 27.4 17.7 13.8 19.5 18.8 20.0 Other (all other reasons) (7.2, 25.3) (20.3, 54.1) (9.3, 52.7) (17.9, 39.5) (13.4, 23.0) (8.1, 22.3) (15.1, 24.8) (15.2, 23.1) (16.6, 24.0) Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table A14: Provider antimalarial treatment knowledge and practices, by outlet type Public Community Private Not ALL Private ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers who: N=280 N=899 N=53 N=1232 N=962 N=463 N=1904 N=3329 N=4561 Correctly state the national first- 94.3 82.3 88.7 83.3 84.5 90.7 84.1 84.3 84.0 line treatment for uncomplicated malaria  (88.3, 97.3) (69.8, 90.3) (74.9, 95.3) (72.1, 90.7) (78.4, 89.1) (85.6, 94.1) (80.1, 87.5) (80.5, 87.5) (78.9, 88.0) Correctly state the first-line

dosing regimen for: 93.4 59.2 84.9 62.6 82.3 87.5 82.1 82.2 75.6 An adult (87.5, 96.7) (47.1, 70.3) (70.9, 92.9) (50.8, 73.0) (75.9, 87.2) (80.7, 92.1) (78.0, 85.6) (78.3, 85.6) (69.0, 81.2) 91.2 65.7 76.2 67.8 75.8 83.8 75.1 75.4 72.9 A two-year old child (85.1, 94.9) (51.9, 77.3) (60.9, 86.8) (55.1, 78.4) (70.0, 80.8) (76.2, 89.3) (71.1, 78.7) (71.7, 78.8) (66.9, 78.1) Report an ACT as the most effective antimalarial medicine for: 96.7 78.7 90.3 80.4 85.2 94.4 84.9 85.1 83.5 Adults (94.0, 98.3) (72.5, 83.8) (79.0, 95.8) (74.6, 85.1) (80.6, 88.9) (89.2, 97.2) (81.6, 87.6) (82.1, 87.7) (80.1, 86.4) 97.0 97.7 94.5 97.5 81.7 87.4 82.0 82.0 87.2 Children (93.3, 98.7) (96.0, 98.6) (83.8, 98.3) (95.8, 98.5) (75.1, 86.8) (80.0, 92.3) (77.7, 85.6) (77.7, 85.6) (83.7, 90.0) Report an ACT as the antimalarial he/she most commonly recommends for: 98.5 60.6 93.4 64.5 87.5 97.2 87.2 87.4 79.7 Adults (96.5, 99.4) (49.0, 71.1) (83.8, 97.5) (53.0, 74.5) (83.5, 90.7) (91.0, 99.2) (83.9, 89.9) (84.4, 89.9) (72.6, 85.4) 96.9 97.9 88.5 97.5 81.8 92.7 82.0 82.1 87.3 Children (92.7, 98.7) (96.1, 98.9) (75.7, 95.0) (95.7, 98.5) (75.2, 86.9) (86.5, 96.2) (77.1, 86.0) (77.5, 85.9) (83.6, 90.2)  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was Uganda’s first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. The number of providers with missing information include: 37 providers were missing information on the national first-line treatment, the first-line dosing regimen for adults and children, 34 providers and 35 providers were missing information on the most effective antimalarial medicine for adults and children and on the most often recommended antimalarial for adults and children, respectively. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Results Section B: Core Indicators across Urban/Rural Location

Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural sub-counties ALL Public Community Private Not Private Public / ALL ALL Health Health For-Profit For-Profit Pharmacy Drug Store Not- For- Private Outlets Facility Worker Facility Facility Profit % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=137 Urban N=772 Urban N=21 Urban N=930 Urban N=567 Urban N=437 Urban N=627 Urban N=1631 Urban N=2561 stocking: Rural N=145 Rural N=4846 Rural N=34 Rural N=5025 Rural N=456 Rural N=56 Rural N=1340 Rural N=1852 Rural N=6877 Any antimalarial at the time of survey visit 97.4 7.5 99.4 12.3 91.9 98.4 95.3 94.2 49.5 Urban (87.5, 99.5) (2.3, 21.8) (95.7, 99.9) (6.2, 25.3) (87.5, 94.8) (96.2, 99.4) (93.5, 96.6) (92.6, 95.4) (37.3, 61.7) 97.8 11.7 97.2 12.6 94.3 97.1 92.7 93.0 28.1 Rural (92.8, 99.3) (5.8, 22.0) (82.4, 99.6) (6.6, 22.6) (90.5, 96.7) (95.2, 98.2) (89.9, 94.8) (90.6, 94.8) (20.7, 36.8) Any ACT 95.1 7.4 99.4 12.7 86.3 98.1 87.3 87.4 46.3 Urban (86.6, 98.3) (2.2, 21.8) (95.7, 99.9) (6.0, 25.1) (80.9, 90.4) (95.9, 99.1) (82.9, 90.7) (84.1, 90.0) (34.4, 58.6) 92.0 11.6 95.7 12.5 74.2 97.1 78.0 77.4 25.0 Rural (84.9, 95.9) (5.8, 22.0) (83.6, 99.0) (6.6, 22.5) (63.7, 82.4) (95.2, 98.2) (73.5, 82.0) (72.7, 81.5) (18.2, 33.4) AL  95.1 7.4 99.4 12.7 78.5 97.9 85.2 83.2 44.4 Urban (86.6, 98.3) (2.2, 21.8) (95.7, 99.9) (6.0, 25.1) (69.4, 85.4) (95.7, 99.0) (80.4, 89.0) (78.8, 86.8) (32.8, 56.7) 92.0 11.6 95.7 12.5 71.6 97.1 77.0 76.1 24.8 Rural (84.9, 95.9) (5.8, 22.0) (83.6, 99.0) (6.6, 22.5) (61.7, 79.8) (95.2, 98.2) (72.3, 81.1) (71.3, 80.3) (17.9, 33.1) ASAQ 1.3 0.0 3.2 0.1 31.0 60.6 22.9 27.4 12.4 Urban (0.4, 4.7) - (0.5, 17.1) (0.0, 0.4) (24.4, 38.6) (48.1, 72.0) (17.8, 29.0) (22.9, 32.2) (8.7, 17.2) 1.6 0.0 10.1 0.1 21.7 47.2 12.5 14.1 2.8 Rural (0.4, 6.3) - (3.5, 26.0) (0.0, 0.2) (14.8, 30.7) (29.2, 66.1) (9.8, 15.8) (11.2, 17.7) (2.1, 3.7) DHA PPQ 2.2 0.0 22.1 0.4 40.0 97.1 30.1 36.4 16.6 Urban (0.9, 5.5) - (7.0, 51.7) (0.2, 1.0) (33.2, 47.1) (94.2, 98.5) (23.3, 38.0) (30.8, 42.3) (12.1, 22.3) 0.5 0.0 6.7 0.0 20.9 95.6 7.9 10.4 2.0 Rural (0.1, 3.5) - (1.8, 22.5) (0.0, 0.1) (13.3, 31.2) (90.6, 98.0) (5.6, 11.2) (7.0, 15.1) (1.2, 3.3) Quality Assured ACT

(QA ACT) 95.1 7.4 95.9 12.7 73.3 95.1 81.7 79.2 42.6 Urban (86.6, 98.3) (2.2, 21.8) (82.3, 99.2) (6.0, 25.0) (65.0, 80.3) (91.4, 97.2) (77.8, 85.1) (74.9, 82.0) (32.0, 53.9) www.ACTwatch.info Page 61

leaf” logo 11.1 2.8 37.1 3.7 70.4 92.5 77.5 75.5 36.0 Urban (5.5, 21.3) (0.5, 13.3) (14.5, 67.1) (1.1, 11.5) (63.0, 76.9) (86.7, 95.9) (73.3, 81.3) (71.3, 79.3) (27.3, 45.7) 10.3 2.3 41.1 2.6 64.1 91.1 64.9 64.9 14.6 Rural (5.0, 20.0) (1.0, 5.5) (23.8, 61.0) (1.2, 5.7) (54.3, 72.8) (81.5, 96.0) (59.0, 70.5) (59.0, 70.3) (11.5, 18.4) QA ACT without the

“green leaf” logo 94.5 4.8 65.0 9.8 8.7 20.1 6.9 8.1 9.1 Urban (86.1, 97.9) (1.1, 19.0) (36.8, 85.6) (4.3, 20.8) (6.1, 12.3) (11.6, 32.6) (4.5, 10.5) (6.0, 10.7) (5.4, 14.9) 90.6 9.3 64.2 10.0 5.1 24.6 5.4 5.4 9.1 Rural (83.1, 94.9) (4.0, 20.1) (42.0, 81.7) (4.6, 20.4) (2.7, 9.4) (14.4, 38.7) (4.1, 7.2) (4.1, 7.1) (4.6, 17.3) QA AL  95.1 7.4 95.9 12.7 66.1 93.4 78.6 74.7 40.5 Urban (86.6, 98.3) (2.2, 21.8) (82.3, 99.2) (6.0, 25.0) (56.1, 74.9) (88.5, 96.3) (74.2, 82.5) (69.5, 79.2) (30.6, 51.3) 92.0 11.6 90.9 12.5 61.5 91.1 67.1 66.2 22.8 Rural (84.9, 95.9) (5.8, 22.0) (77.8, 96.6) (6.5, 22.5) (52.6, 69.7) (81.5, 96.0) (61.8, 72.1) (61.0, 71.1) (16.5, 30.7) Non-Quality Assured ACT

(non-QA ACT) 10.2 0.0 27.9 0.9 56.8 97.7 47.0 52.6 24.1 Urban (4.1, 23.3) - (10.5, 56.0) (0.4, 1.9) (49.9, 63.5) (95.3, 98.9) (39.2, 55.0) (46.3, 58.9) (17.1, 32.9) 0.5 0.0 13.4 0.1 34.8 97.1 25.1 26.9 5.3 Rural (0.1, 3.5) (0.0, 0.1) (5.7, 28.7) (0.0, 0.2) (25.5, 45.4) (95.2, 98.2) (20.5, 30.3) (21.7, 32.9) (3.7, 7.5) Nationally Registered ACT 95.1 3.7 99.4 9.3 82.1 98.0 78.0 80.2 41.2 Urban (86.6, 98.3) (0.9, 14.2) (95.7, 99.9) (4.8, 17.2) (76.5, 86.6) (95.8, 99.0) (70.7, 83.8) (74.4, 85.0) (30.3, 53.0) 92.0 4.2 94.2 5.1 68.2 97.1 66.8 67.1 17.1 Rural (84.9, 95.9) (1.6, 10.3) (79.5, 98.5) (2.4, 10.6) (57.6, 77.2) (95.2, 98.2) (61.9, 71.4) (62.0, 71.8) (12.7, 22.5) Any non-artemisinin therapy 94.1 0.2 82.8 5.7 84.6 97.2 89.4 88.0 42.7 Urban (86.9, 97.5) (0.0, 1.0) (59.5, 94.0) (3.4, 9.3) (77.4, 89.8) (94.3, 98.6) (85.7, 92.2) (85.1, 90.4) (32.8, 53.1) www.ACTwatch.info Page 62

therapy ^ 1.1 0.0 0.0 0.0 7.6 53.8 16.7 14.9 6.7 Urban (0.3, 3.3) - - (0.0, 0.2) (4.4, 13.1) (42.3, 64.9) (11.6, 23.3) (11.3, 19.3) (5.0, 8.9) 0.0 0.0 1.7 0.0 10.6 50.9 8.4 8.8 1.7 Rural - - (0.2, 12.0) (0.0, 0.1) (6.3, 17.3) (27.8, 73.6) (6.4, 10.8) (7.1, 11.0) (1.2, 2.4) Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Non-oral artemisinin monotherapy 75.6 0.7 65.2 5.0 53.2 84.9 14.9 31.6 17.0 Urban (63.5, 84.6) (0.2, 2.2) (36.9, 85.7) (2.9, 8.7) (45.9, 60.4) (76.9, 90.5) (8.5, 24.7) (26.0, 37.9) (12.4, 22.8) 65.9 0.2 60.0 0.9 42.1 77.0 9.5 15.3 3.6 Rural (51.6, 77.9) (0.1, 0.7) (38.6, 78.2) (0.6, 1.3) (33.7, 51.0) (68.0, 84.0) (7.1, 12.8) (12.3, 18.9) (2.7, 4.9)

Any treatment for severe malaria

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=137 Urban N=772 Urban N=21 Urban N=930 Urban N=567 Urban N=437 Urban N=627 Urban N=1631 Urban N=2561 stocking: Rural N=145 Rural N=4846 Rural N=34 Rural N=5025 Rural N=456 Rural N=56 Rural N=1340 Rural N=1852 Rural N=6877 77.8 0.7 83.3 5.4 78.8 89.7 22.8 45.9 23.6 Urban (65.9, 86.4) (0.2, 2.2) (54.3, 95.4) (3.1, 9.2) (72.3, 84.1) (83.3, 93.9) (14.4, 34.2) (38.7, 53.0) (17.4, 31.1) 70.1 0.2 78.7 1.0 78.5 88.3 25.5 34.8 7.5 Rural (55.8, 81.3) (0.1, 0.7) (58.3, 90.7) (0.6, 1.5) (72.1, 83.8) (81.0, 93.1) (21.4, 30.2) (30.7, 39.1) (5.8, 9.6) Artesunate IV/IM # 64.4 0.0 55.9 3.8 26.5 64.7 6.7 16.2 9.4 Urban (50.2, 76.4) - (27.9, 80.5) (2.1, 6.8) (20.3, 33.6) (53.1, 74.7) (2.6, 16.4) (12.3, 21.0) (7.0, 12.4) 38.5 0.0 37.3 0.4 13.3 56.6 0.7 3.0 0.9 Rural (21.8, 58.4) - (19.6, 59.2) (0.2, 0.8) (8.7, 19.9) (46.4, 66.3) (0.3, 1.5) (1.9, 4.8) (0.6, 1.4) Artemether IV/IM 4.6 0.0 26.2 0.6 42.2 74.1 13.1 26.1 12.1 Urban (1.2, 15.8) - (9.9, 53.4) (0.3, 1.2) (34.1, 50.9) (63.2, 82.6) (7.8, 21.0) (20.3, 32.5) (8.5, 16.8) 1.1 0.0 25.2 0.1 34.5 63.4 8.9 13.4 2.7 Rural (0.3, 3.6) - (12.5, 44.3) (0.1, 0.3) (27.6, 42.2) (54.0, 71.9) (6.5, 12.2) (10.6, 16.9) (1.9, 3.8) Quinine IV/IM 21.8 0.0 69.8 2.0 64.3 79.7 18.0 37.3 17.9 Urban (12.9, 34.4) - (44.9, 86.8) (1.2, 3.4) (52.3, 74.8) (68.9, 87.4) (10.1, 30.0) (30.0, 45.3) (12.7, 24.6) 27.6 0.0 71.5 0.5 70.0 77.7 20.7 29.3 6.1 Rural (11.3, 53.4) - (51.7, 85.5) (0.3, 0.9) (62.7, 76.4) (68.1, 85.1) (17.1, 24.8) (25.8, 33.0) (4.7, 7.8) Rectal Artesunate 20.9 0.7 9.6 1.7 2.2 4.7 0.8 1.4 1.6 Urban (12.1, 33.7) (0.2, 2.2) (2.3, 32.3) (0.8, 3.5) (1.1, 4.1) (2.6, 8.3) (0.2, 2.9) (0.8, 2.5) (0.9, 2.7) 43.2 0.2 8.0 0.5 0.9 8.8 0.3 0.4 0.5 Rural (32.2, 54.9) (0.1, 0.7) (2.3, 24.4) (0.3, 0.8) (0.4, 2.4) (5.2, 14.3) (0.1, 1.0) (0.2, 0.9) (0.3, 0.8) * The denominator includes 156 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other types of non-artemisinin therapy – other than SP: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine. # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B2: Availability of antimalarials, among all outlets stocking at least one antimalarial, by outlet type, across urban/rural sub-counties Public Community Private Not ALL Private ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=134 Urban N=104 Urban N=20 Urban N=258 Urban N=524 Urban N=422 Urban N=597 Urban N=1543 Urban N=1801 Proportion of outlets* stocking: Rural N=141 Rural N=615 Rural N=33 Rural N=789 Rural N=432 Rural N=54 Rural N=1252 Rural N=1738 Rural N=2527 Any ACT 97.7 97.7 100.0 98.0 94.0 99.6 91.6 92.8 93.5 Urban (91.9, 99.4) (83.3, 99.7) - (92.3, 99.5) (90.4, 96.3) (98.0, 99.9) (86.9, 94.7) (89.3, 95.2) (90.6, 95.6) 94.1 99.9 98.5 99.6 78.6 100.0 84.2 83.2 89.1 Rural (87.5, 97.3) (98.9, 100.0) (89.7, 99.8) (98.9, 99.8) (67.0, 86.9) - (80.5, 87.2) (79.0, 86.8) (85.6, 91.8) AL  97.7 97.7 100.0 98.0 85.4 99.5 89.4 88.4 89.8 Urban (91.9, 99.4) (83.3, 99.7) - (92.5, 99.5) (77.7, 90.8) (98.1, 99.8) (84.4, 92.9) (84.0, 91.7) (86.1, 92.6) 94.1 99.9 98.5 99.6 75.9 100.0 83.0 81.8 88.2 Rural (87.5, 97.3) (98.9, 100.0) (89.7, 99.8) (98.9, 99.8) (65.0, 84.3) - (79.3, 86.2) (77.5, 85.5) (84.5, 91.2) ASAQ 1.3 0.0 3.3 0.8 33.8 61.6 24.0 29.1 25.0 Urban (0.4, 4.8) - (0.5, 17.2) (0.3, 2.4) (26.0, 42.6) (48.9, 72.9) (18.5, 30.5) (24.2, 34.5) (20.0, 30.7) 1.6 0.0 10.4 0.5 23.0 48.7 13.4 15.2 9.9 Rural (0.4, 6.4) - (3.6, 26.7) (0.2, 1.6) (15.6, 32.6) (29.9, 67.8) (10.6, 16.9) (12.1, 19.0) (7.4, 13.1) DHA PPQ 2.3 0.0 22.2 3.2 43.5 98.6 31.6 38.6 33.5 Urban (0.9, 5.6) - (7.0, 52.0) (1.1, 8.7) (36.0, 51.3) (96.8, 99.4) (24.4, 39.9) (32.5, 44.9) (26.6, 41.1) 0.5 0.0 6.9 0.3 22.1 98.4 8.6 11.1 7.2 Rural (0.1, 3.6) (0.0, 0.2) (1.8, 23.0) (0.1, 1.1) (14.1, 33.0) (92.7, 99.7) (6.1, 11.9) (7.5, 16.2) (4.7, 11.1) Quality Assured ACT (QA

ACT) 97.7 97.7 96.4 97.6 79.8 96.6 85.8 84.1 86.1 Urban (91.9, 99.4) (83.3, 99.7) (82.4, 99.4) (92.2, 99.3) (72.3, 85.7) (93.8, 98.2) (81.8, 89.0) (79.8, 87.6) (82.0, 89.3) 94.1 99.9 95.4 99.4 69.5 95.4 74.4 73.6 82.9 Rural (87.5, 97.3) (98.9, 100.0) (82.8, 98.9) (98.6, 99.8) (58.9, 78.3) (90.2, 97.9) (69.5, 78.8) (68.5, 78.2) (78.5, 86.6) QA ACT with the “green leaf”

logo 11.4 37.2 37.3 28.7 76.7 93.9 81.3 80.2 72.7 Urban (5.6, 21.8) (6.6, 83.2) (14.6, 67.5) (9.2, 60.6) (70.0, 82.2) (89.1, 96.7) (77.3, 84.8) (76.2, 83.7) (65.6, 78.8) 10.6 20.0 42.3 20.6 67.9 93.9 70.0 69.7 52.0 Rural (5.2, 20.5) (7.0, 45.3) (24.2, 62.8) (8.0, 43.5) (56.9, 77.2) (84.5, 97.7) (64.3, 75.2) (63.8, 75.1) (39.5, 64.3) QA ACT without the “green

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(non-QA ACT) 10.5 0.0 28.1 6.7 61.9 99.3 49.3 55.9 48.7 Urban (4.2, 23.9) - (10.6, 56.4) (2.7, 15.4) (54.3, 69.0) (98.0, 99.8) (40.8, 57.9) (49.0, 62.5) (39.7, 57.9) 0.5 0.1 13.8 0.7 36.9 100.0 27.1 29.0 18.8 Rural (0.1, 3.6) (0.0, 0.7) (5.8, 29.4) (0.3, 1.7) (27.1, 47.8) - (22.3, 32.4) (23.5, 35.1) (14.0, 24.7) Nationally Registered ACT 97.7 48.6 100.0 71.2 89.4 99.5 81.8 85.2 83.2 Urban (91.9, 99.4) (10.1, 88.9) - (2.1, 92.8) (83.6, 93.3) (98.0, 99.9) (74.2, 87.6) (78.8, 89.9) (73.4, 89.9) 94.1 35.9 96.9 40.8 72.3 100.0 72.1 72.1 60.9 Rural (87.5, 97.3) (17.4, 59.9) (80.7, 99.6) (22.7, 61.8) (60.5, 81.6) - (67.6, 76.1) (67.3, 76.6) (50.5, 70.3) Any non-artemisinin therapy 96.7 2.1 83.2 43.7 92.1 98.7 93.8 93.4 86.2 Urban (92.8, 98.5) (0.2, 17.2) (59.3, 94.4) (20.7, 69.8) (86.8, 95.4) (97.2, 99.4) (90.3, 96.1) (91.1, 95.1) (76.9, 92.1) 86.6 0.0 96.7 7.5 95.0 100.0 86.6 88.1 59.0 Rural (78.1, 92.2) (0.0, 0.2) (85.3, 99.3) (3.9, 14.0) (91.5, 97.2) - (81.9, 90.2) (84.0, 91.2) (46.2, 70.7) Sulfadoxine-Pyrimethamine 89.9 2.1 62.7 39.1 51.5 84.3 60.8 58.5 55.7 Urban (80.8, 95.0) (0.2, 17.2) (39.1, 81.4) (19.0, 63.9) (40.8, 62.0) (77.4, 89.4) (54.3, 67.0) (52.0, 64.7) (49.5, 61.8) 75.0 0.0 71.6 6.0 52.6 80.8 45.0 46.4 31.8 Rural (66.7, 81.8) (0.0, 0.2) (52.6, 85.1) (3.1, 11.2) (45.4, 59.7) (58.0, 92.8) (37.5, 52.7) (39.4, 53.6) (24.6, 40.0) Oral Quinine 74.3 0.0 82.7 34.7 65.9 96.1 86.4 79.5 73.0 Urban (62.3, 83.5) - (59.3, 94.0) (17.1, 57.8) (60.6, 70.8) (91.5, 98.2) (80.9, 90.5) (74.7, 83.6) (64.7, 79.9)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=134 Urban N=104 Urban N=20 Urban N=258 Urban N=524 Urban N=422 Urban N=597 Urban N=1543 Urban N=1801 Proportion of outlets* stocking: Rural N=141 Rural N=615 Rural N=33 Rural N=789 Rural N=432 Rural N=54 Rural N=1252 Rural N=1738 Rural N=2527 44.8 0.0 88.8 5.5 75.7 92.6 78.2 77.8 51.7 Rural (27.6, 63.4) (0.0, 0.2) (72.7, 95.9) (2.7, 10.9) (67.4, 82.5) (87.6, 95.6) (73.0, 82.6) (73.0, 82.0) (41.0, 62.2) Other non-artemisinin therapy ^ 1.1 0.0 0.0 0.4 8.3 54.7 17.5 15.8 13.6 Urban (0.3, 3.4) - - (0.1, 1.3) (4.7, 14.3) (43.0, 65.9) (12.2, 24.5) (12.0, 20.5) (10.3, 17.7) 0.0 0.0 1.8 0.1 11.2 52.4 9.0 9.5 6.1 Rural - - (0.2, 12.3) (0.0, 0.6) (6.7, 18.3) (27.8, 75.9) (7.0, 11.5) (7.6, 11.8) (4.5, 8.2) Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Non-oral artemisinin monotherapy 77.6 8.7 65.6 38.7 57.9 86.3 15.6 33.6 34.3 Urban (65.6, 86.3) (5.6, 13.4) (37.0, 86.0) (22.4, 58.1) (49.3, 66.1) (78.8, 91.4) (8.9, 25.9) (27.7, 40.1) (28.0, 40.8) 67.4 1.8 61.8 6.9 44.6 79.3 10.3 16.4 13.0 Rural (53.2, 79.0) (0.6, 5.5) (39.2, 80.2) (3.5, 13.1) (35.6, 54.0) (69.8, 86.4) (7.7, 13.7) (13.3, 20.2) (9.9, 16.8) Any treatment for severe malaria 79.9 8.7 83.7 41.5 85.8 91.2 23.9 48.7 47.7 Urban (68.1, 88.1) (5.6, 13.4) (54.1, 95.7) (23.7, 61.9) (79.4, 90.4) (85.3, 94.8) (15.1, 35.7) (41.5, 55.9) (40.6, 54.8) 71.7 1.8 81.0 7.9 83.2 91.0 27.6 37.4 26.7 Rural (57.6, 82.5) (0.6, 5.5) (59.3, 92.6) (4.0, 14.8) (76.0, 88.6) (85.1, 94.7) (23.1, 32.5) (33.2, 41.8) (21.3, 33.0) Rectal Artesunate Urban 21.5 8.7 9.6 13.2 2.3 4.8 0.8 1.5 3.2 (12.4, 34.5) (5.6, 13.4) (2.3, 32.5) (8.6, 19.8) (1.2, 4.4) (2.6, 8.4) (0.2, 3.0) (0.9, 2.7) (2.2, 4.6) Rural 44.1 1.8 8.3 3.7 1.0 9.0 0.3 0.4 1.6 (33.2, 55.7) (0.6, 5.5) (2.4, 25.0) (1.8, 7.6) (0.4, 2.6) (5.3, 14.9) (0.1, 1.1) (0.2, 1.0) (1.0, 2.7) Artesunate IV/IM # 66.1 0.0 56.2 29.0 28.8 65.7 7.0 17.2 18.9 Urban (51.6, 78.1) - (28.1, 80.9) (14.7, 49.1) (21.9, 36.9) (54.2, 75.6) (2.7, 17.2) (13.1, 22.3) (14.7, 23.9) 39.3 0.0 38.4 3.2 14.1 58.3 0.8 3.2 3.2 Rural (22.4, 59.3) - (19.9, 61.0) (1.3, 7.7) (9.1, 21.3) (47.7, 68.3) (0.4, 1.6) (2.0, 5.1) (2.1, 4.8) www.ACTwatch.info Page 67

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=134 Urban N=104 Urban N=20 Urban N=258 Urban N=524 Urban N=422 Urban N=597 Urban N=1543 Urban N=1801 Proportion of outlets* stocking: Rural N=141 Rural N=615 Rural N=33 Rural N=789 Rural N=432 Rural N=54 Rural N=1252 Rural N=1738 Rural N=2527 Artemether IV/IM 4.7 0.0 26.3 4.5 46.0 75.2 13.7 27.7 24.4 Urban (1.3, 16.2) - (9.9, 53.7) (1.8, 10.8) (37.2, 55.1) (64.6, 83.5) (8.2, 22.0) (21.9, 34.5) (18.6, 31.3) 1.1 0.0 26.0 1.1 36.6 65.3 9.6 14.5 9.6 Rural (0.3, 3.7) - (12.9, 45.3) (0.5, 2.8) (29.2, 44.7) (55.8, 73.7) (7.0, 13.1) (11.5, 18.0) (7.1, 12.9) Quinine IV/IM 22.4 0.0 70.2 15.3 70.1 81.0 18.9 39.7 36.1 Urban (13.3, 35.2) - (44.9, 87.3) (8.0, 27.3) (57.5, 80.2) (70.3, 88.4) (10.6, 31.4) (32.0, 47.8) (28.8, 44.2) 28.3 0.0 73.6 4.2 74.2 80.1 22.3 31.5 21.6 Rural (11.6, 54.2) - (52.8, 87.5) (1.9, 9.1) (66.1, 80.9) (70.5, 87.1) (18.5, 26.7) (27.9, 35.4) (17.0, 27.1) * Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 68 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other types of non-artemisinin therapy – other than SP: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine. # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B4: Antimalarial market composition, across urban/rural location Public Private Not ALL Private Community ALL Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Health Worker Private antimalarial in stock on the day of the survey:* Facility Facility For-Profit Facility % % % % % % % % 3.8 7.7 1.5 13.0 29.6 7.1 50.3 87.0 Urban, N= 1,406 outlets (2.5, 5.7) (2.5, 21.1) (0.9, 2.6) (6.6, 24.0) (22.0, 38.6) (4.7, 10.5) (41.6, 58.9) (76.0, 93.4) 7.2 31.2 1.4 39.8 10.5 0.2 49.5 60.2 Rural, N= 2,501 outlets (5.5, 9.3) (19.3, 46.2) (0.9, 2.2) (28.3, 52.6) (7.6, 14.3) (0.1, 0.8) (39.2, 59.9) (47.4, 71.7) * Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD*: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Any ACT $3.20 $2.91 $1.94 $2.15 Urban [1.62-4.85] (1,388) [1.29-4.85] (3,645) [1.29-3.23] (1,487) [1.29-3.88] (6,520) $1.94 $3.88 $1.62 $1.62 Rural [1.29-3.23] (964) [2.26-6.46] (513) [1.29-2.26] (2,227) [1.29-2.59] (3,704) AL  $2.15 $1.62 $1.45 $1.62 Urban [1.62-3.23] (820) [0.97-2.59] (1,592) [0.97-1.94] (976) [1.29-2.59] (3,388) $1.62 $2.59 $1.62 $1.62 Rural [1.29-2.26] (572) [1.62-3.23] (236) [1.16-1.94] (1,647) [1.29-1.94] (2,455) ASAQ $2.59 $1.29 $1.94 $1.94 Urban [1.62-5.17] (266) [0.81-2.59] (368) [0.97-3.23] (212) [0.97-3.88] (846) $1.94 $1.62 $1.94 $1.94 Rural [1.29-3.88] (171) [0.97-3.88] (47) [0.97-3.88] (292) [1.13-3.88] (510) DHA-PPQ $4.85 $3.88 $4.85 $4.85 Urban [3.88-5.82] (258) [3.23-4.85] (1,047) [3.23-4.85] (234) [3.23-4.85] (1,539) $4.85 $4.85 $4.36 $4.85 Rural [3.23-4.85] (200) [3.88-6.14] (143) [3.23-4.85] (244) [3.23-4.85] (587) Quality Assured ACT (QA ACT) $1.94 $1.29 $1.45 $1.62 Urban [1.55-3.23] (802) [0.97-1.94] (1,276) [0.97-1.94] (919) [1.08-2.33] (2,997) $1.62 $1.94 $1.55 $1.62 Rural [1.29-2.59] (563) [1.29-3.23] (191) [1.13-1.94] (1,527) [1.16-1.94] (2,281)

QA ACT with the “green leaf” logo

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Urban $1.94 $1.29 $1.45 $1.62 [1.62-3.23] (741) [0.97-1.62] (1,067) [0.97-1.94] (879) [1.08-2.33] (2,687)

Rural $1.62 $1.62 $1.55 $1.62 [1.29-2.59] (539) [1.29-2.59] (162) [1.13-1.94] (1,423) [1.16-1.94] (2,124) QA ACT without the “green leaf” logo $1.94 $5.82 $1.29 $1.29 Urban [0.86-3.23] (60) [1.94-8.08] (208) [1.13-1.62] (39) [1.13-2.59] (307)

