Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document The Republic of Zambia Outlet Survey 2014

www.ACTwatch.info Copyright © Population Services International (PSI). All rights reserved.

Released May 2015

Suggested citation ACTwatch Group and SFH. (2015). ACTwatch Study Reference Document: The Republic of Zambia Outlet Survey 2014. Washington DC: PSI.

Contact Dr. Megan Littrell Dr. Namwinga Chintu ACTwatch Principal Investigator Principal Investigator – Population Services International PSI | 1120 19th St NW Suit 600 (SFH/PSI) Zambia Washington DC 20036 Plot # 549, Ituna Road, Ridgeway Lusaka, Zambia [email protected] [email protected]

Acknowledgements

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

Society for Family Health Field Supervisors – Zambia Field Team Members Dr. Mutinta Nalubamba Alex Mwilenga Abraham Kaoma Nyongwe Lason Kapata Benny Mubanga Abraham Silwenga Christopher Mbinji Clymore Kalyangile Carol Tracy Matanda Carlos Muleya Derrick Bweupe Catherine Musonda Mwape Lupiya Chilambwe Gift Daka Clive Banda Glenda Chileshe Mumba Cosmas Phiri Ministry of Health Justin Mukupa Daisy Mulenga Chitalu Dr. Kamuliwo Mulakwa Lillian Mambwe Duntu M. Malyenkuku Marksman Foloko Emma Nyirenda ACTwatch Team Mufaya Lindunda Emmanuel Kema Kapandula Andrew Andrada Mukenji Nyembo Enock Mwila Erick Auko Patricia Sakala Febian Mubuyaeta Dr. Hana Bilak Sombo Samuyachi Francis Kaluba Bweupe Dr. Desmond Chavasse Stephen Busiku Hellen Mtonga Kevin Duff Sydney Ticklay Choombe Mulawo Isaac Jere Gloria Kigo Victor Miyanda Jackson Chikampa Makai Tarryn Haslam Jameson Kaunda Dr. Megan Littrell Martin Nsakanya Julius Ngigi Maurice Manyando Ricki Orford Mawana Jere Stephen Poyer Mercy Kumbwa Dr. Justin Rahariniaina Milner Koni Raymond Sudoi Mubanga Bweupe Musekwa Siloka Nancy Mwale Packsivia Sifumbe Pamela Mweene Patrick Chansa Paul K. Mufwaya Peter Mulunda Ruth Mwitwa Sakanya Shimeo Samuel Kapandula Sara Nkhoma Steward Mantanga Wamulume Mumbuna Womba Banda

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Table of Contents

List of Tables ...... 3 List of Figures ...... 5 Definitions ...... 8 Introduction ...... 10 Summary of Methods and Data Collection ...... 11 Summary of Key Findings ...... 13

Results Results Section A: Core Indicators ...... 34 Results Section B: Core Indicators across Urban/Rural Location ...... 50 Results Section C: Core iIndicators by Type of Public Health Facility ...... 74 Results Section D: Core Indicators across Survey Round: 2010, 2011, 2014 ...... 78

Annexes Annex 1: ACTwatch Background ...... 94 Annex 2: Country Background ...... 97 Annex 3: Outlet Survey Methods ...... 101 Annex 4: Sampled Wards ...... 105 Annex 5: Detailed Sample Description ...... 106 Annex 6: Questionnaire ...... 108 Annex 7: Antimalarial Reference ...... 128 Annex 8: RDT Reference ...... 132 Annex 9. Sampling Weights ...... 134 Annex 10: Indicator Definitions ...... 136 Annex 11. Adult Equivalent Treatment Dose (AETD) ...... 144 Annex 12: Antimalarial Volumes...... 146

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List of Tables

Core Indicators Table S1: Key results, by outlet type - 2014 ...... 13 Table A1: Availability of antimalarials, among all screened outlets, by outlet type ...... 34 Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type ...... 36 Table A3: Antimalarial market composition ...... 38 Table A4a: Price of tablet formulation antimalarials, by outlet type ...... 39 Table A4b: Price of pre-packaged antimalarials, by outlet type ...... 40 Table A5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type ...... 41 Table A6: Malaria blood testing market composition ...... 42 Table A7: Price of malaria blood testing, by outlet type ...... 43 Table A8: Antimalarial market share ...... 44 Table A9: Antimalarial market share across outlet type ...... 45 Table A10: Malaria blood testing market share ...... 46 Table A11: Malaria blood testing market share, across outlet type ...... 47 Table A12: Provider case management knowledge and practices, by outlet type ...... 48 Table A13: Provider antimalarial treatment knowledge and practices, by outlet type ...... 49 Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural location ...... 50 Table B2: Availability of antimalarials, among all outlets stocking at least one antimalarial, by outlet type, across urban/rural location ...... 55 Table B3: Antimalarial market composition, across urban/rural location ...... 59 Table B4a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location ...... 60 Table B4b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location ...... 62 Table B5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location ...... 63 Table B7: Price of malaria blood testing, by outlet type, across urban/rural location ...... 64 Table B8.1: Antimalarial market share, urban ...... 66 Table B8.2: Antimalarial market share, rural ...... 67 Table B9.1: Antimalarial market share across outlets, urban ...... 68 Table B9.2: Antimalarial market share across outlets, rural ...... 69 Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location ...... 70 Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location .... 72 Table C1: Availability of antimalarials, among screened outlets, by type of public health facility ...... 74 Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by type of public health facility ...... 75 Table C5: Availability of malaria blood testing among antimalarial-stocking outlets*, by type of public health facility76 Table C12: Provider antimalarial treatment knowledge and practices, by type of public health facility ...... 77 Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round ...... 78 Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round ...... 81 Table D3: Antimalarial market composition, across survey round ...... 84 Table D4a: Price of tablet formulation antimalarials, by outlet type, across survey round ...... 85

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Table D5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round ...... 87 Table D7: Price of malaria blood testing, by outlet type, across survey round ...... 88 Table D8: Antimalarial market share, across survey round ...... 89 Table D9: Antimalarial market share, across outlet type, across survey round ...... 91 Table D12: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round ...... 93 Table X1. Sampled wards ...... 105 Table X2: Detailed sample description ...... 106 Table X3: Number of antimalarials audited ...... 128 Table X4: Quality-Assured (QAACT) and Non-Quality Assured ACTs ...... 129 Table X5: Nationally Registered ACTs ...... 130 Table X6: Severe Malaria Treatment ...... 131 Table X7: Number of RDTs audited ...... 132 Table X8: RDT Brand Names and Manufacturers* ...... 133 Table X9: Adult Equivalent Treatment Dose Definitions ...... 145 Table X10: Antimalarial volumes, by outlet type ...... 146

Grey text for data appearing in report tables indicates that the estimate provided was derived from a small sample size. Specifically, grey text is used to indicate point estimates derived from an n of less than 50 and median prices derived from an n of less than 5.

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List of Figures

Figure 1: Survey flow diagram, Zambia, 2014 ...... 12 Figure 2. Market composition: outlet type distribution, 2009-2014 ...... 15 Figure 3. Market composition: outlet type distribution, 2014, urban/rural ...... 15 Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2009-2014 ...... 16 Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2014, urban/rural... 16 Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2009-2014 ...... 17 Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2014, urban/rural 17 Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2009-2014 ...... 18 Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2014, urban/rural ...... 18 Figure 10. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2009-2014 ...... 19 Figure 11. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2014, urban/rural ...... 19 Figure 12. Types of quality-assured ACT and non-quality-assured ACT found among public and private sector outlets, 2014 ...... 20 Figure 13. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2009-2014 ...... 21 Figure 14. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2014, urban/rural ...... 22 Figure 15. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2009-2014 ...... 22 Figure 16. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2014, urban/rural . 23 Figure 17. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2009-2014 ...... 23 Figure 18. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2014, urban/rural...... 24 Figure 19. Antimalarial market share, 2009-2014 ...... 24 Figure 20. Antimalarial market share within sector, 2009-2014 ...... 25 Figure 21. Antimalarial market share, 2014, urban/rural ...... 25 Figure 22. Antimalarial market share, 2014...... 26 Figure 23. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2014, urban/rural ...... 26 Figure 24. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2009-2014 ...... 27 Figure 25. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2014, urban/rural...... 27 Figure 26. Percentage of antimalarial-stocking outlets with malaria RDTs, 2009-2014 ...... 28 Figure 27. Percentage of antimalarial-stocking outlets with malaria RDTs, 2014, urban/rural ...... 28 Figure 28. Malaria blood testing market share, 2014 ...... 29 Figure 29. Malaria RDT market share by manufacturer, across sector, 2014 ...... 29 Figure 30. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2009-2014 ...... 30 Figure 31. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014 ...... 30

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Figure 32. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014, urban/rural ...... 31 Figure 33. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2009-2014 ...... 31 Figure 34. Median private sector consumer prices for malaria RDT testing for adults and children 2014 ...... 32 Figure 35. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2009-2014 ...... 32 Figure 36. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2014, urban/rural ...... 33

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Acronyms

ACT Artemisinin combination therapy AETD Adult equivalent treatment dose AL Artemether lumefantrine AMFm Affordable Medicines Facility – malaria ASAQ Artesunate amodiaquine BCC Behavioral change communication BMGF The Bill and Melinda Gates Foundation CHA Community Health Assistant CHW Community Health Worker CSA Census Supervisory Areas DALY Disability Adjusted Life Year DFID Department for International Development DHA PPQ Dihydroartemisinin piperaquine EMA European Medicines Agency GFATM Global Fund to Fight AIDS, TB, and Malaria iCCM Integrated Community Case Management IEC Information education communication IM Intramuscular injection IPTp Intermittent preventive treatment in pregnancy IRS Indoor residual spray ITN Insecticide treated net IV Intravenous injection LLIN Long-lasting insecticidal net MOH Ministry of Health MOMCH Ministry of Community Development, Mother and Child Health NGO Non-governmental Organization Oral AMT Oral artemisinin monotherapy OS Outlet survey Pf Plasmodium falciparum PMI President’s Malaria Initiative PPS Probability proportional to size QA RDT Quality-assured rapid diagnostic test QAACT Quality-assured artemisinin combination therapy RDT Rapid diagnostic test SEA Standard Enumeration Areas SP Sulfadoxine pyrimethamine UK United Kingdom USAID United States Agency for International Development USD US Dollar ZAMRA Zambia Medicines Regulatory Authority

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Definitions

Survey Methods Definitions

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

Malaria Product Indicator Definitions

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

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Artemisinin An antimalarial medicine that has a single active compound, where this active compound is monotherapy artemisinin or one of its derivatives. Oral artemisinin Artemisinin or one of its derivatives in a dosage form with an oral route of administration. monotherapy These include tablets, suspensions, and syrups and exclude suppositories and injections. Non-artemisinin An antimalarial medicine that does not contain artemisinin or any of its derivatives. therapy First-line The government recommended treatment for uncomplicated malaria. Zambia's first-line treatment treatment for uncomplicated malaria is artemether lumefantrine (20mg / 120mg). For pregnant women and children under 5kg with uncomplicated malaria, the treatment is sulfadoxine-pyrimethamine (500mg/25mg). Dihydroartemisinin-piperaquine is the alternative first-line treatment (40mg/320mg). Second-line The government recommended second-line treatment for uncomplicated malaria. Zambia's treatment second-line treatment for uncomplicated malaria is quinine. Nationally ACTs registered with a country’s national drug regulatory authority and permitted for sale or registered ACTs distribution in country. Each country determines its own criteria for placing a drug on its nationally registered listing. Severe malaria WHO recommends parenteral artesunate as first-line treatment in the management of severe treatment falciparum malaria, with artemether or quinine injections as acceptable alternatives if parenteral artesunate is not available.1 If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre- referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether. Quality-assured QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Artemisinin-Based Quality Assurance Policy. A QAACT is any ACT that appeared on the Global Fund's indicative Combination list of antimalarials meeting the Global Fund's quality assurance policy prior to data collection Therapies (see http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/), or that (QAACTs) previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. QAACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®.

1 World Health Organization. (2010). Guidelines for the treatment of malaria, 2nd edition. Geneva: WHO. www.ACTwatch.info Page 9

Introduction

This country reference document is a detailed presentation of the 2014 national ACTwatch outlet survey (OS) conducted in Zambia. The 2014 OS follows previous survey rounds conducted by ACTwatch in Zambia in 2008, 2009 and 2011.

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

ACTwatch antimalarial market monitoring in Zambia from 2008 to present has been implemented in the context of strategies designed and implemented to improve coverage of appropriate case management. These include:

 National efforts to improve availability of malaria blood testing in public health facilities and to maintain high ACT availability.  Efforts to extend malaria blood testing and antimalarial treatment to community level through equipping community health workers (CHWS) with RDTs and ACT.

The 2014 OS was the fourth round of ACTwatch outlet surveys conducted in Zambia. This report presents trend lines with three data points: 1) the 2009 outlet survey; 2) the 2011 outlet survey; and 3) the most recent 2014 survey. These surveys are designed to monitor key antimalarial market indicators at national level and within urban/rural domains. ACTwatch outlet survey findings can inform ongoing monitoring, evaluation, and adjustment to policy, strategy, and funding decisions to strengthen malaria case management.

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Summary of Methods and Data Collection

A nationally-representative antimalarial outlet survey was conducted in Zambia between July 14, 2014 and September 22, 2014. A full description of research design and methods is provided in Annex 3. Briefly, a representative sample of wards was selected from urban and rural domains (see sampled wards in Annex 4). Within selected clusters, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was completed. The geographic area for sampling outlets was extended to the constituency level to achieve a sufficient sample size for estimating key indicators for important outlet types. This booster sampling strategy was used to obtain a sufficient sample size for indicator estimates within public health facilities and pharmacies. All pharmacies in Zambia were included in the census.

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

A structured questionnaire was used to complete an audit of all antimalarials and RDTs as well as a provider interview (see Annex 6). See Annex 7 and Annex 8 for detailed summaries of antimalarials and RDTs audited. Key informant interviews were conducted with specific stakeholders to supplement information for the country background.

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

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Figure 1: Survey flow diagram, Zambia, 2014

A Outlets enumerated* Respondent not available [36] [6,321] Outlet closed at time of visit [144] Outlets not

screened Outlet closed permanently [236] [443] Other [1] B

Outlets screened** Refused [26] [5,878] Outlets that did not meet screening criteria C [4,850]

Outlets that met screening criteria [1,028] 1 = [984] Interview interrupted [2] 2 = [41] 3 = [3] Respondent not available [0] Outlets not interviewed Outlet closed at time of visit [0] [4] Other [0] D Outlets interviewed*** Refused [2] [1,024] 1 = [980] 2= [41] 3= [3]

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

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Summary of Key Findings Table S1: Key results, by outlet type - 2014

Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit1 Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Readiness for malaria case management N=493 N=533 N=26 N=123 N=246 N=4,950 N=5,345 N=5,878 Proportion of all screened outlets* with: 91.2 77.5 79.2 46.1 10.8 0.0 0.7 4.0 Availability of malaria blood testing (86.1, 94.6) (63.7, 87.1) (59.3, 90.9) (30.8, 62.1) (3.3, 30.2) - (0.4, 1.2) (3.0, 5.4) 89.9 75.4 43.6 62.7 18.5 0.3 1.1 4.3 Availability of QAACT (84.5, 93.6) (62.3, 85.0) (27.0, 61.8) (48.7, 74.8) (9.2, 33.7) (0.1, 0.8) (0.7, 1.7) (3.4, 5.5) Availability of QAACT and malaria blood 81.8 67.7 35.2 35.2 6.8 0.0 0.4 3.3 testing (75.5, 86.8) (54.9, 78.4) (19.9, 54.3) (23.6, 48.9) (1.6, 24.3) - (0.2, 0.8) (2.4, 4.5) Availability of QAACT, blood testing not 8.1 7.7 8.4 27.4 11.7 0.3 0.7 1.0 available (4.9, 13.1) (3.7, 15.0) (2.0, 29.0) (17.1, 40.8) (6.1, 21.3) (0.1, 0.8) (0.4, 1.2) (0.7, 1.5) Availability of QAACT, malaria blood testing, 80.3 66.8 27.8 29.7 6.2 0.0 0.3 3.2 and provider correct knowledge of first line treatment (74.0, 85.4) (54.0, 77.5) (13.9, 48.0) (19.8, 41.9) (1.5, 21.8) - (0.2, 0.7) (2.3, 4.4) 67.8 45.6 41.1 21.2 0.5 0.0 0.2 2.2 Availability of any severe malaria treatment (54.9, 78.5) (33.2, 58.6) (22.0, 63.4) (12.5, 33.5) (0.1, 3.2) - (0.1, 0.4) (1.6, 2.9) Readiness for malaria case management Proportion of antimalarial-stocking outlets N=491 N=508 N=22 N=118 N=222 N=110 N=472 N=980 with: 91.3 90.4 87.5 49.4 11.1 0.1 12.6 44.8 Availability of malaria blood testing (86.1, 94.6) (81.8, 95.2) (66.4, 96.2) (37.6, 61.2) (3.4, 30.3) (0.0, 0.6) (6.8, 22.1) (36.0, 54.0) 90.1 89.8 48.2 70.6 20.1 12.9 20.8 49.4 Availability of QAACT (84.6, 93.7) (82.5, 94.3) (28.3, 68.7) (56.2, 81.8) (9.8, 36.7) (5.3, 28.1) (12.8, 32.0) (41.2, 57.6) Availability of QAACT and malaria blood 82.0 80.7 38.9 39.7 7.4 0.0 7.4 37.8 testing (75.6, 87.0) (71.0, 87.7) (20.8, 60.6) (29.8, 50.4) (1.7, 26.3) - (3.4, 15.4) (29.7, 46.6) Availability of QAACT, blood testing not 8.1 9.1 9.3 30.9 12.7 12.9 13.4 11.6 available (4.9, 13.1) (4.5, 17.7) (2.3, 31.5) (17.9, 47.9) (6.6, 23.2) (5.3, 28.1) (8.0, 21.6) (7.5, 17.5) Availability of QAACT, malaria blood testing, 80.5 79.6 30.7 33.4 6.7 0.0 6.3 36.7 and provider correct knowledge of first line treatment (74.2, 85.5) (69.8, 86.8) (15.2, 52.3) (24.9, 43.2) (1.6, 23.7) - (2.8, 13.7) (28.6, 45.6) 67.9 54.3 45.5 23.9 0.5 0.0 4.2 25.0 Availability of any severe malaria treatment (55.0, 78.6) (40.0, 68.0) (25.5, 67.0) (15.4, 35.0) (0.1, 3.4) - (2.5, 7.0) (19.1, 31.9)

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Table S1: Key results, by outlet type - 2014

Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit1 Facility Readiness for IPTp *N=493 *N=533 *N=26 *N=123 *N=246 *N=4,950 *N=5,345 *N=5,878 Proportion of outlets with SP available: N=491 N=508 N=22 N=118 N=222 N=110 N=472 N=980 87.2 57.8 59.0 67.5 85.3 2.2 4.7 7.0 Among all screened outlets* (81.6, 91.2) (43.0, 71.4) (32.1, 81.4) (57.2, 76.3) (77.2, 90.8) (1.4, 3.5) (3.6, 6.1) (5.6, 8.6) 87.3 68.9 65.2 76.0 92.6 86.0 87.1 79.5 Among antimalarial-stocking outlets (81.9, 91.3) (51.5, 82.2) (35.4, 86.5) (64.3, 84.8) (84.9, 96.5) (70.9, 93.9) (79.5, 92.1) (71.3, 85.9)

Malaria market performance

% QAACT market share within outlet type^ 31.6 34.5 18.9 21.5 12.3 8.5 12.9 30.3 Median price for one QAACT adult $0.00 $0.00 $5.47 $6.56 $1.97 $1.64 $2.46 $0.00 equivalent treatment dose (AETD) [0.00-0.00] (970) [0.00-0.00] (991) [3.74-10.50] (18) [4.92-9.85] (182) [1.64-3.28] (53) [1.31-2.13] (12) [1.64-4.92] (265) [0.00-0.00] (1,256) Median price for one pre-packaged pediatric $0.00 $0.00 $1.64 $2.79 $0.49 $0.82 $0.82 $0.00 QA AL # [0.00-0.00] (323) [0.00-0.00] (329) [0.00-2.63] (4) [2.46-4.92] (30) [0.33-0.82] (8) [0.49-0.98] (3) [0.49-1.97] (45) [0.00-0.00] (374) $0.00 $0.00 $1.64 $2.46 $0.82 $0.82 $1.23 $0.00 Median price for an RDT ## [0.00-0.00] (502) [0.00-0.00] (521) [0.49-4.92] (15) [1.64-4.10] (54) [0.66-1.15] (18) (1) [0.82-3.28] (88) [0.00-0.00] (609) $0.00 $0.00 $3.28 $0.00 $1.64 - $3.28 $0.00 Median price for malaria microscopy ## [0.00-0.00] (95) [0.00-0.00] (97) [1.64-6.56] (11) [0.00-2.46] (3) (1) - [1.64-6.56] (15) [0.00-0.00] (112) 1 Inclusive of N=35 screened CHWs/5 screened private-not-for-profit outlets and 14 antimalarial-stocking CHWs/3 antimalarial-stocking private-not-for-profit outlets. * The denominator includes 4 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).  Outlets with at least one antimalarial in stock on the day of the survey or reportedly in stock within the past 3 months. ^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by quality-assured ACT (QAACT) sale/distribution within the outlet type. # Pre-packaged QA AL for a 10kg child ## Price inclusive of consultation / service fees for a child under five Source: ACTwatch Outlet Survey, Zambia, 2014.

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Figure 2. Market composition: outlet type distribution, 2009-2014 Among all outlets with at least one antimalarial in stock

Public Health Facility 2009 2011 2014 CHW N=294 N=525 N=472

Private-not-for-Profit Health Facility 25% 29% 30% 29% 28% 28% Private for-Profit Health Facility

Pharmacy 2% 6% 9% 23% 9% Drug Store 24% 13% 6% 26% 2% General Retailer 4% 4% 3%

Antimalarial market composition has remained similar at national level in Zambia over time. Approximately 30% of antimalarial-stocking outlets were public health facilities during each survey round. General retail stores and drug stores accounted for about one-half of all antimalarial-stocking outlets over time. Market composition for private for-profit health facilities has decreased over time from 13% in 2009 to 4% in 2014, and CHWs accounted for 9% of all antimalarial-stocking outlets visited in 2014.

Figure 3. Market composition: outlet type distribution, 2014, urban/rural Among all outlets with at least one antimalarial in stock

Public Health Facility Urban Rural CHW N=374 N=98 15% <1% Private not-for-Profit Health Facility 26% 30% 8% 39% Private for-Profit Health Facility 6% Pharmacy 10% Drug Store 45% 1% 17% General Retailer 3%

Drug stores make up the majority of antimalarial stocking outlets among urban areas (45%) followed by general retailers. In rural areas, public health facilities and general retailers comprise most of the outlets with at least one antimalarial in stock at 39% and 30%, respectively. The rest of the outlet types in rural areas are made up of drug stores and private-for-profit health facilities, not many pharmacies were found.

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Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2009- 2014 Among all screened outlets

100

90

80

70

60

50

40

Percentage ofoutlets 30

20

10

0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Among all outlets approached and screened between 2009-2014, public health facilities, private-for-profit facilities, pharmacies and drug stores commonly stocked antimalarial medicines. General retail outlets typically were not stocking antimalarials; fewer than 5% had antimalarials in stock at the time of the survey across rounds.

Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2014, urban/rural Among all screened outlets

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

The percentage of outlets stocking antimalarials was similar across urban and rural areas in 2014 among public health facilities, drug stores and general retail outlets.

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Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2009- 2014 Among all outlets with at least one antimalarial in stock, across survey round

100

90

80

70

60

50

40

Percentage ofoutlets 30

20

10

0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Data trends suggest increasing ACT availability among antimalarial-stocking outlets across outlet types over time. In 2014, ACT was available among nearly all antimalarial-stocking public health facilities (99%), private for-profit facilities (98%) and pharmacies (96%). ACT availability was much lower among drug shops (29%) and general retail outlets (18%).

Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

ACT availability among antimalarial-stocking outlets was similar across urban and rural areas among public health facilities. ACT availability was higher among antimalarial-stocking drug stores in rural areas (68%) as compared with urban areas (20%) and data trends suggest higher availability among rural (23%) versus urban (11%) general retail outlets.

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Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2009-2014 Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Antimalarial-stocking public health facilities have maintained a high level of QAACT availability over time (90% in 2014). QAACT availability has remained relatively lower among private sector antimalarial-stocking outlets. In 2014 QAACT was available among only half private for-profit health facilities (48%), 71% of pharmacies, 20% of drug stores, and 13% of general retail outlets.

Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

QAACT availability among antimalarial-stocking outlets was similar across urban and rural areas among public health facilities. QAACT availability was higher among antimalarial-stocking drug stores in rural areas (60%) as compared with urban areas (10%) and data trends suggest higher availability among rural (20%) versus urban (3%) general retail outlets.

www.ACTwatch.info Page 18

Figure 10. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2009-2014 Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

The 2009 and 2011 outlet surveys documented very low levels of non-quality assured ACT availability among public health facilities. However in 2014, 88% of public health facilities had non-QA ACT in stock. These facilities were commonly stocking the ACT artemether lumefantrine manufactured by S. Kant Healthcare. This product does not appear on the list of WHO prequalified antimalarial medicines nor has it been granted regulatory approval by the EMA.

Availabilty of non-QA ACT has also increased over time among antimalarial-stocking private sector outlets including private for-profit health facilities (2009, 32%; 2011, 77%; 2014, 84%) and pharmacies (2009, 62%; 2011, 86%; 2014, 93%).

Figure 11. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

Non-QA ACT availability among antimalarial-stocking outlets was similar across urban and rural areas among public health facilities, drug stores and general retail outlets.

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Figure 12. Types of quality-assured ACT and non-quality-assured ACT found among public and private sector outlets, 2014 Among all ACT medicines audited, across sector, 2014

QA ACT Public QA ACT Private Non-QA ACT Public Non-QA ACT Private N=991 N=269 N=941 N=555

AL tablet <1% 9% ASAQ tablet 31% ANAP tablet 41%

AS SP tablet

91% 2% DHA PPQ tablet 100% 99% 25% 1% AL non-tablet

A majority of QAACT and non-QA ACT treatments are composed of AL tablets, especially in the public sector. There is more diversity among non-QA ACTs within the private sector. Almost all of the non-QA ACTs within the public are attributed to AL tablets manufactured by S Kant Healthcare through the GRZ program by the MoH.

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Figure 13. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2009-2014 Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

In 2009, nearly all antimalarial-stocking outlets had non-artemisinin therapies such as SP and quinine in stock. By 2014, availability remained high however data trends suggest declining availability particularly among private sector outlet types.

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Figure 14. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

Availability of non-artemisinin therapy among antimalarial-stocking outlets was similar across urban and rural areas among public health facilities, drug stores and general retail outlets.

Figure 15. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2009- 2014 Among all outlets with at least one antimalarial in stock, across survey rounds

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

SP is used for the intermittent preventive treatment of malaria during pregnancy (IPTp) and is administered to pregnant women in Zambia during antenatal care visits. SP availability among antimalarial-stocking public health facilities has increased over time from 60% in 2009 to 74% in 2011 and 87% in 2014. While data trends suggest a decline in SP availability among private for-profit health facilities (2014, 65%) and pharmacies (2014, 76%), availability remains high among these outlet types as well as among antimalarial-stocking drug stores (2014, 93%) and general retail outlets (2014, 86%).

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Figure 16. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

SP availability was higher among antimalarial-stocking public health facilities in urban (96%) versus rural areas (84%) and data trends suggest higher availability among urban versus rural drug stores and general retail outlets.

Figure 17. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2009-2014 Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Severe malaria treatments include injectable artesunate, artemether, and quinine. Availability of any treatment for severe malaria fluctuated among public and private for-profit health facilities over time. Nearly half of private for- profit facilities (46%) and 68% of public health facilities were stocking severe malaria treatment in 2014.

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Figure 18. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility

Urban Rural

Severe malaria treatment availability was similar among public health facilities across urban and rural areas.

Figure 19. Antimalarial market share, 2009-2014 Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class

100 90 80 70 60 50 40 30 20 10 Percentage ofsector marketvolume 0 Public Private Public Private Public Private 2009 2011 2014

QAACT Non-QA ACT SP Other non-artemisinin therapy Oral artemisinin monotherapy Non-oral artemisinin monotherapy

Public sector relative antimalarial market share increased from 60% in 2009 to over 80% in 2011 (84%) and 2014 (81%). Quality-assured ACT relative market share has increased from 26% in 2009 to 56% in 2011, but decreased to 30% in 2014. The decrease in 2014 is due to the market share captured by non-quality-assured ACT accounting for 27% of all antimalarials distributed at national level. SP accounted for more than half of all antimalarials distributed in 2009 (66%) and SP relative market share declined to 40% in 2014.

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Figure 20. Antimalarial market share within sector, 2009-2014 Relative market volume (sale/distribution) of antimalarial AETDs, within sector, by antimalarial class

100 90 80 70 60 50 40 30 20 10

Percentage ofsector marketvolume 0 Public Private Public Private Public Private 2009 2011 2014

QAACT Non-QA ACT SP Other non-artemisinin therapy Oral artemisinin monotherapy Non-oral artemisinin monotherapy

In 2009, the majority of antimalarials distributed by both public and private sector outlets were SP treatments. However by 2011, 66% of all antimalarials distributed by the public sector were QAACT. In 2014, QAACT public sector market share fell to 35% and non-QA ACT market share was 32%. SP remained commonly distributed among private sector outlets over time, accounting for more than 70% of all antimalarials distributed by the private sector in 2011 (71%) and 2014 (76%).

Figure 21. Antimalarial market share, 2014, urban/rural Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class

100 90 80 70 60 50 40 30 20 10

Percentage ofsector marketvolume 0 Public Private Public Private Urban Rural

QAACT Non-QA ACT SP Other non-artemisinin therapy Oral artemisinin monotherapy Non-oral artemisinin monotherapy

The public sector accounts for nearly 70% of all antimalarials distributed in urban areas (67%) and 90% of antimalarials distributed in rural areas. QAACT relative market share is higher in rural (37%) as compared with urban areas (20%) however non-QA ACT market share is similar (urban, 28%; rural, 27%). SP accounted for half of all antimalarials distributed in urban areas (48%) as compared with one-third of antimalarials distributed in rural areas (34%). www.ACTwatch.info Page 25

Figure 22. Antimalarial market share, 2014 Relative market volume (sale/distribution) of antimalarial AETDs, by outlet type and antimalarial class

100 90 80 70 60 50 40 30 20

10 Percentage oftotal market volume 0 Public Private Private for-Profit Pharmacy Drug Store General Retailer Health Facility

QAACT Non-QA ACT SP Other non-artemisinin therapy Oral artemisinin monotherapy Non-oral artemisinin monotherapy

The private sector accounted for 19% of all antimalarials distributed at national level including distribution by drug stores (10% of the national market share) and general retailers (5% of the national market share).

Figure 23. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2014, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store

Urban Rural

The availability of malaria blood testing was similar across urban and rural areas for public health facilities. Blood testing availability was higher among antimalarial-stocking drug stores in rural (42%) as compared with urban areas (3%).

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Figure 24. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2009-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Malaria microscopy availability is declining among antimalarial-stocking public health facilities from 41% in 2009 to 18% in 2014. In comparison with public health facility availability, microscopy is more commonly available among private for-profit health facilities (2014, 72%).

Figure 25. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2014, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility

Urban Rural

Microscopy availability among antimalarial-stocking public health facilities was higher among urban (48%) as compared with rural areas (8%).

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Figure 26. Percentage of antimalarial-stocking outlets with malaria RDTs, 2009-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

RDT availability among antimalarial-stocking public health facilities was high in 2009 (90%) and 2014 (89%), although at the time of the 2011 survey, RDT availability was lower at 72%. Data trends suggest a decline in RDT availability among private for-profit health facilities (2009, 78%; 2011, 44%; 2014, 68%) and an increase in availability among antimalarial-stocking pharmacies (2009, 15%; 2011, 41%; 2014, 51%).

Figure 27. Percentage of antimalarial-stocking outlets with malaria RDTs, 2014, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban and rural zones

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

RDT availability was similar across urban and rural areas among public health facilities. Among antimalarial-stocking drug stores, RDT availability was lower among urban (3%) versus rural areas (42%).

www.ACTwatch.info Page 28

Figure 28. Malaria blood testing market share, 2014 Relative market volume (sale/distribution) of malaria blood testing using RDTs and microscopy, by outlet type and type of test

100 90 80 70 60 50 40 30 20

Percentage oftotal market volume 10 0 Public Private Private for-Profit Pharmacy Drug Store General Retailer Health Facility

Microscopy RDT

The public sector accounted for over 90% of all malaria blood tests performed at the national level (87%). accounting for over 84%, RDTs were the predominant malaria blood test found within the public sector.

Figure 29. Malaria RDT market share by manufacturer, across sector, 2014 Relative market volume (sale/distribution) of malaria RDTs by manufacturer, within the public sector, private sector, and total market

100 90 80 70 60 50 40 30 20

Percentage oftotal market volume 10 0 Public Private Private for-Profit Pharmacy Drug Store Health Facility

Standard Diagnostics Inc Premier Medical Corporation LTD Orchid Biomedical Systems Other

RDTs manufactured by Standard Diagnostics Inc. accounted for more than half of all RDTs performed within the public (57%) and private sector (64%). Premier Medical Corp. LTD RDTs were distributed by public (9%) and private sector outlets (10%) and Orchid Biomedical Systems RDTs accounted for 18% of the private sector RDT market share. Manufacturers within ‘other’ included Vision Biotech, Span Diagnostics, and Intec Products

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Figure 30. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2009-2014 Among all SP, non-quality-assured, and quality-assured ACT (tablet formulation only) available in the private sector, in 2009 US dollars to account for inflation

$14.00

$12.00 $9.63 $9.65 $10.00 $8.03 $8.00

$5.36

$6.00 $4.87 Medianprice $4.00 $2.09 $2.00 $0.40 $0.54 $0.42 $0.00 2009 2011 2014

Quality-Assured ACT Non-Quality-Assured ACT SP

The median private sector price of one QAACT adult equivalent treatment dose has declined over time. However in 2014, QAACT remained more than 3 times as expensive as the most commonly distributed non-artemisinin therapy, SP.

Figure 31. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014 Among all SP, QAACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2014 US Dollars

$10.00

$8.00 $6.56 $6.00 $5.47

Medianprice $4.00 $2.79 $2.46 $1.97 $2.00 $1.64 $1.64 $0.82 $0.82$0.82 $0.41$0.49$0.49$0.49 $0.49 $0.00 SP AETD QA ACT AETD Pre-packaged pediatric QA AL

Private-For-Profit Facility Pharmacy Drug Store General Retailer ALL Private

The median private sector price for one SP AETD in 2014 was $0.49 and was similar across private sector outlet types with the exception of relatively higher price among private for-profit health facilities ($0.82). The median private sector price for QAACT was $2.46 for one AETD (five times higher than the median price of SP) and $0.82 for one pre-packaged treatment for a two-year old child. QAACT private sector price was higher among private for- profit health facilities and pharmacies as compared with drug stores and general retail outlets. www.ACTwatch.info Page 30

Figure 32. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014, urban/rural Among all SP, QAACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2014 US Dollars

$9.00 $8.00 $7.00 $6.00 $4.92 $5.00

$4.00 Medianprice $3.00 $2.46 $2.00 $1.64

$1.00 $0.49 $0.49 $0.49 $0.00 SP AETD QA ACT AETD Pre-packaged pediatric QA AL Urban Rural

While the median private sector price for one SP AETD was the same across urban and rural areas ($0.49), QAACT was more expensive in urban versus rural areas. The median private sector price for one QAACT AETD was $4.92 in urban areas as compared with $1.64 in rural areas. Pre-packaged pediatric AL was 5 times more expensive in urban ($2.46) versus rural areas ($0.49).

Figure 33. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2009-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Malaria blood testing availability among antimalarial-stocking outlets has remained high over time among public and private for-profit health facilities (2014, 91% and 88% respectively). Blood testing availability has increased among antimalarial-stocking pharmacies from 17% in 2009 to 51% in 2014. Antimalarial-stocking drug shops and general retail outlets most commonly do not provide malaria blood testing.

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Figure 34. Median private sector consumer prices for malaria RDT testing for adults and children 2014 Among all RDTs available within private for-profit health facilities, pharmacies and drug stores, in 2014 US dollars

$6.00

$5.00

$4.00

$3.00

$2.46 $2.46 $2.46 Medianprice $2.00 $1.64 $1.23 $1.23 $1.00 $0.82 $0.82 $0.82 $0.82

$0.00 RDT - Adult RDT - Child

Private-For-Profit Facility Pharmacy Drug Store General Retailer ALL Private

The median private sector price for a malaria RDT was $1.23 for both children under five and adults. However the median price varied across outlet types and was higher among private for-profit facilities and pharmacies as compared with drug stores and general retail outlets.

Figure 35. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2009-2014 Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months or malaria blood testing

100 90 80 70 60 50 40

30 Percentage ofoutlets 20 10 0 2009 2011 2014

Public Health Facility Private-For-Profit Facility Pharmacy Drug Store General Retailer

Provider knowledge of the first-line treatment for uncomplicated malaria was high among public health facilities over time (95% or higher) as well as among private for-profit facilities and pharmacies. Provider knowledge was relatively lower among drug stores (2014, 61%) and general retail outlets (46%).

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Figure 36. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2014, urban/rural Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months or malaria blood testing

100 90 80 70 60 50 40 30

Percentage ofoutlets 20 10 0 Public Health Facility Drug Store General Retailer

Urban Rural

Provider knowledge of the first-line treatment for uncomplicated malaria was similar across urban and rural areas for public health facility providers. Knowledge among providers in drug stores was higher in rural (85%) versus urban areas (55%), and data trends for general retailers suggest a similar pattern of higher knowledge in rural (54%) versus urban areas (36%).

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Results Section A: Core Indicators

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=493 N=533 N=26 N=123 N=246 N=4,950 N=5,345 N=5,878 stocking: Any antimalarial at the time 99.8 84.0 90.5 88.8 92.1 2.5 5.3 8.7 of survey visit (99.2, 100.0) (69.5, 92.3) (76.8, 96.5) (69.8, 96.5) (87.7, 95.0) (1.7, 3.9) (4.2, 6.7) (7.1, 10.7) 99.0 83.5 88.2 85.5 27.0 0.4 1.7 5.2 Any ACT (97.7, 99.6) (69.2, 91.9) (71.1, 95.8) (67.1, 94.4) (16.6, 40.7) (0.2, 1.0) (1.2, 2.3) (4.1, 6.5) Artemether Lumefantrine 99.0 83.5 88.2 85.2 25.2 0.4 1.6 5.2 (AL)  (97.7, 99.6) (69.2, 91.9) (71.1, 95.8) (67.1, 94.2) (15.1, 39.0) (0.2, 1.0) (1.2, 2.3) (4.1, 6.5) Artesunate Sulfadoxine 0.1 0.1 39.1 53.0 1.1 0.0 0.3 0.3 Pyrimethamine (ASSP) (0.0, 0.5) (0.0, 0.3) (13.1, 73.2) (33.2, 71.9) (0.3, 5.0) - (0.2, 0.7) (0.1, 0.6) Artesunate Amodiaquine 0.0 0.0 23.8 11.1 1.8 0.0 0.2 0.2 (ASAQ) - - (10.0, 46.7) (5.7, 20.6) (0.3, 10.2) - (0.1, 0.4) (0.1, 0.4) 0.0 0.0 3.9 7.0 0.0 0.0 0.0 0.0 DHA PPQ - - (0.7, 19.7) (2.9, 16.2) - - (0.0, 0.1) (0.0, 0.1) Quality Assured ACT 89.9 75.4 43.6 62.7 18.5 0.3 1.1 4.3 (QAACT) (84.5, 93.6) (62.3, 85.0) (27.0, 61.8) (48.7, 74.8) (9.2, 33.7) (0.1, 0.8) (0.7, 1.7) (3.4, 5.5) 89.9 75.4 32.3 58.4 16.9 0.3 1.0 4.2 QA AL (84.5, 93.6) (62.3, 85.0) (14.4, 57.5) (46.4, 69.4) (7.9, 32.3) (0.1, 0.8) (0.6, 1.6) (3.3, 5.4) 74.6 58.1 13.0 31.3 7.1 0.2 0.5 3.0 QAACT - child (<5 years) (66.2, 81.5) (45.0, 70.3) (4.9, 30.5) (24.5, 39.1) (3.4, 14.3) (0.1, 0.6) (0.3, 0.9) (2.3, 3.9) 50.2 37.0 28.4 51.2 14.3 0.1 0.7 2.3 QAACT - adult (39.4, 61.0) (26.3, 49.2) (14.3, 48.4) (31.3, 70.6) (5.9, 30.8) (0.1, 0.4) (0.5, 1.2) (1.7, 3.1) Non-quality-assured ACT 88.2 71.4 76.3 82.9 11.1 0.1 0.9 3.9 (non-QA ACT) (83.3, 91.7) (60.0, 80.7) (48.1, 91.8) (66.8, 92.1) (6.7, 17.8) (0.1, 0.3) (0.6, 1.3) (3.0, 5.2) Non-quality-assured ACT AL 88.2 71.4 73.0 81.6 9.9 0.1 0.9 3.9 (non-QA ACT AL) (83.3, 91.7) (60.0, 80.7) (45.4, 89.8) (66.1, 91.0) (5.6, 17.0) (0.1, 0.3) (0.6, 1.2) (2.9, 5.1) 90.6 76.1 87.7 85.5 25.1 0.4 1.5 4.7 Nationally Registered ACT (85.1, 94.2) (62.9, 85.6) (70.9, 95.4) (67.1, 94.4) (15.0, 38.9) (0.2, 0.8) (1.1, 2.1) (3.8, 6.0) 97.6 64.3 78.1 78.5 88.0 2.2 4.9 7.4 Any non-artemisinin therapy (93.1, 99.2) (48.4, 77.6) (54.4, 91.5) (65.6, 87.4) (81.1, 92.6) (1.4, 3.5) (3.8, 6.3) (6.0, 9.1) 87.2 57.8 59.0 67.5 85.3 2.2 4.7 7.0 Sulfadoxine-Pyrimethamine (81.6, 91.2) (43.0, 71.4) (32.1, 81.4) (57.2, 76.3) (77.2, 90.8) (1.4, 3.5) (3.6, 6.1) (5.6, 8.6)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=493 N=533 N=26 N=123 N=246 N=4,950 N=5,345 N=5,878 stocking: 90.4 59.9 45.9 31.4 3.2 0.0 0.3 2.9 Oral Quinine (84.9, 94.1) (45.7, 72.6) (25.1, 68.2) (23.7, 40.2) (0.8, 12.1) - (0.2, 0.6) (2.2, 3.9) 60.3 41.0 18.8 3.9 0.0 0.0 0.1 1.8 Quinine IV/IM (48.1, 71.3) (29.5, 53.5) (5.8, 46.5) (1.3, 10.6) - - (0.0, 0.2) (1.4, 2.5) Other non-artemisinin 0.1 0.1 15.3 32.8 7.1 0.1 0.4 0.4 therapy (0.0, 0.8) (0.0, 0.5) (4.6, 40.5) (21.7, 46.1) (3.5, 13.9) (0.0, 0.2) (0.2, 0.6) (0.2, 0.6) Oral artemisinin 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 monotherapy ------Non-oral artemisinin 22.6 14.2 33.8 20.6 0.5 0.0 0.2 0.8 monotherapy (15.4, 32.0) (9.1, 21.6) (16.8, 56.3) (12.0, 32.9) (0.1, 3.2) - (0.1, 0.4) (0.5, 1.2) 22.6 14.0 33.8 19.7 0.5 0.0 0.2 0.8 Injectable artemether (15.4, 31.9) (8.9, 21.3) (16.8, 56.3) (11.9, 31.0) (0.1, 3.2) - (0.1, 0.4) (0.5, 1.2) 0.4 0.4 3.3 2.5 0.0 0.0 0.0 0.0 Injectable artesunate (0.2, 0.9) (0.2, 1.2) (0.4, 21.0) (0.9, 6.5) - - (0.0, 0.1) (0.0, 0.1) 0.0 0.0 0.0 5.9 0.0 0.0 0.0 0.0 Injectable artemotil - - - (2.8, 11.9) - - - - Any treatment for severe 67.8 45.6 41.1 21.2 0.5 0.0 0.2 2.2 malaria (54.9, 78.5) (33.2, 58.6) (22.0, 63.4) (12.5, 33.5) (0.1, 3.2) - (0.1, 0.4) (1.6, 2.9) * The denominator includes 12 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). ** The denominator includes 35 CHWs and 5 private-not-for-profit outlets  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Source: ACTwatch Outlet Survey, Zambia, 2014.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=491 N=508 N=22 N=118 N=222 N=110 N=472 N=980 stocking: 99.2 99.4 97.5 96.2 29.4 17.6 31.2 59.5 Any ACT (97.8, 99.7) (98.3, 99.8) (84.5, 99.6) (86.9, 99.0) (17.7, 44.6) (7.7, 35.3) (21.4, 43.1) (50.7, 67.7) Artemether Lumefantrine 99.2 99.4 97.5 95.9 27.4 17.6 30.4 59.0 (AL)  (97.8, 99.7) (98.3, 99.8) (84.5, 99.6) (86.9, 98.8) (16.0, 42.7) (7.7, 35.3) (20.7, 42.2) (50.2, 67.2) Artesunate Sulfadoxine 0.1 0.1 43.2 59.7 1.2 0.0 5.9 3.5 Pyrimethamine (ASSP) (0.0, 0.5) (0.0, 0.3) (15.3, 76.2) (43.1, 74.4) (0.3, 5.5) - (2.8, 12.1) (1.7, 7.1) Artesunate Amodiaquine 0.0 0.0 26.3 12.5 1.9 0.0 3.1 1.8 (ASAQ) - - (11.5, 49.4) (6.8, 21.8) (0.3, 11.0) - (1.3, 6.8) (0.8, 4.0) 0.0 0.0 4.3 7.9 0.0 0.0 0.6 0.4 DHA PPQ - - (0.7, 21.5) (3.4, 17.5) - - (0.2, 1.6) (0.1, 0.9) Quality Assured ACT 90.1 89.8 48.2 70.6 20.1 12.9 20.8 49.4 (QAACT) (84.6, 93.7) (82.5, 94.3) (28.3, 68.7) (56.2, 81.8) (9.8, 36.7) (5.3, 28.1) (12.8, 32.0) (41.2, 57.6) 90.1 89.8 35.6 65.8 18.3 12.9 19.0 48.4 QA AL (84.6, 93.7) (82.5, 94.3) (14.4, 64.6) (52.7, 76.8) (8.5, 35.2) (5.3, 28.1) (11.3, 30.3) (40.2, 56.6) 74.7 69.3 14.4 35.3 7.7 7.2 9.1 34.0 QAACT - child (<5 years) (66.5, 81.5) (54.8, 80.7) (4.8, 35.8) (24.3, 48.1) (3.7, 15.5) (2.1, 22.1) (4.9, 16.4) (27.0, 41.8) 50.3 44.1 31.3 57.6 15.5 5.7 13.9 26.4 QAACT - adult (39.4, 61.1) (31.2, 57.8) (16.0, 52.3) (40.3, 73.2) (6.3, 33.5) (2.5, 12.6) (8.2, 22.6) (19.7, 34.4) Non-quality-assured ACT 88.3 85.1 84.3 93.4 12.0 4.6 16.9 45.1 (non-QA ACT) (83.6, 91.8) (78.8, 89.8) (59.6, 95.1) (86.2, 97.0) (7.1, 19.6) (1.9, 10.9) (12.0, 23.1) (37.3, 53.3) Non-quality-assured ACT AL 88.3 85.1 80.7 91.9 10.8 4.6 16.0 44.7 (non-QA ACT AL) (83.6, 91.8) (78.8, 89.8) (55.8, 93.3) (84.6, 95.9) (6.0, 18.6) (1.9, 10.9) (11.3, 22.2) (36.8, 52.8) Nationally Registered 90.8 90.6 96.9 96.2 27.3 13.9 28.6 54.3 ACT (85.2, 94.4) (83.2, 94.9) (85.6, 99.4) (86.9, 99.0) (15.9, 42.6) (6.1, 28.7) (19.4, 40.0) (46.3, 62.1) 97.8 76.6 86.3 88.4 95.6 87.7 91.0 85.0 Any non-artemisinin therapy (93.6, 99.2) (57.5, 88.8) (67.8, 95.0) (76.3, 94.7) (89.8, 98.1) (72.3, 95.1) (83.3, 95.4) (76.3, 91.0) Sulfadoxine- 87.3 68.9 65.2 76.0 92.6 86.0 87.1 79.5 Pyrimethamine (81.9, 91.3) (51.5, 82.2) (35.4, 86.5) (64.3, 84.8) (84.9, 96.5) (70.9, 93.9) (79.5, 92.1) (71.3, 85.9) 90.6 71.3 50.7 35.3 3.4 0.0 6.3 33.2 Oral Quinine (85.1, 94.2) (54.7, 83.6) (29.5, 71.6) (23.7, 49.0) (0.8, 13.0) - (3.4, 11.2) (25.5, 42.0) 60.4 48.8 20.7 4.3 0.0 0.0 1.5 21.1 Quinine IV/IM (48.2, 71.4) (35.7, 62.1) (6.3, 50.3) (1.5, 11.6) - - (0.6, 3.6) (15.9, 27.5)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* N=491 N=508 N=22 N=118 N=222 N=110 N=472 N=980 stocking: Other non-artemisinin 0.1 0.1 17.0 36.9 7.7 2.6 7.2 4.3 therapy (0.0, 0.8) (0.0, 0.6) (4.9, 44.9) (27.4, 47.4) (3.7, 15.1) (0.7, 8.7) (4.6, 11.1) (2.7, 6.6) Oral artemisinin 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 monotherapy ------Non-oral artemisinin 22.7 17.0 37.3 23.2 0.5 0.0 3.6 9.2 monotherapy (15.4, 32.0) (11.0, 25.2) (19.5, 59.5) (14.8, 34.4) (0.1, 3.4) - (2.0, 6.5) (6.5, 12.8) 22.6 16.7 37.3 22.2 0.5 0.0 3.6 9.0 Injectable artemether (15.4, 32.0) (10.8, 24.9) (19.5, 59.5) (14.6, 32.3) (0.1, 3.4) - (2.0, 6.4) (6.3, 12.6) 0.4 0.5 3.6 2.8 0.0 0.0 0.4 0.4 Injectable artesunate (0.2, 0.9) (0.2, 1.4) (0.5, 22.9) (1.1, 7.0) - - (0.1, 1.3) (0.2, 1.0) 0.0 0.0 0.0 6.7 0.0 0.0 0.3 0.2 Injectable artemotil - - - (3.4, 12.5) - - (0.1, 0.8) (0.1, 0.4) Any treatment for severe 67.9 54.3 45.5 23.9 0.5 0.0 4.2 25.0 malaria (55.0, 78.6) (40.0, 68.0) (25.5, 67.0) (15.4, 35.0) (0.1, 3.4) - (2.5, 7.0) (19.1, 31.9) * Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. There were no antimalarial stocking outlets with partially completed interviews. The denominator includes only completed interviews. ** The denominator includes 14 CHWs and 3 private-not-for-profit outlets  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A3: Antimalarial market composition Public Private Not- ALL Private Community General ALL Outlet type, among outlets with at least 1 Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Retailer Private antimalarial in stock on the day of the Facility Facility For-Profit Facility survey:* % % % % % % % % % 28.1 9.3 2.0 39.4 3.9 2.7 26.1 27.9 60.6 N=472 outlets (21.1, 36.4) (4.1, 19.7) (0.3, 10.7) (30.2, 49.5) (2.1, 7.0) (1.0, 6.7) (18.1, 36.0) (19.6, 38.1) (50.5, 69.8) * Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A4a: Price of tablet formulation antimalarials, by outlet type Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility 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) $6.56 $6.56 $2.46 $1.97 $4.10 Any ACT [2.63-16.08] (41) [4.92-9.85] (500) [1.64-3.94] (82) [1.53-2.13] (19) [1.81-7.38] (642) $4.92 $5.74 $2.46 $1.97 $3.28 Artemether Lumefantrine (AL)  [2.63-10.50] (27) [4.92-8.21] (341) [1.64-3.94] (77) [1.53-2.13] (19) [1.75-5.47] (464) Artesunate sulfadoxine pyrimethamine $16.41 $9.85 $7.38 - $9.85 (ASSP) [0.00-26.26] (7) [8.21-10.67] (124) [7.38-7.38] (2) - [7.38-16.41] (133) $5.47 $6.56 $1.97 $1.64 $2.46 Quality Assured ACT (QAACT) [3.74-10.50] (18) [4.92-9.85] (182) [1.64-3.28] (53) [1.31-2.13] (12) [1.64-4.92] (265) $4.92 $6.56 $1.97 $1.64 $2.46 Quality Assured ACT AL [1.75-5.47] (15) [4.92-9.85] (165) [1.64-3.28] (50) [1.31-2.13] (12) [1.64-4.92] (242) $11.49 $6.56 $3.94 $1.97 $5.74 Non-quality-assured ACT (non-QA ACT) [2.63-16.41] (23) [4.92-9.85] (318) [2.46-4.92] (29) [1.64-3.28] (7) [3.28-10.17] (377) Non-quality-assured ACT AL $6.07 $5.58 $3.28 $1.97 $4.51 (non-QA ACT AL) [2.63-11.49] (12) [4.92-6.56] (176) [2.46-4.10] (27) [1.64-3.28] (7) [2.63-6.24] (222) $0.82 $0.41 $0.49 $0.49 $0.49 Sulfadoxine-Pyrimethamine [0.49-2.46] (17) [0.33-0.82] (102) [0.33-0.49] (248) [0.41-0.49] (98) [0.41-0.49] (465) $6.56 $6.89 $1.72 - $6.56 Quinine [0.00-10.34] (7) [4.82-6.89] (24) (1) - [1.72-6.89] (32) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 14 any ACT tablets, 11 artemether lumefantrine tablets, 3 artesunate sulfadoxine pyrimethamine tablets, 4 QAACT tablets, 4 QAACT AL tablets, 10 non-QAACT tablets, 7 non-quality assured ACT AL tablets, 6 sulfadoxine pyrimethamine tablets, 7 quinine tablets. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A4b: Price of pre-packaged antimalarials, by outlet type Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Median price of one Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] pre-packaged (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) therapy: $4.92 $4.92 $2.46 $1.64 $2.46 Adult QA AL [3.74-4.92] (7) [4.10-7.55] (100) [1.64-3.28] (30) [1.31-1.97] (5) [1.64-4.92] (142) $1.64 $2.79 $0.49 $0.82 $0.82 Pediatric QA AL * [0.00-2.63] (4) [2.46-4.92] (30) [0.33-0.82] (8) [0.49-0.98] (3) [0.49-1.97] (45) * Pediatric QA AL is the pre-packaged regimen appropriate for a 2 year old child. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 2 adult QA AL, 1 child QA AL

