Outlet Survey Republic of Benin 2009 Survey Report

Evidence for Malaria Medicines Policy

Country Program Coordinator Principal Investigator Cyprien Zinsou Dr. Kathryn O’Connell Association Béninoise pour le Marketing Social/PSI 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, ABMS/PSI‐Benin, oversaw all aspects of implementation and management of the survey.

Esther Tassiba ACTwatch Country Program Coordinator, ABMS/PSI‐Benin, was responsible for all aspects of implementation and management of the survey.

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

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

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

Sandra Le Fèvre Pfizer Research Fellow, ACTwatch Central, assisted the Country Program Coordinator with the coordination and facilitation of trainings, data collection, and data entry.

Erik Munroe Research Associate, ACTwatch Central, conducted analysis on the data.

Stephen Poyer Research Associate, ACTwatch Central, conducted analysis on the data and compiled the report.

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

Tanya Shewchuk Project Director, ACTwatch Central, provided overall oversight and dissemination.

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, Research Associates.

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

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

Suggested citation:

ACTwatch Group and Association Béninoise pour le Marketing Social (ABMS)/Benin. (2009). Benin Outlet Survey Report 2009. Population Services International: DC. Available from: www.actwatch.info

Table of Contents

TABLE OF CONTENTS ...... I

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 ...... 7 Overview of the ACTwatch Research Project ...... 7 Country background ...... 8

METHODS ...... 12

RESULTS ‐ OUTLET SURVEY ...... 18 Characteristics of the sample ...... 18 Standard ACTwatch tables ...... 20

ADDITIONAL TABLES ...... 32

REFERENCES ...... 34

APPENDICES ...... 35 ACTs classified as quality assured ...... 35 Nationally registered ACTs ...... 37 Final sample ...... 39 Survey team ...... 41 Description of outlet types visited for this survey ...... 42 Questionnaire ...... 45

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List of ACTwatch Tables

Table A.1: Availability of antimalarials, by outlet type ...... 20 Table A.2: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type ...... 22 Table A.3: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type ...... 24 Table A.4: Price of antimalarials, by outlet type ...... 25 Table A.5: Affordability of antimalarials, by outlet type ...... 26 Table A.6: Availability of diagnostic tests and cost to patients, by outlet type ...... 27 Table A.7: Market share, by outlet type ...... 28 Table A.8: Provider knowledge, by outlet type ...... 29 Table A.9: Provider perceptions, by outlet type ...... 30 Table B.1: Market share by antimalarial category within each outlet type ...... 32

List of Figures

Figure 1. Availability of antimalarials by outlet type ...... 2 Figure 2. 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 ...... 5 Figure 6. Market share of AETDs sold/distributed in the past week (7 days) ...... 5 Figure 7. Provider knowledge of recommended first‐line treatment and dosing regimens ...... 6 Figure 8: Location of Benin ...... 8

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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 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 comprised a simple random sample of a further two‐thirds of pharmacies in the department in which a selected arrondissement fell.

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 Arrondissement.

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 (S1 to 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, or (2) they report having stocked them in the past three months.

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 Coartem 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg Coarsucam (Adulte ; Enfant ; Nourisson) Winthrop (Adulte ; Nourisson)

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:

Artefan 20mg/120mg Coartem 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg

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:

Coarsucam (Adulte ; Enfant ; Nourisson) Winthrop (Adulte ; Nourisson)

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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 Combicure Alaxin‐SP Darte‐Q Arco Duo‐Cotexcin Artecom Larimal FD 400 Artedar Lonart Artediam Lufanter Artefan (40mg/240mg; 80mg/480mg) Lumet (Forte) Artemether Lumefantrine (Tong‐Mei Laboratoire) Lumether Artequin Lumiter Artesunate Amodiaquine (Tong‐Mei Laboratoire) Mac Med AsunateDenk Plus Macsunate Plus Camoquin Plus Malacur Co‐Arinate Malmed Co‐Artesiane P‐Alaxin Cofantrine

Other ACT classifications

Government recommended first‐line treatments for uncomplicated Any first‐line ACT malaria, artemether‐lumefantrine 20mg/120mg tablets. Brands included in this category and audited during data collection are:

Artefan 20mg/120mg Artemether Lumefantrine 20mg/120mg (Tong‐Mei Laboratoire, Togo) Coartem 20mg/120mg Cofantrine 20mg/120mg

Lufanter 20mg/120mg Lumartem 20mg/120mg Lumet 20mg/120mg Lumiter 20mg/120mg (MacLeods Pharmaceuticals, India)

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: Appendix B 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 Lonart Alaxin‐SP Co‐Arinate Lufanter Arco Co‐Artesiane Lumartem Artecom Coarsucam Lumether Artedar Coartem Macsunate Plus Artediam Cofantrine Malacur Artefan Darte‐Q Malmed Artequin Duo‐Cotecxin P‐Alaxin

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AsunateDenk Plus

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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 CFA (Franc) de la Communauté financière d’Afrique CHW Community Health Worker CI Confidence interval CQ Chloroquine DHS Demographic and Health Survey 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 Programme National de Lutte contre le Paludisme (National Malaria Control Program) 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 UN United Nations 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 (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo). 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 from April to July 2009.

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. This report presents indicators on availability, price, volumes, affordability in outlets and provider knowledge of antimalarials.

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.

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 (government hospitals, health centres, dispensaries, village health units, and other government health facilities); 2) private‐not‐for‐profit health facilities (mission and NGO health facilities); 3) registered pharmacies; 4) private‐for‐profit health facilities (private clinics and hospitals); 5) stores and boutiques; 6) market stalls; and 7) itinerant drug vendors (hawkers). Refer to the annex for definitions and numbers of each type of outlet included in the analysis.

Three questionnaire modules were administered to participating outlets: 1) screening module 2) audit sheet and 3) provider module. For all outlets, trained interviewers administered the screening module to collect information on the outlet type; location, including the outlet’s longitude and latitude; and information on availability of antimalarials. Among those outlets that stocked antimalarials at the time of survey, the audit sheet was administered. For each antimalarial, information was recorded on the brand and generic names, strength, expiry, amount sold in the last week and price to the consumer. Among outlets that stocked antimalarials at the time of interview or in the past three months, the interviewer collected information on provider demographics, knowledge, perceptions, and medicine storage conditions.

Several validation and data checking steps occurred during and after data collection. Double data entry was conducted using Microsoft Access (Microsoft Cooperation, Seattle, WA, USA). Data was analysed using 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 were collected in two tranches, between 28th April and 13th May, and 11th to 27th July, 2009. A total of 1,870 outlets were approached. Of these, 200 outlets were not screened for various reasons: 132 providers refused to be interviewed; 30 outlets were closed down permanently; 6 outlets were not open at the time of the survey visit; in 29 outlets, providers were not available for interview at the time of survey visit; and 3 providers were unable to be interviewed for other reasons. Overall, 1,670 outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 1,061 outlets met our screening criteria and were interviewed. Of the 1,061 completed interviews, 217 reported having stocked antimalarials at any point in the three months prior to the interview and 844 outlets stocked antimalarials at the time of the interview.

AVAILABILITY OF ANY ANTIMALARIAL: Stocking rates of any antimalarial varied by outlet type, with a clear distinction between ‘formal’ and ‘informal’ outlets. In the public/not for profit sector, 94% of outlets had at least one antimalarial in stock on the day of interview, with 95% of public health facilities stocking antimalarials. In the private (for profit) sector, 97% of pharmacies and 84% of private‐for‐profit health facilities stocked antimalarials on the day of interview. Stocking rates were lower among unregulated outlets in the private‐for‐profit sector: one‐third of boutiques and market stalls, and 43% of hawkers stocked antimalarials. Figure 1. Availability of antimalarials by outlet type

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OUTLET TYPES STOCKING ANTIMALARIALS: Figure 2 shows the relative distribution of all outlets that had at least one antimalarial in stock. Market stalls were the most common type of outlet stocking antimalarials, followed by boutiques. Together with hawkers, the informal sector comprised three‐quarters of outlets stocking antimalarials. Figure 2. Outlet types stocking antimalarials

AVAILABILITY OF DIFFERENT CLASSES ANTIMALARIALS: Among outlets stocking antimalarials, availability of FAACT and oral artemisinin monotherapy varied greatly by outlet type. While 86% of pharmacies and 84% of public health facilities stocked FAACTs, the proportions were much lower for mission/NGO and private health facilities (29% and 19%). Less than 5% of informal outlets stocked FAACTs. Almost one in ten mission/NGO health facilities and four in ten pharmacies had oral artemisinin monotherapies in stock. Non artemisinin monotherapy was available in over 90% of outlets of all types. Figure 3. Availability of antimalarials, among outlets with at least one antimalarial in stock

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AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: Among outlets stocking antimalarials in the past three months, 75% of public/not for profit outlets had diagnostic testing available, compared to only 2% of outlets in the private (for profit) sector. RDTs were much more widely available than microscopy in public health facilities (85% and 16%, respectively). In the private sector, 23% of for‐profit health facilities had tests available, compared to only 1% of pharmacies. No RDTs were available among the 618 informal providers interviewed. Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests

No outlet type systematically provides FAACT free of charge in Benin, and the median price of FAACT in public health facilities was $1.30 [n=464]. The median FAACT price in the private sector was $3.24 [n=689], and pharmacies were substantially more expensive than other private outlets ($6.10 [n=191], compared to $2.59 [n=15] in for‐profit health facilities). By comparison the median price of SP, the most popular antimalarial, was 5 times cheaper than the median FAACT cost ($0.65 [n=577]).