Rural $1.55 $8.08 $1.45 $1.55 [1.29-1.94] (24) [4.85-8.08] (29) [0.97-1.62] (94) [0.97-1.62] (147) Non-Quality Assured ACT (non-QA ACT) $4.85 $3.88 $3.56 $3.88 Urban [3.23-5.17] (586) [2.91-6.21] (2,369) [2.26-4.85] (568) [2.59-4.85] (3,523) $3.23 $4.85 $2.33 $2.59 Rural [1.94-4.85] (401) [3.23-9.31] (322) [1.62-3.88] (700) [1.62-4.20] (1,423) Sulfadoxine-Pyrimethamine

Urban $0.65 $0.48 $0.48 $0.48 [0.48-0.97] (335) [0.32-0.65] (518) [0.48-0.65] (415) [0.48-0.65] (1,268)

Rural $0.65 $0.65 $0.48 $0.48 [0.48-0.65] (270) [0.48-0.65] (69) [0.48-0.65] (707) [0.48-0.65] (1,046) Oral Quinine

Urban $4.07 $2.72 $2.72 $2.72 [2.72-4.07] (231) [2.72-3.39] (338) [2.72-4.07] (350) [2.72-4.07] (919) $3.39 $3.39 $3.39 $3.39 Rural [2.72-4.07] (223) [2.72-4.07] (46) [2.72-4.07] (766) [2.72-4.07] (1,035) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price and/ or product information are as follows: 219 any ACT tablet, 63 AL tablet, 96 QA ACT tablet, 84 QA ACT with the 'green leaf' logo tablet, 11 QA ACT without the 'green leaf' logo tablet, 123 non-Quality Assured ACT tablet, 40 SP tablet. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B5b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store Private Facility Median price of one pre-packaged Median [IQR] Median [IQR] Median [IQR] Median [IQR] therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Adult QA AL $1.62 $1.29 $1.45 $1.62 Urban [1.55-2.59] (386) [0.97-1.62] (586) [0.97-1.62] (476) [1.29-1.94] (1,448) $1.62 $1.62 $1.62 $1.62 Rural [1.29-1.94] (278) [1.55-2.59] (84) [1.29-1.94] (793) [1.29-1.94] (1,155) Pediatric QA AL * $0.81 $0.32 $0.32 $0.48 Urban [[0.48-1.29] (50) [0.32-0.81] (111) [0.32-0.48] (58) [0.32-0.65] (219) $0.48 $0.65 $0.32 $0.39 Rural [0.32-0.81] (34) [0.48-1.13] (23) [0.19-0.48] (115) [0.19-0.48] (172) * Pediatric QA AL is the pre-packaged regimen appropriate for a 2 year old child. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 45 adult AL, 8 child QA AL Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location Public Private Not ALL Private Community ALL ALL Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Private Outlets Facility Facility For-Profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=136 Urban N=120 Urban N=20 Urban N=276 Urban N=527 Urban N=413 Urban N=610 Urban N=1550 Urban N=1826 Proportion of outlets** stocking Rural N=144 Rural N=780 Rural N=33 Rural N=957 Rural N=439 Rural N=54 Rural N=1304 Rural N=1797 Rural N=2754 Any malaria blood testing 98.2 66.9 100.0 79.8 78.8 51.0 24.3 44.4 50.0 Urban (95.3, 99.3) (49.8, 80.5) - (69.8, 86.1) (71.1, 84.8) (42.8, 59.1) (20.2, 28.9) (39.6, 49.2) (45.2, 54.6) 91.8 57.4 94.7 59.9 61.6 55.0 19.8 27.0 40.0 Rural (79.5, 97.0) (32.7, 78.9) (83.2, 98.5) (36.5, 79.4) (50.3, 71.7) (44.0, 65.5) (15.9, 24.3) (22.8, 31.6) (28.7, 52.5)

Microscopic blood tests 71.8 0.0 78.6 29.8 51.2 0.6 1.5 18.8 20.6 Urban (58.3, 82.3) - (42.5, 94.8) (12.0, 55.5) (39.7, 62.6) (0.2, 1.6) (0.3, 7.6) (14.8, 23.6) (15.9, 26.1) 34.8 0.0 59.1 3.2 31.0 0.0 1.0 6.1 5.0 Rural (25.0, 46.2) - (39.0, 76.5) (1.7, 5.9) (23.7, 39.4) - (0.6, 1.8) (4.5, 8.4) (3.7, 6.6)

Rapid diagnostic tests (RDTs) 80.6 66.9 89.5 73.3 48.3 51.0 23.0 33.0 39.4 Urban (67.5, 89.2) (49.8, 80.5) (65.5, 97.5) (63.3, 81.4) (41.7, 54.9) (42.8, 59.1) (19.3, 27.3) (28.3, 38.0) (33.5, 45.5)

Rural 83.3 57.4 85.4 59.3 47.1 55.0 19.0 23.9 37.9 (62.4, 93.7) (32.7, 78.9) (62.1, 95.4) (36.1, 78.9) (37.1, 57.4) (44.0, 65.5) (15.3, 23.4) (20.1, 28.1) (26.7, 50.7) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. 19 antimalarial-stocking outlet was missing information about both availability of microscopy and availability of RDTs. 20 antimalarial-stocking outlet had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.”

Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B8: Price of malaria blood testing, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Total median price to consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Microscopic blood tests Adult

$0.97 $1.62 $0.65 $0.97 Urban [0.65-0.97] (257) [0.97-1.62] (8) [0.65-0.65] (6) [0.65-0.97] (271) $0.65 - $0.65 $0.65 Rural [0.65-0.97] (152) - [0.32-0.97] (13) [0.65-0.97] (165) Child under age five

$0.97 $1.62 $0.65 $0.97 Urban [0.65-0.97] (257) [0.97-1.62] (8) [0.65-0.65] (6) [0.65-0.97] (271) $0.65 - $0.97 $0.65 Rural [0.65-0.97] (153) - [0.32-1.62] (12) [0.65-0.97] (165) Rapid diagnostic tests (RDTs) Adult

$0.97 $0.97 $0.81 $0.97 Urban [0.81-0.97] (281) [0.32-0.97] (39) [0.65-0.97] (133) [0.65-0.97] (453) $0.81 $0.97 $0.65 $0.81 Rural [0.65-0.97] (232) [0.97-0.97] (5) [0.65-0.97] (257) [0.65-0.97] (494) Child under five

$0.97 $0.97 $0.65 $0.97 Urban [0.81-0.97] (281) [0.32-0.97] (39) [0.65-0.97] (133) [0.65-0.97] (453) $0.65 $0.97 $0.65 $0.65 Rural [0.48-0.97] (233) [0.97-0.97] (5) [0.65-0.97] (258) [0.65-0.97] (496) * Total price to the consumer including consultation and/or service fees. Microscopic blood testing price information was not available (missing or “don’t know” response) for: 257 adult RDTs, 7 child RDTs, 5 adult microscopy tests, 5 child microscopy tests Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B9.1: Antimalarial market share, urban Public Community Private Not TOTAL Private ANTI- TOTAL AETDs sold or distributed in the previous week Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store MALARIAL Private by outlet type and antimalarial type as a Facility Worker Facility For-Profit Facility TOTAL** percentage of all AETDs sold/ distributed:* % % % % % % % % % 1. Any ACT 20.3 1.1 1.4 22.8 13.2 14.3 21.3 48.8 71.6 AL  20.3 1.1 1.1 22.5 8.7 8.4 16.4 33.5 56.0 ASAQ 0.0 0.0 0.0 0.0 1.9 1.7 2.2 5.9 5.9 DHA PPQ 0.0 0.0 0.3 0.3 2.4 3.7 2.4 8.6 8.9 Quality Assured ACT (QA ACT) 20.2 1.1 1.1 22.4 8.1 8.0 15.6 31.8 54.1 QA ACT with the “green leaf” logo 0.1 0.0 0.4 0.6 6.8 7.9 14.3 29.0 29.6 QA ACT without the “green leaf” logo 20.1 1.1 0.7 21.8 1.2 0.2 1.2 2.6 24.5 Non-Quality Assured ACT 0.1 0.0 0.3 0.4 5.1 6.2 5.7 17.0 17.4 Nationally Registered ACT 20.2 1.0 1.4 22.6 11.5 12.2 17.0 40.7 63.2 2. Any non-artemisinin therapy 4.9 0.0 0.3 5.1 6.2 6.0 9.0 21.2 26.3 Sulfadoxine-Pyrimethamine 4.7 0.0 0.2 4.9 4.3 3.8 6.3 14.4 19.4 Oral Quinine 0.1 0.0 0.1 0.2 1.0 0.8 1.5 3.3 3.5 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.3 1.1 1.0 2.3 2.3 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.3 0.0 0.0 0.4 0.7 0.7 0.3 1.7 2.1 Artesunate IV/IM # 0.3 0.0 0.0 0.3 0.2 0.2 0.1 0.5 0.8 OUTLET TYPE TOTAL*** 25.5 1.1 1.7 28.3 20.1 21.1 30.6 71.7 100.0 * A total of 32472.389 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 9,717 antimalarials were audited. Of these, 380 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B9.2: Antimalarial market share, rural Public Community Private Not TOTAL Private ANTI- TOTAL AETDs sold or distributed in the previous week Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store MALARIAL Private by outlet type and antimalarial type as a Facility Worker Facility For-Profit Facility TOTAL** percentage of all AETDs sold/ distributed:* % % % % % % % % % 1. Any ACT 34.9 3.4 2.5 40.8 6.2 0.5 20.7 27.4 68.2 AL  34.9 3.4 2.4 40.7 5.0 0.3 19.0 24.2 64.9 ASAQ 0.0 0.0 0.1 0.1 0.6 0.0 1.3 2.0 2.0 DHA PPQ 0.0 0.0 0.0 0.1 0.6 0.1 0.4 1.1 1.2 Quality Assured ACT (QA ACT) 34.9 3.4 2.4 40.7 4.4 0.2 17.3 21.9 62.6 QA ACT with the “green leaf” logo 1.4 0.9 0.6 2.9 4.1 0.2 15.8 20.1 23.0 QA ACT without the “green leaf” logo 33.4 2.6 1.8 37.8 0.2 0.0 1.4 1.7 39.5 Non-Quality Assured ACT 0.0 0.0 0.1 0.2 1.8 0.3 3.4 5.5 5.7 Nationally Registered ACT 34.8 1.0 2.4 38.2 5.2 0.4 16.4 22.0 60.2 2. Any non-artemisinin therapy 14.2 0.0 1.6 15.8 3.7 0.1 11.2 15.0 30.8 Sulfadoxine-Pyrimethamine 8.6 0.0 1.3 9.9 2.4 0.1 7.2 9.7 19.6 Oral Quinine 5.6 0.0 0.3 5.8 0.8 0.0 2.9 3.6 9.5 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.3 0.0 0.5 0.8 0.8 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.6 0.0 0.1 0.6 0.2 0.0 0.2 0.4 1.0 Artesunate IV/IM # 0.3 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.4 OUTLET TYPE TOTAL*** 49.7 3.4 4.1 57.3 10.1 0.6 32.0 42.7 100.0 * A total of 42,277.225 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 10,414 antimalarials were audited. Of these, 179 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B10.1: Antimalarial market share across outlets, urban Public Private Not TOTAL Private Community TOTAL AETDs sold or distributed in the previous week Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Private by outlet type and antimalarial type as a Facility Facility For-Profit Facility percentage of all AETDs sold/ distributed:* % % % % % % % % 1. Any ACT 79.7 99.1 82.9 80.7 65.6 67.8 69.7 68.0 AL  79.6 99.1 67.0 79.6 43.4 39.8 53.6 46.7 ASAQ 0.1 0.0 0.1 0.1 9.6 8.1 7.3 8.2 DHA PPQ 0.0 0.0 15.8 0.9 12.1 17.7 8.0 12.0 Quality Assured ACT (QA ACT) 79.1 99.1 66.2 79.1 40.2 38.2 51.2 44.3 QA ACT with the “green leaf” logo 0.4 2.0 26.4 2.0 33.9 37.4 46.9 40.5 QA ACT without the “green leaf” logo 78.7 97.1 39.8 77.1 6.2 0.8 4.1 3.7 Non-Quality Assured ACT 0.6 0.0 16.7 1.5 25.5 29.6 18.5 23.7 Nationally Registered ACT 79.1 90.0 82.5 79.8 57.3 57.9 55.5 56.7 2. Any non-artemisinin therapy 19.0 0.9 14.9 18.1 30.9 28.7 29.3 29.6 Sulfadoxine-Pyrimethamine 18.5 0.9 11.6 17.4 21.5 18.2 20.6 20.1 Oral Quinine 0.4 0.0 3.1 0.6 5.0 3.9 5.0 4.6 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 1.4 5.1 3.3 3.3 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 1.3 0.0 2.2 1.3 3.4 3.5 1.0 2.4 Artesunate IV/IM # 1.1 0.0 1.5 1.1 1.2 0.9 0.3 0.7 * AETDs reportedly sold or distributed in the previous seven days: 4696.003 public health facilities; 391.41667 community health workers; 715.85464 private not for-profit health facilities; 9411.2769 private for-profit health facilities; 8864.4269 pharmacies; 8393.4114 drug stores. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. ^ Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine # At the time of the 2015 Uganda ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% within each column. A total of 9,717 antimalarials were audited. Of these, 380 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 12 public health facilities; 0 community health workers; 20 private not for-profit health facilities; 121 private for profit health facilities; 175 pharmacies; 52 drug stores. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B10.2: Antimalarial market share across outlets, rural Public Private Not For- TOTAL Private Community TOTAL AETDs sold or distributed in the previous week Health Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Private by outlet type and antimalarial type as a Facility Facility For-Profit Facility percentage of all AETDs sold/ distributed:* % % % % % % % % 1. Any ACT 70.2 99.9 60.5 71.3 61.5 79.1 64.5 64.0 AL  70.2 99.9 57.6 71.0 49.0 50.3 59.2 56.7 ASAQ 0.0 0.0 1.4 0.1 6.2 3.6 4.2 4.7 DHA PPQ 0.1 0.0 1.1 0.1 6.1 21.4 1.1 2.6 Quality Assured ACT (QA ACT) 70.2 99.9 57.6 71.0 43.3 32.3 54.0 51.2 QA ACT with the “green leaf” logo 2.9 25.2 14.1 5.0 40.8 31.3 49.4 47.1 QA ACT without the “green leaf” logo 67.3 74.7 43.5 66.0 2.4 1.0 4.5 4.0 Non-Quality Assured ACT 0.1 0.0 2.9 0.3 18.2 46.8 10.6 12.9 Nationally Registered ACT 70.1 28.7 57.9 66.7 51.5 71.5 51.2 51.5 2. Any non-artemisinin therapy 28.6 0.0 38.0 27.6 36.4 20.4 34.9 35.1 Sulfadoxine-Pyrimethamine 17.3 0.0 30.5 17.2 23.4 16.6 22.6 22.7 Oral Quinine 11.2 0.0 6.1 10.2 7.7 1.3 8.9 8.5 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 3.3 1.2 1.5 1.9 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 1.2 0.0 1.5 1.1 2.1 0.5 0.5 0.9 Artesunate IV/IM # 0.6 0.0 0.3 0.6 0.3 0.3 0.0 0.1 * AETDs reportedly sold or distributed in the previous seven days: 17043.039 public health facilities; 1161.9688 community health workers; 1482.4772 private not for-profit health facilities; 7349.042 private for-profit health facilities; 1168.1897 pharmacies; 14,070.008 drug stores. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. # Other non-artemisinin therapies include: Amodiaquine, Atovaquone-proguanil, Chloroquine, Hydroxychloroquine sulphate, Mefloquine, Primaquine Categories 1 through 4 sum to 100% within each column. A total of 10,414 antimalarials were audited. Of these, 179 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 24 public health facilities; 2 community health workers; 14 private not for-profit health facilities; 43 private for-profit health facilities; 16 pharmacies; 80 drug stores Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B13: Provider case management knowledge and practices, by outlet type, across urban/rural location Public Private Not ALL Private Community ALL ALL Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Private Outlets Facility Facility For-Profit Facility % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2 year old child with Urban N=120 Urban N=120 Urban N=409 Urban N=607 Urban N=1016 Urban N=1136 symptoms of severe malaria to a - - - Rural N=779 Rural N=779 Rural N=54 Rural N=1297 Rural N=1351 Rural N=2130 health facility Yes, would refer to health facility n/a 91.9 n/a 91.9 n/a 91.0 86.1 86.4 87.2 Urban (70.9, 98.1) (69.9, 98.2) (82.6, 95.6) (82.0, 89.4) (82.6, 89.5) (82.2, 91.0) n/a 97.4 n/a 97.4 n/a 97.0 74.5 74.5 84.3 Rural (93.1, 99.1) (93.1, 99.1) (95.0, 98.2) (69.7, 78.7) (69.8, 78.7) (78.7, 88.7) Would recommend that a client Urban N=136 Urban N=118 Urban N=20 Urban N=274 Urban N=514 Urban N=391 Urban N=577 Urban N=1482 Urban N=1756 with a negative malaria blood test Rural N=144 Rural N=734 Rural N=32 Rural N=910 Rural N=434 Rural N=54 Rural N=1232 Rural N=1720 Rural N=2630 take an antimalarial Yes – sometimes 58.1 7.5 76.1 30.1 55.8 65.2 41.8 47.8 44.9 Urban (43.3, 71.6) (3.4, 15.7) (54.0, 89.7) (16.3, 48.8) (47.5, 63.7) (51.0, 77.1) (34.7, 49.2) (42.1, 53.5) (38.1, 51.8) 60.0 9.0 48.0 12.2 52.4 70.3 36.7 39.5 28.7 Rural (45.3, 73.0) (4.7, 16.3) (28.4, 68.3) (7.2, 19.7) (44.6, 60.0) (51.2, 84.3) (32.2, 41.4) (35.0, 44.3) (23.4, 34.7) Yes – always 5.6 0.0 0.0 1.8 9.7 3.6 6.0 7.2 6.3 Urban (1.4, 20.3) - - (0.4, 8.4) (6.3, 14.8) (1.8, 7.2) (3.6, 9.8) (4.8, 10.7) (4.2, 9.6) 3.0 0.6 7.1 0.9 3.5 0.0 3.5 3.5 2.5 Rural (1.2, 7.6) (0.2, 1.9) (1.7, 24.9) (0.4, 2.2) (1.9, 6.3) - (2.3, 5.4) (2.5, 5.0) (1.7, 3.5) Circumstances cited for recommending antimalarial Urban N=82 Urban N=14 Urban N=14 Urban N=110 Urban N=345 Urban N=231 Urban N=271 Urban N=847 Urban N=957 treatment to a client who tested Rural N=82 Rural N=67 Rural N=17 Rural N=166 Rural N=257 Rural N=34 Rural N=517 Rural N=808 Rural N=974 negative for malaria:* Patient has signs and symptoms

of malaria. 89.4 100.0 100.0 93.3 95.5 94.3 93.7 94.5 94.4 Urban (67.9, 97.1) - - (77.5, 98.2) (92.2, 97.4) (86.9, 97.6) (88.8, 96.6) (90.9, 96.8) (91.0, 96.6) 99.7 98.5 100.0 98.9 96.5 98.0 93.5 94.2 95.0 Rural (98.0, 100.0) (91.1, 99.8) - (93.8, 99.8) (91.5, 98.6) (90.3, 99.6) (89.2, 96.2) (91.0, 96.4) (92.3, 96.8)

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antimalarial treatment. 4.3 27.9 - 6.5 6.3 8.8 9.4 8.0 7.9 Urban (0.9, 17.9) (18.5, 39.7) - (2.3, 17.1) (3.0, 12.7) (3.1, 22.4) (5.9, 14.6) (5.4, 11.8) (5.4, 11.4) 2.0 7.9 - 5.7 3.4 8.8 5.3 4.9 5.0 Rural (0.3, 13.8) (3.5, 16.9) - (2.6, 12.3) (1.6, 7.1) (1.0, 47.5) (3.4, 8.4) (3.2, 7.6) (3.3, 7.6) Provider doesn't trust the test

results. 26.1 6.2 - 17.4 25.2 29.4 15.1 20.2 19.9 Urban (12.7, 46.1) (0.6, 43.4) - (7.8, 34.3) (14.3, 40.5) (15.7, 48.3) (10.4, 21.4) (13.7, 28.7) (13.8, 27.7) 20.5 4.5 37.4 12.1 25.7 7.3 17.0 19.0 17.8 Rural (12.5, 31.8) (1.1, 16.5) (15.1, 66.7) (6.0, 23.2) (19.0, 33.8) (1.6, 27.4) (12.8, 22.3) (14.9, 23.9) (14.0, 22.4) Other (all other reasons) 17.1 26.7 38.2 23.3 21.7 10.7 27.9 24.4 24.3 Urban (7.0, 36.3) (16.1, 40.7) (13.9, 70.2) (12.5, 39.0) (15.8, 29.1) (5.3, 20.2) (19.6, 38.0) (18.3, 31.7) (19.1, 30.3) 9.7 36.0 18.4 28.9 13.0 37.2 16.0 15.4 17.6 Rural (4.4, 20.2) (19.8, 56.2) (2.8, 64.2) (17.1, 44.5) (8.1, 20.2) (20.6, 57.5) (11.5, 21.8) (11.6, 20.2) (13.4, 22.9) Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table B14: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location Public Community Private Not ALL Private ALL ALL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=136 Urban N=120 Urban N=20 Urban N=276 Urban N=523 Urban N=409 Urban N=607 Urban N=1539 Urban N=1815 Proportion of providers who: Rural N=144 Rural N=779 Rural N=33 Rural N=956 Rural N=439 Rural N=54 Rural N=1297 Rural N=1790 Rural N=2746 Correctly state the national first-line

treatment for uncomplicated malaria 93.1 81.5 93.6 86.2 87.7 91.3 81.3 84.0 84.3 Urban (81.9, 97.6) (47.2, 95.6) (64.4, 99.2) (66.5, 95.2) (80.0, 92.8) (85.6, 94.9) (73.8, 87.1) (78.7, 88.1) (78.3, 88.9) 96.0 82.3 86.8 82.9 81.2 85.9 85.1 84.5 83.9 Rural (91.6, 98.1) (68.7, 90.9) (68.7, 95.2) (70.0, 91.0) (71.0, 88.5) (75.3, 92.4) (80.2, 89.0) (79.2, 88.6) (77.1, 88.9) Correctly state the first-line dosing regimen for

an adult

92.5 69.7 80.1 77.8 85.5 87.9 80.4 82.5 81.7 Urban (81.8, 97.2) (40.2, 88.8) (51.1, 93.9) (60.0, 89.1) (76.9, 91.2) (80.0, 92.9) (72.7, 86.3) (77.1, 86.8) (75.8, 86.5) 94.6 58.3 86.8 60.5 79.2 84.4 82.7 82.1 73.5 Rural (88.7, 97.5) (45.5, 70.0) (68.7, 95.2) (47.8, 71.8) (68.8, 86.7) (74.9, 90.8) (77.6, 86.8) (76.6, 86.5) (65.0, 80.5) Correctly state the first-line dosing regimen for

a child 90.6 73.4 69.8 78.4 78.5 85.7 74.6 76.4 76.7 Urban (79.5, 96.0) (42.9, 91.1) (38.9, 89.3) (59.8, 89.9) (69.3, 85.5) (77.5, 91.3) (67.7, 80.5) (71.2, 81.0) (70.6, 81.9) 92.0 65.0 78.6 66.4 73.1 68.3 75.3 74.9 71.5 Rural (86.2, 95.5) (50.2, 77.4) (60.0, 90.0) (52.2, 78.1) (64.9, 80.0) (58.8, 76.5) (70.3, 79.7) (69.9, 79.4) (63.8, 78.2) Report an ACT as the most effective

antimalarial medicine for an adult 98.6 73.3 83.7 82.2 85.8 94.6 86.1 86.3 85.7 Urban (95.9, 99.5) (47.0, 89.5) (54.1, 95.7) (66.1, 91.6) (79.6, 90.3) (88.7, 97.5) (81.0, 90.0) (82.1, 89.6) (81.1, 89.3) 94.3 79.2 92.7 80.1 84.7 92.9 84.4 84.5 82.8 Rural (88.3, 97.3) (72.6, 84.5) (80.4, 97.5) (73.8, 85.3) (76.9, 90.2) (70.7, 98.6) (80.3, 87.8) (80.4, 87.9) (78.4, 86.4)

Report an ACT as the most effective

antimalarial medicine for a child

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 98.2 94.2 85.8 94.7 86.8 87.2 83.5 84.8 86.3 Urban (88.7, 99.7) (80.3, 98.5) (53.6, 97.0) (85.5, 98.1) (81.7, 90.7) (79.0, 92.5) (76.0, 88.9) (79.5, 88.9) (80.8, 90.4) 95.5 98.0 97.8 97.9 76.7 89.2 81.5 80.7 87.5 Rural (90.2, 98.0) (96.1, 98.9) (90.6, 99.5) (96.2, 98.8) (64.9, 85.4) (65.7, 97.2) (76.0, 85.9) (74.6, 85.5) (83.0, 90.9) Report an ACT as the antimalarial he/she most

commonly recommends for adults 99.1 57.2 93.5 73.7 86.8 96.8 87.7 87.7 85.5 Urban (96.8, 99.8) (47.7, 66.1) (68.7, 98.9) (59.8, 84.0) (82.1, 90.3) (89.7, 99.1) (81.4, 92.0) (83.6, 90.9) (80.7, 89.2) 97.7 60.9 93.3 63.2 88.2 100.0 87.0 87.3 77.7 Rural (93.3, 99.3) (48.0, 72.4) (80.7, 97.9) (50.4, 74.4) (80.9, 93.0) - (82.9, 90.3) (83.1, 90.5) (68.4, 84.9)

Report an ACT as the antimalarial he/she most

commonly recommends for children

98.1 93.6 73.1 93.1 87.4 92.2 83.3 85.1 86.4 Urban (89.2, 99.7) (79.2, 98.3) (42.6, 90.9) (83.2, 97.3) (83.1, 90.7) (85.0, 96.1) (74.1, 89.7) (79.3, 89.5) (80.6, 90.6) 95.3 98.3 94.3 98.1 76.2 96.9 81.5 80.7 87.6 Rural (88.3, 98.2) (96.1, 99.3) (79.7, 98.6) (96.1, 99.0) (64.2, 85.2) (85.9, 99.4) (75.4, 86.4) (74.2, 85.8) (82.9, 91.1)  At the time of the 2015 Uganda ACTwatch outlet survey, artemether lumefantrine was Uganda first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. The number of providers with missing information include: 37 providers were missing information on the national first-line treatment, the first-line dosing regimen for adults and children, 34 providers and 35 providers were missing information on the most effective antimalarial medicine for adults and children and on the most often recommended antimalarial for adults and children, respectively. Source: ACTwatch Outlet Survey, Uganda, 2015.