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of N=490 N=509 N=22 N=119 N=233 N=134 N=508 N=1,017 outlets*** stocking Any malaria blood 91.3 89.8 87.5 50.9 10.6 0.1 11.3 41.9 testing (86.1, 94.6) (81.4, 94.6) (66.4, 96.2) (38.7, 63.0) (3.3, 29.0) (0.0, 0.5) (6.1, 19.9) (33.3, 51.1) N=488 N=507 N=22 N=119 N=233 N=134 N=508 N=1,015 Microscopic blood 18.0 17.5 72.2 1.8 0.2 0.0 4.3 9.4 tests (13.8, 23.0) (10.1, 28.6) (42.0, 90.3) (0.5, 6.9) (0.0, 1.2) - (1.9, 9.1) (5.9, 14.8) N=490 N=509 N=22 N=119 N=233 N=134 N=508 N=1,017 Rapid diagnostic 88.7 87.9 68.1 50.9 10.6 0.1 10.2 40.5 tests (RDTs) (83.2, 92.5) (79.4, 93.2) (45.6, 84.4) (38.7, 63.0) (3.3, 29.0) (0.0, 0.5) (5.3, 18.6) (32.0, 49.7) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** The denominator contains 16 CHWs and 3 private-not-for-profit outlets *** Results in this table are derived using responses captured among outlets with blood testing information. There weren’t any antimalarial-stocking outlet with missing information about both availability of microscopy and availability of RDTs. There were 2 antimalarial-stocking outlets, which had partial information about blood testing availability.

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A6: Malaria blood testing market composition Public Private Not- ALL Private Community General ALL Outlet type, among outlets with malaria Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Retailer Private blood testing available on the day of the Facility Facility For-Profit Facility survey:* % % % % % % % % % 58.9 19.0 4.3 82.2 7.4 3.7 6.6 0.1 17.8 N=139 outlets (45.7, 70.9) (8.0, 38.8) (0.8, 20.8) (69.2, 90.5) (3.6, 14.4) (1.4, 9.3) (2.3, 17.5) (0.0, 0.4) (9.5, 30.8) * Excluding booster sample outlets. Outlets with malaria blood testing available on the day of the survey, verified by presence of at least one RDT recorded in the RDT audit sheet and/or reported availability of malaria microscopy.

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A7: Price of malaria blood testing, by outlet type Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Total median price to Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Microscopic blood

tests $4.10 $0.00 $1.64 - $4.10 Adult [1.64-6.56] (11) [0.00-2.46] (3) (1) - [1.64-6.56] (15) Child under age $3.28 $0.00 $1.64 - $3.28 five [1.64-6.56] (11) [0.00-2.46] (3) (1) - [1.64-6.56] (15) Rapid diagnostic

tests (RDTs) $2.46 $2.46 $0.82 $0.82 $1.23 Adult [0.49-4.92] (16) [1.64-4.10] (54) [0.82-1.15] (18) (1) [0.82-3.28] (89) $1.64 $2.46 $0.82 $0.82 $1.23 Child under five [0.49-4.92] (15) [1.64-4.10] (54) [0.66-1.15] (18) (1) [0.82-3.28] (88) Median price excluding fees:** Rapid diagnostic

tests (RDTs) - $2.46 $2.46 - $2.46 Adult - [1.64-4.10] (40) [2.46-2.46] (3) - [1.64-4.10] (43) - $2.46 $2.46 - $2.46 Child under five - [1.64-4.10] (39) [2.46-2.46] (3) - [1.64-4.10] (42) * Total price to the consumer including consultation and/or service fees. ** Price to the consumer for an RDT excluding consultation and/or service fees. Microscopic blood testing price information was available for all outlets. There were no outlets with missing or “don’t know” responses. RDT price information was not available (missing or “don’t know” response) for: 29 adult RDTs and 30 child RDTs in median price to consumers and 75 adult RDTs and 76 child RDTs in median price excluding fees. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A8: Antimalarial market share Public TOTAL Private AETDs sold or distributed in the previous TOTAL ANTI-MALARIAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private TOTAL*** as a percentage of all AETDs sold / Facility Profit** Facility distributed:* % % % % % % % % 1. Any ACT 46.3 53.5 0.7 1.4 1.4 0.5 4.0 57.6 Artemether Lumefantrine (AL)  46.3 53.5 0.6 1.1 1.4 0.5 3.6 57.2 Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 DHA PPQ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quality Assured ACT (QAACT) 23.3 27.9 0.3 0.5 1.2 0.5 2.5 30.4 QA AL 23.3 27.9 0.3 0.5 1.2 0.5 2.5 30.4 Non-quality-assured ACT 23.0 25.6 0.5 0.9 0.2 0.0 1.6 27.2 Nationally Registered ACT 23.3 29.0 0.5 1.3 1.4 0.4 3.6 32.6 2. Any non-artemisinin therapy 27.1 27.2 0.6 1.1 8.6 4.9 15.2 42.3 Sulfadoxine-Pyrimethamine 24.9 24.9 0.6 1.0 8.3 4.9 14.7 39.6 Oral Quinine 2.0 2.0 0.0 0.0 0.0 0.0 0.0 2.1 Quinine IV/IM 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Injectable artesunate 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Injectable artemether 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.3 OUTLET TYPE TOTAL**** 73.4 80.7 1.4 2.5 10.1 5.4 19.3 100.0 * A total of 9,312 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets *** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 1,354 antimalarials were audited. Of these, 245 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A9: Antimalarial market share across outlet type Public TOTAL Private AETDs sold or distributed in the previous week by TOTAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer antimalarial type as a percentage of all AETDs sold / Private Facility Profit** Facility distributed within each outlet type:* % % % % % % % 1. Any ACT 63.1 66.3 53.9 56.5 14.4 8.9 21.0  Artemether Lumefantrine (AL) 63.1 66.3 46.3 44.5 14.4 8.9 18.9

Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 5.5 11.4 0.0 0.0 1.8

DHA PPQ 0.0 0.0 0.5 0.0 0.0 0.0 0.0 Quality Assured ACT (QAACT) 31.7 34.6 19.5 21.5 12.3 8.5 12.9 QA AL 31.7 34.6 18.7 21.0 12.3 8.5 12.8 Non-quality-assured ACT 31.3 31.7 34.4 34.9 2.1 0.3 8.1 Nationally Registered ACT 31.7 35.9 39.9 51.4 13.9 7.9 18.8 2. Any non-artemisinin therapy 36.9 33.6 45.6 43.4 85.5 91.1 78.9 Sulfadoxine-Pyrimethamine 34.0 30.9 40.7 40.3 82.4 90.2 76.3 Oral Quinine 2.7 2.5 1.5 0.1 0.0 0.0 0.1 Quinine IV/IM 0.2 0.2 0.5 0.0 0.0 0.0 0.0 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.1 0.5 0.1 0.1 0.0 0.1 Injectable artesunate 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Injectable artemether 0.1 0.1 0.5 0.1 0.1 0.0 0.1 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.3 0.3 1.0 0.1 0.1 0.0 0.1 * AETDs reportedly sold or distributed in the previous seven days: 29,936 public health facility; 79 CHW; 500 private not-for-profit HF; 367 private for-profit HF; 5,483 pharmacy; 2,042 drug store; 383 general retailer. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets  At the time of the 2014 Zambia ACTwatch outlet survey, artesunate amodiaquine was Zambia's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% within each column. A total of 1,354 antimalarials were audited. Of these, 245 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 98 public health facility; 11 private not-for-profit HF; 4 private for profit; 64 pharmacy; 50 drug store; 18 general retailer. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A10: Malaria blood testing market share Public TOTAL Private Number of malaria blood tests provided in TOTAL BLOOD TEST Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer the previous week by outlet type and Private TOTAL*** blood test type as a percentage of all Facility Profit** Facility blood tests provided:* % % % % % % % % 1. Malaria microscopy 6.5 6.6 3.2 0.0 0.0 0.0 3.2 9.8 2. RDT 79.8 84.6 1.1 0.7 3.9 0.0 5.7 90.2 OUTLET TYPE TOTAL**** 86.3 91.2 4.3 0.7 3.9 0.0 8.8 100.0 * A total of 1,322 malaria microscopy tests and 5,229 RDTs were reportedly administered in the previous seven days. ** The denominator includes CHWs and private-not-for-profit outlets *** Row sum – market share for the specified type of blood testing medicine. **** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 184 malaria blood tests were audited. Of these, 8 malaria microscopy tests and 16 RDTs were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A11: Malaria blood testing market share, across outlet type Public TOTAL Private Number of malaria blood tests provided in TOTAL BLOOD TEST Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer the previous week by blood test type as a Private TOTAL*** percentage of all blood tests provided Facility Profit** Facility within each outlet type:* % % % % % % % % Total blood testing market 1. Malaria microscopy 7.6 7.2 74.5 0.0 0.0 0.0 35.9 9.8 2. RDT 92.4 92.8 25.5 100.0 100.0 0.0 64.1 90.2 Malaria RDT market  STANDARD DIAGNOSTICS INC. 59.2 58.4 22.6 20.1 82.9 0.0 63.9 58.8 PREMIER MEDICAL CORPORATION LTD 9.0 8.6 46.6 8.6 0.1 0.0 10.0 8.7 ORCHID BIOMEDICAL SYSTEMS 0.0 0.1 5.9 40.8 17.1 0.0 17.7 1.2 Other 31.8 32.9 24.9 30.5 0.0 0.0 8.4 31.4 Unknown 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 * 6,551 malaria blood tests reportedly administered in the previous seven days: 5,301 public health facility; 77 CHW; 44 private not-for-profit HF; 599 private for-profit HF; 220 pharmacy; 310 drug store. ** The denominator includes CHWs and private-not-for-profit outlets *** Categories 1 through 2 sum to 100% in within each column.  The manufacturer information was captured for all RDTs audited. A total of 184 malaria blood tests were audited. Of these, 8 malaria microscopy tests and 16 RDTs were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A12: Provider case management knowledge and practices, by outlet type Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2 year old child with symptoms of severe - N=16*** - N=119 N=233 N=134 N=486 N=502 malaria to a health facility Yes, would refer to health 84.1 79.7 80.7 88.0 84.5 84.5 NA NA facility (44.9, 97.2) (70.4, 86.6) (67.6, 89.3) (75.9, 94.5) (75.1, 90.9) (74.7, 90.9) Would recommend that a client with a negative malaria N=467 N=485*** N=19 N=68 N=48 N=5 N=140 N=625 blood test take an antimalarial 20.9 15.0 17.4 36.6 20.2 20.1 21.2 16.4 Yes – sometimes (15.0, 28.4) (9.7, 22.6) (5.3, 44.1) (23.0, 52.8) (8.7, 40.3) (3.0, 67.6) (12.3, 34.1) (11.7, 22.6) 0.0 0.0 13.9 9.4 1.9 0.0 6.0 1.4 Yes – always - - (2.8, 47.4) (3.2, 24.7) (0.4, 8.9) - (1.7, 18.9) (0.4, 4.7) Circumstances cited for recommending antimalarial N=98 N=98*** N=8 N=30 N=12 N=2 N=52 N=150 treatment to a client who tested negative for malaria:* Patient has signs and 99.2 99.2 100.0 91.4 100.0 0.0 94.5 97.5 symptoms of malaria. (96.5, 99.8) (96.5, 99.8) - (79.1, 96.8) - - (82.8, 98.4) (93.6, 99.1) Provider doesn't trust the 4.7 4.7 2.2 10.6 15.2 0.0 9.5 6.3 test results. (1.9, 11.1) (1.9, 11.1) (0.3, 16.0) (4.6, 22.7) (3.7, 45.9) - (3.0, 26.3) (3.0, 12.9) When the patient asks for 0.8 0.8 0.0 20.6 0.0 82.1 7.0 2.9 antimalarial treatment. (0.1, 5.5) (0.1, 5.5) - (6.2, 50.1) - (22.4, 98.7) (2.2, 19.8) (1.1, 7.6) 12.6 12.6 11.1 16.1 24.0 17.9 18.1 14.5 Other (all other reasons) (6.3, 23.7) (6.3, 23.7) (1.7, 47.1) (4.0, 46.9) (3.5, 73.1) (1.3, 77.6) (5.3, 46.7) (7.5, 26.2) Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. ** The denominator includes CHWs and private-not-for-profit outlets *** Numbers in the All public/Not-for-profit column: N=16 consists of 16 CHWs. N=485 consists of 368 PHFs, 16 CHWs, and 2 private-not-for-profit outlets. N=98 consists of 98 PHFs Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table A13: Provider antimalarial treatment knowledge and practices, by outlet type Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit* Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers who: N=490 N=509 N=22 N=119 N=233 N=134 N=508 N=1,017 Correctly state the national 98.2 97.7 87.5 84.6 61.1 46.1 56.0 72.3 first-line treatment for uncomplicated malaria (95.3, 99.3) (93.3, 99.3) (67.4, 95.9) (73.2, 91.7) (51.6, 69.9) (37.7, 54.7) (50.1, 61.7) (66.2, 77.7) Correctly state the first-line

dosing regimen for: 97.0 96.6 77.4 78.8 48.6 30.3 42.3 63.5 An adult (94.0, 98.5) (92.5, 98.4) (50.5, 92.0) (68.5, 86.3) (37.2, 60.1) (18.7, 45.2) (34.1, 50.9) (55.0, 71.1) 93.6 87.7 46.1 67.5 41.4 27.9 35.9 56.1 A two-year old child (90.2, 95.9) (80.4, 92.5) (26.7, 66.7) (56.9, 76.6) (30.0, 53.8) (18.0, 40.5) (29.3, 43.2) (49.2, 62.8) Report an ACT as the most effective antimalarial medicine for: 90.5 92.1 93.4 89.0 58.3 39.1 51.9 67.6 Adults (84.8, 94.2) (86.3, 95.6) (78.5, 98.2) (80.8, 94.0) (46.2, 69.5) (27.3, 52.3) (43.4, 60.3) (61.3, 73.3) 89.1 91.3 90.1 89.0 58.9 46.6 55.7 69.6 Children (83.4, 93.0) (86.0, 94.7) (73.6, 96.7) (82.1, 93.5) (48.4, 68.7) (33.5, 60.1) (47.0, 64.0) (62.7, 75.7) Report an ACT as the antimalarial he/she most commonly recommends for: 97.7 97.1 86.2 91.3 60.1 35.2 50.3 68.6 Adults (95.9, 98.8) (93.5, 98.7) (66.3, 95.2) (82.6, 95.9) (49.1, 70.2) (22.2, 50.7) (42.7, 57.9) (61.7, 74.7) 96.5 96.4 86.5 91.2 66.2 40.6 55.5 71.5 Children (94.1, 98.0) (93.5, 98.0) (67.8, 95.1) (85.4, 94.9) (55.8, 75.2) (26.9, 56.1) (47.2, 63.5) (64.3, 77.7)  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. * The denominator includes 16 CHWs and 3 private-not-for-profit outlets Numbers of providers (N) in this table are the total number of providers eligible for table indicators. There were no providers with missing information on the national first-line treatment, the first-line dosing regimen for adults and children, the most effective antimalarial medicine for adults and children and on the most often recommended antimalarial for adults and children. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Results Section B: Core Indicators across Urban/Rural Location

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=157 Urban N=170 Urban N=23 Urban N=121 Urban N=226 Urban N=3,837 Urban N=4,207 Urban N=4,377 stocking: Rural N=336 Rural N=363 Rural N=3 Rural N=2 Rural N=20 Rural N=1,113 Rural N=1,138 Rural N=1,501 Any antimalarial at the time of survey visit 99.9 79.4 93.7 88.7 91.7 2.3 7.0 8.3 Urban (99.1, 100.0) (39.6, 95.8) (79.8, 98.2) (69.2, 96.5) (86.3, 95.1) (1.7, 3.1) (5.6, 8.7) (6.8, 10.1) 99.8 85.1 66.7 100.0 93.8 2.8 3.7 9.1 Rural (98.7, 100.0) (68.8, 93.7) (66.7, 66.7) - (81.3, 98.2) (1.4, 5.7) (2.3, 6.1) (6.3, 13.0) Any ACT 98.6 78.4 91.1 85.3 18.4 0.2 2.1 3.4 Urban (96.0, 99.5) (40.0, 95.2) (71.0, 97.7) (66.6, 94.4) (11.4, 28.3) (0.1, 0.7) (1.5, 2.8) (2.6, 4.6) 99.2 84.7 66.7 100.0 63.4 0.6 1.3 6.8 Rural (97.2, 99.8) (68.6, 93.4) (66.7, 66.7) - (40.1, 81.8) (0.2, 1.7) (0.6, 2.7) (4.9, 9.4) Artemether Lumefantrine

(AL)  98.6 78.4 91.1 85.0 18.1 0.2 2.0 3.4 Urban (96.0, 99.5) (40.0, 95.2) (71.0, 97.7) (66.5, 94.2) (11.1, 28.1) (0.1, 0.7) (1.5, 2.8) (2.5, 4.6) 99.2 84.7 66.7 100.0 55.1 0.6 1.2 6.7 Rural (97.2, 99.8) (68.6, 93.4) (66.7, 66.7) - (29.8, 78.0) (0.2, 1.7) (0.5, 2.7) (4.9, 9.3) Artesunate Sulfadoxine

Pyrimethamine (ASSP) 0.5 0.4 44.3 53.6 1.4 0.0 0.6 0.6 Urban (0.1, 2.0) (0.1, 1.5) (15.4, 77.6) (33.3, 72.8) (0.3, 6.2) - (0.3, 1.4) (0.3, 1.3) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Artesunate Amodiaquine

(ASAQ) 0.0 0.0 26.9 11.2 0.2 0.0 0.3 0.2 Urban - - (11.8, 50.5) (5.7, 20.9) (0.0, 1.4) - (0.1, 0.6) (0.1, 0.6) 0.0 0.0 0.0 0.0 8.3 0.0 0.1 0.1 Rural - - - - (0.9, 48.7) - (0.0, 0.6) (0.0, 0.6)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=157 Urban N=170 Urban N=23 Urban N=121 Urban N=226 Urban N=3,837 Urban N=4,207 Urban N=4,377 stocking: Rural N=336 Rural N=363 Rural N=3 Rural N=2 Rural N=20 Rural N=1,113 Rural N=1,138 Rural N=1,501 DHA PPQ 0.0 0.0 4.4 7.1 0.0 0.0 0.1 0.1 Urban - - (0.7, 22.6) (2.9, 16.5) - - (0.0, 0.2) (0.0, 0.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Quality Assured ACT

