Benin 2011 Outlet Survey Full Report

Evidence for Malaria Medicines Policy

Outlet Survey Republic of Benin 2011 Survey Report

Country Program Coordinator Principal Investigator Cyprien Zinsou Dr. Kathryn O’Connell Association Béninoise pour le Marketing Social ACTwatch, Malaria Control & Child Survival Department Lot 919 Immeuble Montcho Population Services International Sikècodji ‐ Cotonou Regional Technical Office Republic of Benin Whitefield Place, School Lane, Westlands Phone: + 229 21327713/14 P.O. Box 14355‐00800 Nairobi, Kenya Fax: + 229 21328200 Phone: + 254 20 4440125/6/7/8 Email: czinsou@abms‐bj.org Email: [email protected]

Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation. This study was implemented by Population Services International (PSI).

ACTwatch’s Advisory Committee:

Mr. Suprotik Basu Advisor to the UN Secretary General's Special Envoy for Malaria Mr. Rik Bosman Supply Chain Expert, Former Senior Vice President, Unilever Ms. Renia Coghlan Global Access Associate Director, Medicines for Malaria Venture (MMV) Dr. Thom Eisele Assistant Professor, Tulane University Mr. Louis Da Gama Malaria Advocacy & Communications Director, Global Health Advocates Dr. Paul Lalvani Executive Director, RaPID Pharmacovigilance Program Dr. Ramanan Laxminarayan Senior Fellow, Resources for the Future Dr. Matthew Lynch Project Director, VOICES, Johns Hopkins University Centre for Communication Dr. Bernard Nahlen Deputy Coordinator, President's Malaria Initiative (PMI) Dr. Jayesh M. Pandit Head, Pharmacovigilance Department, Pharmacy and Poisons Board‐Kenya Dr. Melanie Renshaw Advisor to the UN Secretary General's Special Envoy for Malaria Mr. Oliver Sabot Vice‐President, Vaccines Clinton Foundation Ms. Rima Shretta Senior Program Associate, Strengthening Pharmaceutical Systems Program, Dr. Rick Steketee Science Director, Malaria Control and Evaluation Partnership in Africa (MACEPA) Dr. Warren Stevens Health Economist Dr. Gladys Tetteh CDC Resident Advisor, President’s Malaria Initiative‐Kenya Prof. Nick White, OBE Professor of Tropical Medicine, Mahidol and Oxford Universities Prof. Prashant Yadav Professor of Supply Chain Management, MIT‐Zaragoza International Logistics Dr. Shunmay Yeung Paediatrician & Senior Lecturer, LSHTM

The following individuals contributed as follows to the research study in Benin:

Chérifatou Bello National Malaria Control Programme, MOH/Benin, (ACTwatch focal point within Adjibabi the Ministry of Health) assisted with advocacy.

Cyprien Zinsou Monitoring and Evaluation Director; ACTwatch Country Program Coordinator, ABMS/Benin, oversaw all aspects of implementation and management of the survey.

Ghyslain Guedegbe Chef Service ACTwatch, ABMS/Benin, assisted the Country Program Coordinator with the coordination and facilitation of trainings, data collection, and data entry.

Aristide Hontonou Chef Service Etudes Qualitatives, ABMS/Benin, assisted with the facilitation of trainings and data collection.

Njara Rakotonirina Maternal and Child Health Director, ABMS/Benin, (PSI focal point for NMCP activity) assisted with advocacy and interpretation of results.

Hellen Gatakaa Senior Research Associate, ACTwatch Central, provided overall guidance on the analysis and construction of indicators.

Stephen Poyer Research Associate, ACTwatch Central, assisted with the facilitation of trainings, data collection, and provided guidance on data quality; conducted analysis on the data and compiled the report.

Dr. Kathryn O’Connell Principal Investigator, ACTwatch Central, provided technical guidance on the study.

Tanya Shewchuk Project Director, ACTwatch Central, provided project oversight.

The ACTwatch Group is comprised of the following individuals:

PSI ACTwatch Central Tanya Shewchuk, Project Director; Dr Kathryn O’Connell, Principal Investigator; Hellen Gatakaa, Senior Research Associate; Stephen Poyer, Illah Evance, Julius Ngigi, Mitsuru Toda, Research Associates; Meghan Bruce, Policy Advocate and Communications Specialist.

PSI ACTwatch Country Cyprien Zinsou, ABMS/Benin; Sochea Phok, PSI/Cambodia; Dr. Louis Akulayi, Program Coordinators SFH/DRC; Jacky Raharinjatovo, PSI/Madagascar; Ekundayo Arogundade, SFH/Nigeria; Peter Buyungo, PACE/Uganda; Felton Mpasela, SFH/Zambia.

LSHTM Dr. Kara Hanson, Principal Investigator; Dr. Catherine Goodman, Benjamin Palafox, Sarah Tougher, Edith Patouillard, Immo Kleinschmidt, co‐investigators.

Suggested citation:

ACTwatch Group and Association Béninoise pour le Marketing Social (ABMS)/Benin. (2011). Benin Outlet Survey Report 2011. Population Services International: DC. Available from: www.actwatch.info

Table of Contents

LIST OF ACTWATCH TABLES ...... II

LIST OF FIGURES ...... II

GENERAL DEFINITIONS ...... III

CLASSIFICATION OF ACTS ...... V

LIST OF ABBREVIATIONS ...... VIII

EXECUTIVE SUMMARY ...... 1 Overview ...... 1 Key findings ...... 2

BACKGROUND ...... 6 Overview of the ACTwatch Research Project ...... 6 Country background ...... 7

METHODS ...... 12

RESULTS ‐ OUTLET SURVEY ...... 18 Characteristics of the sample ...... 18

ADDITIONAL TABLES ...... 30

REFERENCES ...... 31

APPENDICES ...... 32 ACTs classified as quality assured ...... 32 Nationally registered ACTs ...... 33 Final sample ...... 35 Survey team ...... 37 Description of outlet types visited for this survey ...... 38 Questionnaire ...... 41

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List of ACTwatch Tables

Table A.1: Availability of antimalarials, by outlet type ...... 19 Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type ...... 20 Table A.3: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type ...... 23 Table A.4: Price of antimalarials, by outlet type ...... 24 Table A.5: Affordability of antimalarials, by outlet type ...... 25 Table A.6: Availability of diagnostic tests and cost to patients, by outlet type ...... 26 Table A.8: Provider knowledge, by outlet type ...... 27 Table A.9: Provider perceptions, by outlet type ...... 28 Table B.1: Market share by antimalarial category within each outlet type ...... 30

List of Figures

Figure 1. Availability of antimalarials by outlet type ...... 2 Figure 2. Relative distribution of outlet types stocking antimalarials ...... 3 Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock ...... 3 Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests .... 4 Figure 5. Median price of a tablet AETD antimalarial treatment in the private sector ...... 4 Figure 6. Market share of AETDs sold/distributed in the past week (7 days), within outlet types ...... 5 Figure 7. Provider knowledge of recommended first‐line treatment and dosing regimens ...... 5 Figure 8: Location of Benin ...... 7

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General Definitions

Term Definition Adult Equivalent An AETD is the number of milligrams (mg) of an antimalarial drug needed Treatment Dose (AETD) to treat a 60 kg adult.

Antimalarial Any medicine recognized by the WHO for the treatment of malaria. Medicines used solely for the prevention of malaria were excluded from analysis in this report.

Antimalarial The simultaneous use of two or more drugs with different modes of combination therapy action to treat malaria.

Artemisinin‐based An antimalarial that combines artemisinin or one of its derivatives with Combination Therapy an antimalarial or antimalarials of a different class. (ACT) Refer to Combination Therapy (below).

Artemisinin An antimalarial medicine that has a single active compound, where this monotherapy active compound is artemisinin or one of its derivatives.

Artemisinin and its Artemisinin is a plant extract used in the treatment of malaria. The most derivatives common derivatives of artemisinin used to treat malaria are artemether, artesunate, and dihydroartemisinin.

Booster Sample A booster sample is an extra sample of units (in this case, outlets) of a type not adequately represented in the main survey, but which are of special interest. In this survey, public health facilities (PHFs) and pharmacies were targeted by a booster sample. The booster sample of public health facilities aimed to enumerate all PHFs in the commune in which a selected arrondissement fell. The booster sample of pharmacies aimed to enumerate all pharmacies in all departments of Benin (i.e. to conduct a full census of all registered pharmacies in the country).

Censused An arrondissement where field teams conducted a full census of all arrondissement outlets with the potential to sell antimalarials.

Cluster The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit determined by the Ministry of Health (MOH) that host a population size of approximately 10,000 to 15,000 inhabitants. These units frequently are defined by geographical, health, or political boundaries, and are based around wards. In Benin, they were defined as arrondissements.

Combination therapy The use of two or more classes of antimalarial drugs/molecules in the treatment of malaria that have independent modes of action.

Dosing/treatment The posology or timing and number of doses of an antimalarial used to regimen treat malaria. This schedule often varies by patient weight.

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Enumerated Outlets Outlets that were visited by a member of one of the field teams and for which, at minimum, basic descriptive information was collected.

First‐line treatment The government recommended treatment for uncomplicated malaria. Benin’s first‐line treatment for malaria is artemether‐lumefantrine (AL) 20mg/120mg.

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.

Nationally registered ACTs registered with a country’s national drug regulatory authority and ACTs permitted for sale or distribution in‐country. Each country determines its own criteria for placing a drug on its nationally registered listing.

Non‐artemisinin An antimalarial treatment that does not contain artemisinin or any of its therapy derivatives.

Outlet Any point of sale or provision of a commodity to an individual. Outlets are not restricted to stationary points of sale and may include mobile units or individuals. Refer to the annex for a description of the outlet types visited for this survey.

Oral artemisinin Artemisinin or one of its derivatives in a dosage form with an oral route monotherapy of administration. These include tablets, suspensions, and syrups and exclude suppositories and injections.

Rapid‐Diagnostic Test A test used to confirm the presence of malaria parasites in a patient’s (RDT) for malaria bloodstream.

Screened An outlet that was administered the screening questions (S2 and S3) of the outlet survey questionnaire (see Screening criteria).

Screening criteria The set of requirements that must be satisfied before the full questionnaire is administered. In this survey an outlet met the screening criteria if (1) they had antimalarials in stock at the time of the survey visit (S2), or (2) they report having stocked them in the past three months (S3).

Second‐line treatment The government recommended second‐line treatment for uncomplicated malaria. Benin’s second‐line treatment for malaria is quinine. Second‐line treatment indicators include all dosage forms.

Treatment/dosing The posology or timing and number of doses of an antimalarial used to regimen treat malaria. This schedule often varies by patient weight.

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Classification of ACTs

Quality assured ACTs A quality‐assured product must be WHO pre‐qualified and/or (QAACT) authorized for marketing by a Stringent Drug Regulatory Authority. Products that have not yet been WHO pre‐qualified or approved by a Stringent Drug Regulatory Authority must be evaluated and recommended for use by an independent panel of technical experts hosted by World Health Organisation’s Department for Essential Medicines and Pharmaceutical Policies (GFATM, 2010). Quality assured ACTs comply with the Quality Assurance Policy of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Brands included in this category and audited during data collection are:

Artefan 20mg/120mg (5‐14kg; 35+kg) Artemether + Lumefantrine 20mg/120mg (Ipca Laboratories Ltd) Coartem 20mg/120mg (5‐15kg; 15‐25kg; 25‐35kg; 35+kg) Coartem Dispersible 20mg/120mg (5‐15kg; 15‐25kg) Lumartem 20mg/120mg (5‐15kg; 15‐25kg; 25‐35kg; 35+kg) Artesunate + Amodiaquine 50/153mg (Ipca Laboratories Ltd) Coarsucam (Nourrisson ; Petit Enfant ; Enfant ; Adulte) Winthrop (Nourrisson ; Petit Enfant ; Enfant ; Adulte)

First‐line quality Government recommended first‐line treatments for uncomplicated assured ACTs (FAACT): malaria that appear on the WHO list of approved ACTs or the UNICEF procurement list. Brands included in this category and audited during data collection are:

Non first‐line quality ACTs that are not the government’s recommended first‐line treatment assured ACTs (NAACT): for uncomplicated malaria, but which do appear on the WHO list of approved ACTs or the UNICEF procurement list. Brands included in this category and audited during data collection are:

Artesunate + Amodiaquine 50/153mg (Ipca Laboratories Ltd) Coarsucam (Nourrisson; Petit Enfant; Enfant; Adulte) Winthrop (Nourrisson; Petit Enfant; Enfant; Adulte)

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Other ACTs ACTs that appear on neither the WHO list of approved ACTs or the UNICEF procurement list. This includes all audited brands of ACTs not included in the other two ACT categories:

Alaxin‐Plus Darte‐Q Alaxin‐SP Darte‐Q Pediatrique Arco Duo‐Cotexcin Adult Artecom Fantem 20mg/120mg Artecure Fantem Suspension Artedar (Pediatrique; Adulte) Larimal FD 400 (Enfant; Artediam Adulte) Artefan (40mg/240mg; 80mg/480mg) Laritem 20mg/120mg Artefan Suspension Lonart Artel Lonart Forte Artemether Lumefantrine Lufanter (Tong‐Mei Laboratoire) Lufanter Pediatrique Artequin (Pediatrique; 300/375; 600/750) Lumart+ Arthesis+ (Nourrisson; Petit Enfant; Enfant; Lumartem 80mg/480mg Adulte) Lumartem Suppositoires Artiz Lumet Forte Artiz Forte Lumiter Artrim Malacur Artrin Malacur Suspension AsunateDenk Plus P‐Alaxin Bimalaril 80/480 P‐Alaxin Suspension Bimalarial Suspension (Nourrisson; Enfant; Adolescent) Camoquin Plus (Pediatrique; Enfant; Adulte) Co‐Arinate FDC (Enfant; Adulte) Co‐Artesiane Suspension Cofantrine (Enfant; Adulte) Cofantrine Dispersible Cofantrine Suspension Colart Cospherunat

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Other ACT classifications

ACTs registered with a country’s national drug regulatory authority and permitted for sale or distribution in‐country. Each country determines Nationally registered its own criteria for placing a drug on its nationally registered listing. (See ACTs: the appendices for a complete list of Benin’s nationally registered ACTs). Brands included in this category and audited during data collection are*:

Alaxin‐Plus Camoquin Plus Enfants Lonart Alaxin‐SP Camoquin Plus Adultes Lonart Forte Arco Co‐Arinate FDC Lufanter Artecom Co‐Artesiane Lumartem Artecure Coarsucam Lumiter Artedar Coartem 20/120 Malacur Artediam Coartem Dispersible 20/120 P‐Alaxin Artefan 20/120 Cofantrine Winthrop Artefan 40/240 Darte‐Q Artefan 80/480 Darte‐ Q Pediatrique AL (Ipca) Duo‐Cotecxin Artequin ASAQ (Ipca) AsunateDenk Plus

* All strengths and formulations of a brand, unless specified

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List of Abbreviations

‐‐ No data was available *** Undefined ratio as a non‐zero value is being divided by a value of zero ABMS Association Béninoise pour le Marketing Social (PSI affiliate in Benin) ACT Artemisinin‐based Combination Therapy AETD Adult Equivalent Treatment Dose AL Artemether‐Lumefantrine AMFm Affordable Medicines Facility – malaria ASAQ Artesunate Amodiaquine CAME Central Medical Stores (Centrale d’Achat des Médicaments Essentiels et des Consommables médicaux) CFA (Franc) de la Communauté financière d’Afrique CHW Community Health Worker CI Confidence interval CQ Chloroquine DHS Demographic and Health Survey DPM Direction des Pharmacies et du Médicament FAACT First‐line Quality Assured ACT GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria GPS Global Positioning System IQR Inter‐Quartile Range LLIN Long Lasting Insecticidal Net LSHTM London School of Hygiene and Tropical Medicine MOH Ministry of Health n/a Not applicable: Indicates statistic cannot be calculated as the numerator is zero NAACT Non‐first line quality Assured ACT NGO Non‐governmental Organization NMCP National Malaria Control Program (Programme National de Lutte contre le Paludisme, PNLP) PMI President’s Malaria Initiative PPS Probability Proportional to Size PSI Population Services International QAACT Quality Assured ACT RDT Rapid Diagnostic Test SP Sulfadoxine‐Pyrimethamine UNICEF United Nations Children’s Fund WHO World Health Organization

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Executive Summary Overview

The ACTwatch Outlet Survey, one of the ACTwatch project components, involves quantitative research at the outlet level in ACTwatch countries (Benin, Cambodia, the Democratic Republic of Congo [DRC], Madagascar, Nigeria, Uganda and Zambia). Other elements of ACTwatch include Household Surveys led by Population Services International (PSI) and Supply Chain Research led by the London School of Hygiene & Tropical Medicine (LSHTM). This report presents the results of a cross‐sectional survey of outlets conducted in Benin in from the 8th to the 30th of April 2011.

The objective of the outlet survey is to monitor levels and trends in the availability, price and volumes of antimalarials, and providers’ perceptions and knowledge of antimalarial medicines at different outlets. Price and availability data on diagnostic testing services is also collected.

A nationally representative sample of all outlets with the potential to sell or provide antimalarials to a consumer was taken through a census approach in 19 clusters across Benin; clusters being defined as Arrondissements. Sampling was conducted using a one‐stage probability proportion to size (PPS) cluster design, with the measure of size being the relative cluster population. Oversampling of public health facilities and registered pharmacies was conducted to ensure adequate representation of these outlet types in the survey.

The inclusion criteria for this study were outlets that stocked an antimalarial at the time of survey or had stocked antimalarials in the previous three months. An outlet is defined as any point of sale or provision of commodities for individuals. Outlets included in the survey are as follows: 1) public health facilities (national/referral/zone hospitals, health centres, village health units, dispensaries and maternities); 2) private‐not‐for‐profit health facilities (mission and non‐governmental organisation [NGO] health facilities); 3) private‐for‐profit health facilities (private clinics and hospitals); 4) registered pharmacies; 5) general retailers (stores, boutiques, and market stalls); 7) itinerant drug vendors (hawkers); and 8) community health workers (CHW). Refer to the appendices for definitions and numbers of each type of outlet included in the analysis.

Three questionnaire modules were administered to participating outlets: 1) a screening module, 2) an audit module (antimalarial audit sheets and RDT audit sheets), and 3) a provider module. For all outlets, trained interviewers administered the screening module to collect information on the outlet type and location, including the outlet’s longitude and latitude, and information on availability of antimalarials. Among those outlets that stocked antimalarials at the time of survey, the audit module was administered. For each antimalarial, information was recorded on the brand and generic names, strength, expiry, amount sold in the last week and price to the consumer. Among outlets that stocked antimalarials at the time of interview or in the past three months, the interviewer collected information on provider demographics, knowledge, perceptions, and medicine storage conditions using the provider module. Where these outlets had RDTs available, information on RDT brand, manufacturer, price and number of tests sold in the last week was collection using the rapid diagnostic test audit module.

Several validation and data checking steps occurred during and after data collection. Double data entry was conducted using Microsoft Access (Microsoft Cooperation, Seattle, WA, USA). Data were analysed using Stata 11 (Stata Corp, College Station, TX).

More information on the study design is available at www.actwatch.info.

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Key findings

Data collection ran from the 8th to 30th April, 2011. A total of 2,966 outlets were approached for inclusion in the study. 99 outlets were not screened for various reasons: 53 providers refused to participate in screening; 30 outlets were closed down permanently; in 9 outlets an eligible respondent was not available; and 7 outlets were not open at the time of the survey visit. Overall, 2,867 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of the 1,519 outlets that met the screening criteria and were eligible for interview, 104 refused to continue and in 25 outlets an eligible respondent wasn’t available or the time wasn’t convenient for the full interview. 1,390 outlets completed interviews: 178 outlets reported having stocked antimalarials at any point in the three months prior to the interview and 1,212 outlet reported stocking antimalarials at the time of the interview.

AVAILABILITY OF ANY ANTIMALARIAL: Antimalarials were available in over 80% of screened outlets, with the exception of general retailers (shops and markets stalls, [31%]) and itinerant drug vendors (57%) (Figure 1). On the day of interview, any antimalarial was available in 87% of outlets in the public/not for profit sector, including 94% of public health facilities (PHFs). In the private sector, 100% of pharmacies and 82% of private‐for‐profit health facilities stocked antimalarials on the day of interview. Due to the large numbers of general retailers in the private sector, in total only one‐third (34%) of the private sector had any antimalarial available on the day of interview. There is a clear distinction in availability of any antimalarial between these informal outlets (general retailers and itinerant drug vendors) and formal private sector outlets. Figure 1. Availability of antimalarials by outlet type

100

0 Public CHW Private TOTAL Private Pharmacy General Itinerant TOTAL health not for profit PUBLIC / NOT for profit retailer drug PRIVATE facility facility FOR PROFIT facility vendor n=198 n=50 n=75 n=323 n=146 n=193 n=1,971 n=99 n=2,409

Public / Not for Profit Sector Private Sector

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OUTLET TYPES STOCKING ANTIMALARIALS: Figure 2 shows the relative distribution of outlets that had at least one antimalarial in stock on the day of interview. General retailers were the most common type of outlet stocking antimalarials, followed by community health workers (CHWs). In total, the public/not for profit sector comprised one‐quarter of outlets stocking antimalarials. Figure 2. Relative distribution of outlet types stocking antimalarials

N = 1,207 Itinerant Public health drug vendor facility 4% 7%

CHW 15% Private not for profit facility 3% Private for profit facility General Retailer 7% 62% Pharmacy 2%

AVAILABILITY OF DIFFERENT CLASSES ANTIMALARIALS: Among outlets stocking antimalarials on the day of interview there is a large difference between the availability of first‐line quality assured ACT (FAACT) in the public/not for profit sector and the private sector (86% and 23% respectively, see figure 3). All CHWs (n=42) with antimalarials in stock had FAACT, while 70% of PHFs had FAACT in stock. Only 18% of general retailers stocked FAACTs. More than 90% of all outlets stocked non‐artemisinin monotherapy, with the exception of CHWs who only had FAACT in stock. Outlets stocking oral artemisinin monotherapy were rare. Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock

100

% 40

Public / Not for Profit Sector Private Sector

First‐line quality assured ACT (FAACT) Non artemisinin monotherapy Oral artemisinin monotherapy

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AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: Among outlets stocking antimalarials in the past three months, availability of diagnostic blood testing facilities was low (figure 4). In the public/not for profit sector, RDTs were more common than microscopy; however, only 36% of PHFs had RDTs in stock and none of the 49 CHWs interviewed had RDTs available. Levels of any test availability were similar in private not‐for‐profit and private‐for‐ profit health facilities (37% and 34%), but low in other private sector outlets (pharmacies 2%, and general retailers 0%). Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests

100

60 % 40

Public / Not for Profit Sector Private Sector

Any test RDT Microscopy

PRICE OF ANTIMALARIALS: At the time of data collection no outlet type systematically provided FAACT free of charge; the median price of FAACT in PHFs was $1.35 [n=311]. The median FAACT price in the private sector was $2.25 [n=563], and pharmacies were substantially more expensive than other private outlets ($9.18 [n=285], compared to $2.25 [n=183] in general retailers). By comparison the median price of SP, a widely available non‐artemisinin therapy, was 5 times less expensive than the median FAACT cost in the private sector ($0.45 [n=562]). Figure 5. Median price of a tablet AETD antimalarial treatment in the private sector

7 $USD 6

AETD, 5

for

Price 3

0 Private for profit facility Pharmacy General retailer Itinerant drug vendor TOTAL PRIVATE (n=66; n=52) (n=285; n=303) (n=183; n=190) (n=29; n=17) (n=563; n=562)

First‐line quality assured ACT (AL) Most popular treatment (SP)

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VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: Figure 6 presents the market share of different antimalarial classes sold/distributed in the 7 days before the survey, within each outlet type. Distribution of FAACT was more common in the public/not for profit sector than in the private sector (48% compared to 17%). 64% of recent antimalarial sales in pharmacies were non‐quality assured ACTs, a category that includes non‐tablet formulations. Whilst 12% of AETDs sold by general retailers were FAACTs, chloroquine comprised 45% of their market share, and SP comprised 34%. Figure 6. Market share of AETDs sold/distributed in the past week (7 days), within outlet types

100%

80%

60%

40%

20%

0% Public CHW Private TOTAL Private Pharmacy General Itinerant TOTAL Health not for profit PUBLIC / NOT for profit retailer drug PRIVATE Facility facility FOR PROFIT facility vendor (n=793 AETDs) (n=60) (n=448) (n=1301) (n=1200) (n=872) (n=1299) (n=325) (n=3696) First‐line quality assured ACT (FAACT) Non first‐line quality assured ACT (NAACT) Non‐quality Assured ACT Non‐artemisinin monotherapy SP (Public) Non‐oral artemisinin monotherapy Oral artemisinin monotherapy

PROVIDER KNOWLEDGE: Overall, 56% of providers interviewed were able to correctly state AL as the recommended first‐line treatment for uncomplicated malaria in Benin. Knowledge was significantly higher in the public/not for profit sector compared to the private sector (93% vs. 45%). Knowledge of the correct dosing regimen for adults was generally higher than that for children, although 90% of CHWs could state the correct regimen for a child while fewer (55%) could state this correctly for an adult. Figure 7. Provider knowledge of recommended first‐line treatment and dosing regimens

100

60 % 40

Public / Not for Profit Sector Private Sector

Knows first‐line treatment Knows correct adult dosing regimen Knows correct child dosing regimen

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Background

Overview of the ACTwatch Research Project

In 2008, Population Services International (PSI) in partnership with the London School of Hygiene and Tropical Medicine (LSHTM) launched a five‐year multi‐country research project called ACTwatch. The project is designed to provide a comprehensive picture of the antimalarial market to inform national and international antimalarial drug policy evolution. The research is designed to detect changes in the availability, price and use of antimalarials over time and between sectors, and to monitor the effects of policy or intervention developments at country level. ACTwatch addresses both the supply and demand side of the market. The supply side is evaluated by collecting level and trend data on antimalarials and rapid diagnostic tests (RDTs) in public/not for profit and private sector outlets and wholesalers of antimalarial drugs. To evaluate demand, data are collected at the household level on consumer treatment‐seeking behaviour and knowledge. In combination, the research components thread together the antimalarial market and consumer behaviour. Findings can help determine where and to what extent interventions may positively impact access to and use of quality‐assured ACTs and RDTs as well as resistance containment efforts.

The project is being conducted in seven malaria‐endemic countries: Benin, Cambodia, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia between 2008 and 2012. Countries were selected with the aim of studying a diverse range of markets from which comparisons and contrasts could be made. The research in Benin was implemented as follows: three outlet surveys (2008, 2009 and 2011); supply chain research (2009); and two household surveys (2009 and 2011).

This report presents the results of a cross‐sectional survey of outlets conducted in Benin between the 8th and 30th April 2011. Indicators to address the research questions were developed in consultation with partners and the ACTwatch Advisory Committee. Indicators were selected to provide relevant information for policy makers in relation to price, availability, market share, mark‐ ups and treatment seeking behaviour, including type of treatment and source.

Information on other ACTwatch studies can be found at www.actwatch.info.

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Country background

Overview of the country

Benin is located in the West Africa sub‐region and is bordered by Niger and Burkina Faso to the north, Nigeria to the east and Togo to the west (Figure 8).

Figure 8: Location of Benin In 2010 the population was estimated at 8.8 million, with 1.5 million children under 5 years of age (Population Divison, 2011). Approximately 60% of people are live in rural areas (Population Divison, 2010). There are over 40 ethnic groups in Benin, including Fon, Asja, Yoruba, Goun, Bariba and Fulani tribes. The official language is French; Fon, Goun and Yoruba are widely spoken in the south of the country, and Bariba and Fula are most common in the north.

The south of Benin is characterized by low‐lying, marshy coastal plains which give way to flat plains and savanna in the north. The principal rainy season lasts from April to July and covers the whole country, while shorter rains also occur in the south during October and November. Between December and March Benin experiences the Harmattan, winds blowing south from the Sahara.

The country was governed by a Marxist‐Leninist Source: CIA, The World Factbook 2009 dictatorship during the 1970s and 1980s, transitioning to https://www.cia.gov/library/publications/the democratic government in the early 1990s. The most ‐world‐factbook/index.html recent multiparty elections were held in March 2011.

Benin’s gross domestic product (GDP) growth rate was highly volatile during the dictatorship, but stabilized during the 1990s. Annual GDP growth averaged a respectable 4.1% in the 5 years prior to 2010. A steady population growth rate of around 3% per annum puts a check on the country’s per capita growth figures. In the past decade per capita GDP has increased from $1,300 to just over $1,4001; 47% of the population still live below the standard poverty line of $1.25 a day. In 2011 Benin was ranked 167th out of 187 countries in the Human Development Index. One in eight children dies before reaching their fifth birthday (INSAE, 2007), and life expectancy at birth in 2009 was 54 years for men and 60 years for women (WHO, 2011a).