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Results Section C: Core Indicators across Survey Round: 2010, 2011, 2013, 2015 Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round Public Community Private Not ALL Private Itinerant General ALL ALL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store Drug Retailer Private Outlets Facility Worker Facility For-Profit Facility Vendor % % % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2010 N=805 2010 N=788 2010 N=35 2010 N=1,628 2010 N=426 2010 N=376 2010 N=946 2010 N=7,762 2010 N=15 2010 N=9,525 2010 N=11,153 2011 N=692 2011 N=1,021 2011 N=43 2011 N=1,756 2011 N=848 2011 N=415 2011 N=1,213 2011 N=11,931 2011 N=44 2011 N=14,451 2011 N=16207 Proportion of outlets* stocking: 2013 N=703 2013 N=3,989 2013 N=32 2013 N=4,724 2013 N=410 2013 N=471 2013 N=1,084 2013 N=1,241 2013 N=2 2013 N=3,208 2013 N=7,932 2015 N=282 2015 N=5,618 2015 N=55 2015 N=5,955 2015 N=1,023 2015 N=493 2015 N=1,967 2015 N=n/a 2015 N=n/a 2015 N=3,483 2015 N=9,438 Any antimalarial at the time of

survey visit 96.5 5.0 94.7 18.6 95.8 99.7 88.3 0.3 30.5 13.5 14.1 2010 (93.9, 98.0) (1.0, 21.0) (82.0, 98.6) (10.5, 30.6) (90.4, 98.2) (99.3, 99.9) (83.0, 92.1) (0.1, 0.5) (15.1, 52.0) (11.7, 15.5) (12.4, 16.1) 98.7 10.6 94.1 20.8 94.8 99.6 92.2 0.4 0.0 13.9 14.8 2011 (96.4,99.6) (3.0,31.2) (76.7,98.7) (10.1,38.0) (91.0,97.0) (98.0,99.9) (88.4,94.9) (0.1,0.9) -- (12.4,15.5) (12.8,17.1) 96.6 16.9 90.0 19.9 94.8 99.4 93.9 0.0 0.0 11.8 14.4 2013 (93.6, 98.2) (9.2, 29.0) (68.3, 97.4) (12.0, 31.2) (89.7, 97.4) (97.7, 99.9) (92.0, 95.4) -- - (7.6, 17.9) (10.2, 19.9) 97.6 11.2 97.8 12.6 93.1 98.3 93.4 -- - 93.4 31.7 2015 (93.0, 99.2) (5.9, 20.1) (87.6, 99.6) (7.2, 21.1) (90.4, 95.1) (96.4, 99.2) (91.3, 95.0) -- - (91.8, 94.7) (25.1, 39.2)

Any ACT 86.0 4.6 54.5 15.6 70.7 98.4 43.5 <.1. 12.2 7.3 8.3 2010 (79.9, 90.4) (0.9, 20.8) (37.2, 70.7) (8.5, 26.9) (57.1, 81.3) (93.6, 99.6) (32.6, 55.1) (<0.1, 0.1) (6.4, 22.1) (5.4, 9.8) (6.5, 10.5) 90.7 5.9 81.4 15.5 85.2 99.6 63.5 0.3 0.0 10.4 11.0 2011 (85.7,94.0) (1.7,18.9) (58.8,93.1) (8.1,27.6) (78.9,89.9) (98.0,99.9) (54.6,71.6) (0.1,0.9) -- (8.7,12.4) (9.2,13.1) 91.1 16.1 90.0 19.0 86.0 99.0 75.1 0.0 0.0 9.8 12.7 2013 (85.7, 94.6) (8.8, 27.6) (68.3, 97.4) (11.5, 29.8) (78.2, 91.3) (97.4, 99.7) (69.4, 80.1) -- -- (6.2, 15.0) (8.8, 17.9) 93.8 11.1 96.7 12.5 80.3 97.9 80.4 -- - 80.7 28.7 2015 (89.1, 96.5) (5.9, 20.0) (88.0, 99.1) (7.1, 21.1) (74.2, 85.3) (96.1, 98.9) (76.9, 83.5) -- - (77.3, 83.6) (22.4, 35.9) AL 85.1 4.5 49.1 15.4 66.8 93.3 41.3 <0.1 12.2 7.1 8.1 2010 (78.9, 89.71) (0.9, 20.6) (34.5, 64.0) (8.4, 26.5) (55.3, 76.6) (89.6, 95.8) (30.9, 52.6) (<0.1, 0.1) (6.4, 22.1) (5.2, 9.5) (6.4, 10.3) 90.7 5.9 81.4 15.5 82.9 99.6 62.2 0.3 0.0 10.0 10.8 2011 (85.7, 94.0) (1.7, 18.9) (58.8, 93.1) (8.1, 27.6) (76.6, 87.8) (98.0, 99.9) (53.3, 70.2) (0.8, 0.9) -- (8.4, 12.0) (9.1, 12.8) 91.1 16.1 90.0 19.0 85.1 99.0 74.4 0.0 0.0 9.7 12.6 2013 (85.7, 94.6) (8.8, 27.6) (68.3, 97.4) (11.5, 29.8) (77.5, 90.4) (97.4, 99.7) (68.7, 79.3) -- - (6.2, 14.9) (8.8, 17.8)

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Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round Public Community Private Not ALL Private Itinerant General ALL ALL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store Drug Retailer Private Outlets Facility Worker Facility For-Profit Facility Vendor % % % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 93.8 11.1 96.7 12.5 75.1 97.8 79.1 -- - 78.4 28.2 2015 (89.1, 96.5) (5.9, 20.0) (88.0, 99.1) (7.1, 21.1) (68.5, 80.7) (96.0, 98.8) (75.5, 82.3) -- - (75.0, 81.6) (22.0, 35.3)

ASAQ 0.5 0.0 0.0 0.1 5.5 30.6 1.9 0.0 0.0 0.5 0.4 2010 (0.1, 2.4) -- -- (<0.1, 0.2) (3.5, 8.7) (25.6, 36.1) (1.1, 3.5) -- -- (0.3, 0.8) (0.3, 0.7) 0.2 0.0 11.3 0.3 19.3 57.6 5.7 0.0 0.0 1.5 1.3 2011 (<0.1, 0.7) -- (4.8, 24.6) (0.1, 1.0) (16.2, 22.9) (46.9,67.6) (4.2, 7.8) -- -- (1.1, 2.0) (0.9, 1.9) 0.1 0.0 4.3 0.1 12.0 43.3 6.0 0.0 0.0 1.0 0.7 2013 (0.0, 0.5) (0.0, 0.2) (0.6, 26.5) (0.0, 0.4) (8.7, 16.5) (34.1, 52.9) (4.2, 8.6) -- -- (0.6, 1.6) (0.5, 1.1) 1.4 0.0 8.3 0.1 26.4 59.1 15.2 -- - 18.5 4.4 2015 (0.5, 3.6) - (3.2, 19.7) (0.0, 0.2) (21.6, 32.0) (47.9, 69.5) (12.5, 18.3) -- - (15.7, 21.6) (3.5, 5.6) DHA PPQ 1.6 0.0 8.2 0.5 20.4 83.6 5.2 0.0 0.0 1.5 1.3 2010 (0.7, 3.4) -- (3.5, 18.2) (0.2, 1.4) (14.9, 27.2) (78.7, 87.5) (2.9, 9.2) -- -- (0.8, 2.6) (0.7, 2.4) 3.7 0.0 11.6 0.6 21.5 91.4 5.2 0.0 0.0 1.6 1.5 2011 (2.3, 5.9) -- (4.4, 27.6) (0.3, 1.4) (16.8, 27.1) (86.0, 94.9) (3.2, 8.3) -- -- (1.0, 2.5) (0.9, 2.3) 1.8 0.0 14.5 0.2 25.3 90.7 9.2 0.0 0.0 1.8 1.3 2013 (0.7, 4.7) (0.0, 0.2) (6.1, 30.8) (0.1, 0.4) (18.5, 33.4) (78.6, 96.3) (6.6, 12.7) -- - (1.0, 3.1) (0.8, 2.1) 1.5 0.0 10.9 0.1 30.6 96.9 13.7 -- - 18.9 4.5 2015 (0.7, 3.3) - (4.6, 23.5) (0.0, 0.2) (25.2, 36.5) (94.4, 98.3) (10.6, 17.6) -- - (15.3, 23.0) (3.3, 6.2)

Quality Assured ACT (QA ACT) 84.2 1.9 42.8 12.7 12.9 63.9 8.5 0.0 6.1 1.5 2.9 2010 (77.8, 89.1) (0.5, 7.1) (27.6, 59.5) (7.7, 20.1) (9.6, 17.0) (49.4, 76.2) (5.4, 12.9) -- (3.2, 11.2) (1.0, 2.1) (2.3, 3.5) 90.5 5.9 75.6 15.3 72.8 95.4 55.0 0.3 0.0 9.0 9.8 2011 (85.5, 93.9) (1.6, 18.9) (53.9, 89.1) (8.0, 27.4) (67.9, 77.1) (90.5, 97.8) (47.2, 62.6) (0.1, 0.9) -- (7.6, 10.7) (8.3, 11.6) 91.0 16.0 90.0 18.9 81.6 98.9 71.3 0.0 0.0 9.3 12.3 2013 (85.7, 94.4) (8.8, 27.5) (68.3, 97.4) (11.4, 29.7) (75.2, 86.6) (97.0, 99.6) (65.8, 76.1) -- - (5.9, 14.2) (8.6, 17.4) 93.8 11.1 93.6 12.5 69.5 94.8 72.3 -- - 72.0 26.6 2015 (89.1, 96.5) (5.9, 20.0) (84.2, 97.5) (7.1, 21.0) (63.2, 75.1) (91.6, 96.8) (68.2, 76.0) -- - (68.2, 75.4) (20.8, 33.4) QA ACT with the “green leaf” logo

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) ------2010 ------82.2 1.2 37.0 9.5 68.2 89.9 50.6 0.3 0.0 8.4 8.4 2011 (76.5, 86.8) (0.3, 5.1) (22.8, 53.8) (5.6, 15.7) (62.3, 73.5) (83.3, 94.2) (42.0, 59.1) (0.1, 0.9) -- (6.9, 10.1) (7.0, 10.0) 39.7 11.0 45.2 12.2 75.6 98.3 65.1 0.0 0.0 8.5 9.7 2013 (31.2, 48.9) (5.3, 21.8) (31.3, 59.8) (6.3, 22.2) (68.5, 81.5) (95.3, 99.4) (59.4, 70.4) -- - (5.4, 13.1) (6.5, 14.2) 10.8 2.4 40.1 2.7 67.3 92.3 68.2 -- - 68.3 18.3 2015 (6.5, 17.3) (1.1, 5.2) (25.5, 56.5) (1.4, 5.3) (61.2, 72.9) (87.3, 95.5) (63.6, 72.5) -- - (64.1, 72.3) (15.0, 22.1) QA ACT without the “green leaf” logo 83.4 1.9 39.1 12.8 12.3 59.6 7.9 0.0 0.0 1.4 2.8 2010 (76.9, 88.3) (0.5, 7.0) (24.5, 55.9) (7.7, 19.9) (9.2, 16.4) (48.1, 70.2) (5.0, 12.3) -- -- (1.0, 2.0) (2.3, 3.5) 4.1 1.9 0.0 2.1 0.3 <0.1 0.7 <0.1 0.0 0.1 0.4 2011 (2.5, 6.8) (0.5, 6.7) -- (0.7, 5.8) (<0.1, 2.1) (<0.1, 1.6) (0.3, 1.5) (<0.1, <0.1) -- (<0.1, 0.2) (0.2, 0.7) 87.1 5.1 70.8 8.1 12.5 31.3 9.9 0.0 0.0 1.4 3.5 2013 (81.5, 91.1) (1.8, 13.5) (48.0, 86.4) (4.2, 15.0) (9.2, 16.7) (20.6, 44.4) (5.8, 16.4) -- -- (0.7, 2.4) (2.1, 5.8) 92.8 8.8 64.5 10.0 6.9 20.6 5.8 -- - 6.3 9.1 2015 (88.0, 95.8) (4.1, 18.1) (46.8, 78.9) (5.1, 18.7) (5.0, 9.5) (12.8, 31.5) (4.6, 7.3) -- - (5.1, 7.7) (5.2, 15.6) Non-Quality Assured ACT non- QA ACT) 7.7 3.1 34.7 4.6 68.7 98.2 39.7 <0.1 6.1 6.8 6.5 2010 (4.8, 12.2) (0.4, 18.5) (19.1, 54.4) (1.4, 14.3) (54.4, 80.1) (93.5, 99.5) (28.7, 51.9) (<0.1, 0.1) (3.2, 11.2) (4.9, 9.4) (4.7, 9.0) 5.8 <0.1 19.3 1.0 45.2 92.2 20.3 <0.1 0.0 4.5 4.0 2011 (4.0, 8.4) (<0.1, 0.2) (8.0, 39.5) (0.5, 2.2) (34.6, 56.3) (87.2, 95.4) (14.4, 27.9) (<0.1, <0.1) -- (3.1, 6.4) (2.6, 6.0) 3.3 0.2 19.4 0.4 43.0 96.3 18.9 0.0 0.0 3.2 2.3 2013 (1.7, 6.3) (0.1, 0.4) (10.2, 33.8) (0.3, 0.7) (32.5, 54.1) (86.2, 99.1) (14.5, 24.2) -- - (1.9, 5.4) (1.5, 3.6) 6.0 0.0 17.3 0.2 46.0 97.7 30.8 -- - 35.3 8.5 2015 (2.5, 13.6) (0.0, 0.1) (9.3, 30.1) (0.1, 0.3) (39.8, 52.3) (95.6, 98.8) (26.4, 35.6) -- - (30.7, 40.2) (6.5, 11.1)

Any non-artemisinin therapy

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 93.4 0.2 94.5 14.0 95.6 98.0 86.3 0.2 24.4 12.8 13.0 2010 (90.8, 95.3) (<0.1, 0.8) (81.5, 98.5) (8.6, 22.0) (90.0, 98.1) (96.2, 99.0) (81.1, 90.2) (0.1, 0.5) (12.3, 42.5) (11.2, 14.7) (11.6, 14.6) 94.6 <0.1 94.0 11.0 91.7 99.1 87.8 0.1 0.0 12.9 12.6 2011 (6.4,18.3) (11.4,14.5) (11.0,14.4) (92.0, 96.3) (0.0, 0.2) (76.5, 98.7) (88.1, 94.3) (97.4, 99.7) (83.5, 91.1) (0.1, 0.3) -- 83.3 0.2 85.9 3.4 90.1 99.1 87.2 0.0 0.0 11.0 8.6 2013 (77.2, 88.0) (0.1, 0.4) (67.9, 94.6) (2.7, 4.3) (84.7, 93.8) (96.7, 99.8) (83.5, 90.2) -- - (7.1, 16.8) (6.3, 11.7) 90.0 0.0 91.0 1.5 87.1 97.2 82.7 -- - 83.9 21.1 2015 (84.8, 93.6) (0.0, 0.1) (80.1, 96.2) (1.2, 1.9) (83.0, 90.4) (94.7, 98.5) (78.7, 86.0) -- - (80.7, 86.7) (17.4, 25.3)

Sulfadoxine-Pyrimethamine 82.6 0.1 68.2 11.8 66.3 74.1 48.5 0.1 0.0 7.6 8.2 2010 (78.8, 85.9) (<0.1, 0.9) (49.9, 82.2) (7.2, 18.9) (57.8, 73.8) (68.7, 78.8) (40.0, 57.1) (<0.1, 0.2) -- (6.3, 9.2) (6.9, 9.6) 87.8 <0.1 70.4 9.8 58.8 78.8 44.0 <0.1 0.0 7.1 7.4 2011 (84.3, 90.6) (<0.1, 0.2) (56.7, 81.2) (5.8, 16.1) (52.7, 64.7) (71.1, 84.8) (35.4, 52.9) (<0.1, 0.1) -- (5.8, 8.7) (6.1, 8.9) 80.0 0.1 50.0 3.0 55.8 85.8 44.3 0.0 0.0 6.0 5.0 2013 (73.9, 84.9) (0.0, 0.4) (35.8, 64.3) (2.4, 3.8) (47.1, 64.1) (76.9, 91.6) (36.3, 52.7) -- - (3.7, 9.4) (3.6, 7.1) 81.4 0.0 67.6 1.3 48.5 82.5 45.9 -- - 47.1 12.1 2015 (75.0, 86.5) (0.0, 0.1) (53.1, 79.3) (1.0, 1.7) (42.1, 54.8) (76.3, 87.3) (40.3, 51.7) -- - (42.0, 52.1) (9.6, 15.3)

Oral Quinine 40.4 0.0 78.0 7.3 82.8 86.7 76.8 0.2 24.4 11.7 11.1 2010 (34.9, 46.1) (64.8, 87.2) (4.3, 12.0) (79.2, 85.8) (78.7, 92.0) (71.4, 81.4) (0.1, 0.4) (12.3, 42.5) (10.1, 13.4) (9.8, 12.6) 41.3 0.0 70.4 5.5 78.4 97.3 79.8 0.1 0.0 11.6 10.6 2011 (36.3, 46.5) -- (47.8, 86.1) (3.3,9.2) (73.3, 82.7) (94.2, 98.8) (74.5, 84.2) (<0.1, 0.3) -- (10.2,13.2) (9.2, 12.2) 32.2 0.2 73.5 1.7 72.5 97.3 77.9 0.0 0.0 9.6 7.1 2013 (26.4, 38.5) (0.1, 0.3) (44.8, 90.4) (1.3, 2.2) (66.5, 77.7) (93.4, 99.0) (73.3, 81.8) -- -- (6.2, 14.7) (5.2, 9.7) 59.9 0.0 85.2 1.2 65.9 94.1 75.0 -- - 73.2 18.2 2015 (50.1, 69.1) - (73.1, 92.4) (0.9, 1.5) (60.7, 70.8) (89.1, 96.8) (70.8, 78.9) -- - (69.5, 76.6) (15.0, 22.0)

Oral artemisinin monotherapy 0.0 0.0 3.2 0.1 0.2 5.0 0.1 0.0 0.0 0.0 0.0 2010 -- -- (0.4, 22.3) (<0.1, 0.8) (<0.1, 0.9) (3.4, 7.4) (<0.1, 0.6) -- -- (<0.1, 0.1) (<0.1, 0.1) 0.0 0.0 0.0 0.0 0.1 0 0.0 0.0 0.0 <0.1 <0.1 2011 ------(0.0, 0.8) ------(0.0, <0.1) (0.0,<0.1) www.ACTwatch.info Page 86

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2013 ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2015 ------Non-oral artemisinin monotherapy 1.2 0.1 17.9 0.8 27.0 61.3 4.1 0.0 0.0 1.5 1.4 2010 (0.4, 3.4) (<0.1, 0.7) (6.0, 42.6) (0.3, 1.9) (20.8, 34.2) (54.6, 67.5) (2.0, 8.4) -- -- (0.9, 2.5) (0.8, 2.4) 4.2 7.5 33.1 7.9 29.0 75.8 4.3 0.0 0.0 1.8 2.6 2011 (2.8, 6.3) (2.1, 23.9) (16.0, 56.1) (2.6,21.4) (24.3, 34.3) (67.2, 82.7) (2.8, 6.6) -- -- (1.2,2.6) (1.7,4.1) 5.4 4.3 20.8 4.5 45.6 72.4 8.0 0.0 0.0 2.2 2.9 2013 (3.4, 8.4) (1.7, 10.6) (9.7, 39.1) (1.8, 10.4) (40.4, 50.9) (61.6, 81.1) (5.3, 12.0) -- -- (1.3, 3.7) (1.7, 4.8) 71.4 0.3 61.4 1.4 47.7 84.0 10.9 -- - 20.6 5.9 2015 (62.7, 78.7) (0.1, 0.6) (44.0, 76.3) (1.0, 1.9) (42.2, 53.3) (77.0, 89.2) (8.2, 14.4) -- - (17.5, 24.1) (4.7, 7.5) Any treatment for severe malaria 54.8 0.2 75.1 9.0 70.0 71.2 28.4 <0.1 0.0 5.7 6.2 2010 (49.3, 60.2) (<0.1, 0.7) (63.9, 83.7) (5.6, 14.3) (66.9, 72.8) (58.2, 81.4) (23.2, 34.3) (<0.1, 0.1) -- (4.6, 7.2) (5.2, 7.2) 47.9 7.5 77.8 13.0 75.6 87.2 30.1 0.0 0.0 6.4 7.2 2011 (42.5, 53.3) (2.1, 23.9) (44.3, 93.9) (6.0,25.9) (71.7, 79.1) (79.3, 92.4) (24.6, 36.3) -- -- (5.1,7.8) (5.8,8.9) 28.9 4.3 68.2 5.5 77.0 88.2 31.0 0.0 0.0 5.3 5.4 2013 (24.2, 34.1) (1.7, 10.6) (42.0, 86.4) (2.7, 11.0) (72.7, 80.8) (79.3, 93.6) (24.5, 38.3) -- -- (3.3, 8.3) (3.7, 7.7) 74.5 0.3 79.9 1.5 78.6 89.6 24.8 -- - 38.4 10.3 2015 (66.0, 81.5) (0.1, 0.6) (64.0, 89.9) (1.1, 2.1) (74.2, 82.5) (84.0, 93.4) (21.0, 29.1) -- - (34.7, 42.2) (8.3, 12.6) Artesunate IV/IM

0.0 0.0 0.0 0.0 0.4 2.1 0.0 0.0 0.0 <0.1 0.02 2010 ------(0.2, 1.3)) (1.3, 3.3)) ------(<0.1,0.1) (<0.1, 0.7) 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 <0.1 <0.1 2011 ------(0.0,0.0) (0.4, 0.6) (0.0, 0.0) ------(<0.1, <0.1) (<0.1, <0.1) 3.7 0.0 6.9 0.2 7.1 27.7 0.4 0.0 0.0 0.3 0.3 2013 (2.1, 6.4) - (2.0, 21.1) (0.1, 0.3) (4.4, 11.3) (16.7, 42.2) (0.2, 1.1) -- -- (0.2, 0.5) (0.2, 0.4) 53.1 0.0 42.3 0.8 20.0 63.8 2.3 -- - 7.3 2.3 2015 (42.8, 63.1) - (26.4, 59.9) (0.6, 1.1) (16.1, 24.6) (53.65 72.9) (1.0, 5.1) -- - (5.5, 9.8) (1.8, 3.1)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Rectal AS 0.0 0.1 0.0 0.1 0.0 2.7 0.4 0.0 0.0 0.1 0.1 2010 -- (<0.1, 0.7) -- (<0.1, 0.6) -- (1.3, 5.3) (0.1, 2.8) -- -- (<0.1, 0.3) (<0.1, 0.2) 0.0 1.1 0.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 2011 -- (0.3, 4.7) -- (0.2, 4.1) ------(<0.1, 0.5) 0.9 4.3 3.2 4.1 0.8 1.4 0.1 0.0 0.0 0.0 1.3 2013 (0.3, 3.0) (1.7, 10.6) (0.4, 19.5) (1.6, 10.2) (0.3, 2.3) (0.4, 4.7) (0.0, 0.4) -- -- (0.0, 0.1) (0.5, 3.3) 30.6 0.3 8.5 0.6 1.6 5.1 0.4 -- -- 0.7 0.7 2015 (22.7, 39.9) (0.1, 0.6) (3.3, 20.2) (0.4, 1.0) (0.9, 2.6) (3.1, 8.4) (0.2, 1.0) -- -- (0.5, 1.2) (0.5, 0.9) * The denominator includes outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round Public Community Private Not ALL Private Itinerant General ALL ALL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store Drug Retailer Private Outlets Facility Worker Facility For-Profit Facility Vendor % % % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2010 N=766 2010 N=30 2010 N=31 2010 N=827 2010 N=389 2010 N=354 2010 N=819 2010 N=16 2010 N=5 2010 N=1,583 2010 N=2,410 2011 N=678 2011 N=84 2011 N=41 2011 N=803 2011 N=807 2011 N=399 2011 N=1,112 2011 N=18 2011 N=0 2011 N=2,336 2011 N=3,139 Proportion of outlets* stocking: 2013 N=684 2013 N=731 2013 N=29 2013 N=1,444 2013 N=390 2013 N=454 2013 N=1,019 2013 N=0 2013 N=0 2013 N=1,863 2013 N=3,307 2015 N=275 2015 N=719 2015 N=53 2015 N=1,047 2015 N=956 2015 N=476 2015 N=1,849 2015 N=n/a 2015 N=n/a 2015 N=3,281 2015 N=4,328

Any ACT 89.1 98.0 57.6 85.8 73.9 98.6 49.5 16.4 20.0 55.7 60.7 2010 (84.3, 92.6) (74.6, 99.9) (37.3, 75.7) (75.3, 92.3) (61.7, 83.3) (92.4, 99.8) (38.2, 60.7) (6.3, 36.2) -- (43.6, 67.1) (50.9, 69.6) 91.8 55.4 86.6 74.7 89.8 100 69.0 75.6 -- 75.6 75.4 2011 (88.0, 94.5) (27.8, 80.0) (71.2, 94.4) (53.7, 88.3) (85.2, 93.1) -- (61.2, 75.8) (38.9, 93.8) -- (67.7,82.1) (68.4,81.3) 94.3 95.4 100.0 95.4 90.7 99.6 80.0 -- -- 82.7 88.3 2013 (90.2, 96.7) (89.4, 98.1) - (90.6, 97.8) (84.8, 94.5) (98.3, 99.9) (74.7, 84.4) -- -- (77.7, 86.7) (84.3, 91.3) 96.1 99.7 98.9 99.4 86.3 99.7 86.1 -- - 86.4 90.3 2015 (92.6, 98.0) (98.7, 99.9) (92.6, 99.8) (98.6, 99.7) (79.6, 91.0) (98.3, 99.9) (83.2, 88.6) -- - (83.3, 89.0) (87.8, 92.3) AL 89.1 98.1 53.6 85.1 71.8 98.7 48.4 3.8 100.0 54.4 59.5 2010 (84.3, 92.6) (74.6, 99.9) (35.6, 70.6) (74.5, 91.8) (60.3, 81.0) (92.4, 99.8) (37.3, 59.7) (0.7, 17.6) -- (42.7, 65.7) (50.1, 68.3) 91.8 55.4 86.6 74.7 87.4 100 67.5 73.7 -- 73.9 74.0 2011 (88.0, 94.5) (27.8, 80.0) (71.2, 94.4) (53.7, 88.3) (82.7, 90.9) -- (59.7, 74.4) (36.6, 93.1) -- (66.0, 80.5) (67.2, 79.8) 94.3 95.4 100.0 95.4 89.8 99.6 79.2 -- -- 81.9 87.8 2013 (90.2, 96.7) (89.4, 98.1) - (90.6, 97.8) (84.1, 93.6) (98.3, 99.9) (74.0, 83.5) -- -- (77.1, 85.9) (83.9, 90.9) 96.1 99.7 98.9 99.4 80.7 99.5 84.7 -- - 84.0 88.7 2015 (92.6, 98.0) (98.7, 99.9) (92.6, 99.8) (98.6, 99.7) (73.9, 86.0) (98.3, 99.9) (81.8, 87.3) -- - (80.8, 86.7) (85.9, 90.9)

ASAQ 0.5 0.0 0.0 0.3 6.0 32.4 2.3 0.0 0.0 3.6 3.1 2010 (0.1, 2.5) -- -- (0.1, 1.6) (3.8, 9.2) (26.2, 39.3) (1.3, 4.0) -- -- (2.3, 5.6) (2.0, 4.9) 0.2 0.0 12.1 1.4 20.4 58.8 6.2 0.0 -- 10.9 9.1 2011 (<0.1, 0.8) -- (4.7, 27.7) (0.4, 4.9) (17.2, 23.9) (47.2, 67.8) (4.6, 8.4) -- -- (8.5, 14.0) (6.5, 12.4) 0.1 0.2 4.8 0.3 12.7 43.6 6.4 -- -- 8.5 4.9 2013 (0.0, 0.5) (0.0, 1.5) (0.6, 28.9) (0.0, 2.2) (9.1, 17.6) (34.4, 53.1) (4.5, 9.1) -- -- (6.5, 11.1) (3.3, 7.3) 1.4 0.0 8.5 0.5 28.4 60.2 16.2 -- - 19.8 13.9 2015 (0.6, 3.7) - (3.3, 20.0) (0.2, 1.4) (23.0, 34.5) (48.8, 70.5) (13.4, 19.5) -- - (16.8, 23.1) (11.1, 17.3) DHA PPQ

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 1.7 0.0 8.9 2.5 21.9 88.4 6.1 0.0 0.0 11.3 9.8 2010 (0.8, 3.6) -- (3.8, 19.6) (1.0, 6.3) (16.3, 28.7) (79.1, 93.9) (3.4, 10.6) -- -- (6.6, 18.6) (5.6, 16.8) 3.7 0.0 12.4 3.0 22.7 91.8 5.6 0.0 -- 11.7 10.0 2011 (2.3, 6.0) -- (4.7, 28.6) (1.4, 6.5) (18.0, 28.2) (86.5, 95.1) (3.5, 8.9) -- -- (8.0, 16.9) (6.4, 15.3) 1.9 0.3 16.2 1.0 26.6 91.2 9.8 -- -- 15.0 8.9 2013 (0.7, 4.9) (0.1, 1.2) (6.6, 34.6) (0.5, 1.9) (20.0, 34.6) (78.3, 96.8) (7.0, 13.5) -- -- (11.0, 20.2) (6.0, 13.0) 1.5 0.0 11.1 0.7 32.8 98.6 14.7 -- -- 20.2 14.3 2015 (0.7, 3.4) (0.0, 0.2) (4.7, 24.0) (0.3, 1.6) (27.0, 39.2) (97.0, 99.3) (11.4, 18.7) -- -- (16.4, 24.6) (10.9, 18.6)

Quality Assured ACT (QA ACT) 87.3 40.1 45.5 70.3 13.4 64.1 9.6 3.8 0.0 11.3 21.0 2010 (82.0, 91.3) (18.6, 66.1) (29.1, 62.9) (53.5, 83.0) (10.2, 17.5) (49.4, 76.6) (6.3, 14.5) (0.7, 17.6) -- (8.3, 15.2) (17.7, 24.6) 91.7 55.2 80.4 73.9 76.6 95.8 59.7 73.7 -- 62.5 67.1 2011 (87.9, 94.4) (27.8, 79.8) (62.5, 91.0) (53.3, 87.4) (72.8, 80.1) (90.7, 98.1) (52.6, 66.5) (36.6, 93.1) -- (59.2, 71.3) (61.1, 72.7) 94.2 94.9 100.0 94.9 86.1 99.4 75.9 -- -- 78.6 85.7 2013 (90.1, 96.6) (88.9, 97.7) - (90.2, 97.4) (81.3, 89.8) (98.1, 99.8) (71.0, 80.2) -- -- (74.2, 82.4) (81.7, 89.0) 96.1 99.7 95.7 99.2 74.7 96.5 77.4 -- -- 77.1 83.8 2015 (92.6, 98.0) (98.7, 99.9) (87.2, 98.7) (98.3, 99.6) (68.0, 80.3) (94.0, 97.9) (73.6, 80.9) -- -- (73.3, 80.4) (80.6, 86.6)

QA ACT with the “green leaf” logo

------2010

83.3 11.2 39.3 45.7 71.8 90.3 54.9 72.6 -- 60.7 57.7 2011 (78.2, 87.3) (5.0, 23.2) (24.1, 56.8) (29.2, 63.1) (67.0, 76.2) (83.5, 94.5) (46.8, 62.7) (35.4, 92.8) -- (53.4, 67.5) (50.4, 64.7) 41.1 65.3 50.2 61.1 79.7 98.9 69.4 -- -- 72.2 67.4 2013 (32.4, 50.3) (35.7, 86.5) (34.7, 65.6) (37.5, 80.5) (73.7, 84.7) (97.1, 99.6) (63.7, 74.5) -- -- (66.9, 76.9) (55.5, 77.4) 11.0 21.4 41.0 21.6 72.3 93.9 73.0 -- -- 73.2 57.6 2015 (6.7, 17.7) (8.4, 44.6) (25.9, 57.9) (9.6, 41.4) (65.8, 78.0) (89.7, 96.5) (68.6, 77.0) -- -- (69.0, 77.0) (47.2, 67.3)

QA ACT without the “green leaf” logo 87.1 40.1 42.6 69.5 13.2 62.9 9.2 0.0 0.0 10.9 20.5 2010 (81.7, 91.2) (18.6, 66.1) (27.2, 59.6) (53.2, 82.0) (10.0, 17.3) (48.3, 75.5) (6.0, 14.0) -- -- (8.0, 14.7) (17.2, 24.2)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 4.2 18.0 0.0 10.0 0.3 0.0 0.7 1.0 -- 0.6 2.5 2011 (0.1, 8.0) (1.3, 4.6) (2.5, 6.9) (5.5, 47.6) -- (4.4, 20.9) (<0.1, 2.3) -- (0.3, 1.7) -- (0.3, 1.3) 90.1 30.0 78.7 40.8 13.2 31.5 10.5 -- -- 11.5 24.3 2013 (85.5, 93.4) (11.3, 59.0) (62.1, 89.2) (22.1, 62.6) (9.7, 17.7) (20.6, 44.8) (6.2, 17.3) -- -- (7.8, 16.6) (15.9, 35.2) 95.1 78.8 65.9 79.5 7.4 21.0 6.2 -- - 6.7 28.8 2015 (91.5, 97.2) (55.6, 91.7) (48.4, 79.9) (59.6, 91.0) (5.4, 10.2) (12.9, 32.2) (4.9, 7.9) -- - (5.5, 8.2) (18.9, 41.1)

Non-Quality Assured ACT non-QA ACT) 8.0 65.9 36.7 25.4 71.8 98.5 45.1 12.6 20.0 52.0 47.6 2010 (5.0, 12.6) (31.7, 89.0) (19.6, 58.1) (10.5, 49.9) (58.7, 82.0) (92.3, 99.7) (33.6, 57.2) (4.5, 30.2) -- (39.3, 64.4) (36.2, 59.4) 6.0 0.2 20.8 5.1 52.6 98.1 25.4 1.9 -- 33.8 28.1 2011 (4.1, 8.8) (0.0, 2.0) (8.9, 41.2) (2.3, 10.6) (41.5, 63.5) (95.1, 99.3) (18.7, 33.4) (0.2, 14.3) -- (24.3, 44.9) (19.2, 39.2) 3.4 1.2 21.6 2.1 45.3 96.9 20.1 -- -- 27.1 16.2 2013 (1.7, 6.5) (0.5, 2.5) (11.2, 37.5) (1.3, 3.5) (35.2, 55.9) (85.0, 99.4) (15.6, 25.6) -- -- (20.6, 34.8) (11.3, 22.6) 6.1 0.1 17.7 1.5 49.4 99.4 33.0 -- - 37.8 26.8 2015 (2.6, 13.9) (0.0, 0.6) (9.5, 30.7) (0.8, 2.8) (42.8, 56.1) (98.2, 99.8) (28.4, 37.9) -- - (33.0, 42.9) (21.6, 32.8)

Any non-artemisinin therapy 96.8 4.3 100.0 77.2 99.9 98.3 98.0 12.6 80.0 98.3 94.8 2010 (95.3, 97.9) (0.4, 33.5) -- (42.6, 93.9) (99.5, (96.7, 99.1) (96.4, 98.9) (4.5, 30.2) (97.1, 99.0) (85.4, 98.3) 100.0) -- 95.8 0.2 100 53.0 96.6 99.5 95.3 42.2 -- 94.6 86.4 2011 (93.7, 97.2) (<0.1, 2.0) -- (27.3,77.2) (95.2, 97.5) (97.9, 99.9) (93.1, 96.9) (21.6, 66.0) -- (92.2,96.3) (74.3,93.3) 86.2 1.2 95.5 17.2 95.1 99.7 92.8 -- -- 93.5 60.1 2013 (80.2, 90.6) (0.6, 2.5) (78.2, 99.2) (10.7, 26.5) (91.8, 97.1) (98.8, 99.9) (90.2, 94.8) -- -- (91.4, 95.1) (47.9, 71.1) 92.3 0.2 93.0 12.2 93.6 98.9 88.5 -- - 89.9 66.3 2015 (88.4, 94.9) (0.0, 1.2) (82.3, 97.5) (7.0, 20.0) (90.7, 95.6) (97.5, 99.5) (85.0, 91.3) -- - (87.2, 92.1) (55.4, 75.8)