(QAACT) 94.8 74.3 45.0 62.8 9.4 0.1 1.1 2.4 Urban (87.8, 97.9) (40.2, 92.6) (26.2, 65.4) (48.5, 75.2) (5.0, 16.8) (0.0, 0.4) (0.7, 1.7) (1.6, 3.6) 88.3 75.7 33.3 50.0 56.6 0.6 1.1 6.1 Rural (81.3, 92.9) (60.8, 86.2) (33.3, 33.3) (50.0, 50.0) (31.8, 78.6) (0.2, 1.4) (0.5, 2.4) (4.4, 8.4) QA AL 94.8 74.3 32.1 58.5 9.4 0.1 1.0 2.3 Urban (87.8, 97.9) (40.2, 92.6) (12.5, 61.1) (46.3, 69.7) (5.0, 16.8) (0.0, 0.4) (0.6, 1.5) (1.6, 3.4) 88.3 75.7 33.3 50.0 48.4 0.6 1.1 6.0 Rural (81.3, 92.9) (60.8, 86.2) (33.3, 33.3) (50.0, 50.0) (21.9, 75.7) (0.2, 1.4) (0.5, 2.3) (4.3, 8.3) QAACT - child (<5 years) 83.7 64.7 10.3 31.7 2.7 0.1 0.4 1.6 Urban (73.8, 90.4) (37.9, 84.6) (2.9, 30.8) (24.7, 39.6) (1.1, 6.5) (0.0, 0.4) (0.2, 0.7) (1.0, 2.5) 71.5 56.5 33.3 0.0 25.7 0.3 0.6 4.3 Rural (60.8, 80.2) (41.2, 70.6) (33.3, 33.3) - (12.0, 46.7) (0.1, 1.1) (0.2, 1.3) (3.0, 6.0) QAACT - adults 54.7 42.3 32.2 51.2 6.2 0.0 0.8 1.5 Urban (38.6, 69.8) (22.7, 64.6) (17.1, 52.1) (30.9, 71.1) (3.1, 11.9) (0.0, 0.1) (0.5, 1.3) (0.9, 2.5) 48.7 35.7 0.0 50.0 48.4 0.3 0.7 3.0 Rural (35.4, 62.1) (23.4, 50.2) - (50.0, 50.0) (21.9, 75.7) (0.1, 0.7) (0.3, 1.7) (2.2, 4.3) Non-quality-assured ACT

(non-QA ACT) 88.2 70.4 82.1 82.7 11.4 0.2 1.6 2.9 Urban (77.4, 94.3) (39.5, 89.7) (49.9, 95.5) (66.2, 92.1) (6.6, 18.9) (0.1, 0.4) (1.2, 2.3) (2.1, 4.0) 88.1 71.7 33.3 100.0 9.8 0.1 0.2 4.9 Rural (82.2, 92.3) (59.0, 81.7) (33.3, 33.3) - (2.3, 33.6) (0.0, 0.5) (0.1, 0.7) (3.2, 7.5)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=157 Urban N=170 Urban N=23 Urban N=121 Urban N=226 Urban N=3,837 Urban N=4,207 Urban N=4,377 stocking: Rural N=336 Rural N=363 Rural N=3 Rural N=2 Rural N=20 Rural N=1,113 Rural N=1,138 Rural N=1,501 Non-quality-assured AL

(non-QA AL) 88.2 70.4 78.3 81.4 10.0 0.2 1.5 2.8 Urban (77.4, 94.3) (39.5, 89.7) (47.5, 93.5) (65.6, 91.0) (5.3, 18.0) (0.1, 0.4) (1.1, 2.2) (2.0, 3.9) 88.1 71.7 33.3 100.0 9.8 0.1 0.2 4.9 Rural (82.2, 92.3) (59.0, 81.7) (33.3, 33.3) - (2.3, 33.6) (0.0, 0.5) (0.1, 0.7) (3.2, 7.5) Nationally Registered ACT 95.5 76.1 90.5 85.3 18.0 0.2 2.0 3.3 Urban (88.5, 98.4) (40.3, 93.7) (71.0, 97.4) (66.6, 94.4) (11.1, 27.9) (0.1, 0.4) (1.4, 2.7) (2.4, 4.5) 88.9 76.1 66.7 100.0 55.1 0.5 1.1 6.1 Rural (81.8, 93.5) (61.2, 86.5) (66.7, 66.7) - (29.8, 78.0) (0.2, 1.4) (0.5, 2.5) (4.4, 8.3) Any non-artemisinin therapy 99.1 78.8 84.1 78.2 88.1 2.2 6.7 8.0 Urban (96.9, 99.7) (39.8, 95.4) (60.4, 94.9) (65.2, 87.4) (80.3, 93.0) (1.6, 3.0) (5.3, 8.3) (6.5, 9.7) 97.1 60.6 33.3 100.0 87.7 2.3 3.1 6.9 Rural (90.6, 99.2) (42.7, 76.1) (33.3, 33.3) - (65.1, 96.4) (1.0, 5.3) (1.8, 5.4) (4.8, 9.9) Sulfadoxine-Pyrimethamine 96.1 76.4 62.5 67.1 86.8 2.2 6.4 7.7 Urban (91.7, 98.2) (40.3, 94.0) (32.0, 85.5) (56.8, 76.0) (78.3, 92.3) (1.6, 3.0) (5.0, 8.1) (6.2, 9.5) 84.1 53.1 33.3 100.0 78.9 2.2 3.0 6.3 Rural (76.8, 89.5) (36.7, 68.9) (33.3, 33.3) - (56.6, 91.5) (0.9, 5.2) (1.6, 5.3) (4.3, 9.1) Oral Quinine 95.1 75.7 52.0 31.2 0.0 0.0 0.5 1.9 Urban (91.6, 97.2) (41.1, 93.3) (30.6, 72.7) (23.3, 40.2) - - (0.3, 1.0) (1.2, 3.0) 88.9 55.8 0.0 50.0 16.4 0.0 0.2 3.8 Rural (81.4, 93.6) (40.1, 70.5) - (50.0, 50.0) (3.2, 54.0) - (0.0, 0.7) (2.5, 5.9) Quinine IV/IM 51.2 40.6 21.3 3.9 0.0 0.0 0.2 0.9 Urban (38.0, 64.2) (24.8, 58.6) (6.4, 51.6) (1.3, 10.9) - - (0.1, 0.4) (0.6, 1.5) 63.4 41.1 0.0 0.0 0.0 0.0 0.0 2.7 Rural (46.9, 77.2) (27.3, 56.4) - - - - - (1.8, 4.1)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=157 Urban N=170 Urban N=23 Urban N=121 Urban N=226 Urban N=3,837 Urban N=4,207 Urban N=4,377 stocking: Rural N=336 Rural N=363 Rural N=3 Rural N=2 Rural N=20 Rural N=1,113 Rural N=1,138 Rural N=1,501 Other non-artemisinin

therapy 0.0 0.0 12.9 32.6 6.7 0.1 0.6 0.6 Urban - - (2.7, 44.2) (21.3, 46.3) (3.4, 12.6) (0.0, 0.2) (0.4, 0.9) (0.4, 0.9) 0.1 0.1 33.3 50.0 8.8 0.1 0.2 0.2 Rural (0.0, 1.1) (0.0, 0.6) (33.3, 33.3) (50.0, 50.0) (0.9, 50.3) (0.0, 0.5) (0.1, 0.6) (0.1, 0.6) Oral artemisinin

monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Non-oral artemisinin

monotherapy 24.3 19.8 38.3 20.8 0.6 0.0 0.4 0.7 Urban (15.7, 35.6) (11.5, 32.0) (19.8, 61.1) (12.1, 33.5) (0.1, 4.0) - (0.2, 0.7) (0.5, 1.2) 22.1 12.8 0.0 0.0 0.0 0.0 0.0 0.8 Rural (13.1, 34.8) (7.0, 22.2) - - - - - (0.4, 1.6) Injectable artemether 24.0 18.6 38.3 19.9 0.6 0.0 0.4 0.7 Urban (15.5, 35.3) (10.7, 30.3) (19.8, 61.1) (11.9, 31.5) (0.1, 4.0) - (0.2, 0.7) (0.4, 1.2) 22.1 12.8 0.0 0.0 0.0 0.0 0.0 0.8 Rural (13.1, 34.8) (7.0, 22.2) - - - - - (0.4, 1.6) Injectable artesunate 1.4 2.1 3.7 2.5 0.0 0.0 0.0 0.1 Urban (0.6, 3.7) (0.7, 6.2) (0.5, 24.0) (0.9, 6.6) - - (0.0, 0.1) (0.0, 0.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Injectable artemotil 0.0 0.0 0.0 6.0 0.0 0.0 0.0 0.0 Urban - - - (2.8, 12.1) - - (0.0, 0.1) (0.0, 0.1) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=157 Urban N=170 Urban N=23 Urban N=121 Urban N=226 Urban N=3,837 Urban N=4,207 Urban N=4,377 stocking: Rural N=336 Rural N=363 Rural N=3 Rural N=2 Rural N=20 Rural N=1,113 Rural N=1,138 Rural N=1,501 Any treatment for severe

malaria 61.3 48.4 46.7 21.4 0.6 0.0 0.5 1.3 Urban (49.2, 72.1) (29.8, 67.4) (25.7, 68.9) (12.6, 34.1) (0.1, 4.0) - (0.3, 0.8) (0.9, 2.0) 70.0 44.9 0.0 0.0 0.0 0.0 0.0 3.0 Rural (52.1, 83.4) (30.1, 60.7) - - - - - (2.0, 4.5) * The denominator includes 12 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). ** The denominator includes 35 CHWs and 5 private-not-for-profit outlets. Urban: 9 CHWs and 4 private-not-for-profit outlets. Rural: 26 CHWs and 1 private-not-for-profit outlets.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Source: ACTwatch Outlet Survey, Zambia, 2014.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=156 Urban N=158 Urban N=20 Urban N=116 Urban N=204 Urban N=82 Urban N=422 Urban N=580 stocking: Rural N=335 Rural N=350 Rural N=2 Rural N=2 Rural N=18 Rural N=28 Rural N=50 Rural N=400 Any ACT 98.7 98.8 97.2 96.2 20.0 10.8 29.3 41.4 Urban (96.0, 99.6) (96.2, 99.6) (82.8, 99.6) (86.5, 99.0) (12.0, 31.6) (3.8, 27.1) (21.9, 38.0) (32.0, 51.4) 99.4 99.6 100.0 100.0 67.6 22.7 34.8 74.8 Rural (97.1, 99.9) (97.9, 99.9) - - (40.4, 86.5) (7.0, 53.2) (13.5, 64.5) (59.6, 85.7) Artemether Lumefantrine

(AL)  98.7 98.8 97.2 95.9 19.8 10.8 29.1 41.2 Urban (96.0, 99.6) (96.2, 99.6) (82.8, 99.6) (86.6, 98.8) (11.8, 31.2) (3.8, 27.1) (21.7, 37.9) (31.8, 51.4) 99.4 99.6 100.0 100.0 58.7 22.7 32.6 74.0 Rural (97.1, 99.9) (97.9, 99.9) - - (29.2, 83.1) (7.0, 53.2) (12.1, 63.0) (59.1, 84.9) Artesunate Sulfadoxine

Pyrimethamine (ASSP) 0.5 0.5 47.3 60.5 1.5 0.0 9.2 7.7 Urban (0.1, 2.0) (0.1, 1.9) (17.1, 79.6) (43.4, 75.3) (0.3, 6.8) - (4.3, 18.6) (3.7, 15.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Artesunate Amodiaquine

(ASAQ) 0.0 0.0 28.8 12.6 0.2 0.0 3.6 3.0 Urban - - (12.8, 52.5) (6.9, 22.1) (0.0, 1.5) - (1.5, 8.1) (1.3, 6.6) 0.0 0.0 0.0 0.0 8.8 0.0 2.1 0.8 Rural - - - - (0.9, 49.8) - (0.2, 15.9) (0.1, 6.2) DHA PPQ 0.0 0.0 4.7 8.0 0.0 0.0 1.0 0.8 Urban - - (0.8, 23.9) (3.4, 17.9) - - (0.4, 2.6) (0.3, 2.1) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Quality Assured ACT

(QAACT) 94.9 93.6 48.1 70.8 10.2 3.0 15.5 29.1 Urban (87.8, 98.0) (85.1, 97.4) (26.4, 70.5) (56.1, 82.2) (5.4, 18.6) (0.5, 15.1) (10.1, 23.2) (20.4, 39.7) 88.4 88.9 50.0 50.0 60.4 20.4 30.4 66.6 Rural (81.4, 93.0) (79.5, 94.3) (50.0, 50.0) (50.0, 50.0) (31.3, 83.6) (7.0, 46.7) (12.3, 57.7) (55.0, 76.5) www.ACTwatch.info Page 55

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=156 Urban N=158 Urban N=20 Urban N=116 Urban N=204 Urban N=82 Urban N=422 Urban N=580 stocking: Rural N=335 Rural N=350 Rural N=2 Rural N=2 Rural N=18 Rural N=28 Rural N=50 Rural N=400 QA ACT AL 94.9 93.6 34.3 66.0 10.2 3.0 14.0 27.8 Urban (87.8, 98.0) (85.1, 97.4) (12.2, 66.2) (52.6, 77.2) (5.4, 18.6) (0.5, 15.1) (8.9, 21.2) (19.4, 38.1) 88.4 88.9 50.0 50.0 51.5 20.4 28.3 65.8 Rural (81.4, 93.0) (79.5, 94.3) (50.0, 50.0) (50.0, 50.0) (21.1, 80.8) (7.0, 46.7) (10.9, 56.1) (54.4, 75.6) QAACT - child (<5 years) 83.8 81.5 11.0 35.7 2.9 2.7 5.8 18.9 Urban (73.9, 90.4) (70.7, 88.9) (2.8, 34.5) (24.5, 48.8) (1.2, 7.1) (0.4, 16.1) (3.2, 10.2) (12.1, 28.4) 71.7 66.4 50.0 0.0 27.4 10.5 15.2 46.8 Rural (61.1, 80.2) (49.1, 80.1) (50.0, 50.0) - (13.2, 48.4) (2.2, 37.7) (5.6, 35.0) (34.8, 59.2) QAACT - adults 54.7 53.2 34.3 57.7 6.8 0.3 10.7 18.1 Urban (38.7, 69.9) (37.1, 68.7) (17.9, 55.6) (40.0, 73.6) (3.4, 13.2) (0.0, 2.3) (6.5, 17.1) (11.7, 27.0) 48.7 41.9 0.0 50.0 51.5 9.9 19.7 33.5 Rural (35.4, 62.3) (26.9, 58.6) - (50.0, 50.0) (21.1, 80.8) (4.0, 22.3) (7.5, 42.8) (22.3, 46.8) Non-quality-assured ACT

(non-QA ACT) 88.4 88.7 87.6 93.3 12.4 7.7 23.2 34.6 Urban (77.5, 94.4) (78.4, 94.4) (59.3, 97.2) (85.9, 97.0) (7.0, 21.0) (3.1, 18.1) (16.7, 31.3) (25.8, 44.5) 88.3 84.2 50.0 100.0 10.5 2.3 5.2 54.1 Rural (82.5, 92.3) (76.6, 89.7) (50.0, 50.0) - (2.5, 35.1) (0.3, 14.6) (1.4, 17.8) (41.1, 66.5) Non-quality-assured ACT

AL (non-QA ACT AL) 88.4 88.7 83.6 91.8 10.9 7.7 22.0 33.5 Urban (77.5, 94.4) (78.4, 94.4) (55.9, 95.4) (84.3, 95.9) (5.6, 20.0) (3.1, 18.1) (15.5, 30.1) (24.8, 43.6) 88.3 84.2 50.0 100.0 10.5 2.3 5.2 54.1 Rural (82.5, 92.3) (76.6, 89.7) (50.0, 50.0) - (2.5, 35.1) (0.3, 14.6) (1.4, 17.8) (41.1, 66.5) Nationally Registered ACT 95.7 95.8 96.6 96.2 19.6 8.0 28.2 39.9 Urban (88.6, 98.4) (89.0, 98.5) (84.0, 99.3) (86.5, 99.0) (11.7, 31.1) (3.3, 18.2) (21.0, 36.8) (30.5, 50.1) 89.1 89.4 100.0 100.0 58.7 18.3 29.4 66.5 Rural (81.9, 93.6) (79.9, 94.7) - - (29.2, 83.1) (5.8, 45.0) (10.5, 59.6) (54.6, 76.6)

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=156 Urban N=158 Urban N=20 Urban N=116 Urban N=204 Urban N=82 Urban N=422 Urban N=580 stocking: Rural N=335 Rural N=350 Rural N=2 Rural N=2 Rural N=18 Rural N=28 Rural N=50 Rural N=400 Any non-artemisinin

therapy 99.2 99.2 89.8 88.2 96.1 95.6 94.8 95.6 Urban (97.2, 99.8) (97.3, 99.8) (71.3, 96.9) (75.9, 94.7) (89.2, 98.6) (84.1, 98.9) (89.5, 97.5) (91.2, 97.8) 97.3 71.3 50.0 100.0 93.4 81.7 84.0 76.1 Rural (91.3, 99.2) (49.8, 86.1) (50.0, 50.0) - (78.8, 98.2) (55.0, 94.2) (65.2, 93.7) (63.1, 85.6) Sulfadoxine Pyrimethamine 96.2 96.3 66.7 75.7 94.7 94.9 90.9 91.9 Urban (91.9, 98.2) (92.1, 98.3) (33.5, 88.8) (63.8, 84.6) (87.4, 97.8) (84.7, 98.4) (84.8, 94.8) (86.9, 95.1) 84.3 62.4 50.0 100.0 84.1 79.3 80.0 69.1 Rural (77.0, 89.6) (43.1, 78.4) (50.0, 50.0) - (58.4, 95.2) (52.6, 92.9) (61.3, 91.0) (56.9, 79.1) Oral Quinine 95.2 95.3 55.5 35.1 0.0 0.0 7.4 22.6 Urban (91.7, 97.3) (91.8, 97.4) (33.7, 75.4) (23.3, 49.1) - - (3.9, 13.5) (14.9, 32.8) 89.0 65.6 0.0 50.0 17.5 0.0 4.3 42.2 Rural (81.6, 93.7) (47.1, 80.3) - (50.0, 50.0) (3.6, 54.8) - (0.9, 17.3) (28.5, 57.2) Quinine IV/IM 51.2 51.1 22.7 4.4 0.0 0.0 2.3 10.8 Urban (38.1, 64.2) (38.2, 63.9) (6.7, 54.5) (1.5, 11.9) - - (1.0, 5.3) (7.1, 16.1) 63.5 48.3 0.0 0.0 0.0 0.0 0.0 29.8 Rural (47.1, 77.3) (32.3, 64.6) - - - - - (20.0, 42.0) Other non-artemisinin

therapy 0.0 0.0 13.8 36.7 7.3 2.9 8.5 7.0 Urban - - (2.8, 46.7) (27.1, 47.6) (3.6, 14.0) (0.9, 8.5) (5.9, 12.1) (4.9, 10.1) 0.1 0.1 50.0 50.0 9.4 2.4 4.9 1.9 Rural (0.0, 1.1) (0.0, 0.8) (50.0, 50.0) (50.0, 50.0) (1.0, 51.5) (0.3, 18.5) (1.3, 17.0) (0.6, 6.4) Oral artemisinin

monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* Urban N=156 Urban N=158 Urban N=20 Urban N=116 Urban N=204 Urban N=82 Urban N=422 Urban N=580 stocking: Rural N=335 Rural N=350 Rural N=2 Rural N=2 Rural N=18 Rural N=28 Rural N=50 Rural N=400 Non-oral artemisinin

monotherapy 24.3 25.0 40.9 23.5 0.7 0.0 5.6 9.0 Urban (15.8, 35.6) (16.2, 36.3) (21.6, 63.4) (14.9, 35.0) (0.1, 4.3) - (3.2, 9.7) (6.0, 13.2) 22.1 15.1 0.0 0.0 0.0 0.0 0.0 9.3 Rural (13.1, 34.8) (8.4, 25.5) - - - - - (5.3, 15.8) Injectable Artemether 24.1 23.4 40.9 22.5 0.7 0.0 5.6 8.7 Urban (15.5, 35.4) (15.1, 34.4) (21.6, 63.4) (14.7, 32.8) (0.1, 4.3) - (3.2, 9.6) (5.8, 12.7) 22.1 15.1 0.0 0.0 0.0 0.0 0.0 9.3 Rural (13.1, 34.8) (8.4, 25.5) - - - - - (5.3, 15.8) Injectable Artesunate 1.4 2.7 4.0 2.8 0.0 0.0 0.6 0.9 Urban (0.6, 3.7) (0.9, 7.5) (0.5, 25.4) (1.1, 7.1) - - (0.1, 2.1) (0.4, 2.3) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Injectable Artemotil 0.0 0.0 0.0 6.7 0.0 0.0 0.5 0.4 Urban - - - (3.4, 12.8) - - (0.2, 1.2) (0.1, 1.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Any treatment for severe

malaria 61.3 60.9 49.8 24.2 0.7 0.0 6.5 15.9 Urban (49.3, 72.2) (48.9, 71.8) (28.2, 71.5) (15.5, 35.6) (0.1, 4.3) - (4.0, 10.4) (11.0, 22.4) 70.2 52.8 0.0 0.0 0.0 0.0 0.0 32.6 Rural (52.3, 83.5) (35.5, 69.4) - - - - - (21.9, 45.6) * Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes urban and rural outlets that met screening criteria and completed full interviews. No outlets in the denominator had partial interviews. ** The denominator includes 14 CHWs and 3 private-not-for-profit outlets. Urban: 2 private-not-for-profit outlets. Rural: 14 CHWs and 1 private-not-for-profit outlets.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B3: Antimalarial market composition, across urban/rural location Public Private Not- ALL Private Community General ALL Outlet type, among outlets with at least 1 Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Health Worker Retailer Private antimalarial in stock on the day of the Facility Facility For-Profit Facility survey:* % % % % % % % % % 15.6 - 0.5 16.0 7.6 5.7 44.9 25.8 84.0 Rural, N=98 (8.4, 27.1) - (0.2, 1.5) (8.9, 27.3) (4.1, 13.5) (1.6, 18.6) (32.2, 58.3) (16.8, 37.4) (72.7, 91.1) 39.2 17.5 3.3 59.9 0.6 - 9.6 29.8 40.1 Rural, N=98 (25.7, 54.5) (8.1, 33.9) (0.4, 21.5) (42.9, 74.8) (0.1, 4.5) - (3.4, 24.0) (16.6, 47.6) (25.2, 57.1) * Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B4a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility 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) Any ACT $8.21 $6.56 $3.28 $1.97 $5.74 Urban [3.74-16.08] (39) [4.92-9.85] (498) [2.46-4.92] (60) [1.64-4.92] (7) [3.28-9.85] (604) $1.70 $3.61 $1.75 $1.64 $1.75 Rural [1.64-1.75] (2) [3.28-3.94] (2) [1.64-2.46] (22) [1.31-2.13] (12) [1.64-2.46] (38)

Artemether Lumefantrine (AL)  $5.47 $5.74 $3.28 $1.97 $4.92 Urban [2.63-11.49] (25) [4.92-8.21] (339) [2.46-4.10] (56) [1.64-4.92] (7) [3.28-6.56] (427) $1.70 $3.61 $1.75 $1.64 $1.75 Rural [1.64-1.75] (2) [3.28-3.94] (2) [1.64-2.46] (21) [1.31-2.13] (12) [1.64-2.46] (37) Artesunate Sulfadoxine Pyrimethamine

(ASSP) $16.41 $9.85 $7.38 - $9.85 Urban [0.00-26.26] (7) [8.21-10.67] (124) [7.38-7.38] (2) - [7.38-16.41] (133) - - - - - Rural - - - - - Quality Assured ACT (QAACT) $6.56 $6.56 $3.28 $1.64 $4.92 Urban [4.92-10.50] (16) [4.92-9.85] (181) [2.46-4.92] (33) [1.64-1.64] (2) [3.28-8.21] (232) $1.70 $3.28 $1.64 $1.64 $1.64 Rural [1.64-1.75] (2) (1) [1.64-2.19] (20) [1.31-2.13] (10) [1.53-2.13] (33) QAACT AL $4.92 $6.56 $3.28 $1.64 $4.92 Urban [4.92-5.47] (13) [4.92-9.85] (164) [2.46-4.92] (31) [1.64-1.64] (2) [3.28-6.56] (210) $1.70 $3.28 $1.75 $1.64 $1.64 Rural [1.64-1.75] (2) (1) [1.64-2.19] (19) [1.31-2.13] (10) [1.53-2.13] (32)