Malaria is considered to be the leading cause of morbidity and mortality among children under five, accounting for 41% of outpatient visits and 29% of hospitalizations for this age group (INSAE, 2007). Government figures for 2010 report 900,000 confirmed malaria cases across all age groups, and a further 350,000 probable cases2 (WHO, 2010).

Benin is divided into 12 departments, 77 communes or autonomous areas (the cities of Cotonou, Porto Novo, and Parakou), and 546 arrondissements. Arrondissements are sub‐divided into villages (more commonly called quartiers in urban areas).

1 Prices in purchasing power partity‐adjusted 2005 US$. 2 Reporting completeness for 2009 was estimated at 88%

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Description of health care system

The public health system operates through three tiers, linked to the three levels of health care and their associated structures. At the highest level lies the Ministry of Health (MoH), and the National Referral Hospital in Cotonou. This is the Centre National Hospitalier et Universitaire which also serves as a teaching hospital. The second tier is at department level, whose main structures are the department referral hospitals. Although there are 12 departments in Benin, in mid‐2009 there were only 6 functional referral hospitals nationwide (PMI, 2009). The third tier comprises 34 health zones. Health zones are administratively separate from communes, with each zone containing between one and four communes. Health structures at this level are zone‐level hospitals (hôpital de zone); commune‐level health centres (centre de santé de commune); smaller, arrondissement‐level health centres (centre de santé d’arrondissement); and village health units. In addition to government‐run facilities, the health sector includes private‐for‐profit facilities, NGO‐ and faith‐based clinics and hospitals, licensed pharmacies, and unlicensed drug vendors selling from permanent sites or hawking their products from site to site.

In 2006 there were an estimated 442 arrondissement‐level health centres and 75 commune‐level health centres across the whole country (PMI, 2009). Figures for the private sector suggest 305 licensed private health facilities (in 2006) and 202 registered pharmacies (as of early 2011). However, many clinics in the private sector are not registered with the MoH and the true number of facilities may be as much as ten times greater (Tougher et al., 2009).

Healthcare consumers at government facilities are expected to pay for consultations, diagnostic tests, procedures and medicines. Patients must also purchase a carnet de santé in order to access care in public facilities. Fees are kept at the facility‐level and cover, on average, 43% of the operating costs of the facilities. In‐line with the general policy at the time of data collection, treatment of uncomplicated malaria is provided at public facilities for a fee3: blister packs of 6, 12, 18, and 24 artemether‐lumefantrine (AL) tablets are sold for 150CFA, 300CFA, 450CFA, and 600CFA, respectively (PMI, 2009). In 2011 150CFA was on average equivalent to $0.33. Note that prior to October 2009 proceeds from ACT sales were exempt from the system described above and all monies were deposited directly into a central account. Following the policy change in late 2009, health facilities now retain one third of the ACT sale proceeds and an increase in the use of ACTs by public facilities has been noted (PMI, 2010).

Epidemiology of malaria

Malaria epidemiology in Benin can be characterized as stable endemic and, as such, the risk of an epidemic is considered to be low. The entire population is at risk of infection. Transmission is more intense in the (more populated) southern third of the country, while a single seasonal peak is observed in the north. The predominant parasite species is P. falciparum.

3 Data collection for the 2011 ACTwatch outlet survey took place during April 2011. In May 2011 the government announced plans to drop the fees associated with the carnet de santé for all users, and additionally provide consultation, diagnosis and malaria treatment for free for children under five and pregnant women. These changes were implemented in October 2011.

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Antimalarial Policies and Regulatory Environment

Faced with growing resistance to chloroquine and sulfadoxine‐pyrimethamine (SP), Benin adopted AL as the first‐line treatment for uncomplicated malaria in March 2004 (PNLP, 2005). Artesunate‐ amodiaquine (ASAQ) is recommended for children under six months of age, when AL is not available or when patients cannot tolerate AL. Parenteral quinine is recommended for the treatment of severe malaria and as pre‐referral treatment. Artesunate injection and suppositories are included in the national policy as a pre‐referral treatment for severe malaria. Oral artemisinin monotherapies have been banned in Benin since 2008 (WHO, 2010).

Although the political policy change to ACT occurred in 2004, it was a further 4 years before this policy was truly active at the national level, and ACT only became widely available in the public sector in 2009 (PMI, 2009). Prior to 2009 ACT was most commonly available through the private sector, which has historically been an important distribution channel of antimalarials in Benin (Tougher et al, 2009). Procurement of ACT is currently supported by a number of donors, including the Global Fund, President’s Malaria Initiative (PMI) and UNICEF.

Inefficiencies in the public sector supply management system hindered initial distribution of ACTs to public health facilities, despite 2.7 million treatments being delivered to the government during 2009 (WHO, 2010). PMI identified the Central Medical Stores (CAME) as an area requiring support and has worked to implement legal reforms on governance and transparency of CAME operations, and to upgrade the information system (PMI, 2011). Despite these successes, old problems continue. Limited means of transportation from CAME’s central and regional warehouses to public health facilities, insufficient space and inappropriate storage conditions, and (until recently) an inadequate information management system to monitor consumption of antimalarials at public health facilities have been identified as weaknesses at CAME (Ndoye et al, 2009). Intervention by external partners was recently required to conduct an emergency roll‐out of ACTs to public and private health facilities to avoid the expiration of around 400,000 doses of AL (PMI, 2011).

At the time of data collection the operational treatment policy for children under five was presumptive4, while treatment for older patients was recommended only for those with a positive diagnostic test. With donor support rapid diagnostic tests (RDTs) have been extensively scaled‐up alongside ACTs, although implementation and commodity management have been similarly challenging. In mid‐2010 the government had 460,000 RDTs for use in the public health system, divided between health facilities and the central medical stores. However, a health facility survey conducted in early 2011 estimated that 30% of facilities had expired RDTs in their stocks (cited in PMI, 2011). RDTs are to be used at all levels of the health system except the community level, and to be provided free of charge. In addition to RDTs, hospitals and larger health centres are supposed to provide microscopy, although such facilities often lack functional equipment and laboratory worker’s skills are often sub‐optimal.

The NMCP Strategic Plan for 2005‐2010 viewed treatment of uncomplicated malaria by community agents using ACT as an important strategy in case management (PNLP, 2005). It is expected that this will continue during the next five‐year plan, which additional emphasis on diagnostic testing. Through two Global Fund malaria grants (see below), funding is being provided for community‐ based treatment of malaria at the national‐level.

4 In line with WHO standards, the malaria case management guidelines changed in February 2011 to recommend universal diagnostic testing for malaria. Although signaled in February 2011, the change was not widely implemented until late 2011.

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Medicine sales pharmaceutical sector are regulated by the Direction des Pharmacies et du Médicament (DPM), which falls under the umbrella of the MoH. Registered private sector outlets are subject to strict pricing regulations, the intention of which is to ensure that patients pay the same price for medicines, regardless of where they are in the country. Qualitative research conducted in 2009 found that this pricing structure is well‐respected by private sector operators (Tougher et al, 2009). Data from previous ACTwatch survey rounds in Benin indicate that prices of AL in pharmacies are around 5 times more expensive than in public health facilities.5

Malaria control strategy

2010 was the final year in the NMCP’s five‐year National Malaria Strategic Plan 2005‐2010. At the time of data collection for this survey the review process for the 2011‐2015 Plan was ongoing, though the core vision for the next five years was to continue promotion of universal access to prevention and treatment by achieving nationwide scale‐up of interventions.

The core interventions for malaria control in Benin include long lasting insecticide‐treated net (LLIN) distribution through antenatal care clinics (ANC) and immunization visits, universal campaigns, and subsidized and at‐cost sales in the private sector; intermittent preventive treatment for pregnant women (IPTp); case management (following diagnosis) at all levels of health care; and, to a more‐ limited extent, indoor residual spaying (IRS). Benin has removed import tariffs on mosquito nets, antimalarials and RDTs; as of August 2010 tariffs still apply to pumps and insecticides used for IRS (M‐Tap, 2010).

In 2007 a national campaign distributed 1.4 million LLINs to households across Benin. This followed survey estimates that although 56% of households owned a mosquito net, only 25% of households reported owning an ITN, and only 20% of children under five had slept under an ITN the previous night (INSAE, 2007). The NMCP’s universal coverage campaign envisions one net for every two people. A second‐round of mass distribution (of almost 5 million nets) was planned for 2010 but this was delayed and did not begin until July 2011. Routine distribution of LLINs occurs through ANC and immunization visits, where they form part of a kit that includes two doses of SP, one dose of mebendazole, folic acid and iron. These kits cost around $1, although the nets and SP are ‘free’ and provided by funds from PMI, UNICEF and the World Bank. A woman who opts for only the net and SP during an ANC visit receives these items free of charge. A partnership between PMI and PSI‐Benin also plans to sell highly subsidized, socially‐marketed LLINs in the private sector.

The 2006 DHS found that 84% of pregnant women accessed an ANC clinic at least twice during their last pregnancy, but less than 1% of women received two doses of SP from ANC visits. IPTp was officially introduced at a national level in 2005, though training and implementation at the health facility level were not continued until 2010. In addition, problems with the public sector supply chain described above would have impacted the distribution of SP in the public sector. Recent research at selected maternity hospitals shows that coverage for two doses of IPTp has increased in some facilities from 3% in 2005 to 68% in 2009 (d’Almeida et al, 2011). More recently there is anecdotal evidence of major stock outs of SP in the public sector beginning in late 2010 (ABMS, personnel communication; PMI, 2011).

IRS has been recommended by the NMCP since 2006, and spraying rounds have been funded by PMI in 4 communes in Ouémé in 2008 and 2009, covering more than 520,000 people. LLINs were distributed to households following each round of spraying. By 2015, the NMCP aims to scale up IRS

5 The public health facility price excludes the cost of the carnet to santé, consultation, and any diagnostic tests.

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to 20 of the 77 communes in Benin. Additional communes will be selected on the basis of malaria epidemiology and other vector control activities; they are most likely to come from the north of the country where LLIN coverage is lower than the south and malaria transmission is seasonal (PMI, 2009)6.

Malaria financing

Financing for malaria control activities has increased dramatically in recent years, from less than $5 million annually between 2001 and 2005, to over $22 million in 2009 (WHO, 2011b). The main sources are the PMI, World Bank, Government of Benin, and Global Fund. The NMCP received funding from the Global Fund Round 3 Grant ($2.14 million) which was channeled to a project providing 458 villages with ACTs, with the aim (among others) of improving case management of malaria in children under five through health facilities and community‐based management. The project was implemented in Mono and Couffo, two departments with high malaria transmission. A Round 3 Rolling Continuation Channel (RCC) to the implanting partner will provide $94 million to expand this project (as well as financing net distribution campaigns). A Round 7 ($22.6 million) grant launched in July 2008 is providing community‐level ACT distribution for 14 of the 34 health zones (approximately 40% of the population) not already covered by the RCC. Thus, together, these awards will finance community case management of malaria countrywide.

In 2007 a four‐year grant ($31 million) from the World Bank Malaria Booster Program commenced covering an important portion of ACT and LLIN needs, and the bulk of RDTs required up to 2010. In 2010 funds from the Booster Program were also used to train public health facility workers on ACT policy, achieving 87% coverage of staff in the country. The World Bank grant has now ended, putting additional financial pressure on the NMCP and its external partners. Benin continues to receive increasing funding from the PMI for malaria control activities: $13.8 million in 2008/2009 and $21 million in 2009/2010. Funds from 2009/2010 were used to procure 1 million LLINs and 1.2 million ACT treatments. In addition, PMI funds supported the training and supervision of laboratory staff, and public and private health workers.

6 Indeed, in May 2011, following the data collection period for this survey, PMI‐funded IRS activities moved from targeting areas in southern Benin to those in the North, based on malaria epidemiology and frequency of rainy seasons. With the withdrawal of IRS activities in the south, the NMCP has the goal of universal LLIN coverage in areas previously covered by IRS (PMI, 2011).

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Methods

Sampling approach

The outlet survey was designed to allow reliable estimations of key indicators for the country as whole.

Sample units The target sampling units were all types of outlets that have the potential to sell or provide antimalarials in Benin. Determined on the basis of a pilot study prior to the main ACTwatch survey, the following outlet types were included in the sample:

 public health facilities at all levels of the health system;  community health workers;  private not‐for‐profit health facilities (NGO and Mission health facilities);  private for‐profit health facilities (private clinics and hospitals);  registered pharmacies;  general retail outlets: supermarkets, boutiques, market stalls; and  itinerant vendors (hawkers).

Outlets such as diagnostic centres; wholesale medical supply stores; eye, skin, dental and other similarly specialized clinics; and veterinary clinics were all excluded from the sample. In addition, a limitation of the survey is the omission of rural pharmaceutical depots (dépôts pharmaceutiques) from the sample. In 2008 there were 279 rural depots registered in Benin (Tougher et al., 2009). The list of registered depots was not available prior to data collection and they were excluded from the booster sample (see below) for logistical reasons.

Sample size determination The proportion of outlets with any ACT, estimated to be 40%, was used as the primary outcome measure for sample size estimation. A minimum of 290 outlets with antimalarials in stock were needed to provide detectable changes in ACT availability between sectors in a single stratum. With this number, 19 clusters provided a representative sample to detect 20% increase at 80% power, setting the level of significance at 5% and adjusting for an estimated design effect of 3.

Sampling frame Administratively, Benin is divided into 12 departments and subdivided into 77 communes. Communes are further divided into arrondissements. The desired cluster size for the outlet survey was approximately 10,000 to 15,000 inhabitants, which corresponds most closely to an arrondissement in Benin. The 2002 population census was used as a sample frame for the 2011 outlet survey.

In addition, a facility listing of 202 registered pharmacies was used to confirm the location of pharmacies in each department, and to inform the pharmacy booster sample. The list of registered pharmacies was sourced from the Direction des Pharmacies et Medicaments in early 2011 and included the name of the proprietor, and the address and phone number of each pharmacy, grouped by commune.