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Figure 5. Median price of a tablet AETD antimalarial treatment in the private sector

VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: The private sector in Benin comprised over 70% of the antimalarial market. Pharmacies accounted for more than one‐third of total volumes sold/distributed. Three‐quarters of all treatments distributed were non‐artemisinin therapies, mainly SP (40%) and CQ (25%). 23% of treatments were ACTs, although only half of these were FAACT (12%). Although available in 37% of pharmacies stocking antimalarials, oral artemisinin monotherapy comprised 0.1% of all volumes. Figure 6. Market share of AETDs sold/distributed in the past week (7 days)

PROVIDER KNOWLEDGE: Overall, 22% of providers interviewed were able to correctly state AL as the recommended first‐line treatment for uncomplicated malaria in Benin. By sector, knowledge was significantly higher in the public/not for profit sector than the private sector (73% vs. 18%). Knowledge was highest among providers in public health facilities (92%), followed by those in pharmacies (67%). Knowledge of adult and child dosing regimens for AL followed the same trends as first‐line knowledge: around 70% of public/not for profit providers described the correct regimens, compared to 13% of private sector providers.

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Figure 7. Provider knowledge of recommended first‐line treatment and dosing regimens

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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 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, Democratic Republic of Congo, 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 is planned 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 April and July 2009. 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, volumes, 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 2009 the population was estimated at 8.6 million, with 1.5 million children under 5 years of age (World Population Prospects, 2011). Approximately 60% of people are live in rural areas (World Urbanization Prospects, 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.

Source: CIA, The World Factbook 2009 https://www.cia.gov/library/publications/the ‐world‐factbook/index.html

Description of health care system

In the decade leading to 2009, GDP grew at an average annual rate of 4.4% while the population growth rate averaged 3.3%. Over this decade GDP per capita more than doubled, from $370 in 1999 to $771 in 2008 (World Bank, 2010). However, by the end of this period more than one third of the population was living below the government‐defined poverty line (UNDP, 2008). 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, 2011). The total fertility rate remains high, at 5.4 per woman in 2009, while the contraceptive prevalence was estimated at 17.0 in 2006 (INSAE, 2007).

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). 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, 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

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level, whose main structures are the Departmental 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 (Hopital 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 (PM, 2009). In 2009, approximately 180 private pharmacies were registered with the MOH.

Healthcare consumers at government facilities are expected to pay for consultations, diagnostic tests, procedures and medicines. 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, treatment of uncomplicated malaria is provided at public facilities for a fee: blister packs of 6, 12, 18, and 24 AL tablets are sold for 150CFA, 300CFA, 450CFA, and 600CFA, respectively (PMI, 2009). In 2009 150CFA was on average equivalent to $0.33.

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.

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 2009 report just under 900,000 confirmed malaria cases across all age groups, and a further 350,000 probable cases (reporting completeness for 2009 was estimated at 88%) (WHO, 2010).

Antimalarial Policies and Regulatory Environment

Faced with growing resistance to chloroquine and SP, Benin adopted artemether‐lumefantrine (AL) as the first‐line treatment for uncomplicated malaria in March 2004 (PNLP, 2005). Artesunate+amodiaquine (ASAQ) is recommended as the alternative treatment, should AL not be available, for patients who cannot tolerate AL, and for children under six months of age.

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 (PMI, 2009), and ACT only became widely available in the public sector in 2009. Prior to 2009 ACT was most commonly available through the private sector,

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which has historically been an important distribution channel of antimalarials in Benin (Tougher et al, 2009). ACTs were first introduced in the public sector through a Global Fund‐supported pilot project and the Projet Intégré de Santé Familiale (PISAF), a mission‐funded integrated family health project. By late 2008, about one‐third of the country was covered (i.e., ACTs delivered to facilities and staff trained), including the Departments of Mono, Couffo, Zou, and Collines (PMI, 2008).

Inefficiencies in the public sector supply management system have hindered initial distribution of ACTs to public health facilities, despite 2.7 million treatments being delivered to the government during 2009 (WHO, 2010). An assessment conducted by Management Sciences for Health identified both frequent stock‐outs of ACTs at public health facilities, and a large stock of AL warehoused by the Central Medical Stores (CAME) approaching expiration. Limited means of transportation from CAME’s central and regional warehouses to public health facilities, insufficient space and inappropriate storage conditions, and an inadequate information management system to monitor consumption of antimalarials at public health facilities have all contributed to this situation (Ndoye et al, 2009).

The NMCP strategic plan for 2005‐2010 views diagnosis and treatment of uncomplicated malaria by community agents using ACT as an important strategy in case management (PNLP, 2005). As of late 2009, this strategy had not been rolled‐out at scale across the country.

As noted above, public health facilities charge a fee for treatment with AL. In 2009, the treatment policy for children under five was presumptive, 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 since 2007. In early 2009 the government had 586,000 RDTs for use in the public health system, divided between health zones and the central medical stores. The NCMP policy is that RDTs are to be provided free of charge in the public sector.

Malaria control strategy

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, and a second‐round of mass distribution was planned for 2010. LLINs are also available 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 is ‘free’ and provided by funds from PMI, UNICEF and the World Bank. 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 only introduced at a national level in 2005, and problems with the public sector supply chain described

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above would doubtless 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). The results of the 2011 DHS will show whether this finding is generalisable.

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. Looking ahead, PMI intends to find other suitable locations in Benin for IRS, most likely in the north of the country where LLIN coverage is lower than the south and malaria transmission is seasonal (PMI, 2009).

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. The main sources are the President’s Malaria Initiative (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 aims to cover 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 Programme commenced covering an important portion of ACT needs and the bulk of RDTs required. Benin also received $3.6 million in 2007 and $13.8 million in 2008 for malaria control activities from the PMI. Funds from 2008 were used to procure 900,000 LLINs; 250,000 ACT treatment doses for children under five; and kits for the treatment of severe malaria. In addition, PMI funds supported the training and supervision of laboratory staff, and public and private health workers. Of the $13.8 million allocated for 2009, approximately $2 million of this was for malaria treatment and diagnosis (PMI, 2009).

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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 outlets with the potential to sell or provide antimalarials, an outlet being defined as any point of sale or provision of a commodity to an individual. For this study outlets were not restricted to stationary points of sale and included mobile units or individuals. 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;  NGO and Mission health facilities;  Private health facilities;  Part One pharmacies (registered pharmacies) and their rural outposts;  General retail outlets: supermarkets, boutiques, market stalls;  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, at the time of data collection community health workers were not formally included in the MOH structure and were thus excluded from the survey.

Sample size determination The proportion of outlets with any ACT, estimated to be 40% was used as a key indicator for sample size estimation. A minimum of 290 outlets with antimalarials in stock were needed to provide detectable changes in ACT availability for a single stratum and between sectors. With this number, 19 clusters per strata 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 arrondissements in Benin. The last census was conducted in 2002 and used as a sample frame for the 2009 outlet survey.

In addition, a facility listing of 180 registered pharmacies was used to confirm the location of pharmacies in each department, and to inform the pharmacy booster sample. The list of pharmacies is grouped by commune within each department (except for Cotonou, where outlets are grouped by arrondissement) and gives the name of the proprietor, the address, and phone number.

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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 arrondissements in the country were included in the sampling frame.

Selection procedure of the booster sample The main sample was supplemented by a booster sample. The inclusion of a booster sample helped ensure adequate representation of the relatively rare but important antimalarial outlet types: public health facilities and registered pharmacies. The booster sampling approach differed for the two types of outlets. For public health facilities, all facilities located in the commune in which a selected arrondissement fell were censused and invited to participate in the study. The booster sample of pharmacies comprised a simple random sample of two‐thirds of pharmacies in the department in which a selected arrondissement fell, excluding those outlets already enumerated in selected arrondissements. All departments were visited for the booster sample (that is, at least one selected arrondissement fell in each of the 12 departments).

Questionnaire The outlet survey questionnaire comprised 3 modules: a screening module for all outlets; an audit module (the 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 had stocked antimalarials in the past three months. Audit sheets were based on the HAI Action International questionnaire for essential medicines, developed with the World Health Organization. In consultation with the ACTwatch advisory committee and National Malaria Control Program, the questionnaire was modified to reflect issues relevant to malaria in Benin.

Paper questionnaires were administered during data collection. The questionnaires were written in French (the official language in Benin) and administered either in French or in a local language, most commonly Fon, Goun, or Bariba. Prior to finalisation, the questionnaire was pilot‐tested to assess the appropriateness of question wording as well as to verify the skip patterns and interviewer instructions.