Sulfadoxine-Pyrimethamine 85.7 2.3 72.3 65.3 69.3 74.3 55.2 27.0 0.0 58.4 59.5 2010 (81.6, 89.0) (0.1, 29.3) (53.7, 85.5) (39.6, 84.3) (61.8, 75.8) (69.0, 78.9) (47.1, 63.0) (9.2, 57.4) -- (50.5, 66.0) (51.7, 67.0) 88.9 0.2 74.8 47.2 62 79.1 47.8 9.7 -- 51.1 50.7 2011 (85.8, 91.4) (<0.1, 2.0) (57.9, 86.6) (25.3, 70.3) (56.2, 67.4) (71.3, 85.1) (39.2, 56.5) (1.7, 40.9) -- (43.4, 59.6) (43.1, 58.2) www.ACTwatch.info Page 91

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 82.8 0.7 55.6 15.0 58.9 86.3 47.2 -- -- 50.5 35.0 2013 (76.9, 87.4) (0.3, 1.8) (40.5, 69.8) (9.4, 23.3) (51.2, 66.1) (77.6, 92.0) (39.0, 55.6) -- -- (43.1, 57.9) (28.2, 42.4) 83.4 0.2 69.1 10.3 52.1 83.9 49.2 -- - 50.4 38.2 2015 (77.4, 88.1) (0.0, 1.2) (54.2, 80.9) (6.0, 17.0) (45.7, 58.4) (77.6, 88.7) (43.5, 54.9) -- - (45.4, 55.4) (31.9, 45.0)

Oral Quinine 80.2 2010 42.3 0.0 85.1 40.2 88.9 91.7 90.0 80.0 89.5 81.4 (50.4,94.2) (36.6, 48.2) -- (72.3, 92.6) (26.8, 55.4) (84.5, 92.2) (87.0, 94.8) (87.0, 92.3) -- (86.9, 91.7) (75.9, 85.9) 41.8 0.0 74.9 26.6 82.6 97.7 86.6 25.6 -- 84.3 72.9 2011 (36.8, 47.0) -- (53.6, 88.5) (15.0, 42.8) (78.7, 85.9) (94.5, 99.1) (83.4, 89.3) (14.3, 41.5) -- (81.5, 86.7) (64.5, 79.9) 33.3 0.9 81.6 8.4 76.5 97.9 82.9 -- -- 81.7 49.6 2013 (27.4, 39.7) (0.4, 2.1) (48.5, 95.4) (5.3, 13.1) (70.3, 81.7) (94.6, 99.2) (78.7, 86.4) -- -- (77.9, 85.0) (40.3, 59.0) 61.4 0.0 87.1 9.3 70.8 95.7 80.4 -- - 78.4 57.4 2015 (51.4, 70.5) (0.0, 0.2) (74.8, 93.9) (5.3, 15.8) (65.9, 75.3) (91.8, 97.8) (76.3, 83.8) -- - (74.9, 81.5) (48.4, 66.0)

Oral artemisinin monotherapy 0.0 0.0 3.3 0.5 0.2 5.0 0.1 0.0 0.0 0.2 0.3 2010 -- -- (0.4, 23.5) (0.1, 4.2) (<0.1, 0.9) (3.4, 7.4) (<0.1, 0.7) -- -- (0.1, 0.4) (0.1, 0.6) 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 -- <0.1 <0.1 2011 ------(0.0, 0.9) ------(<0.1,0.2) (<0.1,0.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- -- 0.0 0.0 2013 ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2015 ------

Non-oral artemisinin monotherapy 1.2 2.0 19.0 4.3 28.2 61.4 4.7 0.0 0.0 11.4 10.3 2010 (0.4, 3.6) (0.1, 21.9) (6.2, 45.2) (1.9, 9.4) (22.2, 35.2) (54.9, 67.6) (2.3, 9.3) -- -- (7.1, 18.0) (6.3, 16.3) 4.3 71.0 35.2 37.9 30.6 76.1 4.7 0.0 -- 13.1 18.0 2011 (2.9, 6.3) (53.5, 83.9) (17.8, 57.6) (20.9,58.6) (25.8, 35.8) (67.4, 83.0) (3.0, 7.1) -- -- (9.5,17.8) (12.8,2.7) 5.6 25.5 23.1 22.3 48.1 72.9 8.5 -- -- 18.5 20.2 2013 (3.5, 8.7) (12.5, 44.9) (10.4, 43.7) (11.5, 38.8) (42.1, 54.1) (62.0, 81.5) (5.7, 12.6) -- -- (14.8, 22.8) (14.4, 27.6) 73.2 2.3 62.8 11.0 51.3 85.5 11.7 -- - 22.1 18.7 2015 (64.7, 80.2) (1.0, 5.6) (44.7, 77.9) (6.4, 18.3) (45.1, 57.4) (78.9, 90.3) (8.9, 15.3) -- - (18.8, 25.7) (15.3, 22.8)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)

Any treatment for severe malaria 57.4 4.0 81.9 49.9 75.2 75.3 33.3 0.0 0.0 44.1 45.1 2010 (52.0, 62.6) (0.4, 28.6) (66.1, 91.3) (33.7, 66.1) (71.6, 78.4) (64.5, 83.6) (27.3, 39.8) -- -- (38.1, 50.4) (39.5, 50.8) 48.5 71.0 82.8 62.5 79.6 87.5 32.7 0.0 -- 46.2 49.4 2011 (43.1, 54.0) (53.5, 83.9) (54.9, 95.0) (52.2,71.9) (76.5, 82.4) (79.6, 92.7) (26.6, 39.5) -- -- (40.0,52.5) (44.3,54.6) 29.9 25.6 75.8 27.8 81.3 88.8 33.0 -- -- 44.7 37.3 2013 (25.0, 35.3) (12.6, 45.0) (46.9, 91.7) (16.7, 42.6) (76.2, 85.5) (80.1, 94.0) (26.2, 40.5) -- -- (39.5, 50.0) (30.8, 44.3) 76.3 2.3 81.7 12.2 84.5 91.1 26.6 -- - 41.1 32.4 2015 (68.0, 83.0) (1.0, 5.6) (65.1, 91.5) (7.1, 20.2) (79.9, 88.2) (86.0, 94.5) (22.5, 31.1) -- - (37.3, 45.0) (27.1, 38.1) Injectable AS 0.0 0.0 0.0 0.0 0.5 2.2 0.0 0.0 0.0 0.2 0.1 2010 ------(0.2, 1.3) (1.3, 3.6) ------(<0.1, 0.6) (<0.1, 0.5) 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 -- <0.1 <0.1 2011 ------(<0.1, 0.7) ------(<0.1, 0.2) (<0.1, 0.2) 3.7 0.0 6.9 0.2 7.1 27.7 0.4 0.0 0.3 0.3 3.7 2013 (2.1, 6.4) - (2.0, 21.1) (0.1, 0.3) (4.4, 11.3) (16.7, 42.2) (0.2, 1.1) - (0.2, 0.5) (0.2, 0.4) (2.1, 6.4) 54.4 0.0 43.3 6.5 21.5 64.9 2.4 -- -- 7.8 7.4 2015 (44.0, 64.5) - (26.8, 61.3) (3.5, 11.7) (17.1, 26.6) (54.7, 73.8) (1.1, 5.5) -- -- (5.8, 10.4) (5.6, 9.7) Rectal AL 0.0 2.0 0.0 0.4 0.0 2.8 0.4 0.0 0.0 0.4 0.4 2010 -- (0.1, 21.9) -- (0.1, 3.1) -- (1.3, 5.8) (0.1, 3.2) -- -- (0.1, 2.0) (0.1, 1.6) 0.0 10.8 0.0 4.9 0.0 0.0 0.0 0.0 -- 0.0 1.0 2011 -- (3.4, 29.0) -- (1.6, 14.2) ------(0.3, 3.5) 0.9 25.2 3.5 20.8 0.8 1.4 0.1 -- -- 0.3 9.3 2013 (0.3, 3.1) (12.3, 44.7) (0.5, 21.3) (10.2, 37.9) (0.3, 2.5) (0.4, 4.8) (0.0, 0.4) -- -- (0.1, 0.6) (4.2, 19.2) 31.4 2.3 8.6 5.0 1.7 5.2 0.4 -- -- 0.8 2.1 2015 (23.3, 40.8) (1.0, 5.6) (3.3, 20.6) (2.8, 8.7) (1.0, 2.8) (3.1, 8.6) (0.2, 1.1) -- -- (0.5, 1.3) (1.5, 2.9) *Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 56 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C4: Antimalarial market composition, across survey round Public Community Private Not ALL Private General Itinerant ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Retailer Drug Vendor Private antimalarial in stock on the day of the survey:* Facility Worker Facility For-Profit Facility % % % % % % % % % % 10.1 3.6 2.8 16.4 21.3 1.1 59.4 1.5 0.4 83.6 2010, N=1,434 outlets (7.4, 13.6) (0.7, 15.7) (1.5, 5.2) (10.9, 24.1) (12.1, 34.8) (0.5, 2.4) (50.5, 67.7) (0.8, 2.8) (<0.1, 2.5) (75.9, 89.2) 8.3 8.9 2.2 19.5 22.9 1.6 54.3 1.8 0.0 80.5 2011, N=2,252 outlets (6.1, 11.2) (3.0, 23.9) (1.5, 3.3) (11.8, 30.4) (14.1, 34.8) (1.0, 2.7) (45.4, 62.9) (0.6, 4.8) -- (69.6, 88.2) 6.3 35.7 1.4 43.3 12.4 1.5 42.8 0.0 0.0 56.7 2013, N=2,339 outlets (4.9, 8.0) (24.6, 48.6) (0.8, 2.4) (32.6, 54.7) (9.5, 16.2) (0.9, 2.5) (33.9, 52.2) -- -- (45.3, 67.4) 6.3 25.0 1.4 32.8 15.5 2.0 49.7 -- - 67.2 2015, N=3,907 outlets (5.1, 7.8) (15.6, 37.6) (1.0, 2.0) (23.5, 43.7) (12.4, 19.2) (1.3, 3.1) (41.7, 57.7) -- - (56.3, 76.5) * Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C5: Price of tablet formulation antimalarials, by outlet type, across survey round Private Itinerant ALL For-Profit Pharmacy Drug Store General Retailer Drug Vendor Private Facility

Any ACT $4.64 $5.57 $3.25 $2.79 $2.32 $3.71 2010 [3.25-6.27] (466) [3.71-9.29] (2,072) [2.32-4.64] (635) [2.79-3.71] (2) [1.86-2.79] (2) [2.79-5.57] (3,177) $3.13 $3.13 $1.96 $1.17 $- $2.35 2011 [1.96-4.69] (1,758) [1.56-5.87] (3,093) [1.56-3.13] (1,524) [0.94-2.35] (14) [-] (0) [1.56-3.91] (6,389) $2.62 $2.46 $1.96 - - $1.96 2013 [1.96-3.93] (841) [1.31-3.93] (3,814) [1.57-2.62] (1,602) - - [1.57-3.27] (6,257) $2.37 $2.66 $1.48 $- $- $1.78 2015 [1.48-3.85] (2,352) [1.48-4.44] (4,158) [1.18-2.37] (3,714) [-] (0) [-] (0) [1.18-2.96] (10,224)

AL  $3.71 $3.71 $3.02 $2.79 $2.32 $3.25 2010 [3.02-4.64] (337) [2.79-4.64] (971) [2.32-3.71] (510) [2.79-3.71] (2) [1.86-2.79] (2) [2.79-4.64] (1,822) $2.74 $1.96 $1.96 $1.17 $- $1.96 2011 [1.88-3.91] (1,163) [1.04-2.74] (1,480) [1.37-2.82] (1,190) [0.94-2.35] (14) [-] (0) [1.56-3.13] (3,847) $2.36 $1.64 $1.80 - - $1.96 2013 [1.64-3.27] (620) [1.15-2.46] (2,102) [1.31-2.29] (1,301) - - [1.57-2.62] (4,023) $1.78 $1.48 $1.42 $- $- $1.48 2015 [1.33-2.84] (1,392) [1.18-2.37] (1,828) [1.04-1.78] (2,623) [-] (0) [-] (0) [1.18-1.78] (5,843)

ASAQ $3.71 $6.97 $3.25 - - $3.71 2010 [2.32-7.43] (17) [3.71-9.29] (163) [2.79-4.18] (20) - - [2.79-6.97] (200) $2.74 $1.56 $1.96 $- $- $2.35 2011 [1.56-4.69] (298) [0.78-3.91] (427) [1.17-3.13] (178) [-] (0) [-] (0) [1.17-3.91] (903) $2.62 $1.64 $1.96 - - $1.96 2013 [1.64-4.91] (77) [0.98-2.62] (274) [1.31-2.62] (109) - - [1.31-3.93] (460) $1.97 $1.18 $1.78 $- $- $1.78 2015 [1.18-4.44] (437) [0.74-2.37] (415) [0.89-3.26] (504) [-] (0) [-] (0) [0.89-3.55] (1,356) DHA PPQ

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Table C5: Price of tablet formulation antimalarials, by outlet type, across survey round Private Itinerant ALL For-Profit Pharmacy Drug Store General Retailer Drug Vendor Private Facility

Quality Assured ACT (QA ACT) $3.71 $6.97 $2.32 - $2.79 $2.79 2010 [2.79-4.64] (55) [3.71-9.29] (429) [1.39-3.25] (98) - (1) [1.39-3.71] (583) $2.35 $1.56 $1.88 $1.17 $- $1.96 2011 [1.56-3.52] (1,028) [0.78-2.35] (1,251) [1.17-2.54] (999) [0.94-2.35] (13) [-] (0) [1.17-2.82] (3,291) $2.29 $1.31 $1.64 - - $1.96 2013 [1.64-3.27] (559) [0.98-1.96] (1,685) [1.31-2.29] (1,235) - - [1.31-2.36] (3,479) $1.78 $1.18 $1.42 $- $- $1.48 2015 [1.18-2.96] (1,365) [0.89-1.78] (1,467) [0.89-1.78] (2,446) [-] (0) [-] (0) [1.04-1.78] (5,278)

QA ACT with the “green leaf” logo

$4.64 $3.25 $1.39 - $2.79 $2.79 2010 (1) [2.79-12.07] (6) [1.39-6.97] (3) - (1) [1.39-4.64] (11) $2.35 $1.17 $1.88 $1.17 $- $1.96 2011 [1.56-3.52] (934) [0.78-1.96] (980) [1.17-2.35] (907) [0.94-2.35] (11) [-] (0) [1.17-2.82] (2,832) $2.29 $1.31 $1.64 - - $1.96 2013 [1.64-3.27] (498) [0.98-1.96] (1,400) [1.31-2.29] (1,118) - - [1.31-2.36] (3,016) $1.78 $1.18 $1.42 $- $- $1.48 2015 [1.18-2.96] (1,280) [0.89-1.78] (1,229) [0.89-1.78] (2,302) [-] (0) [-] (0) [1.04-1.78] (4,812) QA ACT without the “green leaf” logo

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Table C5: Price of tablet formulation antimalarials, by outlet type, across survey round Private Itinerant ALL For-Profit Pharmacy Drug Store General Retailer Drug Vendor Private Facility

Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD*: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $3.71 $6.97 $2.32 - - $2.79 2010 [2.79-4.64] (54) [3.71-9.29] (423) [1.39-3.25] (94) - - [1.39-3.71] (571) $2.35 $2.54 $1.96 $0.00 $- $1.96 2011 [1.56-3.91] (93) [1.37-5.87] (271) [1.17-2.74] (92) [0.00-0.00] (2) [-] (0) [1.37-3.13] (458) $1.96 $1.96 $1.75 - - $1.96 2013 [1.53-2.62] (60) [1.31-2.62] (285) [1.64-2.09] (113) - - [1.60-2.29] (458) $1.48 $5.92 $1.18 $- $- $1.33 2015 [1.18-2.96] (84) [2.37-7.40] (237) [0.89-1.48] (133) [-] (0) [-] (0) [0.99-1.78] (454) Non-Quality Assured ACT (non-QA ACT) $4.64 $5.57 $3.34 $2.79 $1.86 $3.71 2010 [3.25-6.27] (411) [3.71-8.36] (1,643) [2.79-4.64] (537) [2.79-3.71] (2) (1) [2.79-5.57] (2,594) $3.91 $4.69 $3.13 $0.78 $- $3.91 2011 [2.82-5.87] (730) [3.13-7.82] (1,842) [2.35-4.69] (525) (1) [-] (0) [2.74-5.87] (3,098) $4.91 $3.93 $3.93 - - $3.93 2013 [3.27-5.89] (282) [2.78-7.86] (2,129) [2.62-4.91] (367) - - [2.75-4.91] (2,778) $3.55 $3.55 $2.96 $- $- $2.96 2015 [2.37-4.44] (987) [2.66-5.92] (2691) [1.48-4.44] (1268) [-] (0) [-] (0) [1.78-4.44] (4,946)

SP $0.70 $0.70 $0.70 $0.46 - $0.70 2010 [0.70-0.93] (297) [0.49-0.93] (391) [0.42-0.70] (494) [0.42-0.46] (4) - [0.46-0.70] (1,186) $0.59 $0.59 $0.59 $0.59 $0.59 2011 [0.59-0.78] (529) [0.51-0.59] (369) [0.47-0.78] (616) [0.59-0.78] (3) [0.59-0.78] (1,517) $0.65 $0.49 $0.49 - - $0.49 2013 [0.49-0.82] (247) [0.34-0.65] (471) [0.49-0.65] (528) - - [0.49-0.65] (1,246) $0.59 $0.44 $0.44 $- $- $0.44 2015 [0.44-0.74] (605) [0.44-0.59] (587) [0.44-0.59] (1,122) [-] (0) [-] (0) [0.44-0.59] (2,314) Oral Quinine $3.22 $3.22 $3.22 $3.22 $1.61 $3.22 2010 [3.22-4.83] (274) [3.22-4.03] (297) [3.22-4.03] (567) [2.42-3.22] (8) (1) [3.22-4.03] (1,147) www.ACTwatch.info Page 97

Table C5: Price of tablet formulation antimalarials, by outlet type, across survey round Private Itinerant ALL For-Profit Pharmacy Drug Store General Retailer Drug Vendor Private Facility

Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD*: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $4.93 $3.29 $4.11 $3.29 $- $4.11 2011 [3.29-4.93] (507) [3.29-4.11] (377) [3.29-4.93] (723) [3.29-4.93] (5) [-] (0) [3.29-4.93] (1,612) $0.63 $0.63 $0.63 - - $0.63 2013 [0.32-0.79] (53) [0.32-0.63] (197) [0.48-0.63] (221) - - [0.48-0.63] (471) $3.11 $2.49 $3.11 $- $- $3.11 2015 [2.49-3.73] (454) [2.49-3.73] (384) [2.49-3.73] (1,116) [-] (0) [-] (0) [2.49-3.73] (1,954) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD. Figures in this table are derived using audited products with price information. Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round Public Community Private Not ALL Private Itinerant ALL ALL Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Drug Vendor Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)

2010 N=780 2010 N=34 2010 N=32 2010 N=846 2010 N=396 2010 N=355 2010 N=878 2010 N=n/a 2010 N=1,665 2010 N=2,511 Proportion of outlets** 2011 N=682 2011 N=107 2011 N=41 2011 N=830 2011 N=816 2011 N=399 2011 N=1,158 2011 N=n/a 2011 N=2,397 2011 N=3,227 stocking 2013 N=698 2013 N=836 2013 N=29 2013 N=1,563 2013 N=394 2013 N=453 2013 N=1,058 2013 N=n/a 2013 N=1,907 2013 N=3,470 2015 N=280 2015 N=900 2015 N=53 2015 N=1,233 2015 N=966 2015 N=467 2015 N=1,914 2015 N=n/a 2015 N=3,347 2015 N=4,580

Any malaria blood testing

35.0 11.8 53.6 32.3 46.8 23.9 4.0 14.4 17.3 2010 (29.2, 41.4) (1.0, 65.3) (21.9, 82.7) (21.4, 45.5) (42.1, 51.6) (19.3, 29.3) (2.4, 6.8) (9.3, 21.8) (12.7, 23.2) 74.9 70.2 95.6 74.6 54.5 30.5 7.1 -- 20.3 31.4 2011 (69.2,79.9) (36.4,90.6) (76.8,99.2) (59.4,85.5) (49.1,59.8) (21.9,40.6) (5.0,9.9) -- (15.2,26.5) (24.5,39.2) 90.3 53.4 100 59.9 67.6 55.7 12.3 24.9 40.8 2013 (87.0, 92.8) (30.2, 75.1) -- (39.3, 77.6) (60.6, 73.8) (40.1, 70.3) (9.3, 16.1) (20.9, 29.4) (31.5, 50.8) 95.4 58.2 96.1 62.3 70.1 51.4 20.9 -- 32.6 42.6 2015 (89.5, 98.1) (35.5, 77.9) (87.6, 98.9) (41.8, 79.1) (63.1, 76.3) (44.1, 58.6) (17.8, 24.4) - (29.2, 36.3) (34.2, 51.4) 2010 N=780 2010 N=34 2010 N=32 2010 N=846 2010 N=396 2010 N=355 2010 N=878 2010 N=n/a 2010 N=1,665 2010 N=2,511 2011 N=682 2011 N=107 2011 N=41 2011 N=830 2011 N=816 2011 N=399 2011 N=1,158 2011 N=n/a 2011 N=2,397 2011 N=3,277

2013 N=695 2013 N=832 2013 N=29 2013 N=1,556 2013 N=394 2013 N=451 2013 N=1,055 2013 N=n/a 2013 N=1,902 2013 N=3,458 2015 N=279 2015 N=900 2015 N=53 2015 N=1,232 2015 N=966 2015 N=467 2015 N=1,914 2015 N=n/a 2015 N=3,347 2015 N=4,579

Microscopic blood tests

31.9 1.7 52.2 27.7 41.0 4.0 2.5 11.7 14.3 2010 (26.9, 37.4) (0.2, 15.5) (21.4, 81.4) (17.9, 40.3) (35.8, 46.4) (2.2, 7.3) (1.3, 4.8) (7.9, 17.0) (10.9, 18.5) 40.5 1.6 77.2 24.6 43.5 0.8 2.6 -- 13.7 16.0 2011 (36.0,45.1) (0.3,8.4) (46.2,92.2) (13.9,39.9) (39.2,47.9) (0.2,4.0) (1.4,4.7) -- (10.0,18.6) (12.5,20.2) 38.8 0.1 54.8 7.2 46.6 0.2 2.5 11.9 9.8 2013 (35.1, 42.7) (0.0, 0.6) (38.1, 70.4) (4.5, 11.2) (37.7, 55.7) (0.1, 0.7) (1.5, 4.1) (9.2, 15.3) (7.4, 12.9) 55.7 0.0 64.4 6.4 41.1 0.6 1.2 - 10.3 9.0 2015 (47.6, 63.5) - (47.0, 78.7) (3.8, 10.5) (34.3, 48.1) (0.2, 1.4) (0.6, 2.3) - (8.2, 12.8) (7.1, 11.3) 2010 N=780 2010 N=34 2010 N=32 2010 N=846 2010 N=396 2010 N=355 2010 N=878 2010 N=n/a 2010 N=1,665 2010 N=2,511 2011 N=682 2011 N=107 2011 N=41 2011 N=830 2011 N=816 2011 N=399 2011 N=1,158 2011 N=n/a 2011 N=2,397 2011 N=3,277

2013 N=698 2013 N=836 2013 N=29 2013 N=1,563 2013 N=394 2013 N=453 2013 N=1,058 2013 N=n/a 2013 N=1,902 2013 N=3,470 2015 N=280 2015 N=900 2015 N=53 2015 N=1,233 2015 N=965 2015 N=467 2015 N=1,914 2015 N=n/a 2015 N=3,346 2015 N=4,579

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI)

Rapid diagnostic tests (RDTs)

3.7 11.8 8.6 6.5 10.4 21.7 1.7 4.0 4.4 2010 (1.2, 10.5) (1.0, 65.3) (2.6, 24.7) (2.4, 16.3) (6.8, 15.7) (18.3, 25.6) (0.9, 3.4) (2.1, 7.6) (2.4, 8.0) 53.0 70.2 51.3 61.5 20.8 30.1 4.6 -- 9.3 19.9 2011 (44.7,61.2) (36.4,90.6 (29.2,72.9) (42.0,77.9) (16.0,26.6) (21.6,40.1) (3.1,6.7) -- (6.8,12.6) (12.9,29.5) 79.2 53.4 80.4 57.8 31.4 55.6 10.2 15.5 34.7 2013 (74.5, 83.3) (30.2, 75.1) (60.8, 91.6) (37.5, 75.8) (26.0, 37.2) (40.0, 70.2) (7.5, 13.6) (12.8, 18.6) (25.2, 45.5) 81.7 58.2 86.5 61.0 47.7 51.4 20.1 - 26.8 38.3 2015 (71.2, 89.0) (35.5, 77.9) (69.5, 94.7) (40.6, 78.1) (41.7, 53.8) (44.1, 58.6) (17.1, 23.4) - (23.9, 30.0) (29.7, 47.7) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Microscopy for adults $0.93 $1.40 $0.70 $- $- $0.93 2010 [0.70-0.93] (157) [0.93-1.62] (12) [0.46-0.93] (16) [-] (0) [-] (0) [0.70-0.93] (185) $0.78 $1.17 $0.39 $- $- $0.78 2011 [0.78-1.17] (369) [0.78-1.17] (6) [0.39-0.98] (25) [-] (-) [-] (-) [0.78-1.17] (400) $0.82 $0.98 $0.33 $- $- $0.65 2013 [0.65-0.98] (186) [0.98] (6) [0.33-0.65] (21) [-] (-) [-] (-) [0.65-0.98] (213) $0.89 $1.48 $0.59 $- $- $0.89 2015 [0.59-0.89] (409) [0.89-1.48] (8) [0.44-0.89] (19) [-] (-) [-] (-) [0.59-0.89] (436) Microscopy for children

under five $0.93 $1.40 $0.70 $- $- $0.93 2010 [0.70-0.93] (157) [0.93-1.40] (12) [0.46-0.93] (16) [-] (0) [-] (0) [0.46-0.93] (185) $0.78 $1.08 $0.39 $- $- $0.78 2011 [0.78-1.17] (369) [0.78-1.17] (6) [0.39-0.78] (25) [-] (-) [-] (-) [0.59-1.17] (400) $0.82 $0.98 $0.33 $- $- $0.65 2013 [0.65-0.98] (186) [0.98] (6) [0.33-0.65] (21) [-] (-) [-] (-) [0.65-0.98] (213) $0.89 $1.48 $0.59 $- $- $0.74 2015 [0.59-0.89] (410) [0.89-1.48] (8) [0.44-0.89] (18) [-] (-) [-] (-) [0.59-0.89] (436)

Malaria RDT for adults

$1.40 $1.16 $0.93 $- $- $1.40 2010 [1.16-1.86] (48) [0.93-1.39] (72) [0.70-0.93] (19) [-] (0) [-] (0) [0.93-1.40] (139) $1.17 $0.86 $0.78 $- $- $1.17 2011 [0.98-1.56] (181) [0.78-0.98] (108) [0.39-1.17] (60) [-] (-) [-] (-) [0.78-1.17] (349) $0.98 $0.82 $0.82 $- $- $0.98 2013 [0.98-1.31] (141) [0.65-0.82] (145) [0.65-0.98] (106) [-] (-) [-] (-) [0.65-0.98] (392) $0.89 $0.89 $0.59 $- $- $0.74 2015 [0.59-0.89] (513) [0.30-0.89] (44) [0.59-0.89] (390) [-] (-) [-] (-) [0.59-0.89] (947)

Malaria RDT for children

under five

$1.39 $1.16 $0.93 $- $- $1.39 2010 [1.16-1.86] (48) [0.93-1.39] (72) [0.70-0.93] (19) [-] (0) [-] (0) [0.93-1.39] (139)

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Table C8: Price of malaria blood testing for adults, by outlet type, across survey round Private Itinerant ALL For-Profit Pharmacy Drug Store General Retailer Drug Vendor Private Facility Total median price to Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $1.17 $0.86 $0.78 $- $- $1.17 2011 [0.78-1.56] (179) [0.78-1.02] (107) [0.39-1.17] (59) [-] (-) [-] (-) [0.78-1.17] (345) $0.98 $0.82 $0.65 $- $- $0.98 2013 [0.82-1.31] (141) [0.65-0.82] (144) [0.65-0.98] (107) [-] (-) [-] (-) [0.65-0.98] (392) $0.89 $0.89 $0.59 $- $- $0.74 2015 [0.59-0.89] (514) [0.30-0.89] (44) [0.59-0.89] (391) [-] (-) [-] (-) [0.59-0.89] (949) * Total price to the consumer including consultation and/or service fees. Source: ACTwatch Outlet Survey, Uganda 2010, 2011, 2013, 2015.