Selection procedure of the sub‐districts Nineteen arrondissements were selected from the 2002 census frame using a one‐stage cluster design, with probability of selection proportional to arrondissement population size. All

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arrondissements in the country were included in the sampling frame. In each selected arrondissement, a census of all outlet types listed above was conducted. All outlets that stocked antimalarials at the time of the survey or in the past 3 months were eligible for interview.

Selection procedure of the booster sample The main sample was supplemented by a booster sample to ensure adequate representation of the relatively rare but important antimalarial outlet types: public health facilities and registered pharmacies. All public health facilities located in the commune in which a selected arrondissement fell were included. The booster sample of pharmacies comprised a full census of all registered pharmacies in Benin.

Questionnaire The outlet survey questionnaire comprised 3 modules: a screening module for all outlets; an audit module (the antimalarial audit sheets and RDT audit sheets) for outlets with antimalarials in stock on the day of interview; and a provider module for all eligible outlets, including those with no antimalarials in stock on the day of interview but who had stocked antimalarials in the past three months. Audit sheets were based on the Health Action International questionnaire for essential medicines, developed with the World Health Organization.

The screening module was used to record the type and location of all outlets and to identify outlets that were eligible for the audit and provider modules. The audit module was used to collect data relating to each antimalarial product an eligible outlet had in stock on the day of interview. This information came from the antimalarial packaging: brand name, generic name and strengths, package type and size; and from provider recall: amount sold or distributed in the last 7 days, retail selling price, and the outlet’s wholesale purchase price. Audit sheets in the audit module were also used to collect the characteristics, retail and wholesale prices, and sales/use data on RDTs, in outlets that had RDTs in stock on the day of interview. The provider module was used to collect information on outlet demographics (e.g. number of staff, health qualifications of staff), provider knowledge of the first line treatment, and provider perceptions.

Paper questionnaires were administered during data collection. The questionnaire was finalised in French and local language translations produced in Fon, Goun and Bariba. During training (see below) fieldworkers discussed appropriate local‐language terminology and reached a consensus within language groups on how questions would be administered. During data collection, questionnaires were administered either in French or in a local language. Prior to finalisation and training, the questionnaire was pilot‐tested to assess the appropriateness of question wording as well as to verify the skip patterns and interviewer instructions.

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Data collection

Preparatory Phase Experienced research assistants from the ABMS/Benin pool of consultants were recruited by a data collection agency to be trained as interviewers and team leaders for this study. Final selection of study personnel was made after a rigorous seven‐day training program, which included a practical fieldwork exercise.

Standardised training materials developed by ACTwatch were adapted to the national setting, and sessions were facilitated by staff from ABMS/Benin and the ACTwatch core team. Training consisted of a review of how to fill out the screening, audit, and provider modules; mock interviews; and sessions covering interviewing techniques, how to conduct a census, and how to identify different outlet types. A key element of the training focused on the identification of antimalarial medicines, including the differences between ACTs and non‐ACTs; the difference between brand names and generic names; how to correctly record medicine strengths; how to record packaged and loose tablets; and the various formulations in which medicines are available. Role plays and exercises using antimalarial packages occurred throughout the sessions. Interviewers were also trained how to introduce the study, answer questions a respondent may have; and seek informed consent for participation. During the fieldwork exercise, interviewers followed the full survey methodology in one arrondissement not included in the sample. Trainees were local to the region in which they would work and travelled to Cotonou for the training.

Team leaders were identified from among the strongest candidates during the initial training and participated in an additional two‐day training program. This training covered team management and supervision techniques, but mainly focussed on methods for ensuring data quality in the field.

Fieldwork Fieldwork was conducted by 34 staff, divided into 7 teams of differing sizes depending on the departments to which they were assigned. Generally, teams in the south of Benin comprised more interviewers than those in the northern departments. Quality control and oversight was provided at two levels: firstly by the team leaders, and secondly by staff from ABMS/Benin and the ACTwatch core team.

Data collection started on the 8th April, with all teams in Cotonou where progress and quality could most easily be monitored. The last team finished data collection on the 30th April. During this time all 19 selected arrondissements were censused and the booster sample conducted.

Upon arrival in a study area, field teams first met with local leaders to introduce themselves and seek permission to carry out the study. Arrondissement boundaries (and commune boundaries for the booster sample) were identified in consultation with local leaders and guides; team leaders then assigned interviewers to a particular area.

During fieldwork, interviewers systematically canvassed the arrondissement, approaching every outlet with the potential to sell antimalarials, according to the outlet type definitions designated for this study. Some of these outlets had been signalled in advance through discussions with local authorities and guides. In addition a snowball technique was used, with visited outlets asked to identify other outlets in the locality with the potential to stock medicine.

For each outlet that was identified during the census, the outlet type and location were noted, along with its longitude and latitude coordinates (obtained from hand‐held GPS units). Screening questions were administered to an available member of staff, and if the outlet was eligible for the audit and/or

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provider modules, the fieldworker identified the senior staff member currently present at the outlet before proceeding. The fieldworker then read the information sheet to the senior staff member, answered any questions they may have, and obtained oral consent to conduct the interview. A maximum of three call backs were made to outlets that were either closed at the time of interview, or where interviews were interrupted.

During the audit, interviewers requested to see one example of each antimalarial product that was in stock on that day. This included different formulations and age/weight categories of the same ‘brand’, as these were all considered different products and required separate entries in the audit.

Pilot tests conducted prior to starting the survey indentified hawkers as a potential source of medicines in Benin. Hawkers were screened and administered the questionnaire in the same manner as any stationary point of sale. Longitude and latitude coordinates were taken from the point where the interview was conducted.

Team leaders, ABMS/Benin research staff and ACTwatch core staff accompanied interviewers during data collection. Team leaders were responsible for the review and field editing of questionnaires on a daily basis and conducted spot checks and back checks to verify completed questionnaires. Second reviews of questionnaires, and additional back checks, were conducted by ABMS/Benin and ACTwatch core staff.

Team leaders worked with senior agency staff to follow data safeguarding procedures during data collection. Team leaders collected questionnaires from interviewers at the end of each day and ensured their safe storage. Senior agency staff made regular field visits to collect field questionnaires and return them to Cotonou.

A memorandum of understanding was obtained from the Ministry of Health to conduct the survey.

Data processing Double data entry was performed in Kenya by an external agency, using Microsoft Access. A member of the ACTwatch core team trained data entry clerks on the use of the Access database and then made regular visits to the agency to monitor progress. A trained ABMS/Benin research staff member was responsible for validating the double data entry. After the first round of data entry a core team member validated the double data entry, and errors were corrected by the agency with reference to the hard‐copy questionnaires. This process continued until the two data entry files were identical.

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Data analysis Data were analyzed by the ACTwatch core team following the ACTwatch analysis plans. These plans outline the steps to take in summarizing and analyzing the data, and contain detailed guidance on data cleaning, weighting, numerators and denominators for calculation of key indicators, definition and calculation of AETDs, and a set of blank tables (a tabulation plan).

Indicators were presented by outlet type and nationally. Price, availability and volumes are derived from the audit modules. Additional analyses, derived from provider modules, examine outlet characteristics, provider knowledge, and availability of microscopic testing for malaria. RDT indicators are derived from the RDT audit sheets in the audit module.

Research associates cleaned data in Stata, documenting all decisions and steps in a ‘do’ file. During analyse, statistical tests and means, medians and proportions were calculated using Stata. Sample weights applied to the data to allow for: 1) the oversampling of the booster sample; and, 2) the sampling strategy which involved a full census of outlets in arrondissements of varying size selected using probability proportional to size sampling. Weights were calculated specific to outlet and analysis type but generally involved the inverse of selection probability and corresponding population size. Survey settings were used to account for the clustered design. Data analysis included descriptive summaries, presented with 95% confidence intervals (CIs). All analysis was reviewed by the senior research associate. A summary of the analysis is presented in this section.

Availability and stock‐outs The availability of any antimalarial was measured as the proportion of surveyed outlets that had at least one antimalarial in stock among all surveyed outlets. Only outlets with at least one antimalarial (of any type and dose) were considered to have antimalarials available. Drugs intended solely for malaria chemoprophylaxis were not included. Cotrimoxazole was also excluded, as it is very rarely used as an antimalarial.

Stock‐out information was collected through both the drug audit and provider interviews. For each drug found in stock, providers were asked if the drug, specific to the brand, and dose, had been out of stock at any point over the past three months. Providers were also asked to list all drugs that were not currently in stock, but had been in stock during the previous 3 months. These two measures were combined to calculate the proportion of outlets with a reported stock‐out of at least one drug, amongst those that had recently stocked such drugs (defined as stocking today or in the last 3 months). This information measures the ability of outlets to maintain supply rather than provide a particular treatment at a given point in time.

Volumes and price The volume and price of the antimalarials recorded in the audit module were standardized using the adult equivalent treatment dose (AETD) to allow meaningful comparisons between antimalarials with different treatment courses. One AETD is defined as the amount of the drug, in milligrams (mg), that a 60kg adult would need in order to receive a full course of treatment, based upon WHO, peer reviewed, or/and manufacturer guidelines, in that order. The price per package was scaled to be equivalent to one full AETD course, while the number of packages distributed (volumes) was scaled to the equivalent number of AETD courses sold in the previous week. For combination antimalarials, one drug in the combination was selected for these calculations. For ACTs, this was always the artemisinin‐derivative component (e.g. the artesunate component of artesunate‐amodiaquine).

The ACTwatch project typically calculates volume (market share) indicators by dividing the number of AETDs sold for a given antimalarial category‐outlet type pair, by the total number of AETDs of all antimalarials sold. This allows the total market for antimalarials to be presented by antimalarial

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category and outlet type. Due to the scale and pattern of missing values in the Benin OS3 data for quantity sold/distributed in the past 7 days, the standard ACTwatch market share indicator is not presented in this report. Information on quantity sold/distributed was missing for 11% of antimalarials audited in PHFs and 14% of antimalarials in general retailers; but among pharmacies 71% of antimalarials audited were missing this information. Further analysis of the data shows that when the quantity sold/distributed is missing, it is almost always missing for all antimalarials within an outlet. Given the disproportionate number of missing values from pharmacies we have opted to present relative market share by antimalarial categories restricted to each outlet type (Table B.1). In keeping with the standard analysis procedures, in cases where outlets stocked antimalarials but some or all sales volumes were missing, we did not impute missing values.

Price data were collected in local currencies and converted to their US$ equivalent using the average interbank rate for the data collection period (1 US$ = 445.2 Franc CFA [XOF], source www.oanda.com). Price data are reported using the median and inter‐quartile range, which are appropriate for describing distributions likely to be skewed. Price measures include only tablet formulations in order to ensure meaningful comparisons. We have elected to exclude the price of non‐tablet formulations from the price analysis as these formulations (powders for reconstitution, suspensions, syrups, suppositories and injections) tend to be far more expensive per AETD than their tablet equivalents and this would skew the price results and make interpretation difficult. The most popular non‐ACT was defined as the generic antimalarial that comprised the greatest market share of AETD across all outlets.

Classification of antimalarials For the purpose of analysis, antimalarials were split into three policy‐relevant categories: non‐ artemisinin therapy, artemisinin monotherapy, and artemisinin combination therapy (ACT). ACTs were further sub‐divided as follows:

‐ quality assured ACTs (QAACTs), which divide into:  first‐line, quality assured ACTs (FAACTs),  non first‐line quality assured ACTs (NAACTs) ‐ non quality assured ACTs

These categories are described in more detail on page V. Indicators were also calculated for nationally registered ACTs – those ACTs registered with the national drug authority. Due to difficulties sourcing and verifying a list of nationally registered ACTs from the time of data collection, we have used the list as of September 2008. This is the same list used for the 2009 survey (the previous survey) and thus allows direct comparison across survey rounds of this important subset of ACTs. Nationally registered ACTs are also either quality assured or non‐quality assured.

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Results ‐ Outlet survey

Characteristics of the sample

Figure 3.1.1: Survey flow diagram

A Outlets enumerated* Eligible respondent not available/Time not [9] [2,966] convenient for interview:

Outlets not screened Outlet not open at the time [7] [99] Outlet closed permanently: [30] Other: [0] B Outlets screened Refused: [53] [2,867] Outlets which did not meet screening criteria [1,348]

C Outlets which met screening criteria 1=[1,333] or 2=[186] Eligible respondent not available/Time not convenient for interview: [25]

Outlets not interviewed Outlet not open at the time: [0] [129] Other: [0] D Outlets interviewed** Refused: [104] [1,390]

Outlets with no antimalarials in stock on day of visit*** [178] E Outlets with antimalarials in stock on day of visit [1,212]

Screening Criteria: 1: Antimalarials in stock on day of visit; 2: No antimalarials in stock on day of visit, but antimalarials in stock in previous 3 months

* Enumerated means were visited and filled in at a minimum basic descriptive information (questions C1‐C9 of questionnaire) ** Interviewed means that final interview status was completed or interview interrupted *** but had stock in previous 3 months

Outlet type was recorded for 2,960 of the 2,966 outlets enumerated. Outlets missing outlet type fell into the following categories: did not meet screening criteria (3 cases); antimalarials in stock on day of visit (2 cases); no antimalarials in stock on day of visit but had stocked antimalarials in previous 3 months (1 case). These 6 cases are excluded from the analysis.