The Screening Module was used to record the type and location of all outlets, including GPS coordinates. In addition, basic information was collected on the items sold at the outlet. The main purpose of the screening module was to identify outlets that were eligible for the study, and the results of each interview.

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.

The Provider Module was used to collect information from the main provider in all eligible outlets and covered the following topics:  Outlet characteristics: number of staff, education level of staff, health‐related qualifications amongst staff, registration status, storage conditions;  Knowledge: Benin’s recommended first‐line treatment and its dosing regimen, health danger signs for children under five;  Perceptions: beliefs about the most effective antimalarials;  Provision of credit to customers.

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Data collection

Recruitment of Field Team Experienced research assistants from the ABMS/PSI‐Benin pool of consultants were recruited to be trained as interviewers and team leaders for this study. Trainees were over‐recruited by 20% and final selection of study personnel was made after a rigorous six day training, which included a practical fieldwork exercise.

Training Interview training followed a 6‐day structured agenda, including fieldwork practice on day 5 and formal tests to examine participants’ understanding of the material presented. Standardised training materials developed by ACTwatch were adapted to the national setting, and sessions were facilitated by staff from ABMS/PSI‐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 tips on interviewing, 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 verbal consent for participation. During the fieldwork practice, 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.

Fieldwork Fieldwork was conducted by 25 staff, divided into 7 teams of differing sizes depending on the departments they were assigned. Generally, teams in the south of Benin comprised more interviewers than those in the northern departments. The best performing member of each team was further assigned the role of team leader. Quality control and oversight was provided by ABMS/PSI‐Benin staff and ACTwatch core team staff. These individuals monitored data collection to ensure procedures were employed properly and were on hand to troubleshoot any issues that were encountered.

Initial data collection started on the 28th April and terminated on the 13th May. During this time all 19 selected arrondissements were censused, and the public health facility booster sample conducted. The pharmacy booster sample was conducted from the 11th to the 27th July.

Upon arrival in a study area, team leaders and ABMS/PSI‐Benin staff (if present) first met with local leaders to introduce themselves and seek permission to carry out the study. Arrondissement boundaries were identified in consultation with local leaders and guides; team leaders then assigned data collectors to a particular area.

During fieldwork, data collectors 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.

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For each outlet that was identified during the census, the outlet type and location were noted, along with its GPS coordinates. At the start of the interview fieldworkers recorded the outlet’s basic details and then asked the following screening question about the availability of antimalarials: “Do you have any antimalarial medicines in stock today?” If the outlet did not currently have any antimalarials in stock the interviewer asked: “Are there any antimalarials that are out of stock today, but that you stocked in the past 3 months?” If the interviewee answered no to both questions, the interview was terminated at that point. If the interviewee answered yes to either screening question, the fieldworker proceeded to identify the senior staff member currently present at the outlet. Once presented to the most senior member of staff, the interviewer read the information sheet; answered any questions the respondent may have; obtained informed verbal consent; and then proceeded with the interview. A copy of the questionnaire is included in the annex.

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. Due to the high volume of antimalarials in many urban pharmacies, data collectors worked in pairs when necessary to complete the work in good time and reduce disruption to the outlet.

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.

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

Quality control During data collection, experienced ABMS/PSI‐Benin research staff and ACTwatch core staff accompanied teams to the field and acted as supervisors, monitoring the progress of data collection and resolving queries referred by team leaders. Two reviews of questionnaires were performed during data collection. The team leader performed the first review, scrutinizing for verbal consent; completion; filter errors; and consistency between questions. Second reviews were conducted by an ABMS/PSI‐Benin supervisor. Queries were followed‐up with the interviewer and, as required, a call‐ back was performed.

In addition to reviewing questionnaires, ABMS/PSI‐Benin and ACTwatch core staff also provided monitoring and supervision during data. Staff travelled from team to team and conducted spot‐ checks to ensure team leaders and interviewers were performing their responsibilities adequately.

Control of questionnaires Team leaders followed data safeguarding procedures during data collection, collecting questionnaires from interviewers at the end of each day and ensuring their safe storage. During monitoring visits, ABMS/PSI‐Benin and ACTwatch core staff collected field questionnaires and returned them to Cotonou.

Data processing Double data entry was performed using Microsoft Access by experienced data entry clerks. A trained ABMS/PSI‐Benin research staff member was responsible for validating the double data entry. After the first round of data entry, errors were flagged and corrected with reference to the hard‐copy questionnaires. This process continued until the two data entry files were identical.

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A final Access database file was sent to ACTwatch central. Staff reviewed this data, and any entries requiring clarification were documented and raised with ABMS/PSI‐Benin. ABMS/PSI‐Benin staff responded to these requests by making reference to the hard‐copy questionnaires. In addition to the hard‐copy questionnaires, the electronic data entry files are backed up at ABMS/PSI‐Benin and at ACTwatch central.

Data analysis Data were analyzed by the ACTwatch Central team in Nairobi. The ACTwatch analysis plan was followed to analyze the data. 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 calculated as specified in the indicator table, and presented by outlet type and nationally. Price, availability and volumes are derived from the audit sheets and screening questions. Additional analyses, derived from provider data, examine outlet characteristics, provider knowledge, and availability of microscopic testing for malaria and RDTs.

Research associates cleaned data in SPSS and generated statistical tests and means, medians and proportions, using Stata. 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 antimalarial recorded in the drug audit 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).

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To improve understanding of the state of the antimalarial market and aid comparison between and within countries, pricing information for antimalarials were grouped into the three categories that are believed to be most pertinent to policy level decisions: quality assured ACT (including first‐line quality assured ACT), the most popular non‐ACT (based on volumes), and oral artemisinin monotherapy. The median price per AETD was calculated for each of these categories. 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, suppositories and syrups) 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 fraction of AETD volumes across all outlets.

Price data were collected in local currencies and converted to their US$ equivalent using the average interbank rate for the period of data collection (US$ = 462.6 franc CFA, source: www.oanda.com). Price data are reported using median and inter‐quartile range, which are appropriate for describing distributions likely to be skewed.

Weighting Weighting outlet survey data was done to allow for the difference in sampling probabilities due to: 1) the sampling strategy which involved a full census of outlets in clusters of varying sizes selected by PPS, and 2) the oversampling for the booster sample.

Weights were calculated specific to outlet and analysis type but generally involved the inverse of selection probability and corresponding population size. An exception to this last point is the method used for weighting pharmacies in analysis involving the booster sample (availability and median price or antimalarials), where a sampling fraction was used to mirror the booster sampling approach. For other outlet types we used Arrondissement population sizes for non‐PHFs, and for analysis involving only the non‐booster sample (i.e. estimation of volumes); Commune populations were used for PHF outlet types where analysis included the booster sample (availability and price).

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Results ‐ Outlet survey

Characteristics of the sample

Figure 3.1.1: Survey flow diagram, [Benin], 2009

A Interview interrupted : [0] Outlets enumerated* Eligible respondent not available/Time not [29] [1,870] convenient for interview :

Outlets not screened Outlet not open at the time : [6] [200] Outlet closed permanently : [30] Other : [3] B Outlets screened Refused : [132] [1,670] Outlets which did not meet screening criteria [609]

C Outlets which met screening criteria 1=[844] or 2=[217] Eligible respondent not available/Time not convenient for interview : [0]

Outlets not interviewed Outlet not open at the time : [0] [0] Other : [0] D Outlets interviewed** Refused : [0] [1,061]

Outlets with no antimalarials in stock on day of visit*** [217] E Outlets with antimalarials in stock on day of visit [844]

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

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Standard ACTwatch tables

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=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 Antimalarials in stock at the time of 95.4 91.2 94.0 84.2 96.7 30.5 34.4 42.7 36.3 39.0 survey visit (87.8, 98.4) (67.5, 98.1) (86.7, 97.4) (70.2, 92.3) (92.0, 98.7) (23.9, 38) (23.9, 46.8) (19.9, 69.2) (27.1, 46.6) (30.1, 48.7) 81.8 38.2 67.2 18.6 96.7 1.4 0.6 0.5 2.3 5.4 Any ACT (71.6, 88.9) (12.8, 72.3) (51.8, 79.5) (7.4, 39.8) (92.0, 98.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (1.0, 5.1) (3.8, 7.5) 80.5 26.6 62.4 16.1 89.0 1.4 0.6 0.5 2.1 5.0 Quality Assured ACT (QAACT) (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (5.4, 39.5) (83.7, 92.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.9) (3.5, 7.1) 80.5 26.6 62.4 15.6 83.0 1.4 0.6 0.5 2.1 4.9 First‐line (FAACT) (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (4.9, 39.8) (79.2, 86.2) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.8) (3.4, 7.0) 13.9 0.0 9.2 0.6 67.6 0.0 0.0 0.0 0.5 0.9 Non first‐line (NAACT) (6.3, 27.7) ‐‐ (3.9, 20.1) (0.1, 3.1) (60.2, 74.2) ‐‐ ‐‐ ‐‐ (0.2, 1.4) (0.5, 1.6)