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Table B4a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility 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) Non-quality assured ACT (non-QA ACT) $11.49 $6.56 $3.94 $1.97 $6.07 Urban [2.63-16.41] (23) [4.92-9.85] (317) [2.46-4.92] (27) [1.97-4.92] (5) [3.45-11.41] (372) - $3.94 $3.94 $2.46 $3.28 Rural - (1) [2.63-3.94] (2) [1.64-3.28] (2) [1.64-3.94] (5) Non-quality assured ACT AL (non-QA ACT

AL) $6.07 $5.58 $3.28 $1.97 $4.92 Urban [2.63-11.49] (12) [4.92-6.56] (175) [2.46-4.10] (25) [1.97-4.92] (5) [2.74-6.56] (217) - $3.94 $3.94 $2.46 $3.28 Rural - (1) [2.63-3.94] (2) [1.64-3.28] (2) [1.64-3.94] (5) Sulfadoxine-Pyrimethamine $0.82 $0.49 $0.49 $0.49 $0.49 Urban [0.49-2.46] (16) [0.33-0.82] (98) [0.41-0.49] (231) [0.41-0.49] (77) [0.41-0.49] (422) $0.66 $0.33 $0.49 $0.49 $0.49 Rural (1) [0.33-0.33] (4) [0.33-0.66] (17) [0.41-0.49] (21) [0.33-0.49] (43) Quinine $6.56 $6.89 - - $6.56 Urban [0.00-10.34] (7) [5.17-6.89] (23) - - [4.60-8.21] (30) - $3.45 $1.72 - $1.72 Rural - (1) (1) - [1.72-1.72] (2) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 14 any ACT tablets, 11 artemether lumefantrine tablets, 3 artesunate sulfadoxine pyrimethamine tablets, 4 QAACT tablets, 4 QAACT AL tablets, 10 non-QAACT tablets, 7 non-quality assured ACT AL tablets, 6 sulfadoxine pyrimethamine tablets, 7 quinine tablets. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B4b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Median price of one pre- Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] packaged therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Adult QA AL $4.92 $5.25 $4.10 $4.92 $4.92 Urban [3.74-4.92] (7) [4.10-7.55] (99) [3.28-4.92] (20) (1) [3.74-5.74] (127) - $3.28 $1.64 $1.64 $1.64 Rural - (1) [1.64-2.46] (10) [1.31-1.64] (4) [1.31-1.97] (15) Child QA AL* $1.64 $2.79 $0.82 - $2.46 Urban [0.00-2.63] (4) [2.46-4.92] (30) [0.82-0.82] (4) - [1.64-3.28] (38) - - $0.49 $0.82 $0.49 Rural - - [0.33-0.66] (4) [0.49-0.98] (3) [0.49-0.82] (7) *QA AL is the pre-packaged regimen appropriate for a child under age five. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 2 adult QA AL, 1 child QA AL

Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets*** Urban N=155 Urban N=157 Urban N=20 Urban N=117 Urban N=214 Urban N=99 Urban N=450 Urban N=607 stocking Rural N=335 Rural N=350 Rural N=2 Rural N=2 Rural N=19 Rural N=35 Rural N=58 Rural N=410 Any malaria blood testing 94.9 95.0 86.3 51.5 3.1 0.2 12.0 25.2 Urban (88.7, 97.8) (89.1, 97.8) (62.9, 95.9) (39.0, 63.9) (1.4, 7.1) (0.0, 1.2) (7.4, 18.8) (17.4, 35.1) 90.0 88.6 100.0 0.0 41.6 0.0 10.1 56.1 Rural (83.1, 94.3) (77.7, 94.5) - - (14.0, 75.7) - (1.9, 39.6) (41.8, 69.5)

Microscopic blood tests 47.8 49.3 79.1 1.8 0.3 0.0 6.7 13.5 Urban (31.9, 64.2) (33.4, 65.3) (49.3, 93.6) (0.5, 7.1) (0.0, 1.5) - (3.1, 13.9) (8.9, 20.0) 7.9 10.2 0.0 0.0 0.0 0.0 0.0 6.0 Rural (4.9, 12.4) (3.3, 27.2) - - - - - (1.9, 17.4)

Rapid diagnostic tests (RDTs) 87.4 87.8 65.0 51.5 3.1 0.2 10.2 22.6 Urban (75.8, 93.9) (76.5, 94.1) (42.0, 82.7) (39.0, 63.9) (1.4, 7.1) (0.0, 1.2) (6.5, 15.6) (15.4, 32.0)

Rural 89.1 87.9 100.0 0.0 41.6 0.0 10.1 55.8 (82.1, 93.6) (77.0, 94.1) - - (14.0, 75.7) - (1.9, 39.6) (41.5, 69.2) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** The denominator includes 14 CHWs and 3 private-not-for-profit outlets. Urban: 2 private-not-for-profit outlets. Rural: 14 CHWs and 1 private-not-for-profit outlets. *** Results in this table are derived using responses captured among outlets with blood testing information. There were no antimalarial-stocking outlet with missing information about both availability of microscopy and availability of RDTs. 2 antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.”” Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B7: Price of malaria blood testing, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Total median price to Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Microscopic blood tests Adult

$4.10 $0.00 $1.64 - $4.10 Urban [1.64-6.56] (11) [0.00-2.46] (3) (1) - [1.64-6.56] (15) - - - - - Rural - - - - - Child under age five

$3.28 $0.00 $1.64 - $3.28 Urban [1.64-6.56] (11) [0.00-2.46] (3) (1) - [1.64-6.56] (15) - - - - - Rural - - - - - Rapid diagnostic tests (RDTs) Adult

$3.28 $2.46 $1.64 $0.82 $2.46 Urban [1.64-4.92] (14) [1.64-4.10] (54) [0.82-1.64] (7) (1) [1.64-4.92] (76) $0.74 - $0.82 - $0.82 Rural [0.49-0.98] (2) - [0.82-0.82] (11) - [0.66-0.82] (13) Child under five

$3.28 $2.46 $1.64 $0.82 $1.64 Urban [1.64-4.92] (13) [1.64-4.10] (54) [0.82-1.64] (7) (1) [1.64-4.92] (75) $0.74 - $0.82 - $0.82 Rural [0.49-0.98] (2) - [0.66-0.82] (11) - [0.49-0.82] (13)

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Table B7: Price of malaria blood testing, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Median price excluding Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] fees:** (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Rapid diagnostic tests (RDTs) Adult

- $2.46 $2.46 - $2.46 Urban - [1.64-4.10] (40) [2.46-2.46] (3) - [1.64-4.10] (43) - - - - - Rural - - - - - Child under five

- $2.46 $2.46 - $2.46 Urban - [1.64-4.10] (39) [2.46-2.46] (3) - [1.64-4.10] (42) - - - - - Rural - - - - - * Total price to the consumer including consultation and/or service fees. ** Price to the consumer for an RDT excluding consultation and/or service fees. Microscopic blood testing price information was available for all outlets. There were no outlets with missing or “don’t know” responses. RDT price information was not available (missing or “don’t know” response) for: 29 adult RDTs and 30 child RDTs in median price to consumers and 75 adult and 76 child RDTs in median price excluding fees. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B8.1: Antimalarial market share, urban Public TOTAL Private AETDs sold or distributed in the previous TOTAL ANTI-MALARIAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private TOTAL*** as a percentage of all AETDs sold/ Facility Profit** Facility distributed:* % % % % % % % % 1. Any ACT 36.6 41.8 1.9 3.6 0.8 0.0 6.2 48.0 Artemether Lumefantrine (AL)  36.6 41.8 1.6 2.8 0.8 0.0 5.2 47.0 Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 DHA PPQ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quality Assured ACT (QAACT) 17.9 17.9 0.7 1.4 0.4 0.0 2.4 20.3 QA AL 17.9 17.9 0.7 1.3 0.4 0.0 2.4 20.3 Non-quality-assured ACT 18.7 23.9 1.2 2.2 0.4 0.0 3.8 27.7 Nationally Registered ACT 17.9 20.6 1.4 3.3 0.7 0.0 5.4 26.0 2. Any non-artemisinin therapy 24.4 24.6 1.0 2.8 19.9 3.7 27.3 51.9 Sulfadoxine-Pyrimethamine 22.3 22.3 0.9 2.6 19.6 3.5 26.5 48.8 Oral Quinine 1.8 2.0 0.1 0.0 0.0 0.0 0.1 2.1 Quinine IV/IM 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.3 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 Injectable artesunate 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Injectable artemether 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.2 0.3 0.0 0.0 0.0 0.0 0.1 0.3 OUTLET TYPE TOTAL**** 61.0 66.4 2.8 6.4 20.7 3.7 33.6 100.0 * A total of 6,809 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets *** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 1,015 antimalarials were audited. Of these, 198 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B8.2: Antimalarial market share, rural Public TOTAL Private AETDs sold or distributed in the previous TOTAL ANTI-MALARIAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private TOTAL*** as a percentage of all AETDs sold/ Facility Profit** Facility distributed:* % % % % % % % % 1. Any ACT 52.3 60.9 0.0 0.0 1.9 0.8 2.7 63.6 Artemether Lumefantrine (AL)  52.3 60.9 0.0 0.0 1.9 0.8 2.7 63.6 Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 DHA PPQ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quality Assured ACT (QAACT) 26.7 34.2 0.0 0.0 1.8 0.7 2.5 36.7 QA AL 26.7 34.2 0.0 0.0 1.8 0.7 2.5 36.7 Non-quality-assured ACT 25.7 26.7 0.0 0.0 0.1 0.0 0.1 26.9 Nationally Registered ACT 26.7 34.2 0.0 0.0 1.8 0.7 2.5 36.7 2. Any non-artemisinin therapy 28.8 28.8 0.4 0.0 1.5 5.7 7.6 36.4 Sulfadoxine-Pyrimethamine 26.6 26.6 0.4 0.0 1.2 5.7 7.3 33.8 Oral Quinine 2.1 2.1 0.0 0.0 0.0 0.0 0.0 2.1 Quinine IV/IM 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.1 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.1 Injectable artesunate 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Injectable artemether 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.1 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.2 OUTLET TYPE TOTAL**** 81.1 89.7 0.4 0.0 3.4 6.5 10.3 100.0 * A total of 2,503 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets *** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type.  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 339 antimalarials were audited. Of these, 47 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B9.1: Antimalarial market share across outlets, urban Public TOTAL Private AETDs sold or distributed in the previous TOTAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private as a percentage of all AETDs sold/ Facility Profit** Facility distributed:* % % % % % % % 1. Any ACT 60.0 62.9 65.3 56.5 3.7 0.4 18.5 Artemether Lumefantrine (AL)  60.0 62.9 55.8 44.5 3.7 0.4 15.5 Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 6.8 11.4 0.0 0.0 2.7 DHA PPQ 0.0 0.0 0.7 0.0 0.0 0.0 0.1 Quality Assured ACT (QAACT) 29.3 26.9 24.2 21.5 1.8 0.0 7.2 QA AL 29.3 26.9 23.3 21.0 1.8 0.0 7.0 Non-quality-assured ACT 30.7 36.0 41.0 34.9 1.9 0.4 11.3 Nationally Registered ACT 29.3 31.0 47.9 51.4 3.6 0.4 16.1 2. Any non-artemisinin therapy 39.9 37.1 34.1 43.4 96.2 99.6 81.3 Sulfadoxine-Pyrimethamine 36.6 33.6 30.6 40.3 94.5 95.8 79.0 Oral Quinine 3.0 3.1 1.9 0.1 0.0 0.0 0.2 Quinine IV/IM 0.3 0.4 0.6 0.0 0.0 0.0 0.1 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 0.6 0.1 0.1 0.0 0.2 Injectable artesunate 0.0 0.0 0.1 0.0 0.0 0.0 0.0 Injectable artemether 0.0 0.0 0.6 0.1 0.1 0.0 0.2 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.4 0.4 1.3 0.1 0.1 0.0 0.2 * AETDs reportedly sold or distributed in the previous seven days: 3,275 public health facility; 457 private-not-for-profit HF; 331 private for-profit HF; 687 pharmacy; 1,829 drug store; 230 general retailer. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% within each column. A total of 1,015 antimalarials were audited. Of these, 198 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 70 public health facility; 4 private for profit; 64 pharmacy; 42 drug store; 15 general retailer. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B9.2: Antimalarial market share across outlets, rural Public TOTAL Private AETDs sold or distributed in the previous TOTAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private as a percentage of all AETDs sold/ Facility Profit** Facility distributed:* % % % % % % % 1. Any ACT 64.5 67.9 6.8 0.0 55.7 11.9 26.1 Artemether Lumefantrine (AL)  64.5 67.9 6.8 0.0 55.7 11.9 26.1 Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 DHA PPQ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quality Assured ACT (QAACT) 32.9 38.1 0.0 0.0 52.9 11.6 24.7 QA AL 32.9 38.1 0.0 0.0 52.9 11.6 24.7 Non-quality-assured ACT 31.6 29.8 6.8 0.0 2.9 0.3 1.4 Nationally Registered ACT 32.9 38.1 6.8 0.0 53.6 10.5 24.5 2. Any non-artemisinin therapy 35.4 32.1 93.2 0.0 44.3 88.1 73.9 Sulfadoxine-Pyrimethamine 32.7 29.6 82.2 0.0 35.9 88.1 70.7 Oral Quinine 2.5 2.3 0.0 0.0 0.0 0.0 0.0 Quinine IV/IM 0.2 0.2 0.0 0.0 0.0 0.0 0.0 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.1 0.0 0.0 0.0 0.0 0.0 Injectable artesunate 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Injectable artemether 0.1 0.1 0.0 0.0 0.0 0.0 0.0 Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 5. Any treatment for severe malaria 0.2 0.2 0.0 0.0 0.0 0.0 0.0 * 2,503 AETDs reportedly sold or distributed in the previous seven days: 1,979 public health facility; 79 CHW; 42 private-not-for-profit HF; 37 private for-profit HF; 0 pharmacy; 213 drug store; 154 general retailer. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** The denominator includes CHWs and private-not-for-profit outlets  At the time of the 2014 Zambia ACTwatch outlet survey, artesunate amodiaquine was Zambia's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% within each column. A total of 339 antimalarials were audited. Of these, 47 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 28 public health facility; 8 drug store; 3 general retailer. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2 year old child with Urban N=0 Urban N=117 Urban N=213 Urban N=99 Urban N=429 Urban N=429 symptoms of severe malaria to a - - Rural N=16 Rural N=2 Rural N=20 Rural N=35 Rural N=57 Rural N=73 health facility Yes, would refer to health facility - 80.0 85.9 90.2 87.1 87.1 Urban NA NA - (70.5, 87.1) (74.0, 92.8) (81.6, 95.1) (80.2, 91.9) (80.1, 91.9) 84.1 50.0 59.9 86.3 80.4 81.5 Rural NA NA (44.9, 97.2) (50.0, 50.0) (34.2, 81.0) (62.7, 95.9) (56.2, 92.9) (58.5, 93.2) Would recommend that a client Urban N=133 Urban N=134 Urban N=17 Urban N=68 Urban N=34 Urban N=5 Urban N=124 Urban N=258 with a negative malaria blood test Rural N=334 Rural N=351 Rural N=2 Rural N=0 Rural N=14 Rural N=0 Rural N=16 Rural N=367 take an antimalarial Yes – sometimes 18.8 18.5 19.3 36.6 27.9 20.1 25.4 22.2 Urban (8.4, 36.7) (8.3, 36.2) (5.6, 48.8) (23.0, 52.8) (11.4, 53.9) (3.0, 67.6) (15.4, 39.0) (14.3, 32.7) 21.6 14.3 0.0 - 14.0 - 12.9 14.2 Rural (14.9, 30.2) (8.5, 23.2) - - (3.2, 44.3) - (2.9, 42.3) (8.8, 22.1) Yes – always 0.0 0.0 15.3 9.4 4.3 0.0 9.0 4.8 Urban - - (3.2, 50.1) (3.2, 24.7) (1.1, 15.5) - (2.8, 25.4) (1.4, 14.9) 78.3 85.6 100.0 - 86.0 - 87.1 85.7 Rural (69.7, 85.0) (76.7, 91.4) - - (55.7, 96.8) - (57.7, 97.1) (77.8, 91.2) Circumstances cited for recommending antimalarial Urban N=34 Urban N=34 Urban N=8 Urban N=30 Urban N=10 Urban N=2 Urban N=50 Urban N=84 treatment to a client who tested Rural N=64 Rural N=64 Rural N=0 Rural N=0 Rural N=2 Rural N=0 Rural N=2 Rural N=66 negative for malaria:* Patient has signs and symptoms

of malaria. 97.5 97.5 100.0 91.4 100.0 - 93.5 94.8 Urban (82.7, 99.7) (82.7, 99.7) - (79.1, 96.8) - - (79.6, 98.1) (85.1, 98.3) 99.6 99.6 - - 100.0 - 100.0 99.6 Rural (96.9, 99.9) (96.9, 99.9) - - - - - (97.1, 100.0)

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Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Provider doesn't trust the test

results. 8.6 8.6 2.2 10.6 23.4 - 11.3 10.5 Urban (2.6, 25.1) (2.6, 25.1) (0.3, 16.0) (4.6, 22.7) (6.9, 55.7) - (3.6, 30.5) (4.2, 23.9) 3.6 3.6 - - - - - 3.3 Rural (1.0, 12.3) (1.0, 12.3) - - - - - (0.9, 11.3) When the patient asks for

antimalarial treatment. *** - - - 20.6 - 82.1 8.3 5.7 Urban - - - (6.2, 50.1) - (22.4, 98.7) (2.6, 23.6) (1.8, 16.5) 1.0 1.0 - - - - - 0.9 Rural (0.1, 7.2) (0.1, 7.2) - - - - - (0.1, 6.7) Other (all other reasons) 25.2 25.2 11.1 16.1 - 17.9 8.6 13.9 Urban (11.3, 47.0) (11.3, 47.0) (1.7, 47.1) (4.0, 46.9) - (1.3, 77.6) (2.8, 23.3) (6.2, 28.2) 9.3 9.3 - - 68.6 - 68.6 15.0 Rural (3.5, 22.6) (3.5, 22.6) - - (10.8, 97.5) - (10.8, 97.5) (5.4, 35.2) Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. ** The denominator includes 16 CHWs and 2 private-not-for-profit outlets *** There were no observations for this circumstance in the public/not-for-profit urban strata or private rural strata. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit* Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=155 Urban N=157 Urban N=20 Urban N=117 Urban N=214 Urban N=99 Urban N=450 Urban N=607 Proportion of providers who: Rural N=335 Rural N=352 Rural N=2 Rural N=2 Rural N=19 Rural N=35 Rural N=58 Rural N=410 Correctly state the national first-line

treatment for uncomplicated malaria 98.6 98.7 91.0 84.4 55.3 36.0 53.4 60.6 Urban (96.5, 99.5) (96.6, 99.5) (69.3, 97.9) (72.7, 91.6) (46.4, 63.9) (26.5, 46.8) (47.2, 59.5) (53.7, 67.2) 98.1 97.5 50.0 100.0 85.2 53.9 60.5 82.2 Rural (93.7, 99.4) (91.5, 99.3) (50.0, 50.0) - (66.9, 94.3) (41.5, 65.8) (48.4, 71.4) (72.9, 88.8) Correctly state the first-line dosing

regimen for an adult 96.7 95.3 80.0 78.5 44.2 14.9 39.1 48.1 Urban (92.1, 98.6) (89.1, 98.0) (49.7, 94.2) (68.0, 86.3) (33.5, 55.4) (8.2, 25.5) (32.4, 46.3) (39.6, 56.7) 97.1 96.9 50.0 100.0 66.9 42.3 47.7 76.5 Rural (92.8, 98.9) (91.2, 98.9) (50.0, 50.0) - (43.3, 84.2) (22.7, 64.7) (29.5, 66.4) (63.5, 85.9) Correctly state the first-line dosing

regimen for a child 91.7 90.4 45.7 67.1 35.3 9.7 29.3 39.0 Urban (84.3, 95.7) (81.5, 95.3) (24.7, 68.4) (56.3, 76.3) (25.7, 46.2) (5.2, 17.3) (23.4, 35.9) (31.2, 47.5) 94.2 87.1 50.0 100.0 66.9 42.0 47.4 70.7 Rural (89.8, 96.8) (77.9, 92.8) (50.0, 50.0) - (43.3, 84.2) (27.0, 58.6) (34.9, 60.3) (61.8, 78.2) Report an ACT as the most effective

antimalarial medicine for an adult 89.8 90.1 92.8 89.5 52.7 32.2 51.2 57.4 Urban (77.6, 95.7) (78.1, 95.8) (76.2, 98.1) (81.1, 94.4) (42.0, 63.3) (20.9, 46.1) (44.6, 57.7) (50.5, 64.0) 90.7 92.6 100.0 50.0 81.6 44.4 53.0 76.2 Rural (83.4, 95.0) (85.3, 96.4) - (50.0, 50.0) (49.9, 95.2) (26.0, 64.4) (33.0, 72.1) (66.2, 84.0) Report an ACT as the most effective

antimalarial medicine for a child 88.2 88.5 89.1 89.5 54.3 38.8 54.0 59.5 Urban (76.3, 94.5) (77.0, 94.7) (70.9, 96.5) (82.3, 93.9) (44.9, 63.3) (24.4, 55.6) (46.4, 61.4) (51.6, 66.9) 89.4 92.0 100.0 50.0 78.1 52.5 58.6 78.2 Rural (82.2, 93.9) (85.4, 95.7) - (50.0, 50.0) (50.6, 92.6) (32.0, 72.2) (38.6, 76.1) (67.1, 86.2)

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Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit* Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Report an ACT as the antimalarial he/she

most commonly recommends for adults 96.6 95.3 84.9 91.8 56.6 21.8 49.1 56.4 Urban (92.7, 98.5) (90.3, 97.7) (62.8, 94.9) (82.8, 96.3) (47.1, 65.7) (12.7, 34.8) (43.4, 54.7) (50.0, 62.7) 98.1 97.5 100.0 50.0 74.7 45.5 52.4 78.9 Rural (95.8, 99.2) (92.3, 99.2) - (50.0, 50.0) (40.0, 92.9) (25.6, 67.0) (34.5, 69.8) (67.8, 86.9) Report an ACT as the antimalarial he/she

most commonly recommends for children 94.3 92.9 85.2 91.7 60.9 24.7 52.2 58.7 Urban (90.0, 96.8) (87.8, 96.0) (64.5, 94.8) (85.8, 95.3) (52.1, 68.9) (14.3, 39.0) (45.4, 59.0) (51.2, 65.9) 97.3 97.2 100.0 50.0 88.3 53.0 61.1 82.3 Rural (94.1, 98.8) (93.5, 98.8) - (50.0, 50.0) (59.5, 97.5) (31.6, 73.3) (41.9, 77.4) (71.2, 89.7)  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. * The denominator includes 16 CHWs and 3 private-not-for-profit outlets Numbers of providers (N) in this table are the total number of providers eligible for table indicators. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Results Section C: Core Indicators by Type of Public Health Facility

Table C1: Availability of antimalarials, among screened outlets, by type of public health facility Community Community ALL Health Centre Health Centre Hospital Public Health Level 1 Level 2 Facilities % % % %

(95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=96 N=348 N=49 N=493

99.9 99.8 100.0 99.8 Any antimalarial at the time of survey visit (99.0, 100.0) (98.6, 100.0) - (99.2, 100.0) 99.9 98.8 99.1 99.0 Any ACT (99.0, 100.0) (96.9, 99.5) (94.0, 99.9) (97.7, 99.6) 99.9 98.8 99.1 99.0 Artemether Lumefantrine (AL) (99.0, 100.0) (96.9, 99.5) (94.0, 99.9) (97.7, 99.6) 82.2 92.1 91.6 89.9 Quality Assured ACT (QAACT) (62.6, 92.7) (87.8, 95.0) (75.3, 97.5) (84.5, 93.6) 82.2 92.1 91.6 89.9 QAACT AL (62.6, 92.7) (87.8, 95.0) (75.3, 97.5) (84.5, 93.6) 90.2 87.3 90.1 88.2 Non-quality-assured ACT (non-QAACT) (82.0, 94.9) (81.6, 91.4) (77.3, 96.0) (83.3, 91.7) 93.5 98.6 100.0 97.6 Any non-artemisinin therapy (76.9, 98.4) (93.5, 99.7) - (93.1, 99.2) 87.2 85.7 98.0 87.2 Sulfadoxine-Pyrimethamine (72.0, 94.8) (79.6, 90.2) (92.5, 99.5) (81.6, 91.2) 7.2 24.2 47.0 22.6 Any artemisinin monotherapy (3.2, 15.7) (15.6, 35.5) (27.1, 67.9) (15.4, 32.0) 0.0 0.0 0.0 0.0 Oral artemsinin monotherapy - - - - 7.2 24.2 47.0 22.6 Non-oral artemisinin monotherapy (3.2, 15.7) (15.6, 35.5) (27.1, 67.9) (15.4, 32.0) 53.1 70.8 80.1 67.8 Any treatment for severe malaria (28.5, 76.4) (60.6, 79.2) (61.3, 91.1) (54.9, 78.5) * The denominator includes outlets that met screening criteria for a full interview. There were no outlets that did not complete the interview (were not interviewed or completed a partial interview). Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by type of public health facility Community Community ALL Health Centre Health Centre Hospital Public Health Level 1 Level 2 Facilities % % % %