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Table A.1: Availability of antimalarials, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets that had: N=198 N=50 N=75 N=323 N=146 N=193 N=1,971 N=99 N=2,409 N=2,732 Antimalarials in stock at the time of 93.7 83.7 86.2 86.5 82.1 100.0 30.6 57.0 34.0 39.9 survey visit (80.1, 98.2) (62.4, 94.1) (70.0, 94.4) (72.6, 94.0) (67.9, 90.8) ‐‐ (24.6, 37.3) (34.0, 77.3) (28.5, 40.0) (33.0, 47.3) 74.4 83.7 53.2 78.0 39.9 99.5 5.7 16.4 8.1 16.0 Any ACT (62.3, 83.7) (62.4, 94.1) (28.6, 76.3) (64.0, 87.6) (24.1, 58.2) (98.3, 99.8) (4.1, 7.9) (7.7, 31.7) (5.9, 10.9) (11.7, 21.4) 74.4 83.7 42.8 76.8 36.8 90.7 5.6 16.4 7.8 15.6 Quality Assured ACT (QAACT) (62.2, 83.6) (62.4, 94.1) (20.9, 67.9) (62.8, 86.6) (19.9, 57.7) (83.8, 94.8) (4.1, 7.8) (7.7, 31.7) (5.7, 10.6) (11.3, 21.2) 64.9 83.7 42.8 74.4 36.1 89.1 5.6 16.4 7.8 15.3 First‐line (FAACT) (50.8, 76.8) (62.4, 94.1) (20.9, 67.9) (61.3, 84.2) (19.0, 57.7) (81.9, 93.7) (4.1, 7.8) (7.7, 31.7) (5.7, 10.6) (11.1, 20.8) 43.2 0.0 0.0 10.9 0.6 66.5 0.0 0.0 0.5 1.7 Non first‐line (NAACT) (29.7, 57.8) ‐‐ ‐‐ (6.0, 19.2) (0.1, 3.6) (57.7, 74.3) ‐‐ ‐‐ (0.3, 0.9) (1.2, 2.5)

1.9 0.0 10.4 1.6 6.0 99.5 0.4 0.7 1.3 1.4 Non‐quality Assured ACT (0.7, 4.8) ‐‐ (1.9, 41.3) (0.4, 5.8) (2.0, 16.7) (98.3, 99.8) (0.1, 1.1) (0.1, 3.3) (0.8, 2.2) (0.9, 2.1)

Other ACT Classifications 74.4 83.7 52.6 77.9 38.1 99.5 5.7 16.4 8.0 15.9 Nationally Registered ACT (62.2, 83.6) (62.4, 94.1) (28.0, 76.0) (63.8, 87.5) (21.5, 58.0) (98.3, 99.8) (4.1, 7.9) (7.7, 31.7) (5.9, 10.8) (11.6, 21.3)

91.9 0.0 81.6 32.4 77.1 90.6 29.5 56.7 32.7 32.7 Any non‐artemisinin therapy (80.0, 97.0) ‐‐ (64.4, 91.5) (18.6, 50.0) (65.9, 85.5) (84.6, 94.5) (23.6, 36.2) (33.7, 77.1) (27.3, 38.7) (27.5, 38.4) 0.4 0.0 5.6 0.7 2.0 3.2 23.8 41.4 23.5 20.9 Chloroquine (0.1, 3.0) ‐‐ (2.1, 14.1) (0.2, 2.9) (0.6, 6.1) (1.6, 6.2) (17.3, 31.9) (19.8, 66.9) (16.9, 31.6) (15.6, 27.4) 17.3 0.0 20.8 6.7 16.2 75.3 7.4 13.9 8.5 8.3 Sulfadoxine‐pyrimethamine (SP) (13.2, 22.3) ‐‐ (9.3, 40.0) (3.5, 12.5) (5.6, 38.7) (67.3, 81.8) (5.2, 10.4) (6.9, 26.2) (6.5, 11.0) (6.3, 10.7) 91.5 0.0 81.6 32.3 76.3 69.3 8.9 19.3 12.3 14.6 Second‐line treatment (Quinine) (80.0, 96.6) ‐‐ (64.4, 91.5) (18.6, 49.8) (65.5, 84.5) (63.5, 74.5) (6.3, 12.4) (5.6, 48.9) (8.8, 17.1) (11.4, 18.5) 16.8 0.0 1.8 4.5 15.9 70.0 0.2 0.0 1.3 1.7 Any artemisinin monotherapy (9.6, 27.7) ‐‐ (0.4, 7.5) (2.1, 9.3) (7.2, 31.3) (61.6, 77.2) (<0.1, 1.2) ‐‐ (0.7, 2.5) (1.0, 2.6) 0.0 0.0 0.0 0.0 0.2 2.1 0.0 0.0 <0.1 <0.1 Oral artemisinin monotherapy ‐‐ ‐‐ ‐‐ ‐‐ (<0.1, 1.2) (1.0, 4.6) ‐‐ ‐‐ (<0.1, 0.1) (<0.1, 0.1) 16.8 0.0 1.8 4.5 15.9 69.5 0.2 0.0 1.3 1.6 Non oral artemisinin monotherapy (9.6, 27.7) ‐‐ (0.4, 7.5) (2.1, 9.3) (7.2, 31.3) (60.6, 77.1) (<0.1, 1.2) ‐‐ (0.7, 2.4) (1.0, 2.6) Source: ACTwatch Outlet Survey, Benin, 2011. Page 19

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Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets that had: N=198 N=50 N=75 N=323 N=146 N=193 N=1,971 N=99 N=2,409 N=2,732 Antimalarials in stock at the time of 93.7 83.7 86.2 86.5 82.1 100.0 30.6 57.0 34.0 39.9 survey visit (80.1, 98.2) (62.4, 94.1) (70.0, 94.4) (72.6, 94.0) (67.9, 90.8) ‐‐ (24.6, 37.3) (34.0, 77.3) (28.5, 40.0) (33.0, 47.3) Among outlets with an antimalarial in N=189 N=42 N=62 N=293 N=127 N=193 N=537 N=57 N=914 N=1,207 stock, proportion of outlets that had: 79.5 100.0 61.7 90.1 48.7 99.5 18.6 28.8 23.7 40.0 Any ACT (66.9, 88.1) ‐‐ (34.8, 82.9) (80.6, 95.2) (25.7, 72.4) (98.3, 99.8) (14.2, 24.0) (17.5, 43.6) (17.9, 30.8) (33.0, 47.4) 79.4 100.0 49.6 88.8 44.9 90.7 18.4 28.8 23.1 39.1 Quality Assured ACT (QAACT) (66.8, 88.1) ‐‐ (24.8, 74.6) (78.5, 94.5) (21.0, 71.3) (83.8, 94.8) (14.0, 23.8) (17.5, 43.6) (17.3, 30.0) (31.8, 47.1) 69.3 100.0 49.6 86.0 44.1 89.1 18.4 28.8 22.9 38.4 First‐line (FAACT) (53.9, 81.3) ‐‐ (24.8, 74.6) (75.6, 92.4) (20.0, 71.3) (81.9, 93.7) (14.0, 23.8) (17.5, 43.6) (17.2, 29.9) (31.0, 46.3) 46.1 0.0 0.0 12.6 0.8 66.5 0.0 0.0 1.6 4.3 Non first‐line (NAACT) (32.1, 60.8) ‐‐ ‐‐ (7.2, 21.4) (0.1, 4.1) (57.7, 74.3) ‐‐ ‐‐ (0.8, 3.0) (3.0, 6.0)

2.0 0.0 12.0 1.9 7.3 99.5 1.2 1.2 4.0 3.4 Non‐quality Assured ACT (0.8, 5.0) ‐‐ (2.2, 45.4) (0.5, 6.6) (2.6, 18.9) (98.3, 99.8) (0.4, 3.2) (0.2, 5.7) (2.3, 6.8) (2.0, 5.8)

Other ACT Classifications 79.4 100.0 61.0 90.0 46.5 99.5 18.6 28.8 23.5 39.8 Nationally Registered ACT (66.8, 88.1) ‐‐ (34.0, 82.6) (80.4, 95.2) (22.8, 71.9) (98.3, 99.8) (14.2, 24.0) (17.5, 43.6) (17.7, 30.5) (32.7, 47.4)

98.1 0.0 94.6 37.4 94.0 90.6 96.6 99.6 96.4 82.0 Any non‐artemisinin therapy (94.0, 99.4) ‐‐ (72.4, 99.1) (21.7, 56.2) (76.5, 98.7) (84.6, 94.5) (92.3, 98.5) (96.8, 99.9) (93.0, 98.2) (69.3, 90.2) 0.5 0.0 6.5 0.9 2.4 3.2 78.1 72.7 69.3 52.5 Chloroquine (0.1, 3.2) ‐‐ (2.4, 16.9) (0.2, 3.3) (0.8, 7.0) (1.6, 6.2) (66.1, 86.7) (40.6, 91.2) (55.0, 80.6) (43.9, 60.9) 18.4 0.0 24.1 7.7 19.8 75.3 24.3 24.5 25.0 20.8 Sulfadoxine‐pyrimethamine (SP) (14.2, 23.5) ‐‐ (9.7, 48.3) (4.0, 14.3) (7.3, 43.7) (67.3, 81.8) (17.8, 32.1) (16.5, 34.7) (19.6, 31.4) (15.3, 27.6) 97.7 0.0 94.6 37.3 92.9 69.3 29.2 33.9 36.3 36.5 Second‐line treatment (Quinine) (93.8, 99.1) ‐‐ (72.4, 99.1) (21.7, 56.0) (77.0, 98.1) (63.5, 74.5) (19.2, 41.9) (8.5, 73.9) (23.8, 50.9) (25.8, 48.8)

Continued on following page

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Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Among outlets with an antimalarial in N=189 N=42 N=62 N=293 N=127 N=193 N=537 N=57 N=914 N=1,207 stock, proportion of outlets that had: 17.9 0.0 2.1 5.2 19.4 70.0 0.6 0.0 3.8 4.1 Any artemisinin monotherapy (10.6, 28.8) ‐‐ (0.5, 8.7) (2.4, 10.7) (7.9, 40.3) (61.6, 77.2) (0.1, 3.7) ‐‐ (2.0, 7.1) (2.5, 6.6) 0.0 0.0 0.0 0.0 0.3 2.1 0.0 0.0 0.1 0.1 Oral artemisinin monotherapy ‐‐ ‐‐ ‐‐ ‐‐ (<0.1, 1.5) (1.0, 4.6) ‐‐ ‐‐ (<0.1, 0.2) (<0.1, 0.1) 17.9 0.0 2.1 5.2 19.4 69.5 0.6 0.0 3.8 4.1 Non oral artemisinin monotherapy (10.6, 28.8) ‐‐ (0.5, 8.7) (2.4, 10.7) (7.9, 40.3) (60.6, 77.1) (0.1, 3.7) ‐‐ (2.0, 7.0) (2.5, 6.6) Source: ACTwatch Outlet Survey, Benin, 2011.

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Table A.2b: Availability of QAACTs with the AMFm logo, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Among outlets with an antimalarial in N=189 N=42 N=62 N=293 N=127 N=193 N=537 N=57 N=914 N=1,207 stock, proportion of outlets that had: 79.4 100.0 49.6 88.8 44.9 90.7 18.4 28.8 23.1 39.1 Quality Assured ACT (QAACT) (66.8, 88.1) ‐‐ (24.8, 74.6) (78.5, 94.5) (21.0, 71.3) (83.8, 94.8) (14.0, 23.8) (17.5, 43.6) (17.3, 30.0) (31.8, 47.1) 0.3 0.0 8.2 1.0 1.2 0.5 2.0 10.9 2.4 2.1 QAACT with AMFm Logo7 (0.1, 1.8) ‐‐ (3.6, 17.6) (0.3, 3.4) (0.5, 3.3) (0.1, 4.6) (0.9, 4.5) (2.8, 34.4) (1.2, 4.7) (1.0, 4.2) Among outlets with QAACT in stock, N=145 N=42 N=28 N=215 N=38 N=169 N=108 N=17 N=331 N=546 proportion of outlets that had: 0.4 0.0 16.5 1.1 2.7 0.6 10.7 37.9 10.4 5.3 QAACT with AMFm Logo (0.1, 2.2) ‐‐ (5.4, 40.7) (0.3, 4.1) (0.6, 11.5) (0.1, 5.0) (4.6, 23.0) (6.6, 84.0) (5.0, 20.5) (2.2, 12.1) Source: ACTwatch Outlet Survey, Benin, 2011.

7 In 2010, Nigeria (Benin’s eastern neighbour) signed a Global Fund grant for the AMFm Phase 1. The AMFm initiative in Nigeria officially launched on the 31st March 2011 and by the 28th April, 7.6 million co‐paid ACT treatments had been delivered to the country.

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Table A.3: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets that had: N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 No disruption in stock in the past 3 35.3 45.4 36.8 42.0 26.1 30.0 39.9 51.9 39.2 39.9 months (26.6, 44.9) (36.9, 54.3) (13.9, 67.9) (36.0, 48.3) (11.2, 49.7) (24.8, 35.8) (31.8, 48.7) (21.5, 81.0) (31.3, 47.7) (33.2, 46.9) N=172 N=49 N=40 N=261 N=74 N=175 N=183 N=28 N=460 N=721 No disruption in stock of first‐line quality assured ACT (FAACT) in the 44.4 45.4 52.2 45.7 15.1 81.7 25.8 61.9 29.0 36.8 past 3 months, among outlets that (32.9, 56.5) (36.9, 54.3) (21.6, 81.2) (40.4, 51.0) (3.8, 44.8) (77.2, 85.4) (14.1, 42.3) (36.6, 82.1) (15.6, 47.4) (28.5, 46.0) have stocked FAACT in the past 3 months N=50 N=0 N=35 N=85 N=67 N=151 N=253 N=31 N=502 N=587

No disruption in stock of SP in the 63.5 51.8 59.0 49.2 80.5 41.5 47.9 44.5 45.8 past 3 months, among outlets that ‐‐ (51.2, 74.3) (23.1, 79.4) (41.1, 74.7) (26.9, 71.8) (72.5, 86.7) (28.9, 55.5) (20.9, 76.2) (33.0, 56.6) (34.7, 57.4) have stocked SP in the past 3 months

N=189 N=42 N=62 N=293 N=127 N=193 N=537 N=57 N=914 N=1,207 8.3 0.0 1.6 2.4 0.3 5.9 0.7 0.0 0.7 1.2 Expired stock of any antimalarial8 (3.2, 19.9) ‐‐ (0.3, 7.1) (0.7, 7.4) (0.1, 1.6) (3.4, 10.2) (0.2, 3.0) ‐‐ (0.2, 2.4) (0.5, 2.6) N=131 N=42 N=28 N=201 N=37 N=172 N=108 N=17 N=334 N=535 Expired stock of first‐line quality 1.5 0.0 0.0 0.3 0.0 0.0 0.0 0.0 0.0 0.2 assured ACT (FAACT) (0.3, 8.4) ‐‐ ‐‐ (<0.1, 2.6) ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ (<0.1, 1.4) N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 Acceptable storage conditions for 99.0 100.0 100.0 99.7 98.9 99.0 84.7 35.5 83.3 86.9 medicines9 (95.9, 99.8) ‐‐ ‐‐ (98.8, 99.9) (96.5, 99.7) (97.1, 99.6) (75.0, 91.0) (17.3, 59.2) (74.3, 89.5) (78.2, 92.4) Source: ACTwatch Outlet Survey, Benin, 2011.