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Table C9: Antimalarial market share, across survey round Public Community Private Not TOTAL Private Itinerant ANTI- AETDs sold or distributed in the previous General TOTAL Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Drug MALARIAL week by outlet type and antimalarial type Retailer Private as a percentage of all AETDs sold/ Facility Worker Facility For-Profit Facility Vendor TOTAL* distributed: % % % % % % % % % % %

2010 1. Any ACT 36.3 0.3 1.9 39.0 4.3 1.4 6.0 <0.1 0.0 11.8 50.8 Quality Assured ACT (QA ACT) 36.0 <0.1 2.3 37.9 0.5 0.1 1.4 0.0 0.0 2.0 40.0 QA ACT with the “green leaf” logo ------QA ACT without the “green leaf” logo ------Non-Quality Assured ACT 0.4 0.3 0.3 1.0 3.8 1.3 4.7 <0.1 0.0 9.8 10.8 2. Any non-artemisinin therapy 19.7 <0.1 1.8 21.5 8.0 1.1 18.1 0.3 0.0 27.5 48.9 Sulfadoxine-Pyrimethamine 14.4 <0.1 1.2 15.6 5.6 0.7 10.6 0.2 0.0 17.1 32.8 3. Oral artemisinin monotherapy 0.0 0.0 <0.1 <0.1 0.0 0.0 0.0 0.0 0.0 0.0 <0.1 4. Non-oral artemisinin monotherapy 0.0 0.0 <0.1 <0.1 0.2 <0.1 <0.1 0 0 0.2 0.2 OUTLET TYPE TOTAL** 56.0 0.3 3.7 60.5 12.5 2.5 24.1 0.3 0.0 39.5 100.0

2011 1. Any ACT 33.3 0.3 3.1 36.7 15.2 4.4 11.6 0.1 0.0 31.4 68.1 Quality Assured ACT (QA ACT) 33.1 0.3 2.9 36.2 8.2 2.8 9.4 0.1 0.0 20.5 56.7 QA ACT with the “green leaf” logo 24.3 <0.1 1.0 25.4 7.0 2.5 8.4 0.1 0.0 18.0 43.3 QA ACT without the “green leaf” logo 8.8 0.2 1.9 10.8 1.2 0.3 1.0 0.0 0.0 2.5 13.4 Non-Quality Assured ACT 0.3 <0.1 0.2 0.5 7.0 1.7 2.2 0.0 0.0 10.9 11.4 2. Any non-artemisinin therapy 7.4 0.0 2.6 9.9 9.0 2.0 10.4 0.1 0.0 21.5 31.4 Sulfadoxine-Pyrimethamine 6.6 0.0 1.9 8.5 6.2 1.4 6.4 0.1 0.0 14.1 22.5 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy <0.1 <0.1 0.0 <0.1 0.0 0.0 0.0 0.0 0.0 0.0 <0.1 OUTLET TYPE TOTAL** 40.7 0.3 5.7 46.6 24.2 6.4 22.0 0.2 0.0 52.9 100.0

2013 1. Any ACT 26.3 3.9 2.4 32.7 10.4 7.4 14.3 0.0 0.0 32.0 64.7 Quality Assured ACT (QA ACT) 24.2 3.9 2.3 30.4 7.1 5.1 12.5 0.0 0.0 24.7 55.1 QA ACT with the “green leaf” logo 4.4 2.4 0.3 7.0 6.7 4.6 11.2 0.0 0.0 22.4 29.5 QA ACT without the “green leaf” logo 19.8 1.5 2.0 23.4 0.5 0.5 1.3 0.0 0.0 2.3 25.6 Non-Quality Assured ACT 2.1 0.0 0.1 2.3 3.2 2.3 1.8 0.0 0.0 7.3 9.6 2. Any non-artemisinin therapy 9.9 0.1 0.7 10.8 5.3 4.0 14.4 0.0 0.0 23.8 34.6 Sulfadoxine-Pyrimethamine 9.1 0.1 0.5 9.7 3.8 1.9 8.7 0.0 0.0 14.4 24.1 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 0.0 0.1 0.4 0.1 0.1 0.0 0.0 0.6 0.7 OUTLET TYPE TOTAL** 36.3 4.1 3.2 43.6 16.1 11.5 28.8 0.0 0.0 56.4 100.0

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2015 1. Any ACT 29.1 2.5 2.1 33.6 9.0 6.0 20.9 -- -- 35.9 69.6 Quality Assured ACT (QA ACT) 29.0 2.5 1.9 33.4 5.9 3.3 16.6 -- -- 25.8 59.2 QA ACT with the “green leaf” logo 0.9 0.5 0.5 2.0 5.2 3.3 15.2 -- -- 23.7 25.7 QA ACT without the “green leaf” logo 28.1 2.0 1.3 31.4 0.6 0.1 1.4 -- -- 2.1 33.5 Non-Quality Assured ACT 0.1 0.0 0.2 0.3 3.2 2.7 4.3 -- -- 10.1 10.4 2. Any non-artemisinin therapy 10.5 0.0 1.0 11.5 4.7 2.5 10.3 -- -- 17.5 29.0 Sulfadoxine-Pyrimethamine 7.1 0.0 0.8 7.9 3.2 1.6 6.9 -- -- 11.6 19.5 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- -- 0.0 0.0 4. Non-oral artemisinin monotherapy 0.5 0.0 0.1 0.5 0.4 0.3 0.2 -- -- 0.9 1.4 OUTLET TYPE TOTAL** 40.0 2.5 3.1 45.7 14.1 8.8 31.4 -- -- 54.3 100.0 * Row sum – market share for the specified antimalarial medicine. ** Column sum (within each survey round) – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column (within in survey round). Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C10: Antimalarial market share, across outlet type, across survey round Public Community Private Not TOTAL Private AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store week by outlet type and antimalarial Retailer Drug Vendor Private type as a percentage of all AETDs sold/ Facility Worker Facility For-Profit Facility distributed: % % % % % % % % % % 2010 1. Any ACT 70.3 97.0 55.0 69.3 33.7 56.2 23.5 10.6 0.0 28.6 Quality Assured ACT (QA ACT) 69.6 13.4 46.7 67.5 4.2 4.4 5.3 0.0 0.0 4.8 QA ACT with the “green leaf” logo ------QA ACT without the “green leaf” logo ------Non-Quality Assured ACT 0.7 83.6 8.3 1.8 29.6 51.9 18.2 10.6 0.0 23.7 2. Any non-artemisinin therapy 29.7 3.0 44.0 30.6 64.8 43.3 76.4 89.4 0.0 70.9 Sulfadoxine-Pyrimethamine 27.9 3.0 29.2 27.8 43.8 27.7 41.3 60.3 0.0 41.4 3. Oral artemisinin monotherapy 0.0 0.0 0.5 <0.1 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.5 <0.1 1.5 0.5 0.1 0.0 0 0.5

2011 1. Any ACT 81.9 99.6 54.6 78.7 61.9 68.5 52.7 49.8 0.0 58.9 Quality Assured ACT (QA ACT) 81.3 99.1 50.5 77.6 33.3 43.0 42.7 49.8 0.0 38.5 QA ACT with the “green leaf” logo 59.8 14.6 17.9 54.4 28.3 38.2 38.1 46.1 0.0 33.7 QA ACT without the “green leaf” logo 21.5 84.5 32.6 23.2 5.0 4.8 4.6 3.7 0.0 4.8 Non-Quality Assured ACT 0.6 0.4 4.1 1.0 28.6 25.5 10.0 0.0 0.0 20.4 2. Any non-artemisinin therapy 18.1 0.0 44.8 21.3 36.6 30.7 47.1 50.2 0.0 40.3 Sulfadoxine-Pyrimethamine 16.2 0.0 33.1 18.1 25.3 21.0 29.0 38.5 0.0 26.4 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy <0.1 0.4 0.6 0.1 1.5 0.8 0.2 0.0 0.0 0.9

2013 1. Any ACT 72.5 96.0 75.6 74.9 64.6 64.3 49.5 -- 0.0 56.8 Quality Assured ACT (QA ACT) 66.6 95.4 72.0 69.7 44.4 44.5 43.3 -- 0.0 43.8 QA ACT with the “green leaf” logo 12.0 58.4 9.2 16.2 41.4 40.2 38.7 -- 0.0 39.8 QA ACT without the “green leaf” logo 54.6 36.9 62.9 53.6 2.9 4.3 4.5 -- 4.0 25.6 Non-Quality Assured ACT 5.9 0.7 3.5 5.2 20.2 19.8 6.2 -- 0.0 13.0 2. Any non-artemisinin therapy 27.3 3.6 23.5 24.8 33.0 34.9 50.1 -- 0.0 42.1 Sulfadoxine-Pyrimethamine 25.0 2.9 16.4 22.3 23.3 16.7 30.3 -- 0.0 25.5 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- 0.0 0.0 4. Non-oral artemisinin monotherapy 0.2 0.3 1.0 0.3 2.3 0.9 0.4 -- 0.0 1.1

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2015 1. Any ACT 72.7 99.8 65.3 73.6 63.9 68.2 66.6 -- -- 66.1 Quality Assured ACT (QA ACT) 72.4 99.8 59.5 73.1 41.5 38.0 52.9 -- -- 47.5 QA ACT with the “green leaf” logo 2.3 21.1 16.8 4.3 36.9 37.1 48.4 -- -- 43.6 QA ACT without the “green leaf” logo 70.2 78.7 42.7 68.8 4.6 0.8 4.3 -- -- 3.8 Non-Quality Assured ACT 0.2 0.0 5.8 0.6 22.4 30.3 13.7 -- -- 18.6 2. Any non-artemisinin therapy 26.2 0.2 33.0 25.2 33.3 28.4 32.8 -- -- 32.2 Sulfadoxine-Pyrimethamine 17.6 0.2 26.4 17.3 22.3 18.1 21.8 -- -- 21.3 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- -- 0.0 4. Non-oral artemisinin monotherapy 1.2 0.0 1.6 1.1 2.9 3.4 0.7 -- -- 1.7 Categories 1 through 4 sum to 100% within each column (within each survey round). Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Table C14: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round Public Community Private Not ALL Private Itinerant ALL ALL Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store Drug Vendor Private Outlets Facility Worker Facility for-profit Facility % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2010 N=780 2010 N=34 2010 N=32 2010 N=846 2010 N=396 2109 N=355 2010 N=878 2010 N=5 2010 N=1,665 2010 N=2,511 2011 N=682 2011 N=107 2011 N=41 2011 N=830 2011 N=816 2011 N=399 2011 N=1,158 2011 N=0 2011 N=2,397 2011 N=3,227 Proportion of providers who: 2013 N=698 2013 N=836 2013 N=29 2013 N=1,563 2013 N=393 2013 N=451 2013 N=1,055 2013 N=0 2013 N=1,901 2013 N=3,464 2015 N=280 2015 N=899 2015 N=53 2015 N=1,232 2015 N=962 2015 N=463 2015 N=1,904 2015 N=n/a 2015 N=3,329 2015 N=4,561 Correctly state the national first-line treatment for uncomplicated malaria 95.3 96.6 92.8 95.2 68.9 88.3 75.6 60.0 73.7 77.2 2010 (93.3, 96.8) (93.4, 98.3) (80.3, 97.6) (93.1, 96.8) (64.0, 73.4) (83.2, 92.0) (70.1, 80.5) (60.0-60.0) (69.0, 78.0) (72.4, 81.4) 95.4 92.5 93.0 93.7 80.4 92.0 73.8 -- 74.5 78.4 2011 (92.6, 97.2) (86.8, 95.9) (76.7, 98.2) (90.5, 95.9) (76.1, 84.1) (87.9, 94.8) (69.5, 77.8) -- (69.6, 78.8) (73.6, 82.6) 95.2 90.7 94.6 91.4 82.0 72.9 77.2 -- 77.9 84.1 2013 (92.5, 96.9) (87.4, 93.2) (80.4, 98.7) (88.6, 93.6) (76.6, 86.3) (48.7, 88.4) (73.6, 80.5) -- (74.6, 81.0) (81.1, 86.6) 94.3 82.3 88.7 83.3 84.5 90.7 84.1 -- 84.3 84.0 2015 (88.3, 97.3) (69.8, 90.3) (74.9, 95.3) (72.1, 90.7) (78.4, 89.1) (85.6, 94.1) (80.1, 87.5) - (80.5, 87.5) (78.9, 88.0) Correctly state the first-line dosing regimen for a 2-year old child 92.4 90.9 78.4 89.8 59.4 72.4 63.6 0.0 62.1 66.5 2010 (89.7, 94.5) (84.0, 95.0) (62.6, 88.7) (85.8, 92.7) (53.7, 64.9) (66.2, 77.8) (57.4, 69.3) -- (56.4, 67.4) (60.6, 72.0) 91.1 62.7 81.8 76.0 69.9 79.3 59.5 -- 61.3 64.3 2011 (88.4, 93.2) (59.7, 65.6) (65.0, 91.6) (68.1, 82.4) (65.8, 73.7) (71.9, 85.1) (54.1, 64.8) -- (55.9, 66.4) (60.2, 68.1) 90.9 79.5 85.5 81.3 73.1 66.9 67.7 -- 68.7 74.4 2013 (87.4, 93.4) (71.8, 85.5) (69.5, 93.8) (75.0, 86.3) (66.7, 78.8) (46.3, 82.6) (64.0, 71.2) -- (65.3, 71.9) (70.1, 78.3) 91.2 65.7 76.2 67.8 75.8 83.8 75.1 -- 75.4 72.9 2015 (85.1, 94.9) (51.9, 77.3) (60.9, 86.8) (55.1, 78.4) (70.0, 80.8) (76.2, 89.3) (71.1, 78.7) - (71.7, 78.8) (66.9, 78.1) Report an ACT as the most effective antimalarial medicine

ACT most effective for

adults

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children 88.4 96.4 78.5 88.8 54.3 86.6 47.6 40.0 49.0 55.4 2010 (82.8, 92.4) (76.1, 99.5) (62.3, 88.9) (82.2, 93.1) (47.3, 61.1) (77.1, 92.5) (37.7, 57.8) (40.0-40.0) (40.2, 57.9) (47.4, 63.1) 93.2 99.5 80.7 95.0 69.0 84.6 59.2 -- 62.2 68.9 2011 (91.1, 94.8) (95.5, 99.9) (60.1, 92.1) (90.0, 97.6) (64.4, 73.2) (75.7, 90.7) (52.9, 65.2) -- (56.4, 67.6) (62.8, 74.3) 94.3 99.4 85.4 98.3 74.2 85.6 78.3 -- 77.0 86.7 2013 (92.0, 96.0) (98.7, 99.7) (64.3, 95.0) (97.3, 98.9) (69.2, 78.7) (76.2, 91.7) (73.7, 82.4) -- (73.3, 80.4) (83.0, 89.7) 97.0 97.7 94.5 97.5 81.7 87.4 82.0 -- 82.0 87.2 2015 (93.3, 98.7) (96.0, 98.6) (83.8, 98.3) (95.8, 98.5) (75.1, 86.8) (80.0, 92.3) (77.7, 85.6) - (77.7, 85.6) (83.7, 90.0)  At the time of the 2010, 2011 2013, and 2015 ACTwatch outlet surveys, artesunate amodiaquine was Uganda’s first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. Source: ACTwatch Outlet Survey, Uganda, 2010, 2011, 2013, 2015.

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Annex 1: ACTwatch Background

ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. Project countries include: Benin, Cambodia, the Democratic Republic of Congo, Kenya, Laos, Madagascar, Myanmar, Nigeria, Tanzania (currently mainland only, previous work in Zanzibar), Thailand, Uganda, Vietnam, Zambia. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID, and DFID.

2 ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence. 1F The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. ACTwatch is monitoring antimalarial markets in the context of policy shifts and investments in the scale-up of first-line ACT and blood testing using RDTs. This has included adaptation of 3 project methods for the evaluation of the Affordable Medicines Facility-malaria (AMFm) pilot.2F Project scale-up in the Greater Mekong sub-Region (GMS) in 2015 was designed to deliver key indicators for informing and monitoring strategies and policies for malaria elimination. The project implements a set of research tools designed to:

1) Provide a picture of the total market for malaria case management including: all providers carrying antimalarials and RDTs and providing case management services; the relative antimalarial market share for each provider type; the antimalarial supply chain; and price markups within the supply chain for antimalarials and RDTs.

2) Monitor the readiness of market components for appropriate malaria case management, including: availability of antimalarials and malaria blood testing; consumer price of antimalarial treatment and malaria blood testing; and provider qualifications, training and knowledge.

3) Monitor the performance of market components for appropriate malaria case management, including: the relative market share for quality-assured ACT relative to other antimalarial medicines; the demand for appropriate malaria case management captured through consumer knowledge, attitudes, and fever treatment seeking behavior; and the quality of provider service delivery measured against national policies, guidelines and minimum standards.

ACTwatch research tools for malaria market monitoring include:

1. Outlet surveys

Outlet surveys entail collecting quantitative data from all outlets and providers with the potential to sell or distribute antimalarials and/or provide malaria blood testing. These include health facilities, community health workers, pharmacies, drug stores, retail outlets, market stalls, and mobile providers. A screening process identifies outlets that provide antimalarials and/or malaria blood testing. Among these eligible outlets, service providers are interviewed and all antimalarials and RDTs are audited. The audit collects information about each antimalarial and RDT in stock (e.g. brand name, drug active ingredients and strengths, manufacturer, etc.) and retailer reports on consumer price and sale/distribution volumes for each product. A representative sample of outlets is identified within target study domains such that findings from the outlet survey provide estimates of antimalarial and RDT 4 availability, price, and relative market share across the entire market as well as within key market channels.3F

2 Shewchuk T, O’Connell KA, Goodman C, Hanson K, Chapman S, Chavasse D. 2011. The ACTwatch project: methods to describe anti-malarial markets in seven countries. Malaria Journal, 10: 325. 3 AMFm Independent Evaluation Team. 2012. Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi- country independent evaluation report: final report. Calverton, MD and London: ICF International and London School of Hygiene and Tropical Medicine. 4 O’Connell KA, Poyer S, Solomon T, et al. 2013. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malaria Journal, 12: 52.

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5 From 2008 through 2014, ACTwatch conducted 35 national outlet surveys across the 10 project countries. 4F Reports are available at www.actwatch.info, and peer-reviewed publications have appeared in Malaria Journal and The 6 Lancet.5F

2. Supply chain studies

Supply chain studies employ quantitative and qualitative research methods to effectively map the antimalarial supply chain in a given country. The supply chain is mapped from the antimalarial outlets (service delivery points) identified during an outlet survey to national importers and distributors with identification of all mid-level distributers in between. Retail prices are documented along the supply chain to facilitate calculation of commodity mark-ups. From 2008 through 2012, ACTwatch conducted 8 national supply chain studies. Reports are available at 7 www.actwatch.info, and a peer-reviewed publication has appeared in PLoS One.6F

2015 outlet surveys in the Greater Mekong sub-Region include a component to collect additional information about the supply chain for oral artemisinin monotherapy (oral AMT, e.g. artesunate tablets). Oral AMT identified during the outlet surveys was further investigated and research teams identified and visited named suppliers to collect further information about the supply chain.

3. Population-based surveys

Population-based surveys are conducted among consumers to document fever treatment-seeking behavior. A representative sample of the target population (caregivers of children and/or adults according to burden and risk) is identified, and a screening tool is used to identify individuals who have recently experienced fever. The surveys investigate the extent to which health care was sought, as well as common sources of care received. Respondent reports of malaria blood testing and antimalarials acquired are documented and summarized. The survey includes measures of demographic and other individual, household/family, and community characteristics that can be used to develop consumer profiles as well as monitor equity in access to malaria case management. From 2008 through 2012, ACTwatch conducted 14 household surveys focused on fever treatment-seeking behavior. Reports are 8 available at www.actwatch.info, and a peer-reviewed publication has appeared in Malaria Journal.7F

4. Fever case management quality of care

Fever case management quality of care is monitored using a set of research tools designed to measure aspects of the interaction between providers and clients. ACTwatch launched fever case management quality of care studies in 2015 in a subset of project countries. The following research tools were integrated into the outlet surveys in Cambodia and Uganda and were implemented among private sector outlets providing malaria testing and treatment:

 Exit interviews conducted with target consumers immediately after receiving fever case management services in the private sector. A structured interview documented client reports about key aspects of service delivery including malaria blood testing, test results, medicines recommended/prescribed and obtained, counseling, and costs of services and commodities received. Exit interviews were also used to measure client recall and comprehension of provider counseling including instructions for completing prescribed drug regimens, as well as client satisfaction with services provided.

5 Surveys in the DRC (2) and Myanmar (3) were sub-national. 6 O’Connell K, Gatakaa H, Poyer S, et al. 2011. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malaria Journal, 10: 326. Tougher S, the ACTwatch Group, Ye Y, et al. 2013. Effect of the Affordable Medicines Facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet, 380: 1916-26. 7 Palafox B, Patouillard E, Tougher S, et al. 2014. Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries. PLoS One, 9(4). 8 Littrell M, Gatakaa H, Evance I, et al. (2011). Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 10: 327.

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 A consultation observation checklist was used to document aspects of the provider-client interaction in the private sector. A trained observer completed the checklist designed to document provider compliance with standard practice and procedures as well as aspects of client demand for specific products or services. The observer remained silent during the consultation.

ACTwatch in Uganda

ACTwatch baseline surveys were conducted in Uganda in 2008 and 2009, followed by baseline and end line surveys for AMFm in 2010 and 2011, respectively. Additional surveys were conducted in 2013 and 2015. All reports are available at www.actwatch.info.

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Annex 2: Country Background

Uganda is a landlocked country in East Africa bordered by Kenya, South Sudan, Rwanda, Tanzania, and the Democratic Republic of the Congo. Uganda has an estimated population of 36.6 million people, the majority of 9 whom live in rural areas8F . Uganda has made substantial progress in recent years towards attaining 2015 Millennium Development Goals (MDG). This progress has included early attainment of poverty reduction targets, and strong progress towards targets for reducing hunger and under-nutrition as well as reducing child morbidity and 10 mortality9F . Despite incredible progress, mortality rates for children under five (69 per 1,000 live births) and infants 11 (45 per 1,000 live births) remain high10F .

Administratively, Uganda is divided into 112 districts. Districts are further sub-divided into sub-counties and parishes. Over time, the numbers of districts and lower level administrative units have increased in number with the 12 aim of making administration and delivery of social services easier and closer to the people11F .

Since 1986, the government has acted to rehabilitate and stabilize the economy by undertaking currency reform, raising producer prices on export crops, increasing prices of petroleum products, and improving civil service wages. The policy changes are especially aimed at dampening inflation and boosting production and export earnings. Since 1990, economic reforms ushered in an era of solid economic growth based on continued investment in infrastructure, improved incentives for production and exports, lower inflation, better domestic security, and the 13 return of exiled Indian-Ugandan entrepreneurs12F . From the mid-1980s to the 1990s, Gross Domestic Product (GDP) growth in Uganda averaged about 5.3 percent while population grew at about 3.2 percent per annum only. In the 2000s to 2014, GDP has increased to an average of 6.6 percent while average annual population growth has remained steady at around 3.3 percent. Additionally, per capita income increased from 180 USD in 1984 to 670 USD 14 in 201413F .

Healthcare system

The provision of health services in Uganda is decentralized, with districts and health sub-districts playing a key role in the delivery and management of health services at those levels. The government eliminated user fees in 2001, and 15 services in public health facilities are thus free. User fees remain in place in private wings of public hospitals14F . The public sector is organized into the following health services: 1. Village Health Teams (Health Center I) – Provide services at the community level. They facilitate and are responsible for health promotion, community mobilization to improve health seeking behaviors and treatment of diseases. After the adoption of the integrated community case management in 2010, two out of five VHTs provide diagnosis and treatment. 2. Health Center II – Provide diagnosis, maternity care and are the first referral point in the sub-county. 3. Health Center III – In addition to providing basic preventative and curative care, Health Center IIIs provide support and supervision to Health Center IIs.

9 Uganda Bureau of Statistics. (2014). 2014 Statistical abstract. Available: www.ubos.org/onlinefiles/uploads/ubos/statistical_abstracts/Statistical_Abstract_2014.pdf. Accessed October 22, 2014. 10 Ministry of Finance, Planning and Economic Development (2013). Millennium Development Goals report for Uganda 2013. Kampala: Ministry of Finance, Planning and Economic Development. 11 UNICEF. (2013). Uganda statistics. Available: www.unicef.org/infobycountry/uganda_statistics.html. Accessed October 22, 2014. 12 Ministry of Health. (2010). Health sector strategic & investment plan. Kampala: Uganda Ministry of Health. 13 CIA World Fact Book (2015). Africa: Uganda. Accessed, December 12, 2015. https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html 14 World Bank (2015). Uganda Databank. Accessed, December 12, 2015. http://databank.worldbank.org/data/reports.aspx?source=2&country=UGA&series=&period=# 15 Ibid.

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4. Health Center IV or General Hospitals – These facilities provide overall oversight of all the other lower level health facilities. General Hospitals often provide pre-service training and provide services related to prevention of diseases, blood transfusion and medical imaging. 5. Regional Referral Hospitals – These are often research and teaching hospitals and are involved in specialized services such as medical imaging, psychiatry and surgery. 6. National Referral Hospital – These are often research and teaching hospitals, and are involved in provision of specialized services.

Village Health Teams (VHT) became part of Uganda’s national health strategy in 2001. VHT volunteers serve as a community-based primary health contact with responsibilities including identifying community health needs; mobilizing resources; mobilizing community participation for public health campaigns (e.g. immunization, sanitation, health-seeking behavior, malaria control); birth and death registration; and community-based management of common childhood illnesses including malaria, diarrhea, and pneumonia. Four or five VHT volunteers are selected per village. The target of the 2010-2015 Health Sector Strategic and Investment Plan is to increase VHT coverage to 16 100 percent by 2015. As of 2009, 31 percent of districts had trained VHTs in all villages15F .

Uganda has a total of 155 hospitals – there are two referral hospitals, 14 regional referral hospitals and 139 general 17 hospitals. Out of the 155 hospitals countrywide, there are a total of 27 privately owned hospitals16F .

The medicines distribution system in the public sector is centralized with procurement pooled at the national level and organized through the National Medical Stores, an agency of the Ministry of Health. Nearly all public sector 18 procurements are imported (94 percent)17F .

The private not-for-profit sector is also important in Uganda for medicines delivery and treatment. These outlets include mission/faith-based hospitals and clinics. Faith-based/mission not-for-profit facilities account for 41 percent 19 of hospitals and 22 percent of lower level facilities complementing government facilities especially in rural areas18F .

The private sector

The private sector plays a significant role in the health system in Uganda and is estimated to provide about half of 20 health services in the country19F . The 2012 ACTwatch household survey in Uganda found that more than half of 21 children with fever were taken to a private sector outlet for treatment20F . Private sector outlets in Uganda include for-profit hospitals and clinics. Health professional working in these facilities commonly also have an affiliation with government/public health services. About half of doctors working in the private sector also work in the government sector however more than 90 percent of the nurses, midwives and nursing assistants working in the private sector work full-time in the private sector. Private for-profit facilities have a large urban and peri-urban presence and 22 provide primary and secondary care. More than 90 percent of private for profit facilities offer malaria treatment21F .

The private for-profit sector in Uganda also includes as pharmacies and drug stores (licensed and unlicensed). The pharmaceutical sector in Uganda is regulated by the National Drug Authority (NDA). Drug stores and pharmacies are 23 licensed by the NDA and NDA licensing fees for these outlets recently increased significantly22F . Pharmacies must be staffed by registered pharmacist and may dispense prescription-only and over-the-counter (OTC) medicines. Licensed drug stores must be staffed by a provider with a health qualification (e.g. pharmacy technician, registered/enrolled nurse, clinical officer etc.). Drug stores are permitted to retail a range of OTC medicines but are

16 Ibid. 17 Ministry of Health (2015). Affiliated Institutions: Hospitals. Accessed, November 2, 2015. http://health.go.ug/affiliated- institutions/hospitals?page=1 18 Palafox B, Patoullard E, Tougher S, et al. (2012). ACTwatch 2009 supply chain survey results, Uganda. Nairobi: ACTwatch, PSI. 19 Ministry of Health. (2010). Health sector strategic & investment plan. Kampala: Uganda Ministry of Health. 20 Ibid. 21 ACTwatch Group and PACE. (2013). Household survey, Uganda, 2012 survey report. Washington DC: PSI. 22 Ministry of Health. (2010). Health sector strategic & investment plan. Kampala: Uganda Ministry of Health. 23 NDA doubles license fees for drug shop, pharmacies. (2013). Available: www.newvision.co.ug/news/647578-nda-license-fees-for-drug-shop- pharmacies.html. Accessed: October 22, 2014.

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24 not authorized to sell prescription-only medicines. ACTs were classified as OTC medicines in 200823F . The NDA monitors private outlets for the illegal sale of medicines including medicine sales by unlicensed drug stores and sale of government-procured medicines and supplies found outside of public health facilities. The crackdown on outlets 25 illegally selling medicines has been a topic frequently covered by national media24F .

There are several local drug manufacturers in Uganda including manufacturers of antimalarial medicines. In 2010, the Kampala manufacturing site for Quality Chemicals Industries Limited became Africa’s first local supplier to receive WHO pre-qualification to produce ACTs. The company is licensed to produce artemether lumefantrine through the company Cipla Limited (www.cipla.com), based in India. Although local manufacturers are present in Uganda, the majority (~90 percent) of pharmaceuticals are imported from Asian, Western, and other African countries (Kenya, South Africa). Results of a mapping exercise undertaken in 2008 estimated that 93-95 percent of 26 imported medicines in Uganda are generic products25F .

Malaria risk and burden

The climate of Uganda is tropical and tempered by altitude. In most parts of Uganda, temperature and rainfall allow intense perennial malaria transmission. Malaria is highly endemic across 95 percent of the country, affecting approximately 90 percent of the population (see national control program map in Figure X1). These areas include the entire Central region and the majority of the Northern and Southern regions. Particularly high transmission rates have been documented in some areas of northern Uganda, where prior to indoor residual spray campaigns, entomological inoculation rates were documented as high as 1,600 infective bites per person per year. The 5 percent of the country (10 percent of the population) that does not have endemic malaria consists of unstable and epidemic- prone transmission areas in the highlands of the south- and mid-west, along the eastern border with Kenya, and the 27 northeastern border with Sudan26F .

Malaria continues to be a major public health problem in Uganda and is the leading cause of morbidity and mortality 28 among children under age five27F . The most recent national Malaria Indicator Survey (MIS) indicated that malaria was 29 responsible for 30 to 50 percent of outpatient hospital visits, and 9 to 14 percent of inpatient deaths in 2014 28F . The latest MIS report also documented a parasite prevalence of 19 percent among all children under five when testing 30 with microscopy. Most malaria infections in Uganda are due to Plasmodium falciparum29F .

24 Palafox B, Patoullard E, Tougher S, et al. (2012). ACTwatch 2009 supply chain survey results, Uganda. Nairobi: ACTwatch, PSI. 25 Personal communication, 2013 ACTwatch Key Informant Interviews, Uganda. 26 UMOH (2008). Cited in Medicines Transparency (medicinestransparency.org): The role of local manufacturers in improving access to essential medicine (2010). Accessed May 6, 2016: http://www.medicinestransparency.org/fileadmin/uploads/Documents/MeTA- Uganda_AfricaHealth.pdf 27 Uganda Bureau of Statistics (UBOS) and ICF Macro. (2010). Uganda malaria indicator survey 2009. Calverton, MD: UBOS and ICF Macro. 28 Uganda Bureau of Statistics. (2014). 2014 Statistical abstract. Available: www.ubos.org/onlinefiles/uploads/ubos/statistical_abstracts/Statistical_Abstract_2014.pdf. Accessed October 22, 2014. 29 Uganda Ministry of Health. (2015). Malaria indicator survey, 2014-2015. Retrieved from: https://dhsprogram.com/pubs/pdf/MIS21/MIS21.pdf 30 Uganda Bureau of Statistics (2016). The National Population and Housin Census 2014 – Main Report, Kampala, Uganda Ibid.

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Figure X1. Map of malaria endemicity

Source: PMI FY2014 Malaria Operational Plan.

Malaria case management guidelines

The revised Uganda Malaria Reduction Strategic Plan (UMRSP) 2014-2020 primary targets are to reduce malaria deaths to near zero, reduce malaria morbidity to 30 cases per 1,000 persons, and to reduce malaria parasite prevalence to less than 7 percent nationwide. The UMRSP objectives related to appropriate case management include:

1. At least 90 percent of all malaria cases receive prompt treatment according to national guidelines 2. At least 85 percent of the population practices correct malaria prevention and management measures (including confirmatory diagnosis and treatment with AL)

These goals are supported by specific activities, including strengthening health worker capacity for diagnosis and treatment through training and clinical audits, scaling up and sustaining parasitological diagnosis at all health levels, focusing on iCCM to reduce treatment gaps, and strengthening the management of malaria in pregnancy 30F31.

Diagnosis

The current National Malaria Control Policy adopted in 2012 recommends that all suspected malaria cases receive confirmatory blood testing using microscopy or a rapid diagnostic test in all health facilities and at the community level. Microscopic testing is to be provided free-of-charge in public health facilities and made available at Health Centre III and higher levels. RDTs are to be used at Health Centre III facilities without microscopy, Health Center II 32 facilities, and at community level31F . Training on the use of Malaria Rapid Diagnostic Tests has been performed at all 33 levels of care, including the VHT level32F . A cluster-randomized trial that introduced RDTs for malaria into registered 34 drug shops in central Uganda found that use of RDTs increased the appropriate treatment of malaria with ACTs33F . Policy recommendations have been made following this study regarding the continued scale-up of RDTs in the private sector.