5.2 38.2 16.3 3.8 96.7 0.1 0.0 0.0 0.9 1.6 Non‐quality Assured ACT (2.7, 10.0) (12.8, 72.3) (6.5, 35.5) (1.5, 9.3) (92.0, 98.7) (<0.1, 0.8) ‐‐ ‐‐ (0.4, 2.3) (0.8, 3.3)

Other ACT Classifications 80.5 26.6 62.4 16.2 86.9 1.4 0.6 0.5 2.1 5.0 Any first‐line ACT (69.8, 88.0) (4.9, 71.6) (45.0, 77.1) (5.4, 39.5) (82.1, 90.5) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (0.9, 4.9) (3.5, 7.0) 81.8 38.2 67.2 17.8 96.7 1.4 0.6 0.5 2.3 5.3 Nationally Registered ACT (71.6, 88.9) (12.8, 72.3) (51.8, 79.5) (6.7, 39.6) (92.0, 98.7) (0.6, 3.3) (0.1, 4.2) (0.1, 4.6) (1.0, 5.0) (3.8, 7.4)

90.8 91.2 90.9 83.6 90.7 30.4 34.4 42.7 36.2 38.8 Any non‐artemisinin therapy (82.2, 95.5) (67.5, 98.1) (82.3, 95.6) (68.9, 92.1) (79.3, 96.2) (23.9, 37.8) (23.9, 46.8) (19.9, 69.2) (27.0, 46.5) (29.9, 48.4) 1.4 23.2 8.7 14.3 14.0 27.9 31.2 36.8 29.7 28.7 Chloroquine (0.5, 4.3) (8.3, 50.1) (3.6, 19.6) (7.5, 25.5) (10.9, 17.7) (21.3, 35.5) (21.5, 43.0) (15.1, 65.7) (21.9, 38.9) (21.4, 37.4) 49.7 45.0 48.1 29.2 81.6 2.7 3.7 14.7 5.7 7.7 Sulfadoxine‐pyrimethamine (SP) (32.9, 66.5) (19.3, 73.8) (31.5, 65.1) (14.5, 50.2) (75.6, 86.4) (0.9, 7.7) (1.8, 7.5) (6.2, 31.1) (2.9, 10.8) (4.7, 12.3) 85.9 89.0 86.9 73.0 60.1 6.1 4.5 11.5 8.7 12.4 Second‐line treatment (Quinine) (78.6, 91.0) (67.2, 97.0) (79.6, 91.9) (58.6, 83.7) (52.0, 67.7) (2.6, 13.4) (1.9, 10.2) (2.0, 44.7) (4.3, 16.7) (7.7, 19.4)

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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=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 5.5 34.3 15.2 1.5 72.8 0.0 0.0 0.0 0.6 1.3 Any artemisinin monotherapy (2.7, 10.8) (9.6, 72.1) (5.5, 35.6) (0.5, 4.7) (63.1, 80.7) ‐‐ ‐‐ ‐‐ (0.2, 1.5) (0.6, 2.6) 1.1 8.4 3.6 0.0 35.9 0.0 0.0 0.0 0.3 0.4 Oral artemisinin monotherapy (0.3, 4.4) (1.2, 40.7) (0.8, 14.7) ‐‐ (27.4, 45.4) ‐‐ ‐‐ ‐‐ (0.1, 0.7) (0.2, 0.9) 4.3 26.0 11.6 1.5 61.9 0.0 0.0 0.0 0.5 1.0 Non oral artemisinin monotherapy (1.8, 10.2) (4.6, 71.9) (3.2, 34.5) (0.5, 4.7) (54.5, 68.8) ‐‐ ‐‐ ‐‐ (0.2, 1.3) (0.5, 2.3)

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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=182 N=47 N=229 N=118 N=118 N=433 N=691 N=81 N=1,441 N=1,670 Antimalarials in stock at the time of 95.4 91.2 94.0 84.2 96.7 30.5 34.4 42.7 36.3 39.0 survey visit (87.8, 98.4) (67.5, 98.1) (86.7, 97.4) (70.2, 92.3) (92.0, 98.7) (23.9, 38.0) (23.9, 46.8) (19.9, 69.2) (27.1, 46.6) (30.1, 48.7) Among outlets with an antimalarial in N=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N=844 stock, proportion of outlets that had: 85.7 41.9 71.4 22.2 100 4.7 1.7 1.3 6.4 13.8 Any ACT (78.3, 90.9) (14.3, 75.7) (55.6, 83.3) (7.9, 48.5) ‐‐ (1.9, 11.1) (0.3, 10.7) (0.1, 12.0) (3.1, 12.9) (10.0, 18.8) 84.4 29.1 66.4 19.2 92.0 4.5 1.7 1.3 5.9 12.8 Quality Assured ACT (QAACT) (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.9, 47.4) (87.4, 95.1) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.7, 12.3) (9.1, 17.7) 84.4 29.1 66.4 18.5 85.8 4.5 1.7 1.3 5.7 12.6 First‐line (FAACT) (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.4, 47.5) (82.0, 89.0) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.6, 12.1) (8.9, 17.6) 14.5 0.0 9.8 0.7 69.9 0.0 0.0 0.0 1.5 2.4 Non first‐line (NAACT) (6.7, 28.6) ‐‐ (4.2, 21.3) (0.1, 3.9) (62.5, 76.4) ‐‐ ‐‐ ‐‐ (0.6, 3.8) (1.3, 4.5)

5.5 41.9 17.4 4.6 100 0.3 0.0 0.0 2.5 4.2 Non‐quality Assured ACT (2.8, 10.5) (14.3, 75.7) (6.9, 37.4) (1.6, 12.0) ‐‐ (0.0, 2.5) ‐‐ ‐‐ (1.0, 6.3) (2.2, 7.9)

Other ACT Classifications 84.4 29.1 66.4 19.3 89.8 4.5 1.7 1.3 5.9 12.8 Any first‐line ACT (76.4, 90.0) (5.4, 74.6) (47.8, 80.9) (5.9, 47.4) (85.0, 93.2) (1.8, 11.0) (0.3, 10.7) (0.1, 12.0) (2.7, 12.3) (9.0, 17.7) 85.7 41.9 71.4 21.2 100 4.7 1.7 1.3 6.3 13.7 Nationally Registered ACT (78.3, 90.9) (14.3, 75.7) (55.6, 83.3) (7.2, 48.2) ‐‐ (1.9, 11.1) (0.3, 10.7) (0.1, 12.0) (3.0, 12.8) (9.9, 18.7)

95.2 100 96.7 99.3 93.9 99.7 100 100 99.7 99.4 Any non‐artemisinin therapy (83.5, 98.7) ‐‐ (87.7, 99.2) (95.8, 99.9) (82.0, 98.1) (97.7, 100) ‐‐ ‐‐ (99.3, 99.9) (98.4, 99.8) 1.5 25.4 9.3 17.0 14.5 91.5 91.0 86.3 82.1 73.8 Chloroquine (0.5, 4.6) (9.0, 54.0) (3.9, 20.6) (8.1, 32.2) (11.2, 18.4) (77.6, 97.1) (82.0, 95.7) (53.5, 97.2) (70.9, 89.6) (63.9, 81.8) 52.1 49.4 51.2 34.8 84.4 8.9 10.7 34.5 15.8 19.8 Sulfadoxine‐pyrimethamine (SP) (35.3, 68.4) (20.5, 78.7) (34.0, 68.1) (18.7, 55.3) (79.0, 88.7) (3.0, 23.5) (5.2, 20.7) (17.4, 56.9) (8.6, 27.2) (12.4, 30.1) 90.0 97.6 92.5 86.7 62.2 19.9 13.1 26.8 24.0 31.8 Second‐line treatment (Quinine) (81.8, 94.8) (90.0, 99.5) (86.3, 96.0) (58.6, 96.8) (53.0, 70.6) (7.9, 41.7) (5.9, 26.7) (3.7, 77.9) (12.3, 41.7) (20.0, 46.4)

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=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N=844 stock, proportion of outlets that had: 5.7 37.6 16.1 1.8 75.3 0.0 0.0 0.0 1.7 3.3 Any artemisinin monotherapy (2.9, 11.2) (10.7, 75.3) (5.8, 37.3) (0.5, 5.8) (64.9, 83.4) ‐‐ ‐‐ ‐‐ (0.7, 4.0) (1.8, 6.2) 1.2 9.2 3.8 0.0 37.1 0.0 0.0 0.0 0.7 1.1 Oral artemisinin monotherapy (0.3, 4.6) (1.3, 43.1) (0.8, 15.4) ‐‐ (28.2, 47.1) ‐‐ ‐‐ ‐‐ (0.3, 1.8) (0.5, 2.4) 4.5 28.5 12.3 1.8 64.1 0.0 0.0 0.0 1.5 2.7 Non oral artemisinin monotherapy (1.9, 10.5) (5.1, 74.9) (3.4, 36.3) (0.5, 5.8) (55.9, 71.5) ‐‐ ‐‐ ‐‐ (0.6, 3.4) (1.3, 5.5)