8 Information on expired stock was missing for 13% of cases [n=1,056]. Missing values were particularly common for pharmacies (21%, n=152) and private not‐for‐profit facilities (21%, n=49). 9 Information on acceptable storage condition was unavailable or missing for 6% of cases [n=1,312]. Missing values were particularly common for private‐for‐profit facilities (26%, n=100) and private not‐for‐profit facilities (24%, n=50). Page 23

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Table A.4: Price of antimalarials, by outlet type10 Public Community Private TOTAL Private General Itinerant TOTAL TOTAL Health Health not for profit Public / Not for profit Pharmacy retailer drug vendor Private Outlets Facility Worker HF for profit HF % % % % % % % % % % Proportion of first‐line quality assured ACT distributed free of cost 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (by volumes of AETDs) Median Median Median Median Median Median Median Median Median Median Median price of a tablet AETD:11 [IQR] [IQR] [IQR] [IQR] [IQR] [IQR] [IQR] [IQR] [IQR] [IQR] (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $1.35 $1.35 $2.25 $1.35 $1.35 $8.86 $2.25 $2.47 $5.89 $2.25 Any ACT (412) (53) (64) (529) (89) (3,145) (186) (29) (3,449) (3,978) [1.35‐1.80] [1.35‐1.35] [1.35‐3.37] [1.35‐1.35] [1.35‐3.59] [7.87‐10.03] [1.57‐2.70] [2.25‐3.59] [2.25‐8.86] [1.35‐7.87] $1.35 $1.35 $1.80 $1.35 $1.35 $9.18 $2.25 $2.47 $2.25 $1.35 Quality Assured ACT (QAACT) (410) (53) (60) (523) (67) (530) (183) (29) (809) (1,332) [1.35‐1.80] [1.35‐1.35] [1.35‐2.70] [1.35‐1.35] [1.35‐2.70] [8.74‐12.49] [1.57‐2.70] [2.25‐3.59] [1.57‐3.59] [1.35‐2.70] $1.35 $1.35 $1.80 $1.35 $1.35 $9.18 $2.25 $2.47 $2.25 $1.35 First‐line (FAACT) (311) (53) (60) (424) (66) (285) (183) (29) (563) (987) [1.35‐1.35] [1.35‐1.35] [1.35‐2.70] [1.35‐1.35] [1.35‐2.70] [3.93‐9.18] [1.57‐2.70] [2.25‐3.59] [1.50‐3.14] [1.35‐2.25] $2.70 $ $ $2.70 $3.59 $12.49 $ $ $12.49 $2.70 Non first‐line (NAACT) (99) (0) (0) (99) (1) (245) (0) (0) (246) (345) [1.80‐2.70] [‐] [‐] [1.80‐2.70] [n/a] [8.74‐21.92] [‐] [‐] [8.74‐21.92] [1.80‐8.74]

$2.70 $ $8.65 $8.65 $7.87 $8.66 $5.39 $ $8.66 $8.66 Non‐quality Assured ACT (2) (0) (4) (6) (22) (2,615) (3) (0) (2,640) (2,646) [2.70‐2.70] [‐] [8.65‐8.65] [8.09‐8.65] [5.91‐8.85] [7.87‐9.70] [3.82‐5.39] [‐] [7.87‐9.70] [7.87‐9.70] Other ACT Classifications $1.35 $1.35 $2.25 $1.35 $1.35 $8.92 $2.25 $2.47 $4.49 $2.25 Nationally Registered ACT (410) (53) (63) (526) (81) (2,680) (185) (29) (2,975) (3,501) [1.35‐1.80] [1.35‐1.35] [1.35‐3.37] [1.35‐1.35] [1.35‐3.37] [8.13‐10.49] [1.57‐2.70] [2.25‐3.59] [2.25‐8.86] [1.35‐6.95]

$4.25 $ $4.25 $4.25 $3.93 $2.30 $0.56 $0.56 $0.68 $0.68 Any non‐artemisinin therapy (299) (0) (117) (416) (207) (572) (884) (94) (1,757) (2,173) [3.77‐4.72] [‐] [3.15‐5.66] [3.77‐4.72] [2.83‐7.08] [1.10‐12.26] [0.51‐1.12] [0.54‐3.77] [0.54‐2.83] [0.54‐3.77] $0.41 $ $0.68 $0.54 $0.82 $1.01 $0.54 $0.54 $0.54 $0.54 Chloroquine (1) (0) (6) (7) (4) (2) (406) (21) (433) (440) [n/a] [‐] [0.54‐0.82] [0.41‐0.82] [0.54‐1.09] [n/a] [0.54‐0.68] [0.54‐0.54] [0.54‐0.68] [0.54‐0.68] Sulfadoxine‐pyrimethamine (SP), $0.00 $ $0.45 $0.00 $0.67 $1.10 $0.45 $0.56 $0.45 $0.45 (33) (0) (25) (58) (52) (303) (190) (17) (562) (620) the most popular antimalarial12 [0.00‐0.00] [‐] [0.45‐0.67] [0.00‐0.45] [0.45‐0.90] [1.04‐2.30] [0.34‐0.56] [0.45‐0.67] [0.45‐0.67] [0.36‐0.67] $4.25 $ $4.72 $4.25 $4.72 $16.03 $4.72 $4.72 $4.72 $4.72 Second‐line treatment (Quinine) (265) (0) (86) (351) (150) (229) (279) (56) (714) (1,065) [3.82‐4.72] [‐] [4.04‐5.66] [3.82‐4.91] [2.83‐7.08] [6.27‐28.83] [3.77‐4.72] [3.77‐7.08] [3.77‐5.66] [3.77‐5.66] Any artemisinin monotherapy $ $ $ $ $6.16 $9.93 $ $ $8.30 $8.30 Oral artemisinin monotherapy (0) (0) (0) (0) (1) (4) (0) (0) (5) (5) [‐] [‐] [‐] [‐] [n/a] [8.42‐11.85] [‐] [‐] [6.16‐11.32] [6.16‐11.32] Source: ACTwatch Outlet Survey, Benin, 2011.

10 The US$ conversion in this table is equivalent to the interbank rate for the period of data collection. In the AMFm approach the 2011 prices are adjusted to 2010 (to be in line with the baseline year for the pilot) using the ratio of the average national consumer price index for 2011 to the national average consumer price index for 2010 (IMF, International Financial Statistics). The adjusted 2010 prices are then converted to their US$ equivalent using the average interbank rate for 2010(USD=LCU 486.42, source www.oanda.com). With this approach the price of QAACTs in the total private is 2.00[1.40,3.20] 11 A total of 8,704 antimalarials were found in 1,209 outlets. Of these, 6,159 antimalarials are included in the pricing analysis; price indicators are based on tablet‐formulation AETDs. Free antimalarials were found in 3.2% of outlets with antimalarials, and 45 of the 8,592 antimalarials for which price information was recorded were available for free. 12 Sulfadoxine‐pyrimethamine was the most popular non‐ACT antimalarial by volume sold/distributed in the past week. Page 24

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Table A.5: Affordability of antimalarials, by outlet type

Public Community Private TOTAL Private General Itinerant TOTAL TOTAL Health Health not for profit Public / Not for profit Pharmacy retailer drug vendor Private Outlets Facility Worker HF for profit HF Median price of a tablet AETD relative to SP, the ‘most popular’ antimalarial Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio treatment in Benin: Any ACT *** ‐‐ 5.0 *** 2.0 8.1 5.0 4.4 13.3 5.0 First‐line quality assured ACT *** ‐‐ 4.0 *** 2.0 8.3 5.0 4.4 5.0 3.0 (FAACT) Median price of a tablet AETD relative Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio to CQ:

Any ACT ‐‐ ‐‐ 3.3 2.5 1.6 8.8 4.2 4.6 11.1 4.2 First‐line quality assured ACT ‐‐ ‐‐ 2.6 2.5 1.6 9.1 4.2 4.6 4.2 2.5 (FAACT) Median price of a tablet AETD relative to the minimum legal daily wage Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio ($2.22)13: Any ACT 0.6 0.6 1.0 0.6 0.6 4.0 1.0 1.1 2.7 1.0 First‐line quality assured ACT 0.6 0.6 0.8 0.6 0.6 4.1 1.0 1.1 1.0 0.6 (FAACT) Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Median price of a first‐line quality assured tablet AETD relative to the 1.0 1.0 1.3 1.0 1.0 6.5 1.6 1.7 1.6 1.0 international reference price ($1.42)14 % % % % % % % % % % Proportion of outlets that: ‐‐ N=49 N=66 N=115 N=135 N=193 N=688 N=63 N=1,079 N=1,194 Offer credit to consumers for 9.9 43.3 14.4 56.9 31.8 39.1 49.3 41.1 36.2 antimalarials15 (2.8, 29.6) (19.0, 71.3) (5.4, 32.9) (37.7, 74.2) (26.9, 37.0) (29.7, 49.5) (31.4, 67.4) (31.5, 51.4) (28.5, 44.7) Source: ACTwatch Outlet Survey, Benin, 2011.

13 Minimum daily wage information taken from United States Department of State, 2010. Country Reports on Human Rights Practices. Available at: http://www.state.gov/g/drl/rls/hrrpt/2010/index.htm 14 International reference price taken from Management Sciences for Health, 2010. International drug price indicator guide. Available at: http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2010_en.pdf. $1.42 is the median listed supplier price for 24 tablets of AL 20mg/120mg. 15 This question was not asked in Public Health Facilities. Information on outlets that offer credit to consumers for antimalarials was missing for 3% of cases [n=1,163]. Missing values were particularly common for general retailers (4%, n=660). Page 25

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Table A.6: Availability of diagnostic tests and cost to patients, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets that had:16 N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 38.9 0.0 36.7 12.8 33.6 2.1 0.0 0.0 3.0 5.3 Any diagnostic test (27.4, 51.8) ‐‐ (18.1, 60.4) (8.2, 19.6) (24.0, 44.8) (0.7, 6.2) ‐‐ ‐‐ (1.4, 6.2) (3.4, 8.0) 7.2 0.0 12.6 3.1 22.5 0.0 0.0 0.0 1.9 2.2 Microscopic blood tests (4.4, 11.7) ‐‐ (4.9, 28.7) (1.5, 6.4) (14.4, 33.4) ‐‐ ‐‐ ‐‐ (0.8, 4.6) (1.1, 4.4) 36.1 0.0 21.8 10.9 12.3 2.1 0.0 0.0 1.1 3.4 Rapid diagnostic tests (24.7, 49.3) ‐‐ (5.5, 57.2) (7.2, 16.1) (3.0, 39.0) (0.7, 6.1) ‐‐ ‐‐ (0.3, 4.4) (1.9, 5.9) Proportion of outlets that provided diagnostic tests for free, among N=76 N=0 N=21 N=97 N=41 N=4 N=0 N=0 N=45 N=142 outlets providing diagnostic tests 95.0 47.1 84.1 16.2 16.3 56.0 Any diagnostic test 20.0 ‐‐ ‐‐ (84.8, 98.5) (8.6, 89.4) (63.0, 94.3) (3.5, 50.8) (3.4, 64.1) (3.4, 52.2) (32.2, 77.3) N=19 N=0 N=15 N=34 N=31 N=0 N=0 N=0 N=31 N=65 0.0 0.0 0.0 0.0 0.0 0.0 Microscopic blood tests ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ N=65 N=0 N=7 N=72 N=15 N=4 N=0 N=0 N=19 N=91 100.0 74.1 95.7 44.1 42.9 83.4 Rapid diagnostic tests 20.0 ‐‐ ‐‐ ‐‐ (22.0, 96.7) (82.8, 99.1) (33.1, 55.7) (3.4, 64.1) (30.7, 56.1) (65.0, 93.1) Median US$ Median US$ Median US$ Median US$ Median US$ Median US$ Median US$ Median US$ Median US$ Median US$ Median price of: [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) $2.25 $2.25 $2.25 $4.49 $4.49 $3.37 Microscopic blood tests ‐‐ (0) ‐‐ (0) ‐‐ (0) ‐‐ (0) [1.12‐3.37] (12) [2.25‐3.37] (12) [1.80‐3.37] (24) [2.92‐4.49] (27) [2.92‐4.49] (27) [2.25‐4.49] (51)

$0.00 $0.00 $0.00 $2.70 $3.23 $2.70 $0.00 Rapid diagnostic tests ‐‐ (0) ‐‐ (0) ‐‐ (0) [0.00‐0.00] (70) [0.00‐1.80] (9) [0.00‐0.00] (79) [0.00‐3.37] (11) [2.25‐3.26] (5) [0.00‐3.37] (16) [0.00‐0.00] (95) Source: ACTwatch Outlet Survey, Benin, 2011.

16 Information on proportion of outlets that had diagnostic tests was missing for 3% of cases [n=1,355]. Page 26

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Table A.7: Provider knowledge, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers that: N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 Correctly state the recommended 93.8 96.2 71.6 93.1 83.6 89.1 39.1 55.8 44.7 55.7 first‐line treatment for uncomplicated (88.0, 96.9) (83.8, 99.2) (34.5, 92.3) (84.3, 97.1) (66.6, 92.9) (84.9, 92.2) (30.2, 48.8) (28.7, 79.9) (36.4, 53.3) (45.6, 65.4) malaria17 Correctly state the dosing regimen of 88.0 54.8 53.3 63.1 77.2 84.4 22.8 42.0 29.5 37.2 the first‐line treatment for an adult (77.1, 94.1) (35.2, 73.0) (23.3, 81.1) (47.8, 76.1) (54.9, 90.4) (80.2, 87.8) (18.4, 27.9) (25.1, 60.9) (23.1, 36.8) (30.6, 44.2) Correctly state the dosing regimen of 72.6 89.6 42.8 80.6 65.4 74.0 23.7 33.7 28.7 40.5 the first‐line treatment for a two‐year (62.0, 81.2) (65.9, 97.4) (20.6, 68.4) (63.2, 90.9) (41.4, 83.5) (68.3, 78.9) (16.4, 33.1) (19.4, 51.8) (21.1, 37.7) (29.7, 52.3) old ‐‐ N=49 N=66 N=115 N=135 N=193 N=688 N=63 N=1,079 N=1,194 Can list at least one health danger 89.4 40.1 82.8 56.9 74.6 62.5 70.6 62.7 66.4 sign in a child that requires referral to ‐‐ (69.8, 96.9) (19.0, 65.7) (63.4, 93.0) (45.4, 67.7) (69.3, 79.2) (52.6, 71.5) (55.2, 82.3) (53.3, 71.2) (56.5, 74.9) a public health facility18: 57.4 28.6 53.5 33.1 32.4 11.2 5.3 13.1 20.5  Convulsions ‐‐ (30.6, 80.4) (11.7, 54.7) (29.1, 76.4) (20.8, 48.3) (24.8, 41.1) (5.8, 20.3) (1.4, 17.8) (7.5, 22.0) (11.6, 33.7) 63.6 24.5 58.4 24.6 53.0 48.0 60.6 46.7 48.9  Vomiting ‐‐ (47.2, 77.3) (8.1, 54.6) (42.8, 72.4) (10.5, 47.4) (47.1, 58.8) (39.3, 56.8) (46.6, 73.0) (38.1, 55.6) (39.8, 57.9) 20.0 4.8 17.9 8.7 20.5 15.6 22.1 15.4 15.9  Unable to drink / breastfeed ‐‐ (11.4, 32.6) (1.3, 15.8) (10.7, 28.6) (3.3, 20.8) (14.5, 28.4) (10.1, 23.2) (13.5, 34.1) (10.0, 22.9) (10.6, 23.0)  Excessive sleep / difficult to 8.3 0.7 7.3 4.5 10.8 5.9 1.2 5.6 5.9 ‐‐ wake up (4.1, 16.1) (0.2, 2.9) (3.4, 14.8) (1.4, 13.4) (6.2, 18.2) (2.8, 12.1) (0.1, 8.7) (2.8, 10.9) (3.4, 10.1) 19.4 21.6 19.7 25.6 16.8 11.3 6.5 12.4 13.7  Unconscious / coma ‐‐ (7.2, 42.8) (5.6, 56.3) (8.8, 38.4) (16.2, 37.9) (12.1, 22.7) (6.3, 19.7) (1.0, 33.2) (7.1, 20.7) (8.8, 20.8) Source: ACTwatch Outlet Survey, Benin, 2011.