Treatment

In 2004 the National Malaria Control Program (NMCP) adopted the Artemisinin-based Combination Therapy (ACT) Artemether Lumefantrine (AL) 20mg/120mg as the first-line treatment for uncomplicated malaria. The 2012 National Malaria Treatment Guidelines indicate that alternative first-line treatments include any ACT that has been recommended by the WHO and MOH and is registered with the NDA.

31 Ministry of Health. (2014). The Uganda Malaria Reduction Strategic Plan 2014-2020. The Republic of Uganda Ministry of Health. 32 Ministry of Health. (2012). Uganda clinical guidelines 2012.Available: www.sure.ug/?download=UCG%202012.pdf. Accessed October 22, 2014. 33 Key Informant 1. (2015). 34 Mbonye et al. (2015). Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications. Malaria Journal 14:448

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Implementation of the new ACT policy in public sector facilities began in 2006 and was expanded to community- based services in 2008 through a home-based management of fever program run by community medicine distributors. This expansion followed the declassification of all ACTs to over-the-counter medicines, also in 2008. The second line treatments for uncomplicated malaria are dihydroartemisinin piperaquine (DHA PPQ) or oral quinine. 35 Following on recent WHO guidelines34F stipulating the use of IV/IM artesunate as first-line treatment for severe malaria, the Uganda national program and its partners are now scaling up the use of IV/IM artesunate for severe 36 malaria within health facilities. Rectal artesunate is indicated for pre-referral treatment for severe malaria35F . The sale 37 of oral artemisinin monotherapy was banned in 200736F . The UMRSP also recommends Sulfadoxine Pyrimethamine (SP) for IPTp (intermittent preventive treatment in pregnancy) for malaria.

Financing and major initiatives to improve case management

With funding through the Affordable Medicines Facility, malaria (AMFm) and Global Fund Round 10, Uganda has implemented strategies to increase access to malaria blood testing and appropriate treatment. The AMFm provided first-line buyers in the public and private sector with access to highly subsidized (co-paid) quality-assured ACTs. Medicines subsidized through the AMFm are marked with a ‘green leaf’ logo on the packaging. Phase 1 of the AMFm was implemented from 2010-2012. Uganda signed the AMFm grant in February 2011. Despite delays in grant signature and ordering approvals, significant quantities of co-paid ACTs had arrived in country by the end of 2011: 28 million treatment courses were delivered, mostly destined for the public sector (73 percent). The independent evaluation of the AMFm in Uganda showed a successful increase in availability and market share for quality-assured ACTs. However price data from the private sector indicated very high gross percentage and total retail markups (first-line buyer to retail selling price) and the price of quality-assured ACT remained more than three times higher than the most popular non-artemisinin therapy. It was noted by the independent evaluation team that the high price markups may had been influenced by a lack of awareness of the recommended retail price for co-paid ACTs among 38 providers and consumer37F . Transitional funding was provided in Uganda and other AMFm pilot countries for co-paid ACTs through 2013.

At that time, the program transitioned to the Global Fund co-payment mechanism subsidy program, which was available to the private sector only. The new program was implemented in 2014; the subsidy for first-line buyers reduced to 50 percent for adult courses and 70 percent for child courses. In 2015, the subsidy returned to 70 percent of the cost for both adult and child courses. Between the AMFm program and the co-payment system, there was a gap in funding. To cover this gap, DFID gave Uganda funding to cover the antimalarial medicines.

Improved availability of ACTs and RDTs in public health facilities has been supported by efforts to strengthen supply chain management including improved routine information systems for commodity stocks. Higher-level health facilities operate on a ‘push’ supply system while lower level facilities operate on a ‘pull’ system. The Commodity Security Group is another effort to strengthen the supply of key health commodities in the country. Bringing together a variety of stakeholders in pharmacy, supply chain, and other partners, the group meets regularly to review commodity stock status and to mitigate issues. Specifically regarding RDT availability, the Global Fund and UNITAID have together distributed 17 million RDTs to the public sector through the CARESTART campaign. UNITAID 39 also provided an additional 2 million RDT kits to the private sector38F .

In addition to support from the Global Fund, the Department for International Development (DFID) made a financial commitment in 2010 to increase support for malaria control in Uganda, and forged an arrangement with the U.S. Agency for International Development (USAID) to leverage a funding mechanism from the President’s Malaria

35 WHO. (2015). Guidelines for the Treatment of Malaria. Third Edition. World Health Organization. 36 Ibid 37 Palafox B, Patoullard E, Tougher S, et al. (2012). ACTwatch 2009 supply chain survey results, Uganda. Nairobi: ACTwatch, PSI. 38 AMFm Independent Evaluation Team. (2012). Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi-country independent evaluation report: Final report. Calverton MD and London: ICF International and London School of Tropical Medicine and Hygiene. 39 ACTwatch Key Informant Interviews. (2015). Uganda.

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Initiative (PMI) to scale up contributions to malaria control. The Clinton Health Access Initiative (CHAI) has also provided technical assistance to the Uganda National Malaria Control Program (NMCP) to inform effective case management strategy.

In support of the change in severe malaria treatment guideline to IV/IM artesunate, UNITAID invested USD 17 million in six countries to accelerate the adoption of this treatment. Working together with Clinton Health Access Initiative (CHAI) and Malaria Venture (MMV), additional vials of treatment will be distributed in Uganda, and a market for 40 41 42 injectable artesunate created39F 40F 41F .

Community-based approaches to improving appropriate malaria case management coverage have been implemented for several years in Uganda. In recent years this approach has integrated management of other common childhood illnesses under integrated community case management (ICCM). In 2008 the Ministry of Health committed to revitalizing and expanding the VHT program to deliver ICCM. VHTs trainings began in 2010 and have been designed and implemented to cover diagnosis and treatment of pneumonia, malaria, diarrhea, and newborn 43 care42F . ICCM training is typically provided for two of the four to five VHTs operating per village. The VHT ICCM health kit includes pre-packed AL, amoxicillin, oral rehydration salts and zinc, rectal artesunate, a respiratory timer, MUAC tape, and malaria RDTs. The United Nations Children’s Fund (UNICEF)/Uganda has supported iCCM activities in 19 44 districts43F .

40 Malaria Consortium. Reducing deaths from severe malaria, briefing note. http://www.malariaconsortium.org/media-downloads/328 41 Clinton Health Access Initiative. (2014). Case Study: Increasing uptake of the most effective treatment to reduce severe malaria mortality. Retrieved from: http://www.clintonhealthaccess.org/content/uploads/2015/08/Case-Study_Inj-AS-Uptake.pdf 42 UNITAID. Treating severe malaria in Uganda. Retrieved from: http://unitaid.org/en/resources/1536-treating-severe-malaria-in-uganda 43 Ministry of Health. (2010). Community case management of childhood malaria, pneumonia, and diarrhea: Implementation guidelines. As cited in KayemaKayemba CN, Sengendo HN, Ssekitooleko J et al. (2012). MJTMHIntroduction of newborn care within integrated community case management in Uganda. The American Journal of Tropical Medicine and Hygiene, 87(5 Suppl): 46-53. 44 President’s Malaria Initiative (2016). Uganda Malaria Operational Plan FY 2016. Accessed May 6, 2016. www.pmi.gov

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Annex 3: Outlet Survey Methods

Design and Study Population

ACTwatch implements repeat cross-sectional outlet surveys in project countries. The study population is defined as all outlets with the potential to sell or distribute antimalarial medicines and/or provide malaria blood testing. In Uganda, this includes the following outlet types:

Public health This category is comprised of government facilities including referral hospitals, county facilities health centers (IV), sub-county health centers (III), and parish health centers (II).

Community health Community medicine distributors including Village Health Team (VHT) workers. These health worker workers are community-based volunteers equipped with antimalarial treatment to be provided free of charge. They may be equipped with malaria rapid diagnostic tests. Community health workers are considered public sector outlets.

Private not-for- Non-government or faith-based/mission health facilities including hospitals and health profit health centers. These facilities provide diagnosis and treatment for a nominal service fee and are facilities staffed by providers with health qualifications. They are considered public sector outlets.

Private for profit Private hospitals, clinics, and diagnostic laboratories providing diagnosis and treatment at health facilities commercial rates. These facilities are typically registered and regulated by the Ministry of Health (Uganda Medical and Dental Practitioners Association and Nurses and Midwife Council).

Pharmacies Pharmacies are licensed and regulated by the National Drug Authority and are staffed by pharmacists and qualified health practitioners.

Drug stores Drug stores are smaller than pharmacies and typically stock a smaller range of medicines. Drug stores are authorized to sell over-the-counter medicines. These outlets should be registered and regulated by the National Drug Authority however an unknown proportion of drug stores are not registered. Licensed drug stores are staffed by qualified health dispensers or practitioners.

Stratification

The national Uganda outlet survey was stratified to provide estimates for urban and rural areas. Explicit stratification by location (urban/rural) was used to ensure sufficient sample size for urban and rural estimates. Implicit stratification was used to achieve urban and rural samples that are similar to the population distribution with respect to malaria endemicity. Malaria endemicity classifications have been obtained from the National Malaria Control Program. Approximately 85% of Uganda is defined as holo- or hyper-endemic and for the purposes of this survey were classified as high endemic areas. Areas identified as hypo- or meso-endemic were classified as low endemic. The urban and rural sampling frames were sorted by malaria endemicity to achieve implicit stratification across malaria endemicity.

Eligibility Criteria

The outlet survey conducted a census screening in sampled geographic areas of all outlets with the potential to sell or distribute antimalarials. This included all health facilities (public, private for-profit, private not-for-profit), village health team volunteers, pharmacies and drug shops. Outlets that were excluded from screening included service

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providers that did not stock modern antimalarial medicine including traditional/spiritual healers and general retail outlets. Outlets that exclusively served the military and did not serve the general public were excluded from the study.

Outlets were eligible for a provider interview and malaria product audit if they met at least one of three study criteria: 1) one or more antimalarials reportedly in stock the day of the survey; 2) one or more antimalarials reportedly in stock within the three months preceding the survey; and/or 3) provides malaria blood testing (microscopy or RDT). To participate in the study, the senior most provider at the outlet had to provide informed consent.

Sample Size

The outlet survey was powered to detect a 15 to 20 percentage point change between 2013 and 2015 within each research domain (and nationally) in the indicator, the proportion of outlets that have quality-assured ACT in stock among all outlets with antimalarials in stock at the time of the survey. The required sample size for each research domain (urban and rural strata) was calculated in three steps: 1) determine the required number of antimalarial- stocking outlets; 2) determine the number of outlets to be enumerated to arrive at this number of antimalarial- stocking outlets; and 3) determine the number of clusters for the census to arrive at this number of outlets.

Required number of private sector antimalarial-stocking outlets

The number of antimalarial-stocking outlets required to detect a change over time in availability of ACT between survey rounds is given by:

2 n = deff éZ 2P(1- P) + Z P (1- P )+ P (1- P )ù ë a 1-b 1 1 2 2 û (P - P )2 2 1 where:

 n= desired sample size

 P1= the proportion of antimalarial-stocking outlets with QA ACT/malaria blood testing available in stock in 2013 (see table below)  P2= the expected proportion of antimalarial-stocking outlets with QA ACT/malaria blood testing available in stock in 2015 (15 or 20 percentage point increase.  P= (P1+P2)/2  Zα/2= The standard normal deviate value for a α type I error (two-sided)

 Z1-β= The standard normal deviate value for a β type II error  Deff= design effect anticipated due to the multi-stage cluster survey design. Design effects observed from the 2013 survey were used for sample size calculations.

QA ACT and malaria blood testing availability (weighted estimates), 2013 ACTwatch outlet survey, Uganda QA ACT Malaria blood testing availability* availability** Urban Public sector outlets 99.5% 66.7% Public health facilities 98.5% 91.4% Private sector outlets 89.0% 38.5% Pharmacies 99.4% 56.3% Drug shops 88.1% 8.9%

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Public health facilities 93.5% 90.1% Private sector outlets 74.1% 19.1% Pharmacies 100% 51.2% Drug shops 72.8% 13.2% * Among outlets with antimalarial(s) in stock on the day of the survey ** Among outlets with antimalarial(s) in stock on the day of they survey or within the past 3 months

Required number of antimalarial-stocking outlets

The estimated number of outlets enumerated needed for the QA ACT availability indicator was determined by the following formula for urban and rural domains separately:

Nn/Pam where Pam is the proportion of outlets having antimalarial stocks at the time of the survey among all outlets enumerated. In this equation, the assumptions are as follows: N = desired sample size of all outlets for monitoring availability indicators, n is the number of outlets with antimalarial stocks at the time of the survey. Pam is the proportion of outlets having antimalarials in stock at the time of the survey among all outlets enumerated estimated from 2013 survey data for each of the urban and rural domains. The 2013 survey data indicate that 80% of urban outlets and 50% of rural outlets have antimalarials in stock at the time of the survey. The Pam values documented in the 2013 outlet survey and used for 2015 sample size calculations are summarized in the table below.

Proportion of enumerated outlets with antimalarials in stock, 2013 ACTwatch outlet survey (data not weighted), Uganda In stock on the day of In stock on the day of the survey the survey or within the past 3 months Urban Public sector outlets 33% 38% Public health facilities 97% 97% Private sector outlets 89% 90% Pharmacies 90% 90% Drug shops 89% 91%

Rural Public sector outlets 30% 32% Public health facilities 96% 98% Private sector outlets 84% 87% Pharmacies 90% 90% Drug shops 85% 86%

Required number of clusters (sub-counties)

The primary sampling approach taken for ACTwatch outlet surveys entails sampling a set of administrative units (geographic clusters) with a population of approximately 10,000 to 15,000 inhabitants. Clusters were selected with cluster probability of selection proportionate to size (PPS). A census of all outlets with the potential to sell of distribute antimalarials was then conducted in sampled clusters. The most appropriate administrative unit in Uganda matching this desired population size was sub-county. In urban areas, sub-counties are town councils/divisions. In Kampala, parishes were used as the administrative unit for the sampling frame.

The average numbers of outlets by outlet type in urban and rural sub-counties screened during the 2013 outlet survey were used to estimate the number of clusters required in 2015 to achieve the desired sample sizes. In 2013, the numbers of outlets per sub-county enumerated were as follows: all public 30.2 urban, 117.7 rural; public health facilities: 1.7 urban, 3.3 rural; all private: 79.2 urban, 26.7 rural; private for-profit health facilities: 33.6 urban, 3.2 rural; pharmacies: 5.1 urban, 0.1 rural; and drug shops: 40.5 urban, 23.5 rural. Considering sample size requirements www.ACTwatch.info Page 120 to detect change over time and average numbers of outlets across each outlet type, the optimal minimum number of sub-counties required to reach desired numbers of outlets was 14 urban and 34 rural sub-counties.

Sampling

A representative sample of sub-counties (14 urban and 34 rural) was selected in each research domain. From a list of all sub-counties in each domain, the required number of sub-counties was selected with probability proportional to size (PPS). There are three levels of urbanicity in Uganda, in the order of increasing size: town council, municipality, and city. As Kampala and municipalities are large urban areas, the total population is typically far higher than the average populations in other sub-counties. As such for the urban sampling frame, town councils, divisions within municipalities, and parishes in Kampala were considered as sub-counties. This was necessary to harmonize population sizes in selected areas.

Implicit stratification was used within each domain to ensure proportional allocation of sub-counties from high and low endemic areas. Selection of sub-counties with PPS was completed based on population estimates obtained from the 2014 Housing and Population Census. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling was that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster was correlated with population size.

Within each sub-county, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing (excluding general retail outlets) was conducted. The census approach taken within 48 sub- counties yielded sufficient sample sizes for key outlet types including rural public health facilities. However, to achieve a sufficient sample size for estimating key indicators within urban public health facilities and pharmacies, the geographic area for the census of urban public health facilities and pharmacies was extended to the county level. To ensure that all urban public health facilities within the county were included in the study, a list of public health facilities was obtained from the MOH and verified at district health departments. A list of selected sub-counties is provided in Annex 4.

Data Collection

Interviewers, supervisors, and quality controllers received training that included an orientation to the study, questionnaire, and classroom training on completing antimalarial and RDT audits, and a field exercise. Following training, data collection was implemented from May 18, 2015 to July 2, 2015.

For all interviews, a structured questionnaire was administered electronically on Samsung Grand Neo phones using DroidDB (© SYWARE Inc., Cambridge, MA). The questionnaire is available in Annex 6. A series of screening questions were administered at all outlets to determine eligibility for the survey. Outlets where antimalarial medicines were reportedly sold and/or malaria blood testing was reportedly provided were invited to participate in the survey. Following informed consent procedures, an audit of all available antimalarial medicines and RDTs was conducted. Antimalarial audit information included formulation, package size, brand name, active ingredients and strengths, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. RDT audit information included brand name, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. Detailed descriptions of antimalarials and RDTs audited are provided in Annex 7 and Annex 8. In addition to the product audit, a series of questions was administered to the senior-most provider regarding malaria case management knowledge and practices as well as provider training and qualifications. Geo-coordinates were collected for each outlet using the mobile phone.

Up to three visits were made to all outlets to complete the screening process, audit, and provider interview as needed (e.g. where outlets were closed or providers were not available).

Data Entry, Processing, and Analysis

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Data collection was completed on Samsung Grand Neo phones using DroidDB (© SYWARE Inc., Cambridge, MA). All data cleaning and analysis was completed using Stata 13.1 (©StataCorp, College Station, TX). Sampling weights were applied to account for variations in probability of selection (see Annex 9) and standard error estimation accounted for clustering at the ward and district levels. Indicator definitions are provided in Annex 10.

Protection of Human Subjects

The 2015 outlet survey protocol received ethical approval from the Ethical Review Board of Makerere University Medical School. Provider interviews and product audits were completed only after administration of a standard informed consent form and provider consented to participate in the study. Providers had the option to end the interview at any point during the study. Standard measures were employed to maintain provider confidentiality and anonymity.

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Annex 4: Sampled Sub-Counties

Table X1. Sampled Sub-Counties District County Sub-County Urban/Rural Endemicity Population ABIM LABWOR MORULEM RURAL HIGH 23204 ALEBTONG MOROTO OMORO RURAL HIGH 43411 AMURIA AMURIA AMURIA TOWN COUNCIL URBAN HIGH 7,066 AMURU KILAK PABO RURAL HIGH 53997 ARUA AYIVU PAJULU RURAL HIGH 60210 BUDAKA IKI IKI IKI-IKI RURAL HIGH 18665 BUDUDA MANJIYA BUSHIKA RURAL LOW 31530 BUIKWE BUIKWE KAWOLO RURAL HIGH 40396 BULIISA BULIISA BIISO RURAL HIGH 16595 BUSHENYI-ISHAKA MUNICIPLE BUSHENYI COUNCIL CENTRAL DIVISION URBAN HIGH 16,646 BUTALEJA BUNYOLE BUSABA RURAL HIGH 24813 BUYENDE BUDIOPE KIDERA RURAL HIGH 64748 GULU GULU MUNICIPLE COUNCIL PECE DIVISION URBAN HIGH 48,405 GULU OMORO LALOGI RURAL HIGH 30117 HOIMA BUGAHYA KIGOROBYA RURAL LOW 68402 HOIMA HOIMA MUNICIPLE COUNCIL BUSIISI DIVISION URBAN LOW 19,261 ISINGIRO BUKANGA ENDIINZI RURAL LOW 23525 JINJA BUTEMBE MAFUBIRA RURAL HIGH 78895 KABALE NDORWA RUBAYA RURAL LOW 27727 KABAROLE BURAHYA KICWAMBA RURAL LOW 35100 FORT PORTAL MUNICIPLE KABAROLE COUNCIL EASTERN DIVISION URBAN LOW 18,625 KALANGALA BUJUMBA MUGOYE RURAL HIGH 12253 KAMPALA CAPITAL CITY KAWEMPE DIVISION KAWEMPE II URBAN LOW 19,000 KAMPALA CAPITAL CITY LUBAGA DIVISION KASUBI URBAN LOW 63,200 KAMPALA CAPITAL CITY MAKINDYE DIVISION BUKASA URBAN LOW 28,500 KAMPALA CAPITAL CITY MAKINDYE DIVISION NSAMBYA CENTRAL URBAN LOW 43,800 KAMPALA CAPITAL CITY NAKAWA DIVISION MUTUNGO URBAN LOW 63,200 KAMULI BUGABULA KAMULI TOWN COUNCIL URBAN HIGH 17,725 KAMULI BUGABULA NABWIGULU RURAL HIGH 50488 KAMWENGE KITAGWENDA KICHECHE RURAL HIGH 26883 KASESE BUSONGORA MUHOKYA RURAL HIGH 19531 KIBAALE BUGANGAIZI MPASAANA RURAL LOW 23948 KIBOGA KIBOGA KIBIGA RURAL HIGH 25686 KIRUHURA KAZO KANONI RURAL LOW 16851 KIRYANDONGO KIBANDA KIGUMBA TOWN COUNCIL URBAN HIGH 18,698 KITGUM CHUA NAMOKORA RURAL LOW 14040 KOBOKO KOBOKO LUDARA RURAL HIGH 31821 KUMI KUMI MUKONGORO RURAL HIGH 53466 KYEGEGWA KYAKA KYEGEGWA TOWN COUNCIL URBAN LOW 18,729 KYENJOJO MWENGE KIHUURA RURAL LOW 29214 LUUKA LUUKA BUKANGA RURAL HIGH 41822 LWENGO BUKOTO LWENGO TOWN COUNCIL URBAN HIGH 15,527

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LWENGO BUKOTO KISEKKA RURAL HIGH 49185 MANAFWA BUBULO SISUNI RURAL LOW 4044 MASAKA BUKOTO KYANNAMUKAAKA RURAL HIGH 31540 MAYUGE BUNYA KITYERERA RURAL HIGH 47320 MBARARA MUNICIPLE MBARARA COUNCIL KAKOBA URBAN LOW 55,519 MBARARA RWAMPARA MWIZI RURAL LOW 34798 MITYANA MITYANA SSEKANYONYI RURAL HIGH 38323 MOYO WEST MOYO MOYO TOWN COUNCIL URBAN HIGH 10,507 MUBENDE BUWEKULA KIYUNI RURAL HIGH 35629 MUKONO MUKONO MPUNGE RURAL HIGH 14549 NAKASONGOLA BURULI LWAMPANGA RURAL HIGH 29741 NAMAYINGO BUKOOLI NAMAYINGO TOWN COUNCIL URBAN HIGH 15,741 NAPAK BOKORA LORENGECORA RURAL HIGH 11099 NTUNGAMO RUHAAMA RWEIKINIRO RURAL LOW 36620 NWOYA NWOYA KOCH-GOMA RURAL HIGH 35649 PADER ARUU LAPUL RURAL HIGH 19295 RAKAI KOOKI DDWANIRO RURAL HIGH 33021 RUKUNGIRI RUJUMBURA BUGANGARI RURAL HIGH 30800 SOROTI SOROTI ARAPAI RURAL HIGH 40403 SOROTI SOROTI MUNICIPAL COUNCIL EASTERN DIVISION URBAN HIGH 18,695 TORORO TORORO OSUKURU RURAL HIGH 46612 WAKISO BUSIRO WAKISO TOWN COUNCIL URBAN LOW 60,911 WAKISO BUSIRO NSANGI RURAL LOW 197991 WAKISO KYADONDO KIRA TOWN COUNCIL URBAN LOW 313,761 WAKISO KYADONDO MAKIDYE-SSABAGABO RURAL LOW 284067 YUMBE ARINGA KURU RURAL HIGH 42682

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Annex 5: Detailed Sample Description Table X2: Detailed sample description Public Community Private Not Private ALL Health Health For-Profit For-Profit Pharmacy Drug Store Outlets Facility Worker Facility Facility Number of outlets screened (Figure 1 Box B) 282 5618 55 1023 493 1967 9438 Urban 137 772 21 567 437 627 2561 Census 33 772 21 567 133 627 2153 Booster 104 0 0 0 304 0 408 Rural 145 4846 34 456 56 1340 6877 Census 145 4846 34 456 28 1340 6849 Booster 0 0 0 0 28 0 28 Number of outlets eligible and interviewed (Figure 1 Box D) 281 1012 54 980 476 1921 4724 Urban 136 139 20 539 422 614 1870 Census 33 139 20 539 129 614 1474 Booster 103 0 0 0 293 0 396 Rural 145 873 34 441 54 1307 2854 Census 145 873 34 441 28 1307 2828 Booster 0 0 0 0 26 0 26 Number of outlets eligible but not interviewed (interview non- participation) 0 3 0 19 15 19 56 Urban 0 1 0 13 13 9 36 Census 0 1 0 13 2 9 25 Booster 0 0 0 0 11 0 11 Rural 0 2 0 6 2 10 20 Census 0 2 0 6 0 10 18 Booster 0 0 0 0 2 0 2 Number of interviewed outlets with at least one antimalarial in stock on the day of the survey (Figure 1, Box D1) 275 719 53 956 476 1849 4328 Urban 134 104 20 524 422 597 1801 Census 32 104 20 524 129 597 1406 Booster 102 0 0 0 293 0 395 Rural 141 615 33 432 54 1252 2527 Census 141 615 33 432 28 1252 2501 Booster 0 0 0 0 26 0 26

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Table X2: Detailed sample description Public Community Private Not Private ALL Health Health For-Profit For-Profit Pharmacy Drug Store Outlets Facility Worker Facility Facility Number of interviewed outlets with at least one antimalarial in stock on the day of the survey or at least one antimalarial reportedly in stock in the previous 3 months (Figure 1 sum of Box 1 and Box 2) 280 900 54 967 476 1921 4598 Urban 136 120 20 528 422 614 1840 Census 33 120 20 528 129 614 1444 Booster 103 0 0 0 293 0 396 Rural 144 780 34 439 54 1307 2758 Census 144 780 34 439 28 1307 2732 Booster 0 0 0 0 26 0 26 Number of interviewed outlets that provide malaria blood testing, but do not stock antimalarial medicines (Figure 1 Box D3) 1 112 0 13 0 0 126 Urban 0 19 0 11 0 0 30 Census 0 19 0 11 0 0 30 Booster 0 0 0 0 0 0 0 Rural 1 93 0 2 0 0 96 Census 1 93 0 2 0 0 96 Booster 0 0 0 0 0 0 0 Proportion of eligible and interviewed antimalarial-stocking outlets with at least one provider with a health-related 100 95.82 100 99.47 99.35 97.22 97.93 qualification* Urban 100 99.04 100 99.42 99.27 98.65 99.16 Census 100 99.04 100 99.42 99.19 98.65 99.07 Booster 100 - - - 99.30 - 99.48 Rural 100 95.28 100 99.54 100 96.55 97.06 Census 100 95.28 100 99.54 100 96.55 97.03 Booster - - - - 100 - 100 * Health-related qualifications include: medical doctor, pharmacist, nurse, midwife, lab/pharmacy technologist. Source: ACTwatch Outlet Survey, Uganda 2015.

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OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

Annex 6: Questionnaire

ACTwatch Outlet Survey UGANDA 2015

Section 1: Census Information

Interviewer completes this section for all outlets.

Outlet ID: Interviewer-District- County-Sub-county-Outlet ID [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] C1. Today’s date (dd/mm/yyyy) [___|___]-[___|___]-[_2_|_0_|_1_|_5_] C2. Interviewer’s name [______] C2a. Interviewer’s code [___|___]

C3. District [______] C3a. District code [___|___]

C4. County [______] C4a. County code [___|___|___]

C5. Sub-county [______] C5a. Sub-county code[___|___|___|___] C6. Name of outlet If no name, record “no name” or owner’s name

[______] C6a. Outlet code [___|___|___] C7. Type of Outlet

01 National Referral Hospital 08 Pharmacy 14 Private diagnostics lab (lab only) 02 Regional Referral Hospital 09 Drug shop / Drug store 15 NGO/Mission diagnostics lab 03 District / General Hospital (lab only) 10 Private hospital 04 Health Centre IV – County 11 Private clinic / domiciliary / midwife 96 Other (specify) [___|___] 05 Health Centre III – Sub-county

06 Health Centre II – Parish [______] 12 NGO/Mission hospital

07 Community Medicine Distributor 13 NGO/Mission clinic

C8. Is this area part of the booster sample? 1 = Yes 0 = No [___] Hello, my name is ______, I work on behalf of the Programme for Accessible Health, Communication and Education, PACE. We are conducting a study on the availability of antimalarial medicines and diagnostic testing services. The results will be used to improve the availability of appropriate antimalarial treatment in Uganda. I would like to ask you a few questions to see if you could be part of the survey. Section 2: Screening & Eligibility

S1. Do you have any medicines in stock today? 1 = Yes Go to S3 [___] 0 = No S2. Are there any medicines that are out of stock today, but that you stocked in the past 3 months? 1 = Yes Go to S4 [___] 0 = No Go to S5 8 = Don’t know Go to S5 S3. Do you have any antimalarial medicines in stock today? 1 = Yes Provide information sheet & gain consent. Record start time in C9. [___] Proceed to Section 3: Antimalarial Audit. 0 = No Verify with prompt card. Go to S4 S4. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months? 1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to A16. [___] 0 = No Verify with prompt card. Go to S5 8 = Don’t know Verify with prompt card. Go to S5 S5. Are you offering any diagnostic services or selling any diagnostic tests here today? 1 = Yes Go to S6 [___] 0 = No Verify with prompt card. Record details in C9 then complete Sec 7: ORS & Zinc then Sec X: Ending Interview S6. Are any of these services or tests for suspected malaria? 1 = Yes Provide information sheet & gain consent. Record start time in C9. [___] Proceed to Section 4: Diagnostic Audit

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OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

0 = No Verify with prompt card. Record details in C9 then complete Sec 7: ORS & Zinc and Sec X: Ending Interview Before proceeding to the full interview ensure you have given the respondent a study information sheet, explained the study and obtained informed consent

C9: Result of Visit(s)

Date Visit 1 Visit 2 Visit 3 (dd/mm/yy) [___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_] [___|___]-[___|___]-[_1_|_5_] Time started (in 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Time completed (in 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Result [___|___] [___|___] [___|___] 01 = Outlet eligible & survey completed go to E1 02 = Outlet ineligible: does not meet any screening criteria go to E1 03 = Interview interrupted go to C11 04 = Respondent not available/time not convenient go to C11 05 = Outlet not open at the time go to C11 06 = Outlet closed permanently go to E1 96 = Other (specify):[______] 97 = Refused go to C10 C10. If the provider refused, why?

1 = Client load Ask respondent for a time they would prefer to be interviewed and note in C11 2 = Thinks it’s an inspection / nervous about license go to E1 [___] 3 = Not interested go to E1 6 = Other (specify):[______] 7 = Refuses to give reason go to E1 C11. Use this space to record call back details. If it is not possible to complete the interview at another time, go to E1.