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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=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 No disruption in stock in the past 3 32.9 18.3 28.1 32.4 30.1 22.3 25.9 15.9 24.7 25.0 months1 (23.1, 44.4) (6.4, 42.3) (19.0, 39.4) (16.7, 53.4) (23.1, 38.0) (14.9, 32.1) (18.7, 34.7) (12.6, 19.8) (18.6, 31.9) (19.0, 32.0) N=154 N=9 N=163 N=19 N=100 N=10 N=7 N=1 N=137 N=300 No disruption in stock of first‐line quality assured ACT (FAACT) in the past 56.8 57.1 56.9 39.7 87.5 78.3 14.3 100 44.8 50.6 3 months, among outlets that have (43.8, 69.0) (9.4, 94.5) (38.9, 73.2) (7.7, 83.8) (79.5, 92.6) (44.1, 94.3) (6.8, 27.8) ‐‐ (24.7, 66.9) (41.0, 60.1) stocked FAACT in the past 3 months N=155 N=12 N=167 N=26 N=105 N=10 N=7 N=1 N=149 N=316 No disruption in stock of any first‐line treatment in the past 3 months, among 56.3 55.0 56.0 37.9 84.2 77.9 14.3 100 43.6 49.4 outlets that have stocked the first‐line (43.2, 68.6) (9.4, 93.5) (38.3, 72.3) (8.0, 81.1) (77.6, 89.2) (43.2, 94.2) (6.8, 27.8) ‐‐ (24.4, 64.9) (40.2, 58.7) treatment in the past 3 months N=173 N=39 N=212 N=94 N=114 N=138 N=234 N=52 N=632 N=844 4.5 1.4 3.6 12.1 4.4 0.5 2.0 0.0 2.7 2.8 Expired stock of any antimalarial2 (1.6, 11.9) (0.2, 9.4) (1.4, 9.0) (2.2, 45.4) (0.9, 19.5) (0.1, 2.8) (0.6, 6.6) ‐‐ (1.0, 6.7) (1.2, 6.2) N=143 N=5 N=148 N=11 N=98 N=7 N=2 N=1 N=119 N=267 Expired stock of first‐line quality 2.2 0.0 1.9 0.0 0.0 0.0 0.0 0.0 0.0 1.1 assured ACT (FAACT) (0.6, 7.3) ‐‐ (0.5, 6.5) ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ (0.3, 4.4) N=143 N=5 N=148 N=12 N=103 N=7 N=2 N=1 N=125 N=273 2.2 0.0 1.9 0.0 0.0 0.0 0.0 0.0 0.0 1.1 Expired stock of any first‐line treatment (0.6, 7.1) ‐‐ (0.5, 6.4) ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ ‐‐ (0.3, 4.3) N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Acceptable storage conditions for 97.5 98.1 97.7 83.7 97.7 90.9 86.0 75.4 86.8 87.8 medicines3 (93.9, 99.0) (89.0, 99.7) (94.5, 99.1) (48.8, 96.5) (90.9, 99.5) (85.5, 94.5) (71.0, 93.9) (69.1, 80.8) (78.9, 92.0) (80.9, 92.5)

1 Information on stock disruptions was missing for 4% of cases [n=1,021] 2 Information on expired stock was missing for 10% of cases [n=756]. Missing values were particularly common for boutiques (15%, n=117) and stalls/kiosks (17%, n=195). 3 Information on acceptable storage condition was missing for 16% of cases [n=895]. Missing values were particularly common for boutiques (25%, n=163) and stalls/kiosks (23%, n=261). Page 24

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Table A.4: Price of antimalarials, by outlet type

Public TOTAL General Private not Private for Itinerant TOTAL TOTAL Health Public / Not Pharmacy retailer Market stall for profit HF profit HF drug vendor Private Outlets Facility for profit (Boutique) % % % % % % % % % % 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) 4 Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of a tablet AETD: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $1.30 $6.49 $1.30 $2.59 $8.63 $1.73 $3.03 $3.24 $8.30 $3.03 Any ACT (503) (19) (522) (28) (1,443) (9) (2) (1) (1,483) (2,005) [1.30‐1.30] [1.30‐8.65] [1.30‐1.30] [1.95‐5.19] [7.31‐10.74] [1.73‐3.46] [n/a] [n/a] [5.88‐10.52] [1.30‐8.52] $1.30 $1.30 $1.30 $2.59 $8.83 $1.73 $3.03 $3.24 $5.75 $1.30 Quality Assured ACT (QAACT) (489) (9) (498) (16) (327) (7) (2) (1) (353) (851) [1.30‐1.30] [1.30‐1.30] [1.30‐1.30] [1.95‐2.59] [5.77‐16.82] [1.73‐1.95] [n/a] [n/a] [2.59‐8.83] [1.30‐1.95] $1.30 $1.30 $1.30 $2.59 $6.10 $1.73 $3.03 $3.24 $3.24 $1.30 First‐line (FAACT) (464) (9) (473) (15) (191) (7) (2) (1) (216) (689) [1.30‐1.30] [1.30‐1.30] [1.30‐1.30] [1.95‐2.59] [5.75‐8.83] [1.73‐1.95] [n/a] [n/a] [1.95‐5.77] [1.30‐1.73]

$1.73 (0) $1.73 $2.59 $16.82 (0) (0) (0) $16.82 $16.82 Non first‐line (NAACT) (25) ‐‐ (25) (1) (136) ‐‐ ‐‐ ‐‐ (137) (162) [1.73‐2.59] [1.73‐2.59] [n/a] [16.82‐21.10] [16.82‐21.10] [2.59‐22.10]

$7.78 $8.65 $8.65 $6.49 $8.52 $8.05 (0) (0) $8.52 $8.52 Non‐quality Assured ACT (14) (10) (24) (12) (1,116) (2) ‐‐ ‐‐ (1,130) (1.154) [4.76‐9.51] [6.49‐8.65] [6.49‐8.65] [5.30‐8.28] [7.58‐10.52] [n/a] [7.51‐10.52] [7.32‐10.10] Other ACT Classifications $1.30 $1.30 $1.30 $2.59 $6.69 $1.73 $3.03 $3.24 $5.40 $1.30 Any first‐line ACT (464) (9) (473) (16) (290) (7) (2) (1) (316) (789) [1.30‐1.30] [1.30‐1.30] [1.30‐1.30] [1.95‐2.59] [5.76‐8.83] [1.73‐1.95] [n/a] [n/a] [2.59‐6.69] [1.30‐1.95] $1.30 $6.49 $1.30 $2.59 $8.83 $1.73 $3.03 $3.24 $8.52 $2.59 Nationally Registered ACT (478) (18) (496) (25) (1,229) (9) (2) (1) (1,266) (1,762) [1.30‐1.30] [1.30‐8.65] [1.30‐1.30] [1.95‐4.86] [7.83‐11.33] [1.73‐3.46] [n/a] [n/a] [6.10‐10.53] [1.30‐8.65]

$3.63 $2.27 $2.72 $3.63 $1.15 $0.41 $0.41 $0.54 $0.41 $0.43 Any non‐artemisinin therapy (286) (84) (370) (183) (456) (234) (325) (112) (1,310) (1,680) [0.97‐4.09] [0.32‐3.03] [0.54‐4.09] [0.43‐4.54] [1.01‐6.04] [0.27‐0.65] [0.27‐0.54] [0.27‐3.40] [0.27‐1.95] [0.27‐3.03] $0.22 $0.24 $0.24 $0.32 $0.58 $0.27 $0.32 $0.27 $0.32 $0.32 Chloroquine (5) (8) (13) (20) (4) (112) (182) (28) (346) (359) [0.16‐0.22] [0.16‐0.24] [0.16‐0.24] [0.27‐0.32] [0.28‐0.97] [0.22‐0.41] [0.27‐0.41] [0.22‐0.27] [0.24‐0.41] [0.24‐0.41] Sulfadoxine‐pyrimethamine (SP), $0.32 $0.43 $0.32 $0.43 $1.04 $0.54 $0.43 $1.08 $0.65 $0.65 the most popular antimalarial5 [0.00‐0.97] (94) [0.32‐0.86] (21) [0.16‐0.86] (115) [0.43‐2.14] (34) [0.94‐1.19] (284) [0.43‐0.86] (46) [0.32‐0.65] (62) [0.54‐1.95] (36) [0.43‐1.08] (462) [0.32‐1.04] (577) $3.78 $3.03 $3.68 $4.54 $12.61 $4.54 $4.54 $4.54 $4.54 $4.09 Second‐line treatment (Quinine) (186) (55) (241) (129) (111) (75) (78) (48) (441) (682) [3.63‐4.09] [2.72‐4.09] [3.03‐4.09] [3.63‐5.45] [6.04‐27.99] [3.03‐5.45] [3.18‐4.54] [4.09‐6.81] [3.18‐5.45] [3.18‐5.45] Any artemisinin monotherapy

$6.30 $17.29 $17.29 (0) $8.11 (0) (0) (0) $8.11 $9.86 Oral artemisinin monotherapy (1) (1) (2) ‐‐ (56) ‐‐ ‐‐ ‐‐ (56) (58) [n/a] [n/a] [n/a] [8.08‐10.46] [8.08‐10.46] [8.08‐17.29]