17 Information on proportion of providers that correctly state the recommended first‐line treatment for uncomplicated malaria was missing for 1% of cases [n=1,375]. 18 This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for 3% of cases [n=1,156]. Providers could state multiple responses and totals may sum to more than 100%. Page 27

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Table A.8: Provider perceptions, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers that: N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 Agree with the statement, “Customers 47.4 71.4 58.8 63.8 73.4 77.6 91.0 93.4 89.4 83.8 often request an antimalarial by name.”19 (34.6, 60.6) (49.6, 86.4) (31.6, 81.5) (47.7, 77.4) (47.9, 89.3) (66.9, 85.6) (83.4, 95.3) (83.7, 97.5) (83.7, 93.3) (78.2, 88.2) Agree with the statement, “I generally 53.3 83.5 98.0 77.4 99.5 72.8 50.3 67.5 55.8 60.7 decide which antimalarial medicine (40.0, 66.1) (78.6, 87.4) (91.8, 99.5) (71.4, 82.4) (97.3, 99.9) (66.2, 78.5) (38.1, 62.5) (51.9, 80.0) (44.5, 66.5) (51.1, 69.6) customers receive.” Report that an ACT is the most effective 90.4 81.0 56.2 80.9 67.7 85.5 17.3 39.8 23.9 36.9 antimalarial medicine for an adult20 (85.5, 93.8) (58.2, 92.9) (31.1, 78.5) (65.8, 90.3) (43.6, 85.1) (79.8, 89.8) (12.7, 23.0) (23.0, 59.5) (18.1, 31.0) (28.7, 46.0)

Report that an ACT is the most effective 89.2 100.0 54.4 92.6 63.6 85.5 26.7 38.0 31.5 45.4 antimalarial medicine for a child (85.5, 92.0) ‐‐ (30.4, 76.5) (85.6, 96.3) (49.2, 75.9) (80.8, 89.2) (19.4, 35.6) (21.6, 57.6) (23.8, 40.3) (34.8, 56.5) Proportion of providers than state the following reasons for stocking N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 antimalarials:21 14.4 9.8 8.3 10.8 0.2 12.5 14.8 6.4 13.1 12.6  Most profitable (7.2, 26.9) (5.1, 18.1) (2.1, 27.4) (6.0, 18.7) (<0.1, 1.4) (8.4, 18.2) (7.4, 27.4) (1.5, 23.2) (6.6, 24.5) (6.9, 21.8) 53.8 64.6 27.6 58.1 30.0 18.2 4.3 0.8 6.6 18.3  Recommended by government (36.9, 69.8) (37.7, 84.6) (10.0, 56.7) (38.5, 75.4) (18.6, 44.5) (14.3, 22.9) (1.8, 10.3) (0.1, 5.8) (3.2, 12.9) (9.9, 31.3) 15.4 0.9 36.6 8.2 14.1 16.7 31.6 21.9 29.3 24.5  Lowest priced (8.6, 26.0) (0.1, 7.3) (14.2, 66.9) (3.5, 18.0) (5.0, 34.0) (12.8, 21.5) (20.2, 45.7) (11.1, 38.6) (18.6, 42.9) (15.6, 36.3) 32.6 10.4 18.8 16.9 45.3 77.1 78.6 73.2 75.5 62.1  Consumer demand (18.9, 50.1) (5.4, 19.3) (8.2, 37.5) (9.8, 27.4) (29.9, 61.8) (70.1, 82.9) (71.4, 84.4) (65.4, 79.7) (70.0, 80.3) (51.2, 72.0) 9.1 16.6 3.4 13.4 19.4 14.1 17.7 19.2 17.9 16.8  Easily available (4.2, 18.5) (2.6, 60.3) (0.8, 13.3) (3.0, 43.6) (9.9, 34.5) (9.6, 20.1) (12.3, 24.8) (11.2, 30.8) (12.8, 24.3) (11.1, 24.8) 1.1 4.7 3.4 3.7 1.0 3.1 1.1 0.0 1.1 1.7  Drug company (0.3, 4.1) (0.9, 20.6) (0.8, 13.3) (1.0, 12.8) (0.2, 5.3) (1.5, 6.6) (0.3, 4.1) ‐‐ (0.3, 3.5) (0.7, 4.0) 4.7 0.0 10.5 2.2 2.7 10.4 5.4 1.1 5.0 4.4  Brand reputation (2.4, 9.0) ‐‐ (4.1, 24.3) (0.9, 5.6) (0.7, 9.3) (8.0, 13.5) (1.7, 15.7) (0.2, 5.0) (1.8, 13.2) (1.8, 10.2)

Continued on following page

19 Information on this pair of indicators was missing for no more than 2% of cases [n=1,370, and n=1,366]. 20 Information on this pair of indicators was missing for no more than 1% of cases [n=1,380, and n=1,381]. 21 Information on this indicator was missing for <1% of cases [n=1,380]. Providers could state multiple responses and totals may sum to more than 100%. Page 28

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Table A.8: Provider perceptions, by outlet type

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers than state the following reasons for stocking N=193 N=49 N=66 N=308 N=135 N=193 N=688 N=63 N=1,079 N=1,387 antimalarials: 2.6 0.0 3.0 1.0 3.9 3.7 0.1 0.4 0.5 0.6  Dosage form (0.9, 7.5) ‐‐ (1.1, 8.0) (0.4, 2.6) (1.0, 13.8) (1.2, 10.5) (<0.1, 0.5) (<0.1, 3.0) (0.2, 1.4) (0.3, 1.4) 19.8 1.6 46.0 10.7 26.6 32.8 2.0 0.0 4.5 6.0  Frequently prescribed (11.4, 32.1) (0.2, 11.5) (14.3, 81.2) (5.4, 20.3) (10.4, 53.0) (26.9, 39.3) (0.6, 6.6) ‐‐ (2.0, 9.8) (3.6, 9.7) 5.2 0.7 12.5 3.1 13.6 6.3 2.9 12.5 4.3 4.1  Effectiveness (2.8, 9.6) (0.1, 5.7) (3.7, 34.9) (1.2, 7.9) (5.1, 31.2) (3.0, 12.6) (1.3, 6.3) (3.8, 34.0) (2.4, 7.8) (2.2, 7.3) 0.5 2.1 0.0 1.5 0.5 1.6 <0.1 0.4 0.1 0.4  Other reasons (0.1, 3.1) (0.3, 11.8) ‐‐ (0.3, 7.2) (0.1, 2.7) (0.4, 6.0) (<0.1, 0.2) (<0.1, 3.0) (<0.1, 0.6) (0.1, 1.7) 0.6 0.0 5.7 0.7 2.9 3.7 2.5 1.1 2.5 2.1  Don’t know (0.1, 3.9) ‐‐ (2.2, 14.2) (0.1, 3.7) (1.0, 8.5) (2.1, 6.3) (1.2, 5.4) (0.2, 5.0) (1.2, 5.1) (1.0, 4.6) Source: ACTwatch Outlet Survey, Benin, 2011.

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Additional Tables

Table B.1: Market share by antimalarial category within each outlet type

Public Community Private TOTAL Private General Itinerant TOTAL TOTAL Health Health not for profit Public / Not for profit Pharmacy retailer drug vendor Private Outlets Facility Worker HF for profit HF Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or % % % % % % % % % % distributed within a given outlet type 22 in the past week: Any ACT 43.2 100.0 43.4 49.3 30.2 78.3 11.7 33.1 24.3 34.6 Quality Assured ACT (QAACT) 43.2 100.0 41.7 49.1 28.1 14.3 11.6 33.1 16.7 30.1 First‐line (FAACT) 41.7 100.0 41.7 47.9 27.9 13.0 11.6 33.1 16.5 29.5 Non first‐line (NAACT) 1.5 0 0 1.2 0.2 1.3 0 0 0.2 0.6

Non‐quality Assured ACT 0 0 1.7 0.2 2.1 63.9 0.1 0 7.6 4.6

Other ACT Classifications Nationally Registered ACT 43.2 100.0 42.4 49.1 29.3 57.0 11.6 33.1 21.7 33.1

Any non‐artemisinin therapy 56.7 0 56.5 50.7 69.7 20.5 88.3 66.9 75.5 65.3 Chloroquine <0.1 0 2.4 0.3 0.1 0 44.8 30.4 29.4 17.4 Sulfadoxine‐pyrimethamine (SP) 9.3 0 17.4 9.2 46.1 18.1 34.0 21.2 34.1 23.8 Second‐line treatment (Quinine) 47.4 0 36.7 41.2 20.1 1.2 7.9 15.3 10.2 23.0

Any artemisinin monotherapy 0.1 0 <0.1 0.1 0.1 1.2 0 0 0.1 0.1 Oral artemisinin monotherapy 0 0 0 0 0 0 0 0 0 0 Non oral artemisinin monotherapy 0.1 0 <0.1 0.1 0.1 1.2 0 0 0.1 0.1 Source: ACTwatch Outlet Survey, Benin, 2011.

22 Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACTs and Non‐quality Assured ACT; QAACTs decompose fully into FAACTs and NAACTs; nationally registered ACTs are either QAACTs or non‐QAACTs. Row and column totals exhibit minor rounding errors. Page 30

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References

d’Almeida T. et al., 2011. Field evaluation of the intermittent preventive treatment of malaria during pregnancy (IPTp) in Benin: evolution of the coverage rates since its implementation, Parasites & Vectors, [online] Available at: http://www.parasitesandvectors.com/content/4/1/108 [Accessed: 12 August 2011].

Institut National de la Statistique et de l’Analyse Economique (INSAE) Benin et Macro International Inc., 2007. Demographic and Health Survey (EDSB‐III) – Benin 2006. Calverton, Maryland: INSAE et Macro.

Malaria Taxes and Tariffs Advocacy Project, 2010. Current Status of Tariffs on Antimalarial Commodities, February 2010. [online] Available at: http://www.m‐tap.org [Accessed 12 August 2011].

Ndoye T, et al., 2009. Évaluation de la gouvernance, de la transparence et des opérations de la Centrale d’Achats des Médicaments Essentiels du Bénin, décembre 2008. Présenté à l’Agence des États‐Unis pour le Développement International par le Programme Strengthening Pharmaceutical Systems (SPS). Arlington, VA: Management Sciences for Health.

Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, 2011. World Population Prospects: The 2010 Revision. [online] Available at: http://esa.un.org/unpp [Accessed 2 April 2012].

Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, 2010. World Urbanization Prospects: The 2009 Revision. [online] Available at: http://esa.un.org/wup2009/unup [Accessed 12 August 2011].

President’s Malaria Initiative (PMI), 2009. FY 2010 Malaria Operation Plan: Benin.

President’s Malaria Initiative (PMI), 2010. FY 2011 Malaria Operation Plan: Benin.

President’s Malaria Initiative (PMI), 2011. FY 2012 Malaria Operation Plan: Benin.

Programme National de Lutte contre le Paludisme (PNLP), Ministère de la Sante Publique, 2005. Politique nationale de lutte contre le paludisme et cadre stratégique de mise en œuvre. Cotonou : Les presses d’Afrique.

Tougher S, et al., (2009). The private commercial sector distribution chain for antimalarial drugs in Benin. [online] London: LSHTM. Available at http://www.crehs.lshtm.ac.uk/downloads/publications/ACT_Benin.pdf [Accessed 2 April 2012].

World Bank, 2012. World databank. [online] Available at: http://databank.worldbank.org/ [Accessed 2 April 2012].

World Health Organisation (WHO), 2010. World Malaria Report 2010. Geneva: WHO Press.

World Health Organisation (WHO), 2011a. Global Health Observatory. [online] Available at: http://apps.who.int/ghodata/ [Accessed 12 August 2011].

World Health Organisation (WHO), 2011b. World Malaria Report 2011. Geneva: WHO Press.