(95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=95 N=347 N=49 N=491

100.0 99.0 99.1 99.2 Any ACT - (97.0, 99.6) (94.0, 99.9) (97.8, 99.7) 100.0 99.0 99.1 99.2 Artemether Lumefantrine (AL) - (97.0, 99.6) (94.0, 99.9) (97.8, 99.7) 82.3 92.3 91.6 90.1 Quality Assured ACT (QAACT) (62.6, 92.8) (88.1, 95.1) (75.3, 97.5) (84.6, 93.7) 82.3 92.3 91.6 90.1 QAACT AL (62.6, 92.8) (88.1, 95.1) (75.3, 97.5) (84.6, 93.7) 90.3 87.4 90.1 88.3 Non-quality-assured ACT (non-QAACT) (82.2, 94.9) (81.9, 91.5) (77.3, 96.0) (83.6, 91.8) 93.6 98.8 100.0 97.8 Any non-artemisinin therapy (76.8, 98.5) (92.9, 99.8) - (93.6, 99.2) 87.4 85.8 98.0 87.3 Sulfadoxine-Pyrimethamine (72.1, 94.9) (79.8, 90.3) (92.5, 99.5) (81.9, 91.3) 7.3 24.3 47.0 22.7 Any artemisinin monotherapy (3.2, 15.7) (15.7, 35.6) (27.1, 67.9) (15.4, 32.0) 0.0 0.0 0.0 0.0 Oral artemsinin monotherapy - - - - 7.3 24.3 47.0 22.7 Non-oral artemisinin monotherapy (3.2, 15.7) (15.7, 35.6) (27.1, 67.9) (15.4, 32.0) 53.2 70.9 80.1 67.9 Any treatment for severe malaria (28.5, 76.5) (60.8, 79.3) (61.3, 91.1) (55.0, 78.6) * The denominator includes outlets that met screening criteria for a full interview. There were no outlets that did not complete the interview (were not interviewed or completed a partial interview). Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table C5: Availability of malaria blood testing among antimalarial-stocking outlets*, by type of public health facility Community Community ALL Health Centre Health Centre Hospitals Public Health Level 1 Level 2 Facilities % % % %

(95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets** that stocked: N=95 N=347 N=49 N=491 93.5 89.7 97.5 91.3 Any malaria blood testing (81.7, 97.9) (83.4, 93.8) (90.2, 99.4) (86.1, 94.6) N=95 N=346 N=47 N=488 0.0 14.4 88.6 18.0 Microscopic blood tests - (10.5, 19.4) (72.4, 95.8) (13.8, 23.1) N=95 N=347 N=49 N=491 93.5 87.2 88.3 88.7 Rapid diagnostic tests (RDTs) (81.7, 97.9) (80.8, 91.7) (69.7, 96.1) (83.2, 92.5) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. There were no antimalarial-stocking outlet with missing information about both availability of microscopy and availability of RDTs, and no antimalarial-stocking outlets had partial information about blood testing availability. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table C12: Provider antimalarial treatment knowledge and practices, by type of public health facility Community Community ALL Health Centre Health Centre Hospitals Public Health Level 1 Level 2 Facilities % % % %

(95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers who: N=95 N=347 N=48 N=490 Correctly state the national first-line 99.1 97.8 99.7 98.2  treatment for uncomplicated malaria (96.0, 99.8) (93.5, 99.3) (97.5, 100.0) (95.3, 99.3) Correctly state the first-line dosing regimen

for: 99.1 96.3 96.8 97.0 An adult (96.0, 99.8) (92.3, 98.3) (90.3, 99.0) (94.0, 98.5) 97.1 92.9 90.9 93.6 A two-year old child (89.2, 99.3) (88.7, 95.5) (77.2, 96.7) (90.2, 95.9) Report an ACT as the most effective antimalarial medicine for 86.0 92.8 83.5 90.5 Adults (61.7, 95.9) (88.6, 95.5) (61.4, 94.1) (84.8, 94.2) 84.7 91.0 85.4 89.1 Children (62.1, 94.9) (86.0, 94.3) (61.8, 95.5) (83.4, 93.0) Report an ACT as the antimalarial he/she most commonly recommends for: 99.5 97.3 96.8 97.7 Adults (96.4, 99.9) (94.6, 98.7) (90.3, 99.0) (95.9, 98.8) 99.7 95.6 95.7 96.5 Children (97.9, 100.0) (92.3, 97.5) (89.3, 98.4) (94.1, 98.0)  At the time of the 2014 Zambia ACTwatch outlet survey, artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. There were no providers with missing information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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Results Section D: Core Indicators across Survey Round: 2009, 2011, 2014 Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=165 2009 N=181 2009 N=34 2009 N=50 2009 N=165 2009 N=2,948 2009 N=3,197 2009 N=3,378 Proportion of outlets* stocking: 2011 N=288 2011 N=297 2011 N=58 2011 N=104 2011 N=286 2011 N=4,691 2011 N=5,139 2011 N=5,346 2014 N=493 2014 N=533 2014 N=26 2014 N=123 2014 N=246 2014 N=4,950 2014 N=5,345 2014 N=5,878 Any antimalarial at the time of survey visit 97.4 97.8 92.3 100.0 76.5 2.6 6.3 9.5 2009 (92.5, 99.2) (93.3, 99.3) (76.9, 97.8) - (64.9, 85.1) (1.8, 3.9) (5.2, 7.6) (7.8, 11.5) 98.2 98.4 93.8 96.3 85.8 3.1 6.5 8.4 2011 (94.8, 99.4) (95.4, 99.4) (85.3, 97.5) (91.7, 98.4) (77.3, 91.4) (1.7, 5.6) (4.7, 9.0) (6.3, 11.2) 99.8 84.0 90.5 88.8 92.1 2.5 5.3 8.7 2014 (99.2, 100.0) (69.5, 92.3) (76.8, 96.5) (69.8, 96.5) (87.7, 95.0) (1.7, 3.9) (4.2, 6.7) (7.1, 10.7) Any ACT 85.3 80.4 62.5 77.6 6.2 0.1 1.2 4.0 2009 (76.3, 91.3) (67.8, 88.9) (41.7, 79.6) (56.6, 90.2) (1.7, 19.9) (<0.1, 0.5) (0.7, 2.1) (2.9, 5.5) 92.2 92.6 88.1 90.0 26.8 0.2 2.0 3.9 2011 (82.2, 96.8) (83.5, 96.8) (76.0, 94.5) (83.3, 94.2) (15.1, 42.9) (0.1, 0.8) (1.3, 3.3) (2.9, 5.4) 99.0 83.5 88.2 85.5 27.0 0.4 1.7 5.2 2014 (97.7, 99.6) (69.2, 91.9) (71.1, 95.8) (67.1, 94.4) (16.6, 40.7) (0.2, 1.0) (1.2, 2.3) (4.1, 6.5) Artemether Lumefantrine (AL) 85.3 80.4 61.4 76.7 6.2 0.1 1.2 4.0 2009 (76.3, 91.3) (67.8, 88.9) (40.5, 78.8) (56.9, 89.1) (1.7, 19.9) (<0.1, 0.5) (0.7, 2.1) (2.8, 5.5) 92.2 92.2 76.2 87.0 19.4 0.2 1.8 3.6 2011 (82.2, 96.8) (83.0, 96.6) (59.4, 87.5) (79.9, 91.8) (14.6, 25.5) (0.1,0.7) (1.0, 3.1) (2.6, 5.1) 99.0 83.5 88.2 85.2 25.2 0.4 1.6 5.2 2014 (97.7, 99.6) (69.2, 91.9) (71.1, 95.8) (67.1, 94.2) (15.1, 39.0) (0.2, 1.0) (1.2, 2.3) (4.1, 6.5) Quality Assured ACT (QAACT) 85.2 79.7 51.1 74.1 5.6 0.1 1.0 3.8 2009 (76.2, 91.2) (67.2, 88.2) (34.4, 67.7) (56.6, 86.2) (1.6, 17.8) (<0.1, 0.5) (0.6, 1.7) (2.7, 5.3) 92.1 92.1 52.7 63.4 14.4 0.2 1.3 3.2 2011 (82.1, 96.8) (82.9, 96.5) (33.1, 71.4) (48.0, 76.4) (10.6, 19.2) (0.1, 0.8) (0.8, 2.1) (2.3, 4.4) 89.9 75.4 43.6 62.7 18.5 0.3 1.1 4.3 2014 (84.5, 93.6) (62.3, 85.0) (27.0, 61.8) (48.7, 74.8) (9.2, 33.7) (0.1, 0.8) (0.7, 1.7) (3.4, 5.5)

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Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Non-quality-assured ACT 5.0 5.0 29.9 61.5 1.3 0.0 0.5 0.7 2009 (2.1, 11.3) (2.2, 10.7) (14.2, 52.3) (27.3, 87.2) (0.3, 6.2) - (0.3, 1.0) (0.4, 1.3) 0.6 1.6 72.1 84.3 13.0 0.0 1.3 1.3 2011 (0.2, 1.8) (0.3, 7.1) (53.4, 85.4) (70.9, 92.2) (4.6, 31.3) -- (0.8, 2.1) (0.8, 2.2) 88.2 71.4 76.3 82.9 11.1 0.1 0.9 3.9 2014 (83.3, 91.7) (60.0, 80.7) (48.1, 91.8) (66.8, 92.1) (6.7, 17.8) (0.1, 0.3) (0.6, 1.3) (3.0, 5.2) Nationally registered ACT 84.5 79.7 59.7 77.6 5.9 0.1 1.2 3.9 2009 (76.0, 90.4) (67.6, 88.1) (40.0, 76.7) (56.6, 90.2) (1.7, 18.8) (0.0, 0.5) (0.7, 2.0) (2.8, 5.4) 92.2 92.2 86.7 87.9 18.5 0.2 1.8 3.7 2011 (82.2, 96.8) (83.0, 96.6) (73.6, 93.8) (76.1, 94.3) (13.7, 24.5) (0.1, 0.8) (1.1, 3.1) (2.6, 5.2) 90.6 76.1 87.7 85.5 25.1 0.4 1.5 4.7 2014 (85.1, 94.2) (62.9, 85.6) (70.9, 95.4) (67.1, 94.4) (15.0, 38.9) (0.2, 0.8) (1.1, 2.1) (3.8, 6.0) Any non-artemisinin therapy 95.7 96.3 92.3 100.0 75.8 2.6 6.2 9.4 2009 (90.8, 98.0) (91.9, 98.3) (76.9, 97.8) - (64.5, 84.4) (1.7, 3.9) (5.1, 7.6) (7.6, 11.4) 93.2 93.9 86.9 93.7 82.7 2.9 6.1 7.9 2011 (86.1, 96.8) (87.4, 97.2) (76.8, 93.0) (88.7, 96.6) (74.9, 88.5) (1.6, 5.1) (4.4, 8.3) (6.0, 10.4) 97.6 64.3 78.1 78.5 88.0 2.2 4.9 7.4 2014 (93.1, 99.2) (48.4, 77.6) (54.4, 91.5) (65.6, 87.4) (81.1, 92.6) (1.4, 3.5) (3.8, 6.3) (6.0, 9.1) Sulfadoxine-Pyrimethamine 58.5 64.1 83.3 94.7 69.7 1.7 5.0 7.1 2009 (47.3, 68.9) (54.1, 72.9) (66.5, 92.6) (76.1, 99.0) (58.2, 79.2) (0.9, 3.0) (3.9, 6.4) (5.7, 8.8) 72.9 75.8 79.6 90.7 81.4 2.8 5.9 7.3 2011 (59.7, 83.0) (64.6, 84.3) (64.7, 89.2) (85.2, 94.2) (73.1, 87.6) (1.5, 4.9) (4.3, 8.0) (5.6, 9.6) 87.2 57.8 59.0 67.5 85.3 2.2 4.7 7.0 2014 (81.6, 91.2) (43.0, 71.4) (32.1, 81.4) (57.2, 76.3) (77.2, 90.8) (1.4, 3.5) (3.6, 6.1) (5.6, 8.6)

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Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round Public ALL Private ALL ALL Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Oral Quinine 88.3 84.4 37.9 45.3 4.8 0.0 0.7 3.7 2009 (79.0, 93.8) (73.3, 91.5) (21.9, 57.0) (22.6, 70.2) (1.2, 17.7) - (0.4, 1.2) (2.6, 5.2) 78.0 78.8 51.0 47.9 6.1 0.0 0.8 2.4 2011 (66.2, 86.5) (66.8, 87.2) (29.6, 72.1) (33.5, 62.7) (1.6, 20.5) -- (0.5, 1.4) (1.8, 3.3) 90.4 59.9 45.9 31.4 3.2 0.0 0.3 2.9 2014 (84.9, 94.1) (45.7, 72.6) (25.1, 68.2) (23.7, 40.2) (0.8, 12.1) - (0.2, 0.6) (2.2, 3.9) Oral artemisinin monotherapy 1.3 1.1 2.7 23.7 3.2 0.0 0.2 0.2 2009 (0.3, 4.6) (0.3, 4.0) (0.7, 10.8) (9.8, 47.1) (0.6, 15.7) - (0.1, 0.5) (0.1, 0.5) 0.0 0.0 0.0 5.0 1.2 0.0 0.1 0.1 2011 ------(1.9, 12.6) (0.1, 9.4) -- (<0.1, 0.2) (<0.1, 0.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2014 ------Non-oral artemisinin monotherapy 2.7 2.9 36.9 33.2 0.4 0.0 0.6 0.7 2009 (0.6, 10.4) (0.9, 9.3) (20.2, 57.4) (21.4, 47.7) (0.1, 2.1) - (0.3, 1.0) (0.4, 1.2) 0.0 0.0 63.0 42.4 0.3 0.0 0.7 0.7 2011 -- -- (42.5, 79.7) (27.5, 58.9) (0.1, 0.9) -- (0.3, 1.7) (0.3, 1.7) 22.6 14.2 33.8 20.6 0.5 0.0 0.2 0.8 2014 (15.4, 32.0) (9.1, 21.6) (16.8, 56.3) (12.0, 32.9) (0.1, 3.2) - (0.1, 0.4) (0.5, 1.2) Any treatment for severe malaria 54.6 52.3 62.3 46.3 0.4 0.0 0.9 2.7 2009 (41.1, 67.5) (39.7, 64.6) (48.4, 74.5) (33.0, 60.2) (0.1, 2.1) - (0.5, 1.7) (1.9, 4.0) 40.6 40.3 76.8 46.4 2.5 0.0 0.9 1.8 2011 (31.5, 50.5) (30.8, 50.5) (57.1, 89.1) (31.5, 61.9) (0.4, 12.6) -- (0.5, 1.8) (1.2, 2.5) 67.8 45.6 41.1 21.2 0.5 0.0 0.2 2.2 2014 (54.9, 78.5) (33.2, 58.6) (22.0, 63.4) (12.5, 33.5) (0.1, 3.2) - (0.1, 0.4) (1.6, 2.9) * The denominator includes outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). ** The denominator includes CHWs and private-not-for-profit outlets: 2009: 16 private-not-for-profit outlets. 2011: 9 private-not-for-profit outlets. 2014: 35 CHWs and 5 private-not-for-profit outlets. Source: ACTwatch Outlet Survey, Zambia, 2010, 2011, 2014.

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Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round Public ALL Private ALL ALL Health Public/Not-For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=160 2009 N=176 2009 N=32 2009 N=50 2009 N=128 2009 N=49 2009 N=259 2009 N=435 Proportion of outlets* stocking: 2011 N=282 2011 N=291 2011 N=50 2011 N=97 2011 N=241 2011 N=102 2011 N=490 2011 N=781 2014 N=491 2014 N=508 2014 N=22 2014 N=118 2014 N=222 2014 N=110 2014 N=472 2014 N=980 Any ACT 87.5 82.2 67.7 77.6 8.1 2.2 19.3 42.0 2009 (78.2, 93.2) (68.7, 90.7) (42.0, 85.9) (56.6, 90.2) (2.3, 24.8) (0.3, 16.0) (11.3, 31.0) (32.8, 51.8) 94.0 94.1 94.2 93.6 31.3 7.2 31.8 47.1 2011 (85.5, 97.6) (86.5, 97.5) (81.4, 98.4) (85.7, 97.3) (18.2, 48.3) (2.7, 17.5) (21.3, 44.5) (38.1, 56.3) 99.2 99.4 97.5 96.2 29.4 17.6 31.2 59.5 2014 (97.8, 99.7) (98.3, 99.8) (84.5, 99.6) (86.9, 99.0) (17.7, 44.6) (7.7, 35.3) (21.4, 43.1) (50.7, 67.7) Artemether Lumefantrine (AL) 87.5 82.2 66.5 76.7 8.1 2.2 19.0 41.8 2009 (78.2, 93.2) (68.7, 90.7) (40.8, 85.1) (56.9, 89.1) (2.3, 24.8) (0.3, 16.0) (11.0, 30.8) (32.7, 51.6) 94.0 93.7 85.3 92.8 22.8 7.1 27.4 43.7 2011 (85.5, 97.6) (85.9, 97.3) (62.6, 95.3) (85.6, 96.5) (16.7, 30.3) (2.7,17.5) (17.7, 39.9) (35.2, 52.5) 99.2 99.4 97.5 95.9 27.4 17.6 30.4 59.0 2014 (97.8, 99.7) (98.3, 99.8) (84.5, 99.6) (86.9, 98.8) (16.0, 42.7) (7.7, 35.3) (20.7, 42.2) (50.2, 67.2) Quality Assured ACT (QAACT) 87.4 81.5 55.4 74.1 7.3 2.2 16.3 39.9 2009 (78.1, 93.1) (68.1, 90.0) (36.4, 72.9) (56.6, 86.2) (2.1, 22.2) (0.3, 16.0) (9.8, 26.0) (31.4, 49.0) 93.9 93.6 56.3 65.9 16.8 7.2 20.1 38.1 2011 (85.5, 97.5) (85.7, 97.3) (36.6, 74.2) (49.0, 79.5) (12.0, 23.0) (2.7, 17.5) (13.5, 28.7) (30.5, 46.3) 90.1 89.8 48.2 70.6 20.1 12.9 20.8 49.4 2014 (84.6, 93.7) (82.5, 94.3) (28.3, 68.7) (56.2, 81.8) (9.8, 36.7) (5.3, 28.1) (12.8, 32.0) (41.2, 57.6) Non-Quality Assured ACT (non-QAACT) 5.1 5.1 32.3 61.5 1.7 0.0 8.4 7.2 2009 (2.2, 11.8) (2.3, 11.1) (15.5, 55.5) (27.3, 87.2) (0.4, 7.8) - (4.1, 16.2) (3.8, 13.3) 0.6 1.6 77.1 87.6 15.1 0.0 20.0 15.5 2011 (0.2, 1.8) (0.3, 7.2) (58.4, 89.0) (72.8, 94.9) (5.6, 34.8) -- (12.3, 31.0) (9.0, 25.5) 88.3 85.1 84.3 93.4 12.0 4.6 16.9 45.1 2014 (83.6, 91.8) (78.8, 89.8) (59.6, 95.1) (86.2, 97.0) (7.1, 19.6) (1.9, 10.9) (12.0, 23.1) (37.3, 53.3) www.ACTwatch.info Page 81

Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round Public ALL Private ALL ALL Health Public/Not-For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Nationally registered ACT 86.7 81.5 64.6 77.6 7.7 2.2 18.5 41.2 2009 (77.9, 92.4) (68.6, 89.9) (40.2, 83.3) (56.6, 90.2) (2.2, 23.5) (0.3, 16.0) (10.7, 30.0) (32.3, 50.8) 94.0 93.7 92.7 91.4 21.6 7.2 28.0 44.1 2011 (85.5, 97.6) (85.9, 97.3) (80.9, 97.4) (76.9, 97.1) (15.6, 29.1) (2.7, 17.5) (18.4, 40.1) (35.5, 53.1) 90.8 90.6 96.9 96.2 27.3 13.9 28.6 54.3 2014 (85.2, 94.4) (83.2, 94.9) (85.6, 99.4) (86.9, 99.0) (15.9, 42.6) (6.1, 28.7) (19.4, 40.0) (46.3, 62.1) Any non-artemisinin therapy 98.2 98.4 100.0 100.0 99.1 97.8 98.8 98.7 2009 (95.5, 99.3) (96.1, 99.4) - - (95.9, 99.8) (84.0, 99.7) (94.4, 99.8) (96.5, 99.5) 94.9 95.5 93.0 97.3 96.5 93.1 94.5 94.7 2011 (87.6, 98.0) (88.8, 98.2) (84.2, 97.0) (91.3, 99.2) (91.0, 98.7) (82.5, 97.5) (89.4, 97.2) (89.9, 97.3) 97.8 76.6 86.3 88.4 95.6 87.7 91.0 85.0 2014 (93.6, 99.2) (57.5, 88.8) (67.8, 95.0) (76.3, 94.7) (89.8, 98.1) (72.3, 95.1) (83.3, 95.4) (76.3, 91.0) Sulfadoxine-Pyrimethamine 60.1 65.5 90.2 94.7 91.1 64.1 80.2 74.9 2009 (48.1, 70.9) (55.0, 74.7) (65.0, 97.9) (76.1, 99.0) (81.5, 96.0) (41.4, 81.8) (68.2, 88.4) (65.8, 82.2) 74.3 77.1 85.1 94.2 95.0 90.2 91.4 87.9 2011 (60.9, 84.2) (65.7, 85.5) (73.1, 92.3) (88.2, 97.3) (90.8, 97.3) (81.5, 95.1) (86.8, 94.5) (83.2, 91.4) 87.3 68.9 65.2 76.0 92.6 86.0 87.1 79.5 2014 (81.9, 91.3) (51.5, 82.2) (35.4, 86.5) (64.3, 84.8) (84.9, 96.5) (70.9, 93.9) (79.5, 92.1) (71.3, 85.9) Oral Quinine 90.6 86.3 41.0 45.3 6.3 0.0 11.7 38.6 2009 (82.1, 95.3) (75.0, 93.0) (24.9, 59.4) (22.6, 70.2) (1.6, 21.7) - (6.8, 19.2) (29.4, 48.7) 79.4 80.1 54.6 49.8 7.2 0.0 12.4 29.0 2011 (67.9, 87.6) (68.4, 88.2) (32.8, 74.7) (34.3, 65.3) (2.0, 22.9) -- (6.6, 22.1) (21.2, 38.3) 90.6 71.3 50.7 35.3 3.4 0.0 6.3 33.2 2014 (85.1, 94.2) (54.7, 83.6) (29.5, 71.6) (23.7, 49.0) (0.8, 13.0) - (3.4, 11.2) (25.5, 42.0)