4 A total of 5,233 antimalarials were found in 844 outlets. Of these, 3,743 antimalarials are included in the pricing analysis; price indicators are based on tablet‐formulation AETDs. Free antimalarials were found in 3.1% of outlets with antimalarials, and 35 of the 5,115 antimalarials for which price information was recorded were available for free. 5 Sulfadoxine‐pyrimethamine was the most popular antimalarial by volume sold/distributed in the past week. Page 25

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

Public TOTAL General Private not Private for Itinerant TOTAL TOTAL Health Public / Not Pharmacy retailer Market stall for profit HF profit HF drug vendor Private Outlets Facility for profit (Boutique) 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 4.1 15.1 4.1 6.0 8.3 3.2 7.0 3.0 12.8 4.7 First‐line quality assured ACT 4.1 3.0 4.1 6.0 5.9 3.2 7.0 3.0 5.0 2.0 (FAACT) Any first‐line ACT 4.1 3.0 4.1 6.0 6.4 3.2 7.0 3.0 8.3 2.0 Median price of a tablet AETD relative to the minimum legal daily wage Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio ($2.13)6: Any ACT 0.6 3.0 0.6 1.2 4.1 0.8 1.4 1.5 3.9 1.4 First‐line quality assured ACT 0.6 0.6 0.6 1.2 2.9 0.8 1.4 1.5 1.5 0.6 (FAACT) Any first‐line ACT 0.6 0.6 0.6 1.2 3.1 0.8 1.4 1.5 2.5 0.6 Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Median price of a first‐line quality assured tablet AETD relative to the 0.9 0.9 0.9 1.8 4.2 1.2 2.1 2.2 2.2 0.9 international reference price ($1.45)7 % % % % % % % % % % Proportion of outlets that: ‐‐ N=43 N=43 N=105 N=118 N=218 N=338 N=62 N=841 N=884 Offer credit to consumers for 56.8 56.8 40.5 39.7 39.9 52.2 52.8 47.6 47.8 antimalarials8 (21.8, 86.1) (21.8, 86.1) (23.0, 60.8) (29.0, 51.5) (26.9, 54.5) (38.1, 65.9) (33.7, 71.1) (37.2, 58.2) (37.5, 58.3)

6 Minimum daily wage information taken from United States Department of State, 2009. Country Reports on Human Rights Practices. Available at: http://www.state.gov/g/drl/rls/hrrpt/2009/index.htm 7 International reference price taken from Management Sciences for Health, 2009. International drug price indicator guide. Available at: http://www.erc.msh.org/priceguide. $1.45 is the median listed supplier price for 24 tablets of AL 20mg/120mg. 8 This question was not asked in Public Health Facilities. Information on proportion of outlets that offer credit to consumers for antimalarials was missing for 13% of cases [n=766]. Missing values were particularly common for boutiques (18%, n=179); stalls/kiosks (17%, n=281); and hawkers (15%, n=53). Page 26

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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:9 N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 86.3 52.1 75.1 22.6 1.0 0.0 0.0 0.0 1.7 7.7 Any diagnostic test (77.0, 92.2) (19.2, 83.3) (58.8, 86.5) (10.5, 42.0) (0.3, 3.3) ‐‐ ‐‐ ‐‐ (0.6, 4.4) (5.0, 11.8) 15.6 31.8 20.9 12.4 0.0 0.0 0.0 0.0 0.9 2.5 Microscopic blood tests (9.7, 24.2) (7.2, 73.6) (9.7, 39.4) (4.2, 31.6) ‐‐ ‐‐ ‐‐ ‐‐ (0.3, 3.0) (1.4, 4.4) 84.5 45.7 71.9 10.4 1.0 0.0 0.0 0.0 0.8 6.6 Rapid diagnostic tests (74.1, 91.3) (13.4, 82.1) (53.5, 85.0) (1.8, 42.4) (0.3, 3.3) ‐‐ ‐‐ ‐‐ (0.1, 4.5) (3.9, 11.0) Proportion of outlets that provided diagnostic tests for free, among outlets N=142 N=13 N=155 N=24 N=1 N=0 N=0 N=0 N=25 N=180 providing diagnostic tests 10 96.4 69.2 92.6 0.0 0.0 80.2 Any diagnostic test ‐‐ ‐‐ ‐‐ ‐‐ (88.3, 99.0) (15.6, 96.5) (81.1, 97.3) ‐‐ ‐‐ (53.4, 93.4) N=30 N=9 N=39 N=22 N=0 N=0 N=0 N=0 N=22 N=61 63.8 0.0 49.5 0.0 0.0 25.8 Microscopic blood tests ‐‐ ‐‐ ‐‐ ‐‐ (29.2, 88.3) ‐‐ (20.1, 79.3) ‐‐ ‐‐ (5.9, 65.7) N=135 N=6 N=141 N=3 N=1 N=0 N=0 N=0 N=4 N=145 96.6 40.9 84.3 0.0 0.0 83.8 Rapid diagnostic tests ‐‐ ‐‐ ‐‐ ‐‐ (88.3, 99.1) (4.1, 91.7) (51.7, 96.4) ‐‐ ‐‐ (49.9, 96.4) 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) $0.00 $2.16 $1.08 $3.24 $3.24 $2.16 Microscopic blood tests ‐‐ (0) ‐‐ (0) ‐‐ (0) ‐‐ (0) [0.00‐1.08] (22) [2.16‐2.16] (8) [0.00‐1.73] (30) [2.16‐3.24] (20) [2.16‐3.24] (20) [0.00‐3.24] (50)

$0.00 $0.22 $0.00 $2.70 $2.70 $0.00 Rapid diagnostic tests ‐‐ (0) ‐‐ (0) ‐‐ (0) ‐‐ (0) [0.00‐0.00] (129) [0.00‐0.22] (5) [0.00‐0.00] (134) [2.16‐3.24] (2) [2.16‐3.24] (2) [0.00‐0.00] (136)

9 Information on proportion of outlets that had diagnostic tests was missing for 3% of cases [n=1,031]. 10 Information on diagnostic test pricing was missing for 7% of cases where the outlet was known to provide testing [n=167]. Page 27

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Table A.7: Market share, by outlet type

Public TOTAL General Private not Private for Itinerant TOTAL TOTAL Health Public / Not Pharmacy retailer Market stall for profit HF profit HF drug vendor Private Outlets Facility for profit (Boutique) Each antimalarial category as a proportion of the total volume of all % % % % % % % % % % antimalarials (AETDs) sold or 11 distributed in the past week: Any ACT 6.5 0.8 7.3 0.6 15.1 0.3 0.2 <0.1 16.1 23.4 Quality Assured ACT (QAACT) 6.4 0.6 7.1 0.4 4.9 0.3 0.2 <0.1 5.8 12.9 First‐line (FAACT) 6.4 0.6 7.1 0.4 4.0 0.3 0.2 <0.1 4.9 11.9 Non first‐line (NAACT) <0.1 0 <0.1 0 0.9 0 0 0 0.9 0.9

Non‐quality Assured ACT <0.1 0.2 0.2 0.1 10.2 <0.1 0 0 10.3 10.5

Other ACT Classifications Any first‐line ACT 6.4 0.6 7.1 0.4 5.3 0.3 0.2 <0.1 6.2 13.3 Nationally Registered ACT 6.5 0.8 7.3 0.5 11.2 0.3 0.2 <0.1 12.2 19.5

Any non‐artemisinin therapy 15.9 4.2 20.1 4.4 21.4 8.9 17.7 3.8 56.3 76.4 Chloroquine 0.7 1.2 1.9 1.0 0.1 7.0 12.9 2.4 23.4 25.3 Sulfadoxine‐pyrimethamine (SP) 10.2 1.4 11.6 1.7 20.7 0.9 4.0 1.2 28.5 40.1 Second‐line treatment (Quinine) 5.0 1.5 6.5 1.7 0.2 0.8 0.5 0.2 3.5 10.0

Any artemisinin monotherapy <0.1 <0.1 <0.1 <0.1 0.2 0 0 0 0.2 0.2 Oral artemisinin monotherapy 0 <0.1 <0.1 0 0.1 0 0 0 0.1 0.1 Non oral artemisinin monotherapy <0.1 <0.1 <0.1 <0.1 0.1 0 0 0 0.1 0.1

11 There were a total of 87,451 AETDs (unweighted) sold or distributed in the past 7 days. 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 28