Section 7: ORS, Zinc & Amoxicillin: Read to the provider: I have just a few questions for you about availability of treatments for diarrhea and pneumonia ORS1. Do you have any oral rehydration salts, also known as ORS in stock today? Verify with prompt card. 1 = Yes [___] 0 = No ORS2. Do you have any zinc tablets for treatment of diarrhea in children in stock today? Verify with prompt card. 1 = Yes [___] 0 = No Go to AB1 ORS3. Which strength of zinc tablets for treatment of diarrhea in children do you have in stock today? A Read list, circle ALL that apply 10mg B 20mg C Other(specify ):[______] ORS4. Do you have any ORS that is packaged together with zinc treatment for diarrhea in children in stock today? Verify with prompt card [___] 1 = Yes 0 = No AB1. Do you have any antibiotics in stock today? 1 = Yes [___] 0 = No AB2. Do you have any amoxicillin dispersible tablets, also known as Amox DT? Show prompt card. Interviewer ask to see the product and verify that it is dispersible amoxicillin [___] 1 = Yes 0 = No Go to C9 – Results of visit

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OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

AB3. Which strength of amoxicillin dispersible tablets (Amox DT) do you have in stock today? Read list, circle ALL that apply 125mg A 250mg B Other(specify ):[______] C

Section X: Ending the interview E1. Name of interviewee:

[______]

5 = Not applicable, no respondent; 7 = Refused E2. Physical address or location identifiers of outlet (not PO E3. Telephone number box)(Give detailed description that will help supervisor to find the outlet) [___|___|___|___|___|___|___|___|___|___] 9999999995 = N/A: no respondent or has no telephone 9999999997 = Refused

E4.Latitude: E5.Longitude: [__] - [___|___] . [___|___|___|___|___|___|___|___] [_E_] - [___|___] . [___|___|___|___|___|___|___|___] E7. Additional observations by interviewer (if any)

THANK THE PROVIDER AND END INTERVIEW

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Section 3: Antimalarial Audit

A0. Read to the provider: Can you please show us the full range of antimalarials that you currently have in stock? Do you currently have any of the following? Prompt entire list using antimalarial prompt card; No response to be recorded.  Artemether lumefantrine, such as Lonart, Artefan, Lumartem, Coartem, Lumaren  Artesunate amodiaquine, such as DUAC, Coarsucam, Winthrop  Other artemisinin combination therapies, such as Arco  Artemether monotherapies, such as Larither, Artemether Rtitas, Artemedine, Artenam, Romether  Artesunate monotherapies, such as Plasmotrim, Artesun, G-Sunate  Chloroquine, such as Sugaquin, Mediquine, Kam quin, Bioquin, Renequin, Maxaquin, Oroquin  SP, such as Fansidar, Malaren, Kamsidar, Agosidar, Neosidar  Quinine, such as Quinas, Quine, Quinfer  Amodiaquine, such as Amobin  Mefloquine, such as Mephaquin, Meflotas  Syrups or suspensions, such as Quinine-K, Quinimix ,Requin, Ago-quinine ,Co-malartem suspension, Ago-CQ  Injectables, such as Rogoquin, Artemether, Quinax, Larither, Kwinil  Granules or powders, such as Artequin, Artesun

If the outlet has no antimalarials in stock cross-check screening results then proceed to question A16.

Proceed to the antimalarial audit. Different antimalarial audit sheets will be used to record the antimalarial information based on the dosage form of the medicine.

Separate the antimalarials into two piles:  The first pile should contain all the antimalarials in the form of tablets, suppositories, or granules. Use the Tablets, Suppositories & Granules Drug Audit Sheet to record these.

 The second pile should contain all the antimalarials in any form other than tablets, suppositories or granules. Use the Non-Tablet Drug Audit Sheet to record these.

If additional audit sheets are used, add these sheets after the ones provided and staple the questionnaire again. All pages should be in order before you move onto the next outlet.

Number each drug by assigning a Product Number (starting from 1 for TSG drugs and again from 1 for NT drugs). Number each audit sheet used in the spaces provided at the bottom of the page.

ADDITIONAL NOTES ON THE SUB-OUTLET CODE

In all outlets, complete the Sub-Outlet Code (as well as the Product Number) for each drug audited. These codes are listed below.

SUB-OUTLET CODES X ALL outlets that have only ONE dispensing/distribution point for medicines/diagnostics A Outpatient department / dispensary/Main pharmacy (if used by all patients) B Adult outpatient department / adult dispensary / adult clinic C Child outpatient department / child dispensary / child clinic D Antenatal / maternity clinic/MCH E ART / HIV/AIDS clinic G Private dispensing unit within a public health facility L Laboratory (for RDT audit) Z Other (specify the type in the space for audit comments –TSG 15 or NT 15)

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TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

Sub-outlet 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage 4. Brand name code form/formulation (Include weight and age information) [__|__] [__|__|__].[__]mg [__] [_____] 1 = Yes 1 = Tablet ______[__|__] [__|__|__].[__]mg [__] 0 = No 2 = Suppository Product [__|__] 8 = Don’t know number [__|__|__].[__]mg [__] 3 = Granule If no, specify salt:

[__|__] [___] [______] [__|__] 5. Manufacturer 6. Country of 7. Package size 8. Is product a 9. Does 10. Amount sold/distributed in the last 7 days to individual consumers 11. Stocked out at manufacture fixed-dose product have (Record # of packages / tins described in Q7 OR record the total # of tablets any point in the There are a total of combination the Green / suppositories / granule packs sold) past 3 months? (FDC) leaf logo? [___|___|___|___] This outlet sold [___|___|___] packages/ tins in the last 7 days 1 = Yes tablets/ suppositories/ 1 = Yes 1 = Yes 0 = No granule sachets in each: 0 = No 0 = No OR 8 = Don’t

8 = Don’t 8 = Don’t know 1 = Package This outlet sold [___|___|___] tablets/ suppositories or granule sachets in know know 2 = Pot/tin the last 7 days

[___] Not applicable = 995; Refused = 997; Don’t know = 998 [___] [___] [___]

[__|__|__] 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments Do not read list. For the outlet’s most recent wholesale purchase Circle ALL responses given [___|___|___] tablets, suppositories or granule Free supply A sachets cost an individual customer [___|___|___|___] Profitable B tablets, suppositories or granule sachets cost Recommended by the government C

Low price D [___|___|___|___|___] USH [___|___|___|___|___|___] USH Customer demand or preference E Positive brand reputation F Often prescribed by doctors G Most effective for treating malaria H Free = 00000 Free = 000000 Don’t know X Refused = 99997 Don’t Refused = 999997 Other Z know = 99998 Don’t know = 999998 specify [______]

Tablet Audit Sheet [__|__] of [__|__]

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TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

8 = Don’t 8 = Don’t know 1 = Package This outlet sold [___|___|___] tablets/ suppositories or granule sachets in know know 2 = Pot/tin the last 7 days

[___] Not applicable = 995; Refused = 997; Don’t know = 998 [___] [___] [___]

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NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & othersOUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]- [___|___|___] Sub-outlet 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form/formulation code [__|__] [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] 1 = Syrup [_____] 1 = Yes ______[__|__] 2 = Suspension [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] 0 = No 3=Liquid injection 8 = Don’t know Product [__|__] 4 =Powder injection [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] number 5 = Drops If no, specify salt: [__|__] (Note: no mL recorded for powder injection) 6 = Other (specify) [______] [______] [__|__] [___] 4. Brand name 5. Manufacturer 6. Country of manufacture 7. Package size 9. Does this 10. Amount sold/ distributed in the 11. Stocked out at (Include weight and age information) product have the last 7 days to individual consumers any point in the past There are a total of Green leaf logo? 3 months? This outlet sold [___|___|___|___].[__] mL 1 = Yes 1 = Yes (or mg for powder injections) in 0 = No [___|___|___|___] bottles, ampoules 0 = No each: 8 = Don’t or vials in the 8 = Don’t 1 = Bottle last 7 days know know 2 = Ampoule/vial

Refused = 9997; [___] [___] Don’t know = 9998 [___]

[__|__|__] 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments For the outlet’s most recent wholesale purchase: Do not read list. Circle ALL responses given

[___|___|___] [___|___|___|___] Free supply A bottles ampoules or vials cost an bottles, ampoules or vials cost Profitable B individual customer Recommended by the government C

Low price D [___|___|___|___|___] USH [___|___|___|___|___|___] USH Customer demand or preference E Positive brand reputation F Often prescribed by doctors G Most effective for treating malaria H Don’t know X Free = 00000 Free = 000000 Other Z Refused = 99997 Refused = 999997 specify [______] Don’t know = 99998 Don’t know = 999998

Non-Tablet Audit Sheet [___|___] of [___|___]

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NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & othersOUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]- [___|___|___]

Sub-outlet 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form/formulation code [__|__] [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] 1 = Syrup [_____] 1 = Yes ______[__|__] 2 = Suspension [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] 0 = No 3=Liquid injection 8 = Don’t know Product [__|__] 4 =Powder injection [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__] number 5 = Drops If no, specify salt: [__|__] (Note: no mL recorded for powder injection) 6 = Other (specify) [______] [______] [__|__] [___] 4. Brand name 5. Manufacturer 6. Country of manufacture 7. Package size 9. Does this 10. Amount sold/ distributed in the 11. Stocked out at (Include weight and age information) product have the last 7 days to individual consumers any point in the past There are a total of Green leaf logo? 3 months? This outlet sold [___|___|___|___].[__] mL 1 = Yes 1 = Yes (or mg for powder injections) in 0 = No [___|___|___|___] bottles, ampoules 0 = No each: 8 = Don’t or vials in the 8 = Don’t 1 = Bottle last 7 days know know 2 = Ampoule/vial

Refused = 9997; [___] [___] Don’t know = 9998 [___]

[___|___|___] [___|___|___|___] Free supply A bottles ampoules or vials cost an bottles, ampoules or vials cost Profitable B individual customer Recommended by the government C

Low price D [___|___|___|___] KSH [___|___|___|___|___] KSH Customer demand or preference E Positive brand reputation F Often prescribed by doctors G Most effective for treating malaria H Don’t know X Free = 0000 Free = 00000 Other Z Refused = 9997 Refused = 99997 specify [______] Don’t know = 9998 Don’t know = 99998 Non-Tablet Audit Sheet [___|___] of [___|___]

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OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

Antimalarials recently in stock

A16. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes go to A17 [___] 0 = No go to Section 4: Diagnostic Audit 8 = Don’t know go to Section 4: Diagnostic Audit

A17. What are the names of the treatments that are out of stock? Will accept generic or brand names. Record one medicine per line.

1 = Yes, specify [______] [______]

[______] [______] [___] [______] [______]

[______] [______]

0 = No, provider can’t remember

Interviewer: Go to Section 4: Diagnostic Audit

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OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

Section 4: Diagnostic Audit This section is about availability of malaria blood testing. Completing the questions may require speaking with more than 1 staff member at the outlet. If the respondent does not know the answer to a question in this section, ask to speak with another staff member who can provide the information.

D1. Does this outlet/facility have disposable gloves available today for staff to use when seeing customers/patients?

1 = Yes [___] 0 = No 8 = Don’t know D2. Does this outlet/facility have a sharps container, also called a sharps disposal box or safety box, available today for staff to use?

1 = Yes [___] 0 = No 8 = Don’t know D3. Is malaria microscopic testing available here today?

1 = Yes [___] 0 = No go to D7

D4. How many people were tested for malaria at this facility/outlet using microscopy within the past 7 days? [___|___|___] 997 = Refused; 998 = Don’t know D5. What is the total cost for a microscopic test for malaria for an adult: [___|___|___|___|___] USH

Free = 00000; NA =99995; Refused = 99997; Don’t know=99998

D6. What is the total cost for a microscopic test for malaria for a child under five: [___|___|___|___|___] USH

Free = 00000; NA = 99995; Refused = 99997; Don’t know=99998

D7. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

Are malaria RDTs available here today? [___] 1 = Yes 0 = No go to D9 Don’t know ask to speak with a respondent who has this information

D8. Please show us the full range of RDTs that you currently have in stock. Do you currently have any of the following? Read entire list; No response to be recorded.

 SD Bioline, Wondfo One Step, Nova test, AStel P.f  First Response, ParaCheck, Maleriscan, CTK on site rapid test

Proceed to the RDT audit. If additional audit sheets are used, add these sheets after the ones provided and staple the questionnaire again. All pages should be in order before you move onto the next outlet.

Number each RDT by assigning a Product Number. Number each audit sheet used in the spaces provided at the bottom of the page.

Complete the Sub-outlet Code as well as the Product Number for each RDT audited. Sub-outlet codes are listed on page 4.

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RAPID DIAGNOSTIC TEST AUDIT SHEET (RDT) OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub-outlet 1. Brand name 2. Antigen test 3. Parasite species 4. Manufacturer 5. Country of 5b. Product 6. Lot Number 6b. Is this a self test kit, code (circle ALL that apply) Manufacture Catalogue with each test kit co- (circle ALL that apply) Number packaged with its own [_____] Pf A HRP2 A buffer, pipette and

Pv B lancet? pLDH B Po C 1 = Yes Product Aldolase C pm D number 0 = No Not indicated Z pan E 8 = Don’t know [__|__] vom/Pvom F

Other G [___] Specify [______] Not indicated Z

13. Number of 14. Has this 15a. Do you or other staff use 16a. Does this facility/outlet 17. Wholesale purchase price 18. Why do you stock this RDT [SHOW 13. Comment tests sold/ test been this brand of RDT to test clients provide this brand of RDT for For the outlet’s most recent RDT]? distributed /used in stocked here at this facility/outlet? clients to take away for testing wholesale purchase: Do not read list the last 7 days to out at any somewhere else? Circle ALL responses given individual point in 1 = Yes consumers the past 3 0 = No go to 16a 1 = Yes [___|___|___|___] tests Free supply A (Record total # of months? 8 = Don’t know go to 16a 0 = No go to 17 tests) 8 = Don’t know go to 17 Profitable B This outlet sold or 1 = Yes [___] cost distributed 0 = No [___] 8 = Don’t 15b. If yes, what is the total Recommended by the government C know cost for an adult to have a test 16b. If yes, what is cost of this RDT [___|___|___|___|___|___] [___|___|___|___] conducted with this RDT, for an adult? USH Low price D tests in the last 7 including RDT cost and service days fee? [___|___|___|___|___] USH Free = 000000 Customer demand or preference E [___] NA = 999995 Refused = 9997; [___|___|___|___|___] USH 16c. If yes, what is the cost of this Refused = 999997 Positive brand reputation F Don’t know=9998 RDT for a child under the age of Don’t know=999998 five? 15c. If yes, what is the total Don’t know X cost for a child under the age of [___|___|___|___|___] USH five to have a test conducted Other Z with this RDT, including RDT specify cost and service fee? [______]

[___|___|___|___|___] USH

Free = 00000; NA = 99995; Refused = 99997; Don’t know=99998

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RAPID DIAGNOSTIC TEST AUDIT SHEET (RDT) OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] RDT Audit Sheet [___|___] of [___|___]

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RDT stock outs

D9. Are there any malaria RDTs that are out of stock today, but that you stocked in the past 3 months?

1 = Yes 0 = No go to D11 [___] 8 = Don’t know go to D11

D10. What are the brand names of the malaria RDTs that are out of stock? Record one brand per line.

1 = Yes, specify [______] [___] [______] [______] 0 = No, provider can’t remember D11. Does this facility/outlet provide medicines or prescription for medicines?

1 = Yes go to Section 5: Provider Module

0 = No check that S1 is no and S2 is no (the outlet has no medicines/had no [___] medicines recently) and that C7 is 14 or 15. Go to Section 7: ORS and ZINC and then Go to Section 6: Audit Tracking Sheet.

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Section 5: Provider Module

This section is for the senior-most staff member who is responsible for providing treatment, prescriptions or medicines to clients/patients.

P1. Do your responsibilities at this outlet/facility include: providing prescriptions, treatment, or medicines to clients?

|___] 1 = Yes No ask to speak with the senior-most person at the outlet with 1 or more of these responsibilities. P2. For how many years have you worked in this outlet/facility? If less than 1 year, enter 01 [___|___] P3. What age are you today? Write age in years 97 = Refused [___|___] 98 = Don’t know

P4. Don’t read: Is respondent male or female?

1 = Male [___|___] 2 = Female P5. What is the highest level of education you completed?

1 = No formal education 2 = Some primary school 3 = Completed primary school 4 = Some secondary school [___] 5 = Completed secondary school 6 = Some university/college 7 = Completed a university/college degree/diploma

P6. Have you received any training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy? Include pre-service training and stand-alone workshops. [___] 1 = Yes 0 = No 8 = Don’t know P7. Have you received any training in the last 12 months on the national treatment guidelines for malaria? Include pre-service training and stand-alone workshops.

1 = Yes [___] 0 = No 8 = Don’t know P8. Do you have any of the following health qualifications? Read list. Record 1 for yes, 0 for no

I. Dispenser (diploma in Pharmacy) [___] II. Pharmacist (Degree in Pharmacy) [___] III. Medical doctor [___] IV. Clinical Officer [___] V. Nurse / Nursing Officer [___] VI. Midwife [___] VII. Laboratory technician / Lab assistant [___] VIII. Pharmaceutical technologist [___] IX. Pharmacy technician [___] X. Public Health Technician/Officer [___]

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XI. Health Assistant, Medical Assistant / Nursing Assistant / Nursing Aid [___] XII. Community Medicine Distributor/Village Health Team [___]

P9. Not including yourself, do any other people working in this outlet or facility have the following health qualifications? Read list. Record 1 for yes, 0 for no, 8 for don’t know

I. Dispenser (Diploma in Pharmacy) [___] II. Pharmacist (Degree in Pharmacy) [___] III. Medical doctor [___] IV. Clinical Officer [___] V. Nurse / Nursing Officer [___] VI. Midwife [___] VII. Laboratory technician / Lab assistant [___] VIII. Pharmaceutical technologist [___] IX. Pharmacy technician [___] X. Public Health Technician/Officer [___] XI. Health Assistant, Medical Assistant / Nursing Assistant / Nursing Aid [___] XII. Community Medicine Distributor/Village Health Team [___]

Interviewer: For the following questions record the antimalarial brand name or generic name, and dosage form, in the spaces provided. Ask the provider to show you the medicine if it is in stock to verify the name and dosage form.

P10. In your opinion, for treating uncomplicated malaria in adults, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation

01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

P11. In your opinion, for treating uncomplicated malaria in children under five, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation

01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______]

[___|___] Don’t know = 98

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P12. What antimalarial medicine for treating uncomplicated malaria in adults do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

P13. What antimalarial medicine for treating uncomplicated malaria in children under five do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

P14. In your opinion, for treating severe malaria in children under five, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

P15. What antimalarial medicine for treating severe malaria in children under five do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock. Generic or brand name Dosage form/formulation 01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = IM/IV Injection 98 = Don’t know (liquid or powder)

[______] [___|___]

Don’t know = 98

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P16. Please name the first line medicine recommended by the government to treat uncomplicated malaria. Do not read list. Only one response allowed.

01 = Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem) …………………………… Go to P17 02 = ACT...... Go to P17 03 = ACTm...... Go to P17 04 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop) 05 = Dihydroartemisinin Piperaquine (Duo-cotecxin, P-alaxin) 06 = Amodiaquine [___|___] 07 = Artemether(Artenam, Paluther, Artesiane, Larither) 08 = Artemisinin 09 = Artesunate (Artesun, Larinate, Plasmotrim) Go to P19 10 = Chloroquine (Sugarquin) 11 = Quinine 12 = Sulfadoxine Pyrimethamine (Fansidar, SP, Orodar, Ekelfin, Metakelfin) 96 = Other specify: [______] 98 = Don’t know

P17. Please explain the government recommended treatment regimen for this drug for an adult (60kg)

What is the dosage formulation?

01 = Tablet 04 = Syrup 07 = Drop 02 = Suppository 05 = Suspension 95 = None specified 03 = Granule 06 = Injection (IV/IM) 96 = Not applicable [___|___] 98 = Don’t know If provider responded not tablet then skip to p18

Read the following 3 questions to the provider

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___] If respondent has the medicine available use the package to complete the table below. Don’t know = 98 If the medicine is not available ask respondent to identify from prompt card. If identification not possible, ask respondent to recall medicine details. Generic name Strength in mg Brand name

[__|__] ______[__|__|__].[__]mg

______[__|__|__].[__]mg [__|__]

[___|___] Don’t know=999.8

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Manufacturer Is this drug a fixed-dose combination

1 = Yes

0 = No

8 = Don’t know

[___] Don’t know = 98

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P18. Please explain the government recommended treatment regimen for this drug for a 2-year old child (10kg) Read the following 3 questions to the provider

What is the dosage formulation?

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___] If respondent has the medicine available use the package to complete the table below. If the medicine is not available ask respondent to identify from prompt card. Don’t know = 98 If identification not possible, ask respondent to recall medicine details. Generic name Strength in mg Brand name

[__|__] ______[__|__|__].[__]mg

[___|___] Don’t know=999.8 Manufacturer Is this drug a fixed-dose combination

1 = Yes

0 = No

8 = Don’t know

[___] Don’t know = 98

P19. Please name the medicine recommended by the government to treat severe malaria. Do not read list. Only one response allowed.

01 = Artesunate (Artesun, Larinate, Plasmotrim) ………………………………………………………………. Go to P20 02 = Artemether (Artenam, Paluther, Artesiane, Larither) ...... Go to P20 03 = Quinine...... Go to P20 04 = ACT/ACTm 05= Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem) [___|___] 06 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop) 07 = Dihydroartemisinin Piperaquine (Duo-cotecxin, P-alaxin) Go to P21 08 = Chloroquine (Sugarquin) 09 = Sulfadoxine Pyrimethamine (Fansidar, SP, Orodar, Ekelfin, Metakelfin) 96 = Other (specify): [ ______] 98 = Don’t know P20. What is the drug formulation for the recommended medicine by the government to treat severe malaria? Do not read dosage form options

01 = Tablet 04 = Syrup 07 = Drops 02 = Suppository 05 = Suspension 95 = None specified [___|___] 03 = Granule 06 = IM/IV Injection (Liquid or powder) 98 = Don’t know

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P21. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

Have you ever seen or heard of malaria RDTs? [___] 1 = Yes Go to P22 0 = No Go to P29 8 = Don’t know Go to P29

P22. Have you ever tested a client for malaria using an RDT?

1 = Yes 0 = No 8 = Don’t know [___] P23. Would you ever recommend a patient/customer take an antimalarial if a blood test using a rapid diagnostic test produced a negative test result for malaria? Read list. Record only one response.

1 = Yes, Sometimes 2 = Yes, Always [___] 3 = No, Never go to P29 8 = Don’t know go to P29 P24. Under what circumstances would you recommend a patient/customer take an antimalarial following a negative RDT test for malaria? Do not read list. Prompt “anything else” until the respondent is finished. Circle ALL responses given A When they have signs/symptoms of malaria

B When they ask for antimalarial treatment

C When they are a child

D When they are an adult

E When they are a pregnant woman

F When I do not trust/believe the test

G When I know the patient/customer

Other (specify) [______] X

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P29. What are the danger signs of severe illness in a child under 5? Do not read list. Prompt “anything else” until the respondent is finished.

Circle ALL responses given A Unable to drink /unable to breastfeed

B Vomits everything

C Convulsions

D Lethargic or unconscious

Z Don’t know

Other (specify) [______] X

P30. What would you do if a 2-year old child was brought to this outlet with the danger signs of severe illness? Do not read list. Only one response allowed.

01 = Seek advice/help from someone in this facility 02 = Treat the child in this facility

03 = Refer to a health facility (clinic, hospital) with or without treating here [___|___] 04 = Refer to a non health facility outlet (not a clinic or hospital) with or without treating here 05 = Send them away/home without medicine 06 = Send them away/home with medicine 96 = Other (specify): [______] 98 = Don’t know

Complete the audit sheet tracker on the next page then follow the instructions for ending the interview.

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Section 6: Audit Tracking Sheet

T1. Were there any antimalarial TABLETS/SUPPOSITORIES/GRANULES in stock at this outlet?

1 = Yes [___] 0 = No go to T4 8 = Don’t know go to T4

T2. Total number of TABLET/SUPPOSITORY/GRANULE audit sheets completed [___|___]

T3. Did you complete audit sheet information for all available TABLETS/SUPPOSITORIES/GRANULES?

1 = Yes, audit complete [___] 0 = No, audit not complete

T4. Were there any antimalarial NON TABLETS (Syrups, suspensions, Injectables) in stock at this outlet?

1 = Yes [___] 0 = No go to T7 8 = Don’t know go to T7

T5. Total number of NON-TABLET audit sheets completed [___|___]

T6. Did you complete audit sheet information for all available NON-TABLETS?

1 = Yes, audit complete [___] 0 = No, audit not complete

T7. Were there any RDTs in stock at this outlet?

1 = Yes [___] 0 = No go to T10 8 = Don’t know go to T10

T8. Total number of RDT audit sheets completed [___|___]

T9. Did you complete audit sheet information for all available RDT?

1 = Yes, audit complete [___] 0 = No, audit not complete

T10. COMMENTS: Reason for incomplete audit sheets (if response is no to T3, T6, or T9):

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Be sure to complete Section 7: ORS, Zinc & Amoxicillin, then to C9 and record the final status of the interview and time completed and proceed to Section X: Ending the

Interview.

Annex 7: Antimalarial Reference Table X3: Number of antimalarials audited

Public Community Private Not Private ALL Health Health For-Profit for-Profit Pharmacy Drug Store Outlets Facility Worker Facility Facility

Urban 942 143 149 3466 7703 3308 15711 Census 206 143 149 3466 2427 3307 9698 Booster 736 0 0 0 5276 0 6012 Rural 695 1000 226 2615 1088 5324 10948 Census 695 1000 226 2615 548 5324 10408 Booster 0 0 0 0 540 0 540 TOTAL 1637 1143 375 6081 8791 8631 26658 Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table X4: Quality Assured (QA ACT) and Non-Quality Assured ACTs Quality Assured ACT (QA ACT) QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Quality Assurance Policy. A QA ACT is any ACT that appeared on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy* prior to data collection, or that previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®. Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets

Apmod Adult +14 years^# Artefan 20/120 15-24kg^# Apmod Child 6-13 years# Artefan 20/120 25-34kg^# Apmod Infant 2-11 months# Artefan 20/120 35kg+ Adults^# Apmod Toddler 1-5 years# Artefan 20/120 5-14kg^# Artesun-Plus Adult +14 years# Artefan Dispersible 20/120 15-24kg^# Artesun-Plus Child 6-13 years# Artefan Dispersible 20/120 5-14kg^# Artesun-Plus Infant 2-11 months# Ipca Artemether + Lumefantrine 3-8 years^# Artesun-Plus Toddler 1-5 years^# Ipca Artemether + Lumefantrine 9-14 years^# Winthrop Adult +14 years^# Ipca Artemether + Lumefantrine < 3 years^# Winthrop Child 6-13 years^# Ipca Artemether + Lumefantrine > 14 years^# Winthrop Infant 2-11 months^# Coartem 20/120 15-25kg^# Winthrop Toddler 1-5 years^# Coartem 20/120 25-35kg^# Coartem 20/120 35kg and above^# Coartem 20/120 5-15kg^ Coartem 80/480 35kg and above# Coartem Dispersible 15-25kg^# Coartem Dispersible 5-15kg^# Combiart^# Lumartem 15kg to <25kg^# Lumartem 25kg to <35kg^# Lumartem 35kg and above^# Lumartem 5kg to <15kg^# Non-Quality Assured ACT ACTs that do not meet the definition of being quality-assured. Artesunate Mefloquine Tablets Artemether Lumefantrine Tablets

Artequin 300/375 Child# Artrin# Artequin 600/750 Adult# Aurother# Co-Malartem# Artemisinin Napthoquine Tablets Co-Mether^# Arco 125mg/50mg^# Fantem 20/120 +35kg Adult# Arco 250mg/100mg^# Laritem 80/480# Lonart^# Arterolane Piperaquine Tablets Lonart DS^# Synriam^ Lonart Forte^# Lumaren# Artesunate Mefloquine Granules Lumether^# Artequin paediatric#

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Table X4: Quality Assured (QA ACT) and Non-Quality Assured ACTs

Dihydroartemisinin Piperaquine Tablets Artemether Lumefantrine Suspension

Arteraquin^# Artemether And Lumefantrine# Co-Artemax# Co-Artesiane Pediatric^# D-Artepp^# Co-Malaren# Dipi Adult After 16 years# Co-Malartem# Duo-Cotecxin 40/320 Adults & Children Over 6 years^# Co-Mether# Duo-Cotecxin Children 5-20kg# Lonart Pediatric^# Duoquin# Malacur 40/320 Adults & Children Over 6 years# Dihydroartemisinin Piperaquine Suspension P-Alaxin^# P-Alaxin^# Ridmal 40/320#

* http://www.theglobalfund.org/en/procurement/quality/pharmaceutical ^ Product audited in the public sector # Product audited in the private sector

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Table X5: Nationally Registered ACTs

ACT registered with Country’s national drug regulatory authority and permitted for sale or distribution in country.

Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets

Apmod Adult +14 years^# Artefan 20/120 15-24kg^# Artesun-Plus Adult +14 years# Artefan 20/120 25-34kg^# Artesun-Plus Child 6-13 years# Artefan 20/120 35kg+ Adults^# Artesun-Plus Toddler 1-5 years^# Artefan 20/120 5-14kg^# Winthrop Adult +14 years^# Artefan 80/480^# Winthrop Child 6-13 years^# Ipca Artemether + Lumefantrine 3-8 years^# Winthrop Infant 2-11 months^# Ipca Artemether + Lumefantrine 9-14 years^# Winthrop Toddler 1-5 years^# Ipca Artemether + Lumefantrine < 3 years^# Ipca Artemether + Lumefantrine > 14 years^# Artemisinin Napthoquine Tablets Artrin# Arco 250mg/100mg^# Co-Mether^# Coartem 20/120 15-25kg^# Dihydroartemisinin Piperaquine Tablets Coartem 20/120 25-35kg^# Arteraquin^# Coartem 20/120 35kg and above^# Duo-Cotecxin 40/320 Adults & Children Over 6 years^# Coartem 20/120 5-15kg^ Duo-Cotecxin Children 5-20kg# Coartem Dispersible 15-25kg^# Duoquin# Coartem Dispersible 5-15kg^# P-Alaxin^# Laritem 80/480# Ridmal 40/320# Lonart^# Lonart Ds^# Artemether Lumefantrine Suspension Lonart Forte^# Co-Artesiane Pediatric^# Lumaren# Co-Mether# Lumartem 15kg To <25kg^# Lonart Pediatric^# Lumartem 25kg To <35kg^# Lumartem 35kg And Above^# Dihydroartemisinin Piperaquine Susoension Lumartem 5kg To <15kg^# P-Alaxin^# Lumether^# ^ Product audited in the public sector # Product audited in the private sector

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Table X6: Severe Malaria Treatment WHO recommends intravenous or intramuscular artesunate as first-line treatment in the management of severe falciparum malaria. If artesunate is not available, artemether in preference to quinine should be used for treating severe malaria cases. Rectal artesunate is 45 suitable for pre-referral treatment in children under 6 years of age. 44F Quinine Liquid Injection (manufacturer) Artemether Liquid Injection (manufacturer)

Falcimax-600 (Jiangsu Pengyao Pharmaceutical Co. Ltd.)^# Arcomether (Strides Arco Labs)# Quinax (Troikaa Pharmaceuticals Ltd.)# ARH-A (Lincoln Pharmaceuticals Ltd)^# Quinine 600mg (Wuhan Grand Pharmaceutical Group Co Ltd (China) Co. Ltd.)^# Artemedine (Kunming Pharmaceutical Corp.)^# Quinine Dihydrochloride (Ningbo Dahongying Pharmaceutical Co. Ltd.)^# Artemether Injection (Hebei Kaiwei Pharmaceutical Co. Ltd.)^# Quinine Dihydrochloride Injection (Zhejiang Tianfeng Pharmaceutical Factory)^# Artenam (Arenco Pharmaceutica N.V.)# Quinine Dihydrochloride Injection 600mg/2ml (Rotexmedica Gmbh Arzneimittelwerk)^# Artenam Paediatric (Arenco Pharmaceutica N.V.)# Quinine Hcl 600mg (Sterop)# Artesiane 100 (Dafra Pharma Gmbh)# Quinine Injectable Solution (Zhejiang Ruixin Pharmaceutical Co. Ltd.)^# Artesiane 20 Pediatric (Dafra Pharma Gmbh)^# Rogoquin (Zhejiang Tianfeng Pharmaceutical Factory)^# Artesiane 40 (Dafra Pharma Gmbh)# Sterile Quinine Dihydrochloride Concentrate Bp 300mg/Ml (Gland Pharma Ltd.)^# Artesiane 80 (Dafra Pharma Gmbh)^# Arti (Swiss Parenterals Pvt. Ltd.)^# Artesunate Powder Injection (manufacturer) Larither-80 (Ipca Laboratories Ltd)^# Artesun 120mg (Guilin Pharmaceutical Co. Ltd)^# Lartrm (Sakar Healthcare Pvt. Ltd.)# Artesun 30mg (Guilin Pharmaceutical Co. Ltd)^# Malasan (Pharmedic Laboratories (Pvt) Ltd.)# Artesun 60mg (Guilin Pharmaceutical Co. Ltd)^# Romether (Zhejiang Tianfeng Pharmaceutical Factory)^# Falci Care (Swiss Parenterals Pvt. Ltd.)^# Rtitas (Intas Pharmaceuticals Ltd.)^# Larinate 120 (Ipca Laboratories Ltd)^ Larinate 60 (Ipca Laboratories Ltd)^# Arteether Liquid Injection (manufacturer) Artesunate Suppository (manufacturer) ARH 150mg/2ml Injection (Lincoln Pharmaceuticals Ltd)# Gsunate 200 (Bliss Gvs Pharma Ltd)^# ARH Forte 225mg/3ml Injection (Lincoln Pharmaceuticals Ltd)# Gsunate 50 (Bliss Gvs Pharma Ltd)^# Betamotil (Ipca Laboratories Ltd)^# Plasmotrim-50 (Acino/ Mepha)^# E Mal (Themis Medicare Limited)# Troyther (Troikaa Pharmaceuticals Ltd.)^# Troyther (Troikaa Pharmaceuticals Ltd.)^# * Guidelines for the treatment of malaria, 3rd edition. WHO. Geneva: 2015. ^ Product audited in the public sector # Product audited in the private sector

45 World Health Organization. (2015). Guidelines for the treatment of malaria, 3rd edition. Geneva: WHO.

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Annex 8: RDT Reference

Table X7: Number of RDTs audited

Public Private Not Private Community ALL Health For-Profit for-Profit Pharmacy Drug Store Health Worker Outlets Facility Facility Facility Urban 155 113 18 292 228 151 957 Census 39 113 18 292 71 151 684 Booster 116 0 0 0 157 0 273 Rural 177 566 28 236 32 271 1310 Census 177 566 28 236 14 271 1292 Booster 0 0 0 0 18 0 18 TOTAL 332 679 46 528 260 422 2267 Source: ACTwatch Outlet Survey, Uganda, 2015.

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Table X8: RDT Brand Names and Manufacturers*

Brand Name Manufacturer Abon# Abon Biopharm (Hangzhou) Co. Ltd Accucare# Lab-Care Diagnostics (India) Pvt. Ltd Astel^# Astel Diagnostics Care Start^# Access Bio Inc. Clearview^# British Biocell International Ltd Diagnosticks# SSA Diagnostics & Biotech Systems Ezdx# Advy Chemical Pvt. Ltd Fastep# Polymed Therapeutics Inc First Response^# Premier Medical Corporation Ltd Humasis# Humasis Co. Ltd ICT Malaria Cassette Test Dual# ICT Diagnostics Malaria (Pf/Pv) One Step Rapid Test# Zhejiang Orient Gene Biotech Co. Ltd One Step Malaria (Pf) Whole Blood Strip# Nantong Egens Biotechnology Co. Ltd Malaria (Pf/Pv) Antibody Card Test# Shubham Diagnostics Malascan# Zephyr Biomedicals Maleriscan# Bhat Bio-Tech India Ltd Meriscreen# Meril Diagnostics Pvt. Ltd Necviparum^# Nectar Lifesciences Limited Nova Test# Atlas Link Technology Co. Ltd Onsite Rapid Test# CTK Biotech Inc. Paracheck^# Orchid Biomedical Systems Parahit# Span Diagnostics Ltd Rapitest# Orem Access Bio Inc. Rightsign# Hangzhou Biotest Biotech Co. Ltd SD Bioline^# Standard Diagnostics Inc.

* 2267 RDTs were audited. No RDT was missing brand name information (missing or don’t know) and 65 were missing manufacturer name (missing or don’t know). ^ Product audited in the public sector # Product audited in the private sector

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Annex 9. Sampling Weights

Sampling weights were applied for analysis of the Uganda 2015 outlet survey data to account for variations in probability of selection as a result of the sampling design:

1) Stratification: Disproportionate allocation stratification was used to ensure adequate sample size within the urban and rural domains to allow for domain-specific estimates. The research domains were based on national designation of urban and rural communes. A representative sample was selected within each domain.

2) One-stage cluster sampling: Sub-counties were selected from sampling frames within each domain with probability proportional to size (in Kampala, town councils, divisions and parishes were considered sub- counties). Within each sub-county, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted.

3) Booster sample – public health facilities (PHFs): The geographic area for the outlet census was extended to the county level for pharmacies and urban public health facilities. All urban public health facilities and pharmacies within counties in which the selected sub-counties were located were included in the study.

The sampling weights applied during analysis are the inverse of the probability of selection:

Where:

 Mα = estimated cluster (population size)  ΣMα = sum of estimated cluster sizes (population size) in the entire stratum  a = number of clusters selected within the stratum

Sampling weights are calculated at the cluster level and are applied to all outlets within a given cluster, irrespective of outlet type.

Market share was calculated using the full census data at the sub-country level only (i.e. the booster sample was not included in market share calculations). Sub-county sampling weights were created using the sampling weight formula (Wi), where:

 Mα = estimated sub-county population size  ΣMα = sum of estimated sub-county population size in the entire stratum  a = number of sub-counties selected within the stratum

The sub-county sampling weights were applied to all other indicators in the report for all outlet types with the exception of pharmacies and urban public health facilities. Given that pharmacies and urban public health facilities were included in the sample through a county-wide census, the weights applied to pharmacies and urban public health facilities for all indicators other than market share were calculated using the sampling weight formula, where:

 Mα = estimated county population size  ΣMα = sum of estimated county population size in the entire stratum  a = number of counties selected within the stratum

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The population estimates used to select sub-counties with PPS and to create sampling weights were obtained from the 2014 Housing and Population Census. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size.

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Annex 10: Indicator Definitions

Table 1: Availability of antimalarials, among all screened outlets

Table 1 reports the proportion of all outlets enumerated that had any antimalarial in stock at the time of the survey visit. Antimalarial availability is reported among all outlets as well as among individual outlet types, all public outlets, and all private outlets. Availability is reported for any antimalarial as well as specific types of antimalarial medicines.

Numerator Number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Denominator Number of outlets screened.

Calculation Numerator divided by denominator.

Handling missing All screened outlets will contribute to the denominator. This includes outlets that were eligible values for interview (including antimalarial audit) but: 1) were not interviewed; or 2) the interview was partially completed.

Notes and Given partial or non-completion of interviews among eligible outlets and the inclusion of these considerations outlets in the denominator, these availability indicators can be considered conservative estimates of antimalarial availability.

Table 2: Availability of antimalarials, among outlets stocking at least one antimalarial

Table 2 reports the proportion of antimalarial-stocking outlets with specific antimalarial in stock at the time of the survey visit. Antimalarial availability is reported among all outlets as well as among individual outlet types, all public outlets, and all private outlets. Availability is reported for any antimalarial as well as specific types of antimalarial medicines.

Denominator Number of outlets with at least 1 antimalarial audited.

Calculation Numerator divided by denominator.

Handling missing All outlets with at least one antimalarial recorded in the antimalarial audit sheet will contribute values to the denominator. This includes outlets where the interview was not fully completed (partial interview).

Notes and Given partial completion of interviews among antimalarial-stocking outlets and the inclusion of considerations these outlets in the denominator, these availability indicators can be considered conservative estimates of antimalarial availability.

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Table 3: Types of quality-assured and Non-Quality Assured ACTs

Table 3 reports the types of quality-assured (QA) and Non-Quality Assured (non-QA) ACTs audited in the public and private sector, including generic name and formulation.

Numerator By sector, the number of QA and non-QA ACTs audited within each generic and formulation category (e.g. number of QA artemether lumefantrine tablets audited in the public sector).

Denominator By sector, total number of QA and non-QA ACTs audited.

Calculation Numerator divided by the denominator within QA and non-QA ACTs for each sector.

Handling missing By definition, the generic name of all ACTs is known. ACTs with missing formulation information values are excluded.

Notes and considerations

Table 4: Antimalarial market composition

Table 4 reports the distribution of outlet types among outlets with at least one antimalarial in stock on the day of the survey.

Numerator By outlet type, the number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Denominator Total number of outlets with any antimalarial in stock at the time of the survey visit, as confirmed by presence of at least one antimalarial (defined as a medicine with antimalarial ingredients) recorded in the antimalarial audit section.

Calculation Numerator for each outlet type divided by the denominator.

Handling missing All outlets with at least one antimalarial recorded in the antimalarial audit sheet will contribute values to the indicator. This includes outlets where the interview was not fully completed (partial interview).

Notes and Market composition is calculated among outlets located within the representative sample of considerations clusters, and excludes the booster sample.

Table 5: Price of antimalarials

Table 5a provides the median price of an adult equivalent treatment dose (AETD, see Annex 11) for select tablet formulation types of antimalarials across outlet types. The inter-quartile range (IQR) is provided as a measure of dispersion.

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Calculation Median antimalarial AETD (see Annex 11) price in US dollars with inter-quartile range (25th and 75th percentiles).

Handling missing Antimalarials with missing price information are excluded from the median price calculation. values

Notes and Price in US dollars is calculated based on exchange rates available from www.oanda.com using considerations the historical exchange rates tool. The average exchange rate over the entire data collection period is used for converting local currency captured during data collection to US dollars.

A. Table 5b also provides the median price of two pre-packaged QA ACT therapies: pediatric appropriate for a 10kg child (2 years of age), and adult appropriate for a 60kg adult. The inter-quartile range (IQR) is provided as a measure of dispersion.

Calculation Median pre-packaged therapy price in US dollars with inter-quartile range (25th and 75th percentiles.

Handling missing Antimalarials with missing price information are excluded from the median price calculation. values

Table 6: Availability of malaria blood testing among antimalarial-stocking outlets

Table 6 reports the proportion of antimalarial-stocking outlets that had malaria blood testing available. Testing availability is reported among all outlets as well as among individual outlet types, all public outlets, and all private outlets. Availability is reported for any blood test as well as specific test types: microscopy and rapid diagnostic test (RDT) including quality-assured RDTs. Quality-assured RDTs are RDTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Quality Assurance Policy.

Numerator Number of outlets with malaria blood testing available (any, microscopy, RDT, QA RDT).

Denominator Number of outlets with any antimalarial in stock at the time of the survey visit or reportedly stocked any antimalarial in the previous three months.

Calculation Numerator divided by denominator.

Handling missing  Antimalarial-stocking outlets with missing information about both availability of microscopy values and availability of RDTs are excluded from malaria testing indicators. The number of such outlets is provided in a footnote.  Outlets with partial information about availability of blood testing (information about microcopy or RDTs) are included in the denominator of the indicator “any blood testing available.” The number of such outlets is provided in a footnote.  Indicators for RDT and microscopy availability exclude outlets with missing availability information respectively (i.e. outlets missing information about microscopy availability are excluded from the microscopy indicator).

Notes and Survey inclusion criteria extended to outlets providing blood testing but not stocking considerations antimalarials (“diagnosis/testing-only outlets”). These outlets are excluded from this availability table.

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Table 7: Malaria blood testing market composition

Table 7 reports the distribution of outlet types among outlets with malaria blood testing (microscopy or RDT) available on the day of the survey.

Numerator By outlet type, the number of outlets with malaria blood testing (microscopy or RDT) available at the time of the survey visit, as confirmed by presence of at least one RDT recorded in the RDT audit section or microscopy available indicated in the diagnostics section.

Denominator Total number of outlets with malaria blood testing available at the time of the survey visit, as confirmed by presence of at least one RDT recorded in the RDT audit section or microscopy available indicated in the diagnostics section.

Calculation Numerator for each outlet type divided by the denominator.

Handling missing All outlets with at least one RDT recorded in the RDT audit sheet or microscopy available values recorded in the diagnostics section will contribute to the indicator. This includes outlets where the interview was not fully completed (partial interview).

Notes and Market composition is calculated among outlets located within the representative sample of considerations clusters, and excludes the booster sample.

Table 8: Price of malaria blood testing

Table 8 reports the median price of blood testing to consumers including any consultation or service fees. The inter- quartile range (IQR) is provided as a measure of dispersion.

Calculation Median total blood test price in US dollars with inter-quartile range (25th and 75th percentiles).

Handling missing Microscopy-stocking outlets that are missing information about price of microscopy are excluded values from this indicator. Audited RDTs with missing information about price of testing are excluded from this indicator.

Table 9: Antimalarial market share

Antimalarial market share is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/distributed in the previous week. Expressed as a percentage, market share is the amount of a specific antimalarial sold/distributed by a specific outlet type relative to the entire antimalarial market (all antimalarial types sold/distributed by all outlet types). Totals are reported per antimalarial medicine type and per outlet type. Across antimalarial medicine types and outlet types, percentages in the entire table sum to 100% (the total market).

Numerator Number of AETDs sold/distributed for a specific antimalarial drug category and outlet type.

Denominator Total number of AETDs sold/distributed.

Calculation Numerator divided by denominator.

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Handling missing AETDs sold/distributed are calculated among audited medicines with complete and consistent values information. Antimalarials with incomplete or inconsistent information among key variables that define AETD sold/distributed (active ingredients, strength, formulation, package size, amount sold/distributed) are excluded from the calculation.

Notes and See Annex 11 for a description of AETD calculation. considerations

Table 10: Antimalarial market share across outlet type

Antimalarial market share across outlet type is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by antimalarial type within each outlet type as a percentage of all AETDs sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific antimalarial sold/distributed relative to the entire antimalarial market segment for the specified outlet type (all antimalarial types sold/distributed by the specific outlet type). Totals are reported per antimalarial medicine type for each outlet type. Across antimalarial medicine types within each outlet type, percentages sum to 100%.

Numerator Number of AETDs sold/distributed for a specific antimalarial drug category within the specified outlet type.

Denominator Total number of AETDs sold/distributed within the specific outlet type.

Calculation Numerator divided by denominator.

Notes and See Annex 11 for a description of AETD calculation. considerations

Table 11: Malaria blood testing market share

Malaria blood testing market share is the number of malaria blood tests reportedly sold or distributed in the previous week by outlet type and malaria blood test type (RDT, microscopy) as a percentage of all malaria blood tests sold/distributed in the previous week. Expressed as a percentage, market share is the number of a specific malaria blood test type by a specific outlet type relative to the entire malaria blood testing market (all malaria blood tests sold/distributed by all outlet types). Totals are reported per test type and per outlet type. Across malaria blood test types and outlet types, percentages in the entire table sum to 100% (the total market).

Numerator Number of malaria blood tests sold/distributed for a specific blood test type (RDT, microscopy) and outlet type.

Denominator Total number of malaria blood tests sold/distributed.

Calculation Numerator divided by denominator.

Handling missing Malaria blood tests sold/distributed are calculated among audited RDTs and microscopy services values with complete and consistent information. RDTs and microscopy services with incomplete or inconsistent information about the amount sold/distributed) are excluded from the calculation.

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Notes and Records and/or recall of testing with microscopy versus malaria RDT may differ within a given considerations outlet, introducing an unquantifiable bias in estimating total tests performed.

Table 12: Malaria blood testing market share across outlet type

Malaria blood testing market share across outlet type is the number of malaria blood tests reportedly sold or distributed in the previous week by blood test type within each outlet type as a percentage of all blood tests sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific malaria blood test sold/distributed relative to the entire blood testing market segment for the specified outlet type (all malaria tests sold/distributed by the specific outlet type). Totals are reported per test type for each outlet type. Across malaria blood test types within each outlet type, percentages sum to 100%.

The market share for each RDT manufacturer is also reported across outlet type. Within each outlet type, the number of RDTs for a specific manufacturer sold/distributed relative to all RDTs distributed within that outlet type is reported as a percentage. Totals for RDT market share across all manufacturers’ sums to 100% within each outlet type.

Numerator Number of malaria blood tests sold/distributed for a specific blood test type (RDT, microscopy), or number of malaria RDTs sold/distributed for a specific manufacturer, within the specified outlet type.

Denominator Total number of malaria blood tests/RDTs sold/distributed within the specific outlet type.

Calculation Numerator divided by denominator.

Notes and Records and/or recall of testing with microscopy versus malaria RDT may differ within a given considerations outlet, introducing an unquantifiable bias in estimating total tests performed.

Table 13: Provider case management knowledge and practices

Table 13 reports key indicators of provider case management knowledge and practices. These include referral practices for severe malaria; and self-reported practices for managing clients who test negative for malaria.

Numerator A. Referral: respondents who indicated that they would refer to a health facility (response option #3). Note this numerator excludes providers located in a public or private health facility. B. Recommends antimalarials to test-negative clients: respondents who indicated “yes, always,” or “yes sometimes.” C. Circumstances for recommending an antimalarial: individual indicators for the most common responses provided to this open-ended question. Note this numerator excludes providers who did not respond to the previous question about recommending antimalarials to test- negative clients with “yes always” or “yes sometimes.”

Denominator A. Referral: respondents who provided a response to this question, including “don’t know.” Note this denominator excludes providers located in a public or private health facility. B. Recommends antimalarials to test-negative clients: respondents who provided a response to this question, including “don’t know.” C. Circumstances for recommending an antimalarial: respondents who provided at least 1

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response to this question, including “don’t know” (i.e. at least 1 variable in this series is non- missing). Note this denominator excludes providers who did not respond to the previous question about recommending antimalarials to test-negative clients with “yes always” or “yes sometimes.”

Calculation Numerator divided by denominator.

Handling missing A. Providers missing a response to this question will be excluded from the indicator. values B. Providers missing a response to this question will be excluded from the indicator. C. This indicator is assessed using an open-ended multiple response option question. Providers with at least one non-missing response in the variable series for this question will be included in the indicator. Among these sets of responses, missing will be treated as not mentioned.

Notes and In some cases, multiple providers were interviewed at one outlet. A provider with responsibilities considerations related to diagnosis may have responded to questions about malaria diagnosis and diagnostics (indicators B and C in Table 9), while a different provider responsible for prescribing and/or dispensing medicines may have responded to questions about danger signs of severe illness and referral for severe malaria (indicator A in Table 8). In all cases, the questions assessing provider knowledge and practices were administered only one time per outlet. As such, indicators are tabulated at the outlet level.

Table 14: Provider antimalarial treatment knowledge and practices

Table 14 reports key indicators of provider antimalarial treatment knowledge and practices. These include knowledge of the first-line treatment; knowledge of the first-line treatment dosing regimen for adults and children; citing ACT as most effective to treat malaria in adults and children; and citing ACT as most commonly recommended by the provider to manage malaria in adults and children.

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Numerator A. State first-line: providers who responded to p17 with a generic or brand name consistent with a national first-line treatment, or responded to p17 with “ACT,” or “ACTm” and in p18 provided a generic or brand name consistent with a national first-line treatment. In other words, providers must specifically name the first-line treatment using generic or brand name language in either p17 or p18. B. First-line regimen, adult: providers who correctly stated the first-line generic ingredients and strengths in p18, and correctly stated: number of days, times per day, and tablets per dose to be taken. C. ACT most effective, adult & child: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect. D. ACT most often recommended, adult & child: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect.

Denominator A. State first-line: All providers who responded to p17 – please name the first-line medicine. B. First-line regimen, adult: All providers who responded to p17 (starting the series on first-line knowledge). C. ACT most effective, adult & child: All providers who responded to p13/14, including providers who responded with “don’t know,” who provided names of non-antimalarial medicines, and who responded with more than one antimalarial medicine not intended to be used as combination therapy. D. ACT most often recommended, adult & child: All providers who responded to p13/14, including providers who responded with “don’t know,” who provided names of non- antimalarial medicines, and who responded with more than one antimalarial medicine not intended to be used as combination therapy.

Calculation Numerator divided by denominator.

Handling missing A. Providers missing a response to this question will be excluded from this indicator. values B. Providers with partial information for the regimen questions will be included in the denominator (i.e. missing treated as not mentioned). C. Providers missing a response to this question will be excluded from the indicator. D. Providers missing a response to this question will be excluded from the indicator.

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Annex 11. Adult Equivalent Treatment Dose (AETD)

Definition

Antimalarial medicines are manufactured using a variety of active pharmaceutical ingredients, dosage forms, strengths, and package sizes. ACTwatch uses the adult equivalent treatment dose (AETD) as a standard unit for price and sale/distribution analyses. One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat an adult weighing 60 kilograms (kg). For each antimalarial generic, the AETD is defined as the number of mg recommended in treatment guidelines for uncomplicated malaria in areas of low drug resistance issued by the WHO. Where WHO treatment guidelines do not cover a specific generic, the AETD is defined based on peer-reviewed research or the product manufacturer’s recommended treatment course for a 60kg adult. Table X9 lists AETD definitions used in this report.

While it is recognized that the use of AETDs may over-simplify and ignore many of the complexities of medicine consumption and use, this analytical approach was selected because it standardizes medication dosing across drug types and across countries (which may sometimes vary) thus permitting comparisons on both prices and volumes calculated on the basis of an AETD.

Additional considerations:

 Where combination therapies consist of two or more active antimalarial ingredients packaged together (co- formulated or co-blistered), the strength of only one principal ingredient issued. The artemisinin derivative is used as the principal ingredient for ACT AETD calculations.

 Co-blistered combinations are generally assumed to be 1:1 ratio of tablets unless otherwise documented during fieldwork or through manufacturer websites.

 Sulfamethoxpyrazine-pyrimethamine is assumed to have the same full course adult treatment dose as sulfadoxine-pyrimethamine.

Calculation

Information collected on drug strength and unit size as listed on the product packaging was used to calculate the 46 total amount of each active ingredient found in the package. The number of AETDs in a unit was calculated.45F The number of AETDs in a monotherapy is calculated by dividing the total amount of active ingredient contained in the unit by the AETD (i.e. the total number of mg required to treat a 60kg adult). The number of AETDs for a combination therapy was calculated by dividing the total amount of the active ingredient that was used as the basis for the AETD by the AETD.

46 The unit is dependent on the drug dosage form. The unit for antimalarials in tablet, suppository, or granule form is the package. The unit for injectable antimalarials is the ampoule. The unit for syrup and suspension antimalarials is the bottle.

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Table X9: Adult Equivalent Treatment Dose Definitions

Antimalarial Generic Dose used for calculating 1 [Ingredient used for AETD AETD (mg required to treat a Source mg dose value] 60kg adult)

Amodiaquine 1800mg WHO Model Formulary, 2008 Arteether / Artemotil 1050mg WHO Use of Antimalarials, 2001 Artemether 960mg WHO Use of Antimalarials, 2001 Artemether-Lumefantrine 480mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artemether] Artemisinin-Naphthoquine 2400mg WHO Use of Antimalarials, 2001 [Artemisinin] Arterolane-Piperaquine 450mg WHO CM Guidelines, 2015 [Arterolane] Artesunate 960mg WHO Use of Antimalarials, 2001 Artesunate-Amodiaquine 600mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artesunate] Artesunate-Mefloquine 600mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artesunate] Atovaquone-Proguanil 3000mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Atovaquone] Chloroquine 1500mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 Dihydroartemisinin- Piperaquine 360mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Dihydroartemisinin] Manufacturer Guidelines Hydroxychloroquine 2000mg (Plaquenil – Sanofi Aventis) 1000mg Mefloquine WHO Model Formulary, 2008

Primaquine 45mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 Quinine 10408mg WHO Model Formulary, 2008 Quinine-Sulfadoxine- Pyrimethamine 10408mg WHO Model Formulary, 2008 [Quinine] Sulfadoxine-Pyrimethamine 1500mg WHO Model Formulary, 2008

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Annex 12: Antimalarial Volumes

Table X10: Antimalarial volumes, by outlet type Public Community Private Not ALL Private TOTAL AETDs sold or distributed in the Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store ALL Outlets Private previous week by outlet type and Facility Worker Facility For-Profit Facility antimalarial type:* % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) 280053.1 24097.5 19792.0 323942.6 86839.7 57753.0 201713.7 346306.3 670248.9 1. Any ACT (192433.2, (11178.0, (11926.7, (232425.4, (67920.1, (13990.6, (150186.0, (251875.6, (533608.8, 367673.1) 37017.0) 27657.3) 415459.8) 105759.3) 101515.3) 253241.4) 440737.1) 806889.1) 279697.4 24091.5 18068.7 321857.6 62336.3 34028.9 172825.8 269191.0 591048.6 AL  (192138.5, (11170.2, (10917.2, (230373.5, (49826.4, (14771.4, (131307.9, (209986.8, (476214.2, 367256.3) 37012.9) 25220.1) 413341.6) 74846.2) 53286.3) 214343.7) 328395.2) 705882.9) 133.5 0.0 332.8 466.3 11066.2 6685.1 16365.5 34116.8 34583.1 ASAQ (5892.4, (0.0, (9408.7, (17476.8, (17890.5, - - - (0.0, 1176.0) 16239.9) 15484.3) 23322.3) 50756.7) 51275.7) 222.2 6.0 1296.6 1524.8 12931.9 15118.2 11486.1 39536.3 41061.0 DHA PPQ (8894.0, (0.0, (4436.1, (16359.0, (17869.8, - - (0.0, 3615.4) (0.0, 3645.9) 16969.8) 31002.3) 18536.2) 62713.5) 64252.3) 279278.7 24091.5 18021.3 321391.5 56433.3 32126.6 160315.6 248875.5 570267.0 Quality Assured ACT (QA ACT) (191557.1, (11170.2, (10872.2, (229750.4, (44875.5, (9565.3, (121771.9, (191706.8, (455455.3, 367000.3) 37012.9) 25170.4) 413032.7) 67991.1) 54687.8) 198859.3) 306044.2) 685078.7) 8706.1 5092.7 5077.6 18876.4 50106.5 31435.2 146804.3 228346.0 247222.4 QA ACT with the “green leaf” (727.5, (1473.6, (1938.8, (10334.9, (40072.9, (9205.1, (110423.7, (176023.8, (195170.6, logo 16684.7) 8711.9) 8216.4) 27417.9) 60140.2) 53665.2) 183184.8) 280668.2) 299274.1) 270572.7 18998.8 12943.7 302515.2 6204.6 691.4 13148.8 20044.8 322559.9 QA ACT without the “green (182467.1, (6338.0, (6223.7, (212221.0, (2920.0, (192.4, (6552.9, (11000.7, (229120.7, leaf” logo 358678.2) 31659.6) 19663.7) 392809.3) 9489.1) 1190.4) 19744.7) 29088.9) 415999.1) 774.4 6.0 1770.7 2551.1 30406.4 25626.4 41398.0 97430.9 99981.9 Non-Quality Assured ACT (363.2, (20562.6, (4051.9, (24690.6, (55475.7, (58099.3, - - (0.0, 3902.6) 4738.9) 40250.2) 47200.9) 58105.4) 139386.0) 141864.6) 279068.5 9555.9 19147.5 307771.8 74526.6 49440.3 160168.2 284135.1 591906.9 Nationally Registered ACT (191350.4, (1807.9, (11308.5, (218343.9, (57096.8, (10670.5, (116632.4, (199877.4, (466971.2, 366786.6) 17303.9) 26986.4) 397199.8) 91956.4) 88210.0) 203704.0) 368392.8) 716842.7) 100882.6 48.8 10005.9 110937.3 45232.2 24036.6 99277.1 168545.9 279483.2 2. Any non-artemisinin (39463.3, (4729.5, (49709.4, (28548.1, (8495.0, (77617.1, (130149.8, (205869.2, therapy 162302.0) - 15282.2) 172165.2) 61916.4) 39578.2) 120937.2) 206942.1) 353097.2) 67956.9 48.8 8002.2 76008.0 30379.3 15353.0 66033.5 111765.8 187773.8 Sulfadoxine-Pyrimethamine (42697.4, - (3555.4, (50535.2, (19560.7, (4521.5, (51544.1, (87024.2, (150766.7,

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Table X10: Antimalarial volumes, by outlet type Public Community Private Not ALL Private TOTAL AETDs sold or distributed in the Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store ALL Outlets Private previous week by outlet type and Facility Worker Facility For-Profit Facility antimalarial type:* % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) 93216.5) 12449.1) 101480.8) 41198.0) 26184.5) 80523.0) 136507.5) 224781.0) 32522.5 0.0 1658.5 34181.0 8330.0 3176.6 22345.3 33851.9 68032.9 Oral Quinine (0.0, (533.7, (0.0, (4754.8, (17.3, (16411.4, (24897.2, (11441.4, 89407.7) - 2783.2) 90733.4) 11905.2) 6335.9) 28279.3) 42806.7) 124624.4) 0.0 0.0 0.0 0.0 3011.6 4199.9 6649.5 13861.0 13861.0 Other non-artemisinin therapy ^ (913.3, (2601.6, (6566.6, (6566.6, - - - - 5109.9) (0.0, 9503.9) 10697.3) 21155.3) 21155.3) 3. Oral artemisinin 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 monotherapy ------4542.3 3.6 494.1 5040.0 3898.9 2843.5 2057.4 8799.9 13839.9 4. Non-oral artemisin (2102.7, (2528.5, (2082.0, (825.3, (3433.0, (7977.8, monotherapy 6982.0) (0.0, 9.6) (86.5, 901.8) 7551.6) 5715.8) (0.0, 5717.0) 3289.5) 14166.8) 19702.0) 2945.4 0.0 175.6 3120.9 1093.2 715.8 376.1 2185.1 5306.0 Artesunate IV/IM # (1593.1, (1660.3, (62.4, (2589.0, 4297.7) - (13.1, 338.0) 4581.6) 2124.0) (0.0, 1672.9) (0.0, 829.8) (0.0, 4529.6) 8023.1) 385478.1 24149.9 30292.0 439919.9 135970.8 84633.1 303048.2 523652.2 963572.1 OUTLET TYPE TOTAL*** (263050.5, (11241.4, (19103.4, (314344.2, (103808.3, (25513.7, (236595.6, (394793.2, (773764.5, 507905.6) 37058.4) 41480.5) 565495.7) 168133.4) 143752.5) 369500.9) 652511.1) 1153379.8) *A total of 74,749.61.114 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation.  At the time of the 2013 ACTwatch outlet survey artemether lumefantrine was Country's first line treatment for uncomplicated malaria. A total of 20,138 antimalarials were audited. Of these, 566 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Uganda, 2015