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Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round Public ALL Private ALL ALL Health Public/Not-For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Oral artemisinin monotherapy 1.3 1.1 3.0 23.7 4.1 0.0 2.5 2.0 2009 (0.3, 4.7) (0.3, 4.1) (0.7, 11.4) (9.8, 47.1) (0.7, 20.9) - (0.8, 7.9) (0.8, 5.2) 0.0 0.0 0.0 5.2 1.4 0.0 0.7 0.5 2011 ------(1.9, 13.0) (0.2, 10.7) -- (0.2, 2.9) (0.1, 2.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2014 ------Non-oral artemisinin monotherapy 2.7 3.0 39.9 33.2 0.6 0.0 9.1 6.9 2009 (0.7, 10.7) (0.9, 9.5) (22.6, 60.3) (21.4, 47.7) (0.1, 2.7) - (5.3, 15.1) (3.9, 11.8) 0.0 0.0 67.4 44.1 0.3 0.0 11.4 8.6 2011 -- -- (45.3, 83.8) (28.5, 61.0) (0.1, 1.1) -- (5.1, 23.7) (3.7, 18.9) 22.7 17.0 37.3 23.2 0.5 0.0 3.6 9.2 2014 (15.4, 32.0) (11.0, 25.2) (19.5, 59.5) (14.8, 34.4) (0.1, 3.4) - (2.0, 6.5) (6.5, 12.8) Any treatment for severe malaria 56.0 53.4 67.5 46.3 0.6 0.0 15.1 28.9 2009 (42.1, 69.1) (40.5, 66.0) (49.9, 81.2) (33.0, 60.2) (0.1, 2.7) - (8.7, 24.9) (21.9, 37.1) 41.4 40.9 82.1 48.2 2.9 0.0 14.6 21.1 2011 (31.9, 51.6) (31.2, 51.5) (61.6, 92.9) (32.4, 64.4) (0.5, 14.1) -- (7.8, 25.6) (14.6, 29.5) 67.9 54.3 45.5 23.9 0.5 0.0 4.2 25.0 2014 (55.0, 78.6) (40.0, 68.0) (25.5, 67.0) (15.4, 35.0) (0.1, 3.4) - (2.5, 7.0) (19.1, 31.9) * Antimalarial‐stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. ** The denominator includes CHWs and private-not-for-profit outlets: 2009: 16 private-not-for-profit outlets. 2011: 9 private-not-for-profit outlets. 2014: 35 CHWs and 5 private-not-for-profit outlets. Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D3: Antimalarial market composition, across survey round Public ALL Private ALL Outlet type, among outlets with at least 1 Health Public / Not- For- For-Profit Pharmacy Drug Store General Retailer Private antimalarial in stock on the day of the Facility Profit** Facility survey:* % % % % % % % 29.3 35.3 13.0 3.7 23.3 24.7 64.7 2009, N=294 outlets (19.9, 40.9) (25.5, 46.6) (8.6, 19.1) (0.6, 20.6) (16.3, 32.1) (16.6, 35.1) (53.4, 74.5) 28.6 30.9 9.2 5.9 23.8 30.3 69.1 2011, N=525 outlets (19.1, 40.4) (21.0, 42.9) (5.0, 16.4) (2.2, 14.5) (14.8, 35.9) (16.9, 48.0) (57.1, 79.0) 28.1 39.4 3.9 2.7 26.1 27.9 60.6 2014, N=472 outlets (21.1, 36.4) (30.2, 49.5) (2.1, 7.0) (1.0, 6.7) (18.1, 36.0) (19.6, 38.1) (50.5, 69.8) * Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. ** The denominator includes CHWs and private-not-for-profit outlets

Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D4a: Price of tablet formulation antimalarials, by outlet type, across survey round Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility 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) Any ACT $10.03 $8.43 $4.82 $2.51 $9.03 2009 [6.02-12.04] (28) [7.02-10.43] (133) [4.01-8.03] (26) (1) [4.82-11.04] (188) $11.79 $8.58 $4.29 $2.29 $7.50 2011 [7.50-13.94] (91) [6.86-11.79] (438) [2.57-4.72] (95) [2.29-3.43] (9) [4.29-12.86] (633) $5.56 $5.56 $2.09 $1.67 $3.48 2014 [2.23-13.63] (41) [4.17-8.35] (500) [1.39-3.34] (82) [1.30-1.81] (19) [1.53-6.26] (642) Quality-assured ACT (QAACT) $10.03 $10.03 $4.01 $2.51 $9.63 2009 [3.01-12.04] (17) [8.43-12.04] (46) [4.01-7.49] (25) (1) [3.01-11.04] (89) $12.86 $10.72 $3.22 $2.29 $5.36 2011 [6.69-15.44] (33) [7.72-14.90] (133) [2.14-4.29] (78) [2.29-3.43] (9) [2.57-12.86] (253) $4.64 $5.56 $1.67 $1.39 $2.09 2014 [3.17-8.90] (18) [4.17-8.35] (182) [1.39-2.78] (53) [1.11-1.81] (12) [1.39-4.17] (265) Non-quality assured ACT $10.03 $8.03 $8.03 - $8.03 2009 [6.42-10.03] (11) [6.02-10.03] (87) (1) - [6.42-10.03] (99) $10.72 $8.58 $6.43 - $9.65 2011 [7.50-12.86] (58) [6.43-10.72] (305) [4.29-9.65] (17) - [6.43-12.86] (380) $9.74 $5.56 $3.34 $1.67 $4.87 2014 [2.23-13.91] (23) [4.17-8.35] (318) [2.09-4.17] (29) [1.39-2.78] (7) [2.78-8.62] (377) Sulfadoxine-Pyrimethamine $0.50 $0.50 $0.40 $0.40 $0.40 2009 [0.36-0.60] (33) [0.30-0.60] (47) [0.30-0.60] (150) [0.30-0.50] (30) [0.30-0.60] (260) $0.64 $0.43 $0.54 $0.43 $0.54 2011 [0.64-0.96] (33) [0.32-0.54] (95) [0.43-0.64] (268) [0.43-0.54] (97) [0.43-0.64] (493) $0.70 $0.35 $0.42 $0.42 $0.42 2014 [0.42-2.09] (17) [0.28-0.70] (102) [0.28-0.42] (248) [0.35-0.42] (98) [0.35-0.42] (465)

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Table D4a: Price of tablet formulation antimalarials, by outlet type, across survey round Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility 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) Adult QA pre-packaged AL $9.63 $10.03 $4.01 $2.51 $9.03 2009 [3.01-11.04] (15) [8.83-12.04] (39) [3.01-6.02] (14) (1) [2.51-10.03] (69) $11.79 $8.58 $4.29 $2.29 $7.50 2011 [7.50-13.94] (91) [6.86-11.79] (438) [2.57-4.72] (95) [2.29-3.43] (9) [4.29-12.86] (633) $4.17 $4.17 $2.09 $1.39 $2.09 2014 [3.17-4.17] (7) [3.48-6.40] (100) [1.39-2.78] (30) [1.11-1.67] (5) [1.39-4.17] (142) Pediatric QA pre-packaged AL $9.03 - $1.00 - $9.03 2009 (1) - [1.00-1.00] (2) - [1.00-9.03] (3) $12.86 $10.72 $3.22 $2.29 $5.36 2011 [6.69-15.44] (33) [7.72-14.90] (133) [2.14-4.29] (78) [2.29-3.43] (9) [2.57-12.86] (253) $1.39 $2.36 $0.42 $0.70 $0.70 2014 [0.00-2.23] (4) [2.09-4.17] (30) [0.28-0.70] (8) [0.42-0.83] (3) [0.42-1.67] (45) * AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD. Figures in this table are derived using audited products with price information. Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round Public ALL Private ALL ALL Health Public/Not-For- For-Profit Pharmacy Drug Store General Retailer Private Outlets Facility Profit** Facility % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets*** 2009 N=162 2009 N=178 2009 N=33 2009 N=49 2009 N=142 2009 N=56 2009 N=280 2009 N=458 2011 N=287 2011 N=296 2011 N=50 2011 N=97 2011 N=269 2011 N=149 2011 N=565 2011 N=861 stocking 2014 N=490 2014 N=509 2014 N=22 2014 N=119 2014 N=233 2014 N=134 2014 N=508 2014 N=1,017 Any malaria blood testing 91.4 87.9 94.4 16.8 3.8 0.0 20.4 43.2 2009 (82.3, 96.0) (71.6, 95.5) (77.0, 98.8) (7.0, 35.1) (0.7, 18.8) - (13.9, 28.8) (34.4, 52.4) 82.7 81.5 91.8 41.1 9.8 0.5 14.9 28.7 2011 (72.6, 89.7) (68.7, 89.8) (79.6, 97.0) (29.1, 54.2) (2.0, 36.8) (0.1, 3.0) (8.7, 24.4) (21.6, 37.1) 91.3 89.8 87.5 50.9 10.6 0.1 11.3 41.9 2014 (86.1, 94.6) (81.4, 94.6) (66.4, 96.2) (38.7, 63.0) (3.3, 29.0) (0.0, 0.5) (6.1, 19.9) (33.3, 51.1) 2009 N=162 2009 N=178 2009 N=33 2009 N=49 2009 N=142 2009 N=56 2009 N=280 2009 N=458 2011 N=287 2011 N=296 2011 N=50 2011 N=97 2011 N=269 2011 N=149 2011 N=565 2011 N=861 2014 N=488 2014 N=507 2014 N=22 2014 N=119 2014 N=233 2014 N=134 2014 N=508 2014 N=1,015 Microscopic blood tests 40.6 40.6 74.4 2.2 3.1 0.0 15.9 24.3 2009 (31.7, 50.2) (30.5, 51.6) (57.8, 86.1) (0.3, 15.5) (0.4, 21.1) - (10.9, 22.7) (18.7, 30.8) 31.6 35.8 86.9 0.7 0.0 0.5 9.9 15.3 2011 (21.3, 44.1) (24.9, 48.5) (73.1, 94.2) (0.1, 6.1) -- (0.1, 3.0) (5.4, 17.5) (10.7, 21.3) 18.0 17.5 72.2 1.8 0.2 0.0 4.3 9.4 2014 (13.8, 23.1) (10.1, 28.6) (42.0, 90.3) (0.5, 6.9) (0.0, 1.2) - (1.9, 9.1) (5.9, 14.8) 2009 N=162 2009 N=178 2009 N=32 2009 N=49 2009 N=142 2009 N=56 2009 N=279 2009 N=457 2011 N=287 2011 N=296 2011 N=50 2011 N=97 2011 N=269 2011 N=149 2011 N=565 2011 N=861 2014 N=490 2014 N=509 2014 N=22 2014 N=119 2014 N=233 2014 N=134 2014 N=508 2014 N=1,017 Rapid diagnostic tests (RDTs) 89.5 85.7 78.3 14.6 3.8 0.0 16.9 40.3 2009 (80.6, 94.6) (70.3, 93.8) (57.9, 90.5) (5.1, 35.3) (0.7, 18.8) - (12.2, 23.1) (31.9, 49.3) 71.8 69.1 43.8 41.1 9.7 0.0 9.3 21.7 2011 (59.8, 81.4) (55.9, 79.7) (23.6, 66.2) (29.1, 54.2) (2.0, 36.8) -- (4.8, 17.1) (15.2, 29.9) 88.7 87.9 68.1 50.9 10.6 0.1 10.2 40.5 2014 (83.2, 92.5) (79.4, 93.2) (45.6, 84.4) (38.7, 63.0) (3.3, 29.0) (0.0, 0.5) (5.3, 18.6) (32.0, 49.7) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. **The denominator contains CHWs and private-not-for-profit outlets: 2009:16 private-not-for-profit outlets. 2011: 9 private-not-for-profit outlets. 2014: 16 CHWs and 3 private-not-for-profit outlets. ** Results in this table are derived using responses captured among outlets with blood testing information.

Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D7: Price of malaria blood testing, by outlet type, across survey round Private ALL For-Profit Pharmacy Drug Store General Retailer Private Facility Total median price to Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] consumers:* (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) Microscopic blood tests $3.01 $3.01 $1.00 - $3.01 2009 [2.01-4.01] (20) [3.01-3.01] (1) [1.00-1.00] (1) - [1.00-4.01] (22) Adult $3.40 - - - $3.40 2011 [3.40-4.26] (37) - - - [3.40-4.26] (37) $3.48 $0.00 $1.39 - $3.48 2014 [1.39-5.56] (11) [0.00-2.09] (3) (1) - [1.39-5.56] (15) Child under age five $3.40 - - - $3.40 2011 [2.55-4.26] (37) - - - [2.55-4.26] (37) $2.78 $0.00 $1.39 - $2.78 2014 [1.39-5.56] (11) [0.00-2.09] (3) (1) - [1.39-5.56] (15) Rapid diagnostic tests (RDTs) Adult N/A N/A N/A N/A N/A 2009

$6.81 $6.47 $1.70 - $3.40 2011 [3.40-6.81] (4) [4.26-6.47] (4) (1) - [1.70-6.47] (9) $2.09 $2.09 $0.70 $0.70 $1.04 2014 [0.42-4.17] (16) [1.39-3.48] (54) [0.70-0.97] (18) (1) [0.70-2.78] (89) Child under five N/A N/A N/A N/A N/A 2009

$6.81 $6.47 $1.70 - $3.40 2011 [3.20-6.81] (4) [4.26-6.47] (4) (1) - [1.70-6.47] (9) $1.39 $2.09 $0.70 $0.70 $1.04 2014 [0.42-4.17] (15) [1.39-3.48] (54) [0.56-0.97] (18) (1) [0.70-2.78] (88) * Total price to the consumer including consultation and/or service fees. Notes: In 2009, microscopy and RDT cost to consumer were not captured specifically for children under five and adults. Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D8: Antimalarial market share, across survey round Public TOTAL Private AETDs sold or distributed in the previous TOTAL ANTI-MALARIAL Health Public/Not- For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private TOTAL* as a percentage of all AETDs sold/ Facility Profit** Facility distributed: % % % % % % % % 2009 1. Any ACT 22.0 22.7 2.9 2.1 0.1 0.0 5.1 27.8 AL 22.0 22.6 2.8 1.6 0.1 0.0 4.5 27.1 Quality Assured ACT (QAACT) 21.9 22.5 2.2 0.9 0.1 0.0 3.2 25.7 Quality Assured ACT AL (QAACT AL) 21.9 22.5 2.2 0.8 0.1 0.0 3.2 25.6 Non-quality-assured ACT 0.1 0.2 0.7 1.2 0.0 0.0 1.9 2.1 2. Any non-artemisinin therapy 34.1 37.5 8.8 5.2 15.2 5.0 34.2 71.7 Sulfadoxine-Pyrimethamine 31.0 34.2 8.1 4.4 14.6 4.7 31.9 66.1 Oral quinine 3.0 3.1 0.4 0.5 0.0 0.0 0.9 4.1 Quinine IV/IM 0.1 0.2 0.0 0.0 0.0 0.0 0.0 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.1 0.3 0.0 0.4 0.4 4. Non-oral artemisinin monotherapy 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.1 5. Any treatment for severe malaria 0.1 0.2 0.1 0.0 0.0 0.0 0.1 0.3 OUTLET TYPE TOTAL*** 56.1 60.2 11.8 7.4 15.6 5.0 39.8 100.0

2011 1. Any ACT 49.4 55.3 1.3 2.5 0.4 0.1 4.2 59.5 AL 49.4 55.3 0.9 1.9 0.3 0.1 3.1 58.5 Quality Assured ACT (QAACT) 49.4 55.3 0.2 0.5 0.3 0.1 1.0 56.3 Quality Assured ACT AL (QAACT AL) 49.4 55.3 0.2 0.4 0.3 0.1 0.9 56.1 Non-quality-assured ACT 0.1 0.1 1.1 2.0 0.1 0.0 3.1 3.2 2. Any non-artemisinin therapy 27.9 28.2 0.9 2.9 6.4 2.0 12.2 40.4 Sulfadoxine-Pyrimethamine 25.0 25.0 0.8 2.8 6.1 1.9 11.7 36.7 Oral quinine 2.7 3.0 0.1 <0.1 <0.1 0.0 0.1 3.1 Quinine IV/IM 0.2 0.2 <0.1 <0.1 0.0 0.0 <0.1 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 <0.1 0.0 0.0 <0.1 <0.1 4. Non-oral artemisinin monotherapy 0.0 0.0 <0.1 <0.1 0.0 0.0 0.1 0.1 5. Any treatment for severe malaria 0.2 0.2 <0.1 <0.1 0.0 0.0 0.1 0.3 OUTLET TYPE TOTAL*** 77.3 83.6 2.2 5.4 6.8 2.1 16.4 100.0

2014 1. Any ACT 46.3 53.5 0.7 1.4 1.4 0.5 4.0 57.6 AL 46.3 53.5 0.6 1.1 1.4 0.5 3.6 57.2 Quality Assured ACT (QAACT) 23.3 27.9 0.3 0.5 1.2 0.5 2.5 30.4 Quality Assured ACT AL (QAACT AL) 23.3 27.9 0.3 0.5 1.2 0.5 2.5 30.4 Non-quality-assured ACT 23.0 25.6 0.5 0.9 0.2 0.0 1.6 27.2 2. Any non-artemisinin therapy 27.1 27.2 0.6 1.1 8.6 4.9 15.2 42.3 Sulfadoxine-Pyrimethamine 24.9 24.9 0.6 1.0 8.3 4.9 14.7 39.6 Oral quinine 2.0 2.0 0.0 0.0 0.0 0.0 0.0 2.1 www.ACTwatch.info Page 89

Table D8: Antimalarial market share, across survey round Public TOTAL Private AETDs sold or distributed in the previous TOTAL ANTI-MALARIAL Health Public/Not- For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private TOTAL* as a percentage of all AETDs sold/ Facility Profit** Facility distributed: % % % % % % % % Quinine IV/IM 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 5. Any treatment for severe malaria 0.2 0.2 0.0 0.0 0.0 0.0 0.0 0.3 OUTLET TYPE TOTAL*** 73.4 80.7 1.4 2.5 10.1 5.4 19.3 100.0 * Row sum – market share for the specified antimalarial medicine. ** The denominator includes CHWs and private-not-for-profit outlets *** Column sum (within each survey round) – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column (within in survey round). Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

www.ACTwatch.info Page 90 Table D9: Antimalarial market share, across outlet type, across survey round

Public TOTAL Private AETDs sold or distributed in the previous TOTAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer week by outlet type and antimalarial type Private as a percentage of all AETDs sold/ Facility Profit* Facility distributed: % % % % % % %

2009 1. Any ACT 39.2 37.6 24.8 28.2 0.7 0.2 12.9 AL 39.2 37.5 23.6 22.0 0.7 0.2 11.4 Quality Assured ACT (QAACT) 39.0 37.3 18.9 11.5 0.7 0.2 8.0 Quality Assured ACT AL (QAACT AL) 39.0 37.3 18.9 11.3 0.7 0.2 8.0 Non-quality-assured ACT 0.1 0.4 5.8 16.7 0.1 0.0 4.9 2. Any non-artemisinin therapy 60.8 62.3 74.7 70.1 97.6 99.8 86.0 Sulfadoxine-Pyrimethamine 55.2 56.8 69.1 59.6 93.8 94.9 80.2 Oral quinine 5.4 5.2 3.5 6.7 0.2 0.0 2.4 Quinine IV/IM 0.2 0.3 0.2 0.0 0.0 0.0 0.1 3. Oral artemisinin monotherapy 0.0 0.0 0.1 1.2 1.7 0.0 0.9 4. Non-oral artemisinin monotherapy 0.0 0.0 0.5 0.5 0.0 0.0 0.2 5. Any treatment for severe malaria 0.2 0.3 0.7 0.5 0.0 0.0 0.3

2011 1. Any ACT 63.9 66.2 59.1 45.2 5.6 3.0 25.4 AL 63.9 66.2 41.7 34.4 4.1 3.0 18.9 Quality Assured ACT (QAACT) 63.8 66.1 9.9 9.2 4.0 3.0 6.3 Quality Assured ACT AL (QAACT AL) 63.8 66.1 8.1 6.7 4.0 3.0 5.3 Non-quality-assured ACT 0.1 0.1 49.2 36.0 1.7 0.0 19.0 2. Any non-artemisinin therapy 36.1 33.8 39.4 53.6 94.4 97.0 74.0 Sulfadoxine-Pyrimethamine 32.4 30.0 36.1 52.1 90.8 92.5 71.0 Oral quinine 3.4 3.6 2.6 0.4 0.1 0.0 0.5 Quinine IV/IM 0.3 0.2 0.5 <0.1 0.0 0.0 0.1 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.7 0.0 0.0 0.2 4. Non-oral artemisinin monotherapy 0.0 0.0 1.5 0.5 0.0 0.0 0.4 5. Any treatment for severe malaria 0.3 0.2 2.0 0.5 0.0 0.0 0.4

2014 1. Any ACT 63.1 66.3 53.9 56.5 14.4 8.9 21.0 AL 63.1 66.3 46.3 44.5 14.4 8.9 18.9 Quality Assured ACT (QAACT) 31.7 34.6 19.5 21.5 12.3 8.5 12.9 Quality Assured ACT AL (QAACT AL) 31.7 34.6 18.7 21.0 12.3 8.5 12.8 Non-quality-assured ACT 31.3 31.7 34.4 34.9 2.1 0.3 8.1 2. Any non-artemisinin therapy 36.9 33.6 45.6 43.4 85.5 91.1 78.9 Sulfadoxine-Pyrimethamine 34.0 30.9 40.7 40.3 82.4 90.2 76.3 Oral quinine 2.7 2.5 1.5 0.1 0.0 0.0 0.1

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Public TOTAL Private AETDs sold or distributed in the TOTAL Health Public / Not-For- For-Profit Pharmacy Drug Store General Retailer previous week by outlet type and Private antimalarial type as a percentage of Facility Profit* Facility all AETDs sold/ distributed: % % % % % % % Quinine IV/IM 0.2 0.2 0.5 0.0 0.0 0.0 0.0 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.1 0.5 0.1 0.1 0.0 0.1 5. Any treatment for severe malaria 0.3 0.3 1.0 0.1 0.1 0.0 0.1 Categories 1 through 4 sum to 100% within each column (within each survey round). * The denominator includes CHWs and private-not-for-profit outlets

Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Table D12: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round Public ALL Private ALL ALL Health Public / Not for- for-profit Pharmacy Drug Store General Retailer Private Outlets Facility profit* HF % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=162 2009 N=178 2009 N=33 2009 N=50 2009 N=143 2009 N=57 2009 N=283 2009 N=461 Proportion of providers who: 2011 N=287 2011 N=296 2011 N=50 2011 N=97 2011 N=269 2011 N=149 2011 N=565 2011 N=861 2014 N=490 2014 N=509 2014 N=22 2014 N=119 2014 N=233 2014 N=134 2014 N=508 2014 N=1,017 Correctly state the national first-line treatment for uncomplicated malaria 94.8 92.7 98.3 73.3 69.4 31.1 59.3 70.5 2009 (89.5, 97.5) (87.2, 95.9) (88.9, 99.8) (28.4, 95.0) (54.3, 81.3) (20.8, 43.7) (49.5, 68.5) (63.2, 76.9) 98.5 98.3 91.3 87.9 52.3 34.8 48.3 58.7 2011 (95.6, 99.5) (95.5, 99.4) (79.2, 96.7) (75.0, 94.7) (43.1, 61.4) (24.4, 46.8) (39.7, 57.1) (50.7, 66.2) 98.2 97.7 87.5 84.6 61.1 46.1 56.0 72.3 2014 (95.3, 99.3) (93.3, 99.3) (67.4, 95.9) (73.2, 91.7) (51.6, 69.9) (37.7, 54.7) (50.1, 61.7) (66.2, 77.7) Report an ACT as the most effective antimalarial medicine

2009** N/A N/A N/A N/A N/A N/A N/A N/A ACT most effective for

adults 88.5 89.0 71.5 84.3 40.9 46.0 48.6 57.0 2011 (79.5, 93.9) (80.8, 94.0) (51.9, 85.4) (74.6, 90.7) (30.4, 52.3) (33.8, 58.8) (39.9, 57.4) (49.9, 63.7) 90.5 92.1 93.4 89.0 58.3 39.1 51.9 67.6 2014 (84.8, 94.2) (86.3, 95.6) (78.5, 98.2) (80.8, 94.0) (46.2, 69.5) (27.3, 52.3) (43.4, 60.3) (61.3, 73.3) ACT most effective for

children 85.2 85.5 76.1 83.1 46.0 48.1 51.8 58.8 2011 (77.0, 90.9) (77.3, 91.0) (58.8, 87.7) (71.9, 90.4) (33.9, 58.6) (36.2, 60.2) (41.3, 62.1) (49.6, 67.4) 89.1 91.3 90.1 89.0 58.9 46.6 55.7 69.6 2014 (83.4, 93.0) (86.0, 94.7) (73.6, 96.7) (82.1, 93.5) (48.4, 68.7) (33.5, 60.1) (47.0, 64.0) (62.7, 75.7)  At the time of the 2009, 2011 and 2014 ACTwatch outlet surveys, artemether lumefantrine was Zambia’s first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. * The denominator includes CHWs and private-not-for-profit outlets. 2009: 16 private-not-for-profit outlets. 2011: 9 private-not-for-profit outlets. 2014: 16 CHWs and 3 private-not-for-profit outlets. ** The 2009 results were unable to be determined based on missing data Source: ACTwatch Outlet Survey, Zambia, 2009, 2011, 2014.

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Annex 1: ACTwatch Background

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

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

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

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

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

ACTwatch research tools for malaria market monitoring include:

1. Outlet surveys

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

2 Shewchuk T, O’Connell KA, Goodman C, Hanson K, Chapman S, Chavasse D. 2011. The ACTwatch project: methods to describe anti-malarial markets in seven countries. Malaria Journal, 10: 325. 3 AMFm Independent Evaluation Team. 2012. Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi- country independent evaluation report: final report. Calverton, MD and London: ICF International and London School of Hygiene and Tropical Medicine. 4 O’Connell KA, Poyer S, Solomon T, et al. 2013. Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malaria Journal, 12: 52. www.ACTwatch.info Page 94

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

2. Supply chain studies

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

3. Population-based surveys

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

4. Fever case management quality of care

Fever case management quality of care is monitored using a set of research tools designed to measure aspects of the interaction between providers and clients. In 2015-2016, ACTwatch will launch fever case management quality of care studies in a subset of project countries. The tool or set of tools that is most appropriate and feasible in a given context is employed. These include:

 Exit interviews conducted with target consumers immediately after receiving fever case management services from target providers. A structured interview documents client reports about key aspects of service delivery including malaria blood testing, test results, medicines recommended/prescribed and obtained, counseling, and costs of services and commodities received. Exit interviews are also used to measure client recall and comprehension of provider counseling including instructions for completing prescribed drug regimens, as well as client satisfaction with services provided. Exit interviews may include measures of demographic characteristics to monitor equity in access to services and commodities.