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Table A.8: 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=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Correctly state the recommended first‐ 91.5 31.0 73.1 56.1 66.9 14.0 13.5 12.6 17.7 22.4 line treatment for uncomplicated (84.9, 95.4) (8.0, 69.8) (54.2, 86.1) (42.0, 69.3) (55.4, 76.6) (5.1, 33.2) (6.0, 27.9) (7.1, 21.4) (10.1, 29.1) (14.7, 32.5) malaria12 Correctly state the dosing regimen of 88.5 29.6 70.5 47.6 62.1 6.6 3.2 2.1 8.4 13.7 the first‐line treatment for an adult (81.6, 93.0) (7.4, 69.0) (51.9, 84.1) (33.3, 62.3) (48.8, 73.8) (2.8, 14.7) (0.9, 10.7) (0.3, 13.0) (4.4, 15.2) (8.8, 20.5) Correctly state the dosing regimen of 87.8 28.2 69.7 47.7 57.7 5.3 2.6 2.1 7.6 12.9 the first‐line treatment for a two‐year (81.1, 92.4) (6.7, 68.5) (51.1, 83.5) (32.9, 63.0) (44.0, 70.3) (2.4, 11.5) (0.6, 10.8) (0.3, 13.0) (4.0, 14.1) (8.4, 19.3) old ‐‐ N=43 N=43 N=105 N=118 N=218 N=338 N=62 N=841 N=884 Can list at least one health danger sign 54.2 54.2 73.1 71.6 62.5 61.1 55.2 62.2 61.9 in a child that requires referral to a ‐‐ (23.5, 82.0) (23.5, 82.0) (41.6, 91.2) (63.8, 78.2) (45.5, 76.9) (39.0, 79.4) (39.2, 70.1) (44.8, 76.9) (44.9, 76.4) public health facility13: 29.6 29.6 38.3 40.1 25.4 24.3 31.3 26.4 26.5  Convulsions ‐‐ (8.0, 67.0) (8.0, 67.0) (18.0, 63.6) (28.9, 52.5) (14.6, 40.4) (10.6, 46.5) (15.2, 53.7) (15.0, 42.0) (15.4, 41.7) 46.3 46.3 44.7 46.4 31.8 37.5 26.9 35.8 36.2  Vomiting ‐‐ (18.6, 76.5) (18.6, 76.5) (25.7, 65.4) (32.5, 60.9) (23.3, 41.6) (27.3, 49.1) (19.7, 35.6) (29.6, 42.6) (30.3, 42.5) 3.7 3.7 20.0 21.7 21.3 17.3 17.5 18.8 18.3  Unable to drink / breastfeed ‐‐ (0.6, 20.5) (0.6, 20.5) (4.0, 59.9) (13.6, 33.0) (8.4, 44.5) (10.9, 26.5) (9.8, 29.3) (10.6, 30.9) (10.3, 30.4)  Excessive sleep / difficult to 0.0 0.0 4.8 11.5 2.5 2.3 1.9 2.7 2.6 ‐‐ wake up ‐‐ ‐‐ (1.9, 11.6) (5.0, 24.4) (0.9, 7.1) (0.8, 6.1) (0.3, 12.4) (1.4, 5.1) (1.3, 5.0) 7.8 7.8 22.2 27.2 7.9 7.4 10.3 9.1 9.1  Unconscious / coma ‐‐ (1.4, 33.5) (1.4, 33.5) (8.3, 47.4) (16.8, 40.9) (2.4, 23.5) (2.6, 19.3) (1.3, 49.7) (3.3, 23.1) (3.2, 23.1)

12 Information on proportion of providers that correctly state the recommended first‐line treatment for uncomplicated malaria was missing for 10% of cases [n=953]. Missing values were particularly common for boutiques (15%, n=186); stalls/kiosks (16%, n=285); and hawkers (13%, n=54). 13 Information on proportion of providers that correctly state at least one health danger sign was missing for 18% of cases [n=728]. Missing values were particularly common for boutiques (24%, n=165); stalls/kiosks (22%, n=264); and hawkers (16%, n=52). Page 29

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Table A.9: Provider perceptions, by outlet type

Public TOTAL Private not for Private for General retailer Itinerant TOTAL TOTAL Health Public / Not for Pharmacy Market stall profit HF profit HF (Boutique) drug vendor Private Outlets Facility profit % % % % % % % % % %

(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=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 Agree with the statement, “Customers often 15.1 12.9 14.4 31.9 22.9 81.5 78.8 91.9 75.9 70.3 request an antimalarial by name.” 14 (8.7, 25.1) (2.9, 41.8) (8.3, 23.8) (13.0, 59.3) (13.2, 36.8) (72.0, 88.3) (66.9, 87.3) (61.7, 98.8) (65.8, 83.7) (60.1, 78.9) Agree with the statement, “I generally 46.1 56.4 49.5 88.4 41.9 23.1 33.5 29.4 34.7 36.0 decide which antimalarial medicine (34.7, 57.9) (24.4, 83.8) (34.7, 64.3) (71.7, 95.8) (33.0, 51.4) (15.6, 32.9) (21.5, 48.0) (17.6, 44.9) (24.6, 46.4) (26.3, 47.1) customers receive.” Report that an ACT is the most effective 68.8 28.1 55.5 38.4 62.5 5.0 3.5 1.0 7.4 11.6 antimalarial medicine 15 (58.0, 78.0) (5.0, 74.2) (38.0, 71.8) (14.8, 69.1) (57.3, 67.5) (2.1, 11.5) (0.5, 19.2) (0.1, 9.5) (3.3, 15.6) (7.0, 18.6) Proportion of providers than state the following reasons for stocking N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 antimalarials:16 1.6 0.0 1.1 13.1 15.1 33.0 19.9 6.5 22.1 20.3  Most profitable (0.6, 4.4) ‐‐(0.4, 2.8) (3.3, 39.7) (10.6, 21.0) (14.9, 58.1) (12.4, 30.3) (1.4, 25.7) (12.7, 35.7) (11.5, 33.3) 52.8 35.3 47.1 25.6 28.3 1.2 0.2 0.7 2.9 6.7  Recommended by government (32.9, 71.8) (12.1, 68.5) (29.0, 66.1) (11.4, 47.9) (19.9, 38.4) (0.3, 5.1) (<0.1, 1.3) (0.1, 6.0) (1.3, 6.0) (3.9, 11.2) 9.2 2.5 7.0 7.8 9.9 21.8 26.7 13.9 22.6 21.3  Lowest priced (4.6, 17.4) (0.4, 14.2) (3.5, 13.3) (2.3, 23.2) (5.7, 16.7) (12.7, 34.7) (14.3, 44.2) (2.8, 47.5) (12.5, 37.4) (11.7, 35.5) 21.4 46.2 29.5 52.5 71.1 82.1 88.2 92.3 83.8 79.1  Consumer demand (11.7, 36.0) (16.0, 79.5) (15.4, 49.1) (25.8, 77.8) (61.4, 79.1) (71.8, 89.1) (70.8, 95.9) (60.7, 99.0) (71.9, 91.2) (67.6, 87.3) 7.9 17.7 11.1 12.1 11.4 5.2 5.4 16.6 6.8 7.1  Easily available (3.7, 16.2) (6.2, 41.3) (6.0, 19.7) (4.3, 29.6) (5.6, 21.8) (2.1, 12.2) (1.7, 15.6) (10.8, 24.8) (3.3, 13.3) (3.7, 13.3) 0.0 10.2 3.3 0.8 1.5 1.5 0.3 0.0 0.7 0.9  Drug company ‐‐ (1.9, 39.9) (0.6, 16.1) (0.1, 5.0) (0.4, 6.2) (0.4, 6.3) (<0.1, 2.4) ‐‐ (0.2, 2.1) (0.4, 2.4) 6.7 14.4 9.2 11.4 5.3 5.7 16.5 6.5 12.0 11.8  Brand reputation (2.6, 16.2) (4.4, 38.4) (4.4, 18.3) (4.8, 24.7) (2.9, 9.6) (2.3, 13.5) (8.8, 28.9) (0.9, 34.7) (6.8, 20.5) (6.8, 19.8) 2.9 5.0 3.6 3.5 3.1 0.1 0.6 0.7 0.7 1.0  Dosage form (0.7, 11.4) (0.8, 26.3) (1.2, 10.5) (0.5, 21.0) (0.9, 10.2) (<0.1, 0.5) (0.1, 4.4) (0.1, 6.0) (0.2, 2.5) (0.3, 3.0) 37.2 17.2 30.7 28.6 30.8 4.7 1.9 5.8 5.5 7.7  Frequently prescribed (20.3, 57.9) (6.0, 40.6) (17.3, 48.4) (14.4, 48.7) (18.9, 45.9) (1.6, 13.2) (0.6, 6.2) (0.8, 32.3) (2.4, 11.9) (4.5, 12.9)

14 Information on this pair of indicators was missing for 12% of cases [n=932, and n=929]. 15 Information on the most effective antimalarial was missing for 9% of cases [n=961]. Missing values were particularly common for General retailers (14%, n=187) and Market stalls (15%, n=289). 16 Information on this indicator was missing for 9% of cases [n=964]. Providers could state multiple responses and totals may sum to more than 100%. Page 30

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Table A.9: 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) Continued on following page