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Appendices

ACTs classified as quality assured

Formulation Active ingredients Manufacturer Manufacture site Brand name Package size and strength Artesunate + Tablets 50mg + Guilin Guilin, Guangxi, China Arsuamoon (1‐6yrs;7‐ 6;12;24 Amodiaquine 150mg Pharmaceutical Co. 13yrs; Adults) Ltd Artesunate + Tablets 50mg + Ipca Laboratories Dadra and Nagar Haveli AS‐AQ Generic (Child; 6;12;24 Amodiaquine 153mg / Limited (U.T.), India Junior; Adult) 153.1mg Artesunate + Tablets 50mg + Ipca Laboratories Dadra and Nagar Haveli Larimal (Child; Junior; 6;12;24 Amodiaquine 153mg / Limited (U.T.), India Adult) 153.1mg Artesunate + Tablets 25mg + Sanofi‐Aventis MAPHAR Laboratories, Coarsucam 25mg/67.5mg 3 Amodiaquine 67.5mg Group Casablanca, Morocco (Infant) Artesunate + Tablets 50mg + Sanofi‐Aventis MAPHAR Laboratories, Coarsucam 50mg/135mg 3 Amodiaquine 135mg Group Casablanca, Morocco (Toddler) Artesunate + Tablets 100mg Sanofi‐Aventis MAPHAR Laboratories, Coarsucam 3;6 Amodiaquine + 270mg Group Casablanca, Morocco 100mg/270mg (Child; Adult) Artesunate + Tablets 25mg + Sanofi‐Aventis MAPHAR Laboratories, Winthrop 25mg/67.5mg 3 Amodiaquine 67.5mg Group Casablanca, Morocco (Infant) Artesunate + Tablets 50mg + Sanofi‐Aventis MAPHAR Laboratories, Winthrop 50mg/135mg 3 Amodiaquine 135mg Group Casablanca, Morocco (Toddler) Artesunate + Tablets 100mg Sanofi‐Aventis MAPHAR Laboratories, Winthrop 100mg/270mg 3;6 Amodiaquine + 270mg Group Casablanca, Morocco (Child; Adult) Artesunate + Tablets 50mg + Strides Arcolab Bangalore, India ACTipal (Madagascar) 3, 6, 12 Amodiaquine 153mg Limited Artesunate + Tablets 50mg + Cipla Ltd Patalganga, India; Falcimon Kit & 6;12;24 Amodiaquine 153mg (200mg Goa, India Serenadose (DRC) salt) (Young children up to 6yrs; Children 7‐13yrs; Adults) Artemether + Tablets 20mg + Novartis Pharma Beijing, China; Coartem 20/120 6;12;18;24 Lumefantrine 120mg Suffern, USA Artemether + Tablets 20 gm+ Ajanta Pharma Ltd Paithan, Aurangabad, Artefan 20/120 6;12;18;24 Lumefantrine 120mg Maharashtra, India Artemether + Dispersible Novartis Pharma AG Novartis Pharmaceuticals Coartem‐D 6;12 Lumefantrine Tablets 20mg + Corporation, Suffern, USA 120mg Artemether + Tablets 20mg + Cipla Ltd Patalganga, India; Lumartem (5‐15kg; 15‐ 3;6;12;18;24 Lumefantrine 120mg Himachal Pradesh, India 25kg; 25‐35kg; >=35kg) Artemether + Tablets 20mg + Ipca Laboratories Dadra and Nagar Haveli Lumerax 20/120 6;12;24 Lumefantrine 120mg Ltd (U.T.), India Artemether + Tablets 20mg + Ipca Laboratories Dadra and Nagar Haveli AL Generic 6;12; 18;24 Lumefantrine 120mg Ltd (U.T.), India Artesunate + Tablets 50mg + Guilin Guilin, Guangxi, China Artecospe Co‐blistered Sulfadoxine / 500mg/25mg Pharmaceutical Co. 6+2 Pyrimethamine Ltd

Artesunate + Tablets 100mg Guilin Guilin, Guangxi, China Artecospe Co‐blistered Sulfadoxine / + 500mg/25mg Pharmaceutical Co. 6+3 Pyrimethamine Ltd

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Nationally registered ACTs

Benin’s nationally registered ACTs as of September 200823 Manufacture Active ingredients Formulation Strength Manufacturer Brand Name Site Artesunate / Amodiaquine Tablet 200mg / 200mg Dafra Belgium Amonate Artesunate / Amodiaquine Tablet 50mg / 153mg Ajanta India Apoxin Artesunate / Amodiaquine Tablet 50mg / 150mg Guilin pharma China Arsuamoon Artesunate / Amodiaquine Tablet 50mg / 153mg Sanofi Aventis Morocco Arsucam Artesunate / Amodiaquine Tablet 100mg / 153mg Odypharm England Artediam Artesunate / Amodiaquine Tablet 100mg / 300mg Pfizer USA Camoquin Plus Artesunate / Amodiaquine Tablet 200mg / 600mg Pfizer USA Camoquin Plus Artesunate / Amodiaquine Tablet 25mg / 67.5mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 50mg / 135mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 100mg / 270mg Sanofi Aventis Morocco Coarsucam Artesunate / Amodiaquine Tablet 50mg / 153mg Ipca India Larimal Artesunate / Amodiaquine Tablet 50mg / 200mg Macleods India Macsunate Plus Artesunate / Amodiaquine Tablet 25mg / 75mg Medinomics India Malmed Artemether / Lumefantrine Tablet 20mg / 120mg Ajanta India Artefan Artemether / Lumefantrine Tablet 40mg / 240mg Ajanta India Artefan Artemether / Lumefantrine Tablet 80mg / 480mg Ajanta India Artefan Artemether / Lumefantrine Tablet 20mg / 120mg Novartis Switzerland Coartem Artemether / Lumefantrine Powder 15mg / 90mg Dafra Belgium Co‐Artesiane Artemether / Lumefantrine Suspension 360mg / 2160mg / Dafra Belgium Co‐Artesiane 120ml Artemether / Lumefantrine Suspension 360mg / 2160mg / Dafra Belgium Co‐Artesiane 120ml Artemether / Lumefantrine Suppository 20mg / 120 mg Bliss Gvs India Lonart Artemether / Lumefantrine Tablet 20mg / 120mg Bliss Gvs India Lonart Artemether / Lumefantrine Suspension 180mg / 1080mg / Bliss Gvs India Lonart 60ml Artemether / Lumefantrine Tablet 40mg / 240mg Imex Health India Lufanter Artemether / Lumefantrine Tablet 20mg / 120mg Cipla India Lumartem Artemether / Lumefantrine Tablet 20mg / 120mg Macleods India Lumether Artesunate / Mefloquine Granules 50mg / 125mg Mepha Switzerland Artequin Paediatric Artesunate / Mefloquine Tablet 100mg / 125mg Mepha Switzerland Artequin Artesunate / Mefloquine Tablet 100mg / 250mg Mepha Switzerland Artequin Artesunate / Mefloquine Tablet 200mg / 250mg Mepha Switzerland Artequin Artemisinine / Naphthoquine Tablet 125mg / 50mg Kunming China Arco Artesunate / Tablet Stallion India Artecure Sulfamethoxypyrazine / ‐‐ Pyrimethamine Continued on following page

23 Nationally registered ACTs were compiled through the Ministry of Health in Benin.

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Manufacture Active ingredients Formulation Strength Manufacturer Brand Name Site Artesunate / Sulfadoxine / Tablet 100mg / 500mg / Plethico India Artedar Pyrimethamine 25mg Artesunate / Tablet 100mg / 250mg / Denk pharma Germany AsunateDenk 100 Plus Sulfamethoxypyrazine / 12.5mg Pyrimethamine Artesunate / Tablet 200mg / 500mg / Denk pharma Germany AsunateDenk 200 Plus Sulfamethoxypyrazine / 25mg Pyrimethamine Artesunate / Tablet 100mg / 250mg / Dafra Belgium Co‐Arinate Sulfamethoxypyrazine / 12.5mg Pyrimethamine Artesunate / Tablet 200mg / 500mg / Dafra Belgium Co‐Arinate Sulfamethoxypyrazine / 25mg Pyrimethamine Dihydroartemisinin / Granules 15mg / 120mg Steyuan pharm China Darte‐q Piperaquine Dihydroartemisinin / Capsule 40mg / 320mg Steyuan pharm China Darte‐q Piperaquine Dihydroartemisinin / Tablet 40mg / 320mg Holleypharm China Duo‐cotecxin Piperaquine Dihydroartemisinin / Tablet 40mg / 320mg Laboratoire Salvat India Malacur Piperaquine Dihydroartemisinin / Suspension 80mg / 640mg / 80ml Bliss Gvs India P‐Alaxin Piperaquine Dihydroartemisinin / Tablet 32mg / 320mg / 90mg Tonghe Pharma China Artecom Piperaquine / Trimethoprim Dihydroartemisinin / Tablet 60mg / 500mg / 25mg Bliss Gvs India Alaxin Plus Sulfadoxine / Pyrimethamine

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Final sample

List of clusters (Arrondissements) sampled, Benin, 2011. Refer to page 13 for an explanation of the booster sample approach for this survey.

Department Commune Arrondissement Censused cluster or booster sample?

Alibori Banikoara Toura Census Alibori Banikoara PHF booster sample Alibori Karimama Birni‐Lafia Census Alibori Karimama PHF booster sample Alibori Pharmacy booster sample Atacora Boukoumbe Tabota Census Atacora Boukoumbe PHF booster sample Atacora Pharmacy booster sample Atlantique Abomey‐Calavi Godomey Census Atlantique Abomey‐Calavi PHF booster sample Atlantique Toffo Ague Census Atlantique Toffo PHF booster sample Atlantique Pharmacy booster sample Borgou Bembereke Gomia Census Borgou Bembereke PHF booster sample Borgou Perere Sontou Census Borgou Perere PHF booster sample Borgou Pharmacy booster sample Collines Dassa‐Zoume Kpingni Census Collines Dassa‐Zoume PHF booster sample Collines Ouesse Kilibo Census Collines Ouesse PHF booster sample Collines Save Kaboua Census Collines Save PHF booster sample Collines Pharmacy booster sample Couffo Djakotome Djakotomey I Census Couffo Djakotome PHF booster sample Couffo Pharmacy booster sample Donga Bassila Penessoulou Census Donga Bassila PHF booster sample Donga Pharmacy booster sample Littoral Cotonou 1st Arrondissement Census Littoral Cotonou 9th Arrondissement Census Littoral Cotonou PHF and pharmacy booster sample Mono Grand‐Popo Sazoue Census Mono Grand‐Popo PHF booster samples Mono Pharmacy booster sample

Continued on following page

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Department Commune Arrondissement Censused cluster or booster sample?

Oueme Bonou Bonou Census Oueme Bonou PHF booster sample Oueme Porto‐Novo 2nd Arrondissement Census Oueme Porto‐Novo PHF booster sample Oueme Pharmacy booster sample Plateau Pobe Pobe Census Plateau Pobe PHF booster sample Plateau Pharmacy booster sample Zou Bohicon Lissezoun Census Zou Bohicon PHF booster sample Zou Pharmacy booster sample

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Survey team

List of staff members involved in the survey, Benin, 2011.

Team Leaders Interviewers Moudachirou BIAOU Laminou ASHANTI Abdoul Ramane CHABI Ben Youssouf BIO BANGANA Tayéwo CHACON Israel DOVONOU Roland AGBESSI Rachidatou CHABI GADO Gilles ACCROMBESSY Jean Claude GLELE Nellie AGUIDI Yves KOTAN Epiphane ABOGOURIN Marcellin ODOULAMI Ghyslaine BALOGOUN Additional quality control and supervision Noel Dona HOUETO Emmanual ACAKPO Rafatou KOKOKO Wilfred ADJANOHOUN Géraldo OGNIN Roger ATCHOUTA Rémi EKON K. Abdou Raman OLODO Gilles CODJIA Sai Sotima TCHANTIPO Hermine Lisette LOKOSSOU Prudencio NOUGLOKOU Armelle DAHOUNLINTON Augustine KPOTON Thierry ASSOGBA Oscar MEDO Baudoin ADINAKOU Hermione DAGNON Constant GANDJI Gynette GINDEHOU Maryse OGOULOLA Marc ADJERAN Serge Arnaud HOUNNOU Virginie GANGBADJO

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Description of outlet types visited for this survey 24

Public / Not for Profit Sector

Public Health Facilities N Description Government‐run health facilities that provide prescription Referral hospital 10 medicine following medical consultation or diagnosis. Fees (Hôpital de zone, or larger) are usually charged for consultations and medicines.

Arrondissement health centres are the first‐level of facility‐ Commune health centre 27 based public health care, and are usually staffed by nurses, a midwife, and auxiliary staff. They usually include a dispensary and maternity ward, although these facilities may also exist on their own. Arrondissement health centre 117 Commune health centres ‐ the next level ‐ are usually staffed by a doctor, nurses, and midwives. Across Benin’s 34 health zones, there is an average of 2 communes per Dispensary 17 zone.

Health‐zone level hospitals and the national referral hospital in Cotonou receive first‐level referral services and Maternity 11 typically are staffed with a surgeon and offer specialist health practitioners.

Village health units are staffed by voluntary community Village health unit 22 health workers and are linked to an arrondissement or communal health centre. Community health workers N Description This cadre of staff works at the community‐level, providing diagnosis and treatment where appropriate, and referring Community health workers (CHWs) 54 patients when required. CHWs are trained and supported by a variety of international NGOs, in partnership with the Ministry of Health. Private, not for profit facilities N Description

Non‐Governmental Organization 85 These facilities provide prescription medicine following (NGO) hospital / health centre medical consultation or diagnosis. They are usually staffed with qualified health practitioners, though some smaller Missionary hospital / clinic 8 clinics run by NGOs have less well qualified staff.

24 In total, 2,966 outlets were enumerated during data collection. The outlet classification was missing for 6 cases and they are therefore excluded from the breakdown presented here.

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Private‐for‐Profit Sector

Private facilities N Description

These are non‐governmental health facilities. Private clinics are smaller than hospitals and many of them are not Private hospital / clinic 171 registered with the Ministry of Health. They provide consultations and examinations, and sell prescription medicines at commercial prices.

Registered Pharmacies N Description

Registered pharmacies are licensed by the Ministry of Health and sell prescription medicine at commercial prices. The Pharmacy 205 outlets are staffed by qualified health practitioners, with oversight/supervision provided by a pharmacist. They sell all classes of drugs and are highly regulated.

General Retailers N Description

Businesses/points‐of‐sale which sell fast moving consumer Supermarket 12 goods (e.g. food, household products), in addition to some medicines (most often antipyretics). Drugs sold at these locations are not regulated. Boutiques are more formal Boutique 815 structures than stalls, ranging from lockable‐steel structures in markets, to outlets located in an arcade of shops, or occupying the ground floor of a house. Supermarkets are larger than boutiques, both in floor space and in the range of Boutique (in a market) 33 products they stock.

Stall (outside a market) 1,011 Stalls sell a variety of products that are displayed on tables (for example, on the roadside or in populated areas). They sell fast moving consumer goods and sometimes medicines. Stall (in a market) 221 Drugs sold at these locations are not regulated.

Itinerant drug vendors N Description

Itinerant salesmen who often sell products of unknown Hawkers 141 origin, including medicines.

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Pharmacy

NGO health centre (Centre medico social) Medicine selection carried by a hawker

Boutique (in a market) Stall (outside a market)

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Questionnaire

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Evidence for Malaria Medicines Policy