Proportion of providers than state the following reasons for stocking N=177 N=43 N=220 N=105 N=118 N=218 N=338 N=62 N=841 N=1,061 antimalarials: 4.2 7.1 5.2 18.9 12.7 5.1 3.7 7.1 5.7 5.6  Effectiveness (1.5, 11.4) (1.7, 24.9) (2.2, 11.8) (6.0, 45.9) (4.8, 29.6) (1.5, 16.5) (1.4, 9.4) (0.7, 43.5) (1.9, 15.8) (1.9, 15.2) 2.0 0.0 1.4 1.2 0.8 1.2 0.1 0.0 0.5 0.6  Other reasons (0.8, 5.4) ‐‐(0.6, 3.3) (0.1, 9.0) (0.1, 6.9) (0.2, 7.3) (<0.1, 0.7) ‐‐ (0.1, 1.9) (0.2, 1.8) 0.9 26.8 9.3 1.2 0.7 0.9 2.2 0.5 1.6 2.3  Don’t know (0.2, 3.9) (4.4, 74.6) (1.7, 38.3) (0.4, 3.7) (0.1, 5.3) (0.2, 5.2) (0.3, 14.4) (0.1, 5.2) (0.3, 7.2) (0.7, 6.9)

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Additional Tables

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

Public TOTAL General Private not Private for Itinerant TOTAL TOTAL Health Public / Not Pharmacy retailer Market stall for profit HF profit HF drug vendor Private Outlets Facility for profit (Boutique) Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or % % % % % % % % % % distributed within a given outlet type in 17 the past week: Any ACT 29.0 16.3 26.7 11.1 41.1 3.0 1.1 0.2 22.2 23.4 Quality Assured ACT (QAACT) 28.8 12.8 25.8 8.2 13.4 3.0 1.1 0.2 8.0 12.9 First‐line (FAACT) 28.6 12.8 25.7 8.2 10.9 3.0 1.1 0.2 6.7 11.9 Non first‐line (NAACT) 0.2 0 0.1 0 2.5 0 0 0 1.3 0.9

Non‐quality Assured ACT 0.2 3.5 0.8 2.9 27.7 <0.1 0 0 14.2 10.5

Other ACT Classifications Any first‐line ACT 28.8 16.3 26.5 10.5 30.6 3.0 1.1 0.2 16.9 19.5 Nationally Registered ACT 28.6 12.8 25.7 8.8 14.5 3.0 1.1 0.2 8.6 13.3

Any non‐artemisinin therapy 71.0 83.4 73.3 88.9 58.4 97.0 98.9 99.8 77.5 76.4 Chloroquine 3.2 24.1 7.1 20.4 0.2 76.9 71.8 62.3 32.2 25.3 Sulfadoxine‐pyrimethamine (SP) 45.4 28.7 42.3 34.3 56.4 9.3 22.2 32.1 39.2 40.1 Second‐line treatment (Quinine) 22.4 30.7 23.9 34.2 0.5 9.2 3.1 5.4 4.8 10.0

Any artemisinin monotherapy <0.1 0.2 0.1 0.1 0.5 0 0 0 0.3 0.2 Oral artemisinin monotherapy 0 0.2 <0.1 0 0.2 0 0 0 0.1 0.1

17 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 32

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Non oral artemisinin monotherapy <0.1 <0.1 <0.1 0.1 0.3 0 0 0 0.1 0.1

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References

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].

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.

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 12 August 2011].

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 15 March 2011].

President’s Malaria Initiative (PMI), 2008. FY 2009 Malaria Operation Plan: Benin.

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

World Bank, 2010. World databank. [online] Available at: http://databank.worldbank.org/ [Accessed 12 Agust 2011]. Values given in current US$.

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

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

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 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.

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.

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].

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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) Artesunate + Tablets 50mg + Ipca Laboratories Dadra and Nagar Haveli Larimal (Child; Junior; 6;12;24 Amodiaquine 153mg Limited (U.T.), India Adult) 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); Lumartem Forte & Lumet Forte 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

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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 200818 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 /

18 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 Pyrimethamine

Continued on following page 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 160mg / 500mg / Bliss Gvs India Alaxin Sulfadoxine / Pyrimethamine 25mg

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Final sample

List of clusters/Arrondissements sampled, Benin, 2009. Refer to page 12 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 Booster sample of PHFs Alibori Karimama Birni‐Lafia Census Alibori Karimama Booster sample of PHFs Alibori Booster sample (SRS) of Pharmacies Atacora Boukoumbe Tabota Census Atacora Boukoumbe Booster sample of PHFs Atacora Booster sample (SRS) of Pharmacies Atlantique Abomey‐Calavi Godomey Census Atlantique Abomey‐Calavi Booster sample of PHFs Atlantique Toffo Ague Census Atlantique Toffo Booster sample of PHFs Atlantique Booster sample (SRS) of Pharmacies Borgou Bembereke Gomia Census Borgou Bembereke Booster sample of PHFs Borgou Perere Sontou Census Borgou Perere Booster sample of PHFs Borgou Booster sample (SRS) of Pharmacies Collines Dassa‐Zoume Kpingni Census Collines Dassa‐Zoume Booster sample of PHFs Collines Ouesse Kilibo Census Collines Ouesse Booster sample of PHFs Collines Save Kaboua Census Collines Save Booster sample of PHFs Collines Booster sample (SRS) of Pharmacies Couffo Djakotome Djakotomey I Census Couffo Djakotome Booster sample of PHFs Couffo Booster sample (SRS) of Pharmacies Donga Bassila Penessoulou Census Donga Bassila Booster sample of PHFs Donga Booster sample (SRS) of Pharmacies Littoral Cotonou 1st Arrondissement Census Littoral Cotonou 9th Arrondissement Census Littoral Cotonou Booster sample of PHFs and Pharamcies Mono Grand‐Popo Sazoue Census Mono Grand‐Popo Booster sample of PHFs Mono Booster sample (SRS) of Pharmacies

Continued on following page

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Department Commune Arrondissement Censused cluster or booster sample?

Oueme Bonou Bonou Census Oueme Bonou Booster sample of PHFs Oueme Porto‐Novo 2nd Arrondissement Census Oueme Porto‐Novo Booster sample of PHFs Oueme Booster sample (SRS) of Pharmacies Plateau Pobe Pobe Census Plateau Pobe Booster sample of PHFs Plateau Booster sample (SRS) of Pharmacies Zou Bohicon Lissezoun Census Zou Bohicon Booster sample of PHFs Zou Booster sample (SRS) of Pharmacies

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Survey team

List of staff members involved in the survey, Benin, 2009.

Team Leaders Interviewers Moudachirou BIAOU Laminou ASHANTI Abdoul Ramane CHABI Rachidatou CHABI GADO Marcellin ODOULAMI Habib BIO YIRO Roland AGBESSI Ben Youssouf BIO BANGANA Francois DADEDJI Rafatou KOKOKO Prudencio NOUGLOKOU Ghyslaine BALOGOUN Epiphane ABOGOURIN Tayewo CHACON Remy EKON Kike PADONOU Renaud ACCOMBESSY Armelle DAHOUNLINTON Augustine KPOTON Nellie AGUIDI Baudoin ADINAKOU Gynette GINDEHOU Maryse OGOULOLA Harence FAGNIBO Marc ADJERAN

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Description of outlet types visited for this survey

Public Health Facilities N Description Government‐run health facilities that provide prescription Referral hospital 9 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 21 based public health care, and are usually staffed by nurses, a midwife, and auxiliary staff. They usually include a dispensary and maternity, although these facilities may also exist on their own. Arrondissement health centre 116 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 15 zone.

Health‐zone level hospitals and the national referral hospital in Cotonou receive first‐level referral services and Maternity 10 typically staffed with a surgeon and offer specialist health practitioners.

Village health units are staffed by voluntary community Village health unit (and smaller) 11 health workers and are linked to an arrondissement or communal health centre.

Private, not for profit facilities N Description Non‐Governmental Organization 42 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 5 clinics run by NGOs have less well qualified staff.

Private for profit facilities N Description

These are non‐governmental health facilities. Private clinics are smaller than hospitals and many of them are not Private hospital / clinic 118 registered with the Ministry of Health. They provide consultations and examinations, and sell prescription medicines at commercial prices.

Pharmacies N Description Registered pharmacies are licensed by the Ministry of Health and sell prescription medicine at commercial prices. They Pharmacy 115 outlets are staffed by qualified health practitioners, with oversight/supervision provided by a pharmacist. They sell all classes of drugs and are highly regulated.

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Rural outpost pharmacies are smaller pharmacies that are affiliated with and supplied by larger pharmacies in towns Rural outpost pharmacy 3 and urban areas. These small "sister" pharmacies are located (Dépôt pharmaceutique) in remote and rural areas and act as extensions of the larger pharmacies.

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General Retailers N Description Businesses/points of sale which sell fast moving consumer Boutique (outside a market) 396 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 structures than stalls, ranging from lockable‐steel structures Boutique (in a market) 37 in markets, to outlets located in an arcade of shops, or occupying the ground floor of a house.

Stalls N Description Stalls sell a variety of products that are displayed on tables Stall (outside a market) 526 (for example, on the roadside or in populated areas). They sell fast moving consumer goods and sometimes medicines, Stall (in a market) 165 which are usually antipyretics. Drugs sold at these locations are not regulated.

Itinerant drug vendors N Description Itinerant salesmen who often sell products of unknown Hawkers 81 origin, including medicines.

Pharmacy Rural outpost pharmacy

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

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Questionnaire

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Evidence for Malaria Medicines Policy