 Structured observation documents aspects of the provider-client interaction using a checklist. A trained observer completes the checklist designed to document provider compliance with standard practice and procedures as well as aspects of client demand for specific products or services. The observer remains silent during the consultation.

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

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ACTwatch in Zambia

ACTwatch baseline surveys were conducted in Zambia in 2008-09 including an outlet survey (2009) and a household survey (2009). Follow-up outlet surveys were conducted in 2011 and 2014. A supply chain study was conducted in 2009 and a follow-up household survey was conducted in 2011. All reports are available at www.actwatch.info.

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Annex 2: Zambia Background

The Republic of Zambia is sparsely populated with about 14.6 million residents.9 More than half (61%) of the population resides in rural areas and the average population density is 17.3 persons per square kilometer. Administratively, Zambia is divided into ten provinces. Divisions below the provincial level are as follows: district, constituency, ward, census supervisory area (CSA), standard enumeration areas (SEA).10 Zambia benefits from a steady government and economy, relying mainly on mining and agriculture. Despite a stable economy, poverty remains a problem due to high birth rates (42.46 births/1,000), high HIV/AIDS burden, and fluctuating agricultural policies.10 Fortunately, the country’s health indicators are overall positive regardless of the high poverty rate.10

Healthcare system

Health care in Zambia is a three-tiered system. The first tier is comprised of health posts, health centers, and district hospitals. This tier is the main source of primary health care and preventive health services for the community. More advanced health services, including curative care and a wider range of diagnostics, are provided in the second tier at provincial and general hospitals. The third tier is comprised of central hospitals and national university teaching hospitals providing specialized care. The organization of the health care system is aligned with administrative zones; first, second, and third tier health care facilities are organized at the district, provincial, and national levels, respectively.

According to the Ministry of Health, there are a total of 1,958 health facilities in Zambia. This includes 1,131 rural health centers, followed by 409 urban health centers, and 307 health posts. There are 81 level 1 hospitals, 24 level 2 hospitals, and 6 level 3 hospitals.11

The health care system is bolstered through various religious, private, and other non-governmental organizations that also work to provide health care to the community. Nearly one-quarter (22%) of health facilities in Zambia are operated by private non-profit or for-profit individuals or organizations.12

Malaria risk and burden

Malaria is endemic throughout Zambia and 100% of the population is at risk of acquiring the disease.12 The primary parasite species found in Zambia is Plasmodium falciparum, which accounts for more than 95% of malaria cases.13 Malaria is the leading cause for child mortality under the age of five and the third leading cause of both morbidity and mortality in Zambia. The WHO reported that 4,500 deaths occurred due to malaria in 2012.13 Those living in rural areas are the most susceptible with the Eastern province being the most affected by malaria, followed closely by the Luapula and Northwestern provinces.14

9 CIA (2014). [The World Factbook - Zambia]. 10 PMI. (2014). Malaria Operational Plan FY 2014 (pp. 55). 11 MOH. (2014) Annual Health Statistical Bulletin 2012. 12 WHO. (2014). World Malaria Report. Geneva, Switzerland. 13 MOH. (2014). Guidelines for the Diagnosis and Treatment of Malaria in Zambia (pp. 124-124). 14 UNDP. (2013). Millenium Development Goals Progress Report Zambia. Lusaka, Zambia. www.ACTwatch.info Page 97

Based on the data gathered from routine information systems and national surveys, Zambia is divided into three zones according to malaria epidemiology. These zones are defined as:

Zone 1) Areas where malaria transmission has been significantly reduced and parasite prevalence is less than 1%. Zone 2) Areas where parasite prevalence is between 1% and 14% in young children at the peak of transmission. Zone 3) Areas where progress in malaria controls has not been sustained and parasite prevalence in young children is at 15% or more at the peak of transmission.

Figure 1: Epidemiologic Strata for Malaria Transmission in Zambia

Source: Zambia Malaria Programme Review 2010

Targeted strategies have been developed for each zone: Zone 1) Scale up surveillance monitoring and emergency preparedness and response. Zone 2) Scale up insecticide-treated net (ITN) coverage to universal coverage and sustain use through routine distribution and a reduced scale IRS. Zone 3) Scale up ITNs to universal coverage and sustain use through routine distribution and scale up IRS. Sustain with ITNs and centralized indoor residual spraying (IRS) as part of surveillance response.

Malaria case management guidelines

Diagnosis

According to the 2014 guidelines for the diagnosis and treatment of malaria in Zambia, all suspected cases of malaria are subject to parasitological confirmation, either through microscopy or rapid diagnostic tests (RDTs). Microscopy is utilized in public health facilities and RDTs are deployed in all health facilities, with priority given to facilities that do not offer microscopy. RDTs are not intended to supplant microscopy as the first choice for parasitological confirmation; all laboratory staff trained in malaria diagnostics are encouraged to use microscopy whenever possible. RDTs are used in situations where health facilities do not have trained (or poorly trained) laboratory staff, the laboratory is closed and microscopy is not available, the workload for the laboratory is excessively high, and emergency cases where immediate malaria results are needed in outpatient/inpatient departments. RDTs are also employed at the community level in the context of integrated community case management (iCCM) of malaria. All private health facilities managing fever cases should adhere to the recommended policy of parasitological confirmation using either microscopy or RDTs.

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Evidence from population-based surveys suggests that confirmatory testing is common at health facilities. About half of individuals with a current or recent fever seek treatment from a trained health provider. Of those receiving care from an appropriate provider, 71% of children aged less than 5 years and 64% of individuals older than 5 years received a malaria blood test.15

Treatment

For many years, chloroquine was the first-line antimalarial drug used in Zambia.16 As chloroquine treatment failure rates began to exceed 50%, well over the WHO’s recommended levels for changing national drug policy, Zambia began searching for a suitable replacement. Sulfadoxine-pyrimethamine was the first drug considered, however resistance was already documented in neighboring countries as well as in areas of Zambia.17

The first-line treatment for uncomplicated malaria is currently the ACT, artemether lumefantrine (AL) taken over the course of three days. AL was selected as the first-line treatment in 2002 and has a high treatment efficacy rate in Zambia.18 In cases where AL is contraindicated, ineffective, or unavailable, dihydroartemisinin-piperaquine (DHA PPQ) is the alternative first-line treatment, taken orally over the course of three days. Sulfadoxine-pyrimethamine (SP) is used for intermittent preventive treatment of pregnant women (IPTp) with a total of three or more doses for the entire duration of the pregnancy.18 SP is also the recommended first-line medicine for treating uncomplicated malaria in children who weigh less than 5kg. The distribution of oral artemesinin monotherapies (oral AMT) was banned in October, 2008.

In cases of severe malaria, after parasitological diagnosis and other immediate needs are met, antimalarial treatment is carried out with injectable artesunate for adults and children. If injectable artesunate is unavailable, injectable artemether or injectable quinine are the alternatives.

Financing and major initiatives to improve malaria case management

The Ministry of Community Development, Mother and Child Health (MOMCH) was established in 2012 and is responsible for primary health care in Zambia. The MOMCH is accountable for newly decentralized integrated service delivery at the district and local levels.19 Emphasis has been placed on communication between first tier facilities and local district health offices to facilitate the procurement of adequate antimalarials and RDTs and ensure that all districts have the capability to respond to any increases in malaria cases.20

Artemisinin based combination therapy (ACT) is distributed free of charge at all public health facilities.21 Over 80% of ACTs distributed in Zambia are through the public health system.22 The MOH recommends malaria diagnostic testing for all fever cases; the tests are provided free of charge at all public health facilities.21

Historically Zambia has been dependent on partners for procuring antimalarials. However since 2013 the Ministry of Health has procured ACTs using national funds. In 2013 and 2014, the MOH spent approximately $5.6 million USD annually on antimalarial medicines. The MOH procured RDTs using approximately $4 million USD in national funds.

15 Littrell, M., Miller, J. M., Ndhlovu, M., Hamainza, B., Hawela, M., Kamuliwo, M., . . . Steketee, R. W. (2013). Documenting malaria case management coverage in Zambia: a systems effectiveness approach. Malaria journal, 12(1), 371-371. doi: 10.1186/1475-2875-12-371 16 Sipilanyambe, N., Simon, J.L., Chanda, P., Olumese, P., Snow, R.W. & Hamer DH. (2008) From chloroquine to artemether lumefantrine: the process of drug policy change in Zambia. Malaria Journal, 25‐31. 17 Bijl, H.M., Kager, J., Koetsier, D.W., van der Warf, T.S. (2000).Chloroquineand sulfadoxinepyrimethamineresistant falciparum malaria in vivo – a pilot study in rural Zambia. Tropical Medicine and International Health, 5, 10, 692‐695 18 MOH. (2014). Guidelines for the Diagnosis and Treatment of Malaria in Zambia (pp. 124-124). 19 PMI. (2014). Malaria Operational Plan FY 2014 (pp. 55). 20 NMCP. (2015). National Malaria Control Programme Strategic Plan For Fy 2011-2015 (pp. 1-100). 21 WHO. (2012). World Malaria Report 2012. Geneva, Switzerland. 22 ACTwatch Group. (2011). Outlet Survey Republiv of Zambia 2011 Survey Report (pp. 1-100). www.ACTwatch.info Page 99

Donor contributions to national malaria control program efforts have been made in recent years by DFID, PMI, the Global Fund, Novartis and Malaria No More including funding for ACT and RDT procurement .23,24

Since 2011, there has been an increased focus on trainings of the community health worker cadre and ensuring adherence to proper treatment guidelines. In the context of iCCM, CHWs and community health assistants (CHAs) are tasked with diagnosing potential cases (with RDTs when available), administering AL, treating fever, and providing education to the community. CHWs and CHAs refer cases to health facilities when certain danger signs or treatment failures occur. Treatment guidelines recommend confirmatory testing in all cases with exceptions for situations where a parasitological diagnosis is not immediately accessible.

Challenges in Zambia for improving appropriate malaria case management coverage include provider adherence to blood test results, appropriate treatment, and commodity stock-outs. In a recent study of fever case management in Zambia, two in three children under the age of five were treated with antimalarials despite having negative RDT results and 19% received treatment before receiving laboratory results.25 Given the potential threat of artemisinin drug resistance, the MOH updated treatment guidelines and conducted trainings to ensure provider adherence to blood test results. According to a study assessing the systems effectiveness of malaria case management in Zambia, the greatest threat identified was appropriate treatment-seeking behaviour.26 Appropriate behaviour can range from approaching the correct service provider to employing that service. Based on a recent review of Zambia’s national malaria strategic plan, Zambia has made great strides in increasing parasitological confirmation at a rate of 192 per 1,000 population in 2012 from 101/1,000 in 2010.27 Despite this progress, testing rates are still below universal coverage.

Stock outs of both RDTs and ACTs reportedly have a negative impact on achieving high coverage of appropriate malaria case management in Zambia.28 To address stock outs, focus has been on improving RDT procurement and establishing new distribution hubs within public sector supply chains to prevent stock outs. In conjunction with USAID and the Deliver Project, the MOH plans to scale up their Essential Medicines Logistics Improvement Program (EMLIP) to strengthen their supply chain and logistics in order to prevent future stock outs. This program was piloted in 27 districts throughout Zambia and reduced stock out rates from 50 percent in 2012 to about 28 percent in 2013.28

23 Personal communication, 2014 ACTwatch Key Informant Interviews, Zambia 24 President’s Malaria Initiative. (2014). FY 2014 Zambia Malaria Operational Plan. President’s Malaria Initiative. Retrieved from http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy14/zambia_mop_fy14.pdf?sfvrsn=8 25 Manyando, C., Njunju, E. M., Chileshe, J., Siziya, S., & Shiff, C. (2014). Rapid diagnostic tests for malaria and health workers’ adherence to test results at health facilities in Zambia. Malaria Journal, 13(1), 166. doi:10.1186/1475-2875-13-166 26 Littrell, M., Miller, J. M., Ndhlovu, M., Hamainza, B., Hawela, M., Kamuliwo, M., . . . Steketee, R. W. (2013). Documenting malaria case management coverage in Zambia: a systems effectiveness approach. Malaria journal, 12(1), 371-371. doi: 10.1186/1475-2875-12-371 27 NMCC. (2013). Mid-Term Review Report of National Malaria Strategic Plan 2011-2015. (pp.1-70). 28 USAID, Deliver Project. Available:http://deliver.jsi.com/dhome/countries/countrynews?p_persp=PERSP_DLVR_CNTRY_ZM www.ACTwatch.info Page 100

Annex 3: Outlet Survey Methods

Design and Study Population

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

Public health facilities Government public health facilities including health centers, and national, regional and district hospitals.

Community health worker A network of government and non-governmental community health volunteers.

Private not-for-profit health Non-governmental (NGO) or mission/faith-based health facilities including facilities hospitals and clinics. Private for profit health Private hospitals, clinics and diagnostic laboratories. facilities Pharmacies Pharmacies are licensed and regulated by the Zambia Medicines Regulatory Authority (ZAMRA). Pharmacies are owned by registered pharmacists or individuals who employ the services of a registered pharmacist. Pharmacies are authorized to sell all classes of medicines including prescription-only medicines.

Drug stores Typically located in rural areas, drug shops are medicine sellers that are licensed by the ZAMRA and are legally permitted to sell over-the-counter medicines including antimalarial medicines. These outlets are staffed by qualified health dispensers/practitioners.

General retailers Grocery stores, kiosks, and kantembas primarily sell fast-moving consumer goods, food and provisions. Kantembas are points of sale located in small wooden booths that serve food, beverages and household goods. Although retailers may have over-the-counter medicines including antimalarials available, national authorities do not regulate the sale of medicines by retailers.

Itinerant drug vendors Mobile providers selling medicines and other goods. They are not registered with any national regulatory authority.

Stratification

The Zambia 2014 outlet survey is stratified to provide estimates for urban and rural domains. Urban and rural designations for all wards in the sampling frame were obtained from the 2010 census of population and housing conducted by the Central Statistical Office of Zambia.29

Eligibility Criteria

All outlets with the potential to sell or distribute antimalarials were included in the census screening. Outlets were eligible for a provider interview and malaria product audit if they met at least one of three study criteria: 1) one or more antimalarials reportedly in stock the day of the survey; 2) one or more antimalarials reportedly in stock within the three months preceding the survey; and/or 3) provides malaria blood testing (microscopy or RDT). Outlets that do not serve the general public (e.g. military facilities) were excluded from the study.

29CSO. (2011). 2010 Census Populuation and Housing Report (pp. 1-71). www.ACTwatch.info Page 101

Sample Size

The outlet survey was powered to detect a 20 percentage point increase between 2011 and 2014 within each research domain (and nationally) in the indicator, the proportion of outlets that have quality-assured ACT in stock among all outlets with antimalarials in stock at the time of the survey. The required sample size for each research domain (urban and rural strata) was calculated in three steps: 1) determine the required number of antimalarial-stocking outlets; 2) determine the number of outlets to be enumerated to arrive at this number of antimalarial-stocking outlets; and 3) determine the number of clusters for the census to arrive at this number of outlets.

Required number of private sector antimalarial-stocking outlets

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

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

 n= desired sample size  P1= the proportion of antimalarial-stocking outlets with quality-assured ACT in stock in 2011

 P2= the expected proportion of antimalarial-stocking outlets with quality-assured ACT in stock in 2013.  P= (P1+P2)/2  Zα/2= The standard normal deviate value for a α type I error (two-sided)

 Z1-β= The standard normal deviate value for a β type type II error  Deff= design effect anticipated due to the cluster survey design. A design effect of 3 was used for all calculations.

The required size for the 2014 survey has been calculated based on the following assumed values of key parameters, taken from the 2011 ACTwatch survey:

Urban Rural P1 0.339 0.419 P2 0.539 0.619 Zα 1.96 1.96 Z1-β 0.84 0.84 Deff 6.18 3.2

Applying the above parameters to the stated formula yields the following required sample sizes: urban: 590; rural 310; total: 491.

Required number of antimalarial-stocking outlets

The estimated total number of outlets enumerated needed for the QAACT availability indicator was determined by the following formula for each urban/rural strata separately:

Nn/Pam

Where Pam is the proportion of outlets having antimalarial stocks at the time of the survey among all outlets enumerated. In this equation, the assumptions are as follows: N = desired sample size of all outlets for monitoring availability indicators, n is the number of outlets with antimalarial stocks at the time of the survey. Pam is the proportion of outlets with antimalarials in stock at the time of the survey among all outlets enumerated estimated from 2011 survey data for each domain (see below).

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Urban Rural Proportion of outlets with 0.085 0.082 antimalarials in stock

Applying the above parameters to the stated formula yields the following required sample sizes: urban: 6,917; rural 3,781; total: 10,698.

Required number of clusters (wards)

The primary sampling approach entails sampling a set of administrative units (geographic clusters) with a corresponding population of approximately 10,000 to 15,000 inhabitants. The appropriate administrative unit in Zambia corresponding to this desired population size is ward. The desired number of clusters (wards) is selected with probability of cluster selection proportionate to size (PPS). A census of all outlets with the potential to sell or distribute antimalarials will be conducted in sampled wards.

The average number of outlets screened per cluster from the 2011 outlet survey was used to estimate the number of clusters required in 2014 to achieve the desired sample size. Applying these averages to the required number of outlets for the study, the number of clusters required in each domain was: urban: 25; rural: 26; total: 51.

Sampling

A representative sample of wards was selected in each research domain. From a list of all wards in each domain, the required number of wards was selected with probability proportional to size (PPS). Selection of wards with PPS was completed based on the 2010 census of population and housing conducted by the Central Statistical Office of Zambia.30 A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. A list of selected wards is provided in Annex 4.

In 2014, a one-stage cluster sampling approach was taken for all outlet types. In addition to the census of selected wards, a booster sample was employed for pharmacies and public health facilities to reach the desired sample size for these key market segments. The booster strategy for pharmacies consisted of a national census of all pharmacies. The booster strategy for public health facilities extended the boundaries for the census from sampled ward to the constituency level.

Data Collection

Interviewers, supervisors, and quality controllers received training that included an orientation to the study, questionnaire, and classroom training on completing antimalarial and RDT audits, and a field exercise. Following training, data collection was implemented from July 14, 2014 to September 22, 2014.

For all interviews, a structured questionnaire was administered using paper questionnaires (see Annex 6). A series of screening questions were administered at all outlets to determine eligibility for the survey. Outlets where antimalarial medicines were reportedly sold and/or malaria blood testing was reportedly provided were invited to participate in the survey. Following informed consent procedures, an audit of all available antimalarial medicines and RDTs was conducted. Antimalarial audit information included formulation, package size, brand name, active ingredients and strengths, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. RDT audit information included brand name, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. Detailed descriptions of antimalarials and RDTs audited are provided in Annex 7 and Annex 8. In addition to the product audit, a series of questions was administered to the senior-most provider regarding malaria case management knowledge and practices

30CSO. (2011). 2010 Census Populuation and Housing Report (pp. 1-71). www.ACTwatch.info Page 103 as well as provider training and qualifications. Geo-coordinates were recorded for each outlet using a handheld Global Positioning System (GPS) unit.

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

Data Entry, Processing, and Analysis

Data was collected using paper questionnaires. All data cleaning and analysis was completed using Stata 13.1 (©StataCorp, College Station, TX). Sampling weights were applied to account for variations in probability of selection (see Annex 9) and standard error estimation accounted for clustering at the ward and district levels. Indicator definitions are provided in Annex 10.

Protection of Human Subjects

The 2014 outlet survey protocol received ethical approval from the Republic of Zambia Ministry of Health in Zambia. The PSI Research Ethics Board ceded review to the ethics committee in Zambia. Provider interviews and product audits were completed only after administration of a standard informed consent form and provider consented to participate in the study. Providers had the option to end the interview at any point during the study. Standard measures were employed to maintain provider confidentiality and anonymity.

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Annex 4: Sampled Wards Table X1. Sampled wards Province District Constituency Ward Urban/Rural Population CENTRAL KABWE BWACHA KANGOMBA 4856 URBAN CENTRAL KAPIRI MPOSHI KAPIRI MPOSHI NGABWE 5692 RURAL CENTRAL MKUSHI MKUSHI NORTH MUNDA 15730 RURAL CENTRAL MUMBWA MUMBWA MUPONA 20390 URBAN CENTRAL SERENJE MUCHINGA MASANINGA 13516 RURAL COPPERBELT CHINGOLA NCHANGA BUNTUNGWA 12193 URBAN COPPERBELT KITWE CHIMWEMWE BUNTUNGWA 17483 URBAN COPPERBELT KITWE KWACHA RIVERSIDE 28359 URBAN COPPERBELT LUANSHYA LUANSHYA LEVI CHIKO 7254 URBAN COPPERBELT MASAITI MASAITI CHILULU 3318 RURAL COPPERBELT MUFULIRA MUFURILA KASEMPA 4549 URBAN COPPERBELT NDOLA CHIFUBU FIBOBE 15011 URBAN COPPERBELT NDOLA NDOLA CHIPULUKUSU 37703 URBAN EASTERN CHIPATA CHIPATA CENTRAL MSANGA 66455 URBAN EASTERN CHIPATA KASENEGWA CHINGAZI 15149 RURAL EASTERN KATETE SINDA CHIWUYU 8482 RURAL EASTERN LUNDAZI LUNDAZI CHIMALIRO 10180 RURAL EASTERN LUNDAZI LUNDAZI MNYAMAZI 34442 RURAL EASTERN PETAUKE MANZALA ONGOLWE 16133 RURAL LUAPULA KAWAMBWA PAMBASHE ILOMBE 12103 RURAL LUAPULA MWENSE MWENSE NKANGA 6287 RURAL LUAPULA NCHELENGE NCHELENGE CHILONGO 37808 URBAN LUSAKA CHONGWE CHONGWE CHINKULI 22662 RURAL LUSAKA KAFUE KAFUE MATANDA 10923 URBAN LUSAKA LUSAKA CHAWAMA JOHN HOWARD 28900 URBAN LUSAKA LUSAKA KABWATA KAMULANGA 25935 URBAN LUSAKA LUSAKA KANYAMA HARRY MWAANGA NKUMBULA 167542 URBAN LUSAKA LUSAKA LUSAKA CENTRAL LUBWA 32885 URBAN LUSAKA LUSAKA MANDEVU CHAISA 19858 URBAN LUSAKA LUSAKA MATERO MUCHINGA 40985 URBAN LUSAKA LUSAKA MATERO MWEMBESHI 68878 URBAN LUSAKA LUSAKA MUNALI MTENDERE 106128 URBAN MUCHINGA CHAMA CHAMA NORTH KALINKHU 2222 RURAL MUCHINGA MAFINGA MAFINGA KALANGA 13019 RURAL NORTH WESTERN KABOMPO KABOMPO EAST KAWANDA 6566 RURAL NORTH WESTERN MWINILUNGA MWINILUNGA MULUMBI 15704 URBAN NORTH WESTERN SOLWEZI SOLWEZI EAST MAPUNGA 3857 RURAL NORTHERN KAPUTA KAPUTA MOWA 12825 RURAL NORTHERN KASAMA KASAMA MULILANSOLO 36470 URBAN NORTHERN MBALA MBALA KAWIMBE 8768 RURAL NORTHERN MUNGWI MALOLE CHIBAMBA 17739 RURAL SOUTHERN ITEZHI-TEZHI ITEZHI-TEZHI ITUMBI 5803 RURAL SOUTHERN KAZUNGULA KAZUNGULA NYAWA 13405 RURAL SOUTHERN LIVINGSTONE LIVINGSTONE MUSI-O-TUNYA 8213 URBAN SOUTHERN MAZABUKA MAGOYE MAGOYE 16557 RURAL SOUTHERN MONZE MONZE BBOMBO 5787 RURAL SOUTHERN MONZE MONZE MANUNGU 38590 URBAN WESTERN KALABO KALABO NDOKA 7774 RURAL WESTERN LUKULU LUKULU WEST MUYONDOTI 2979 RURAL WESTERN MONGU MONGU MULAMBWA 9814 URBAN WESTERN SESHEKE SESHEKE MAONDO 8491 RURAL

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Annex 5: Detailed Sample Description Table X2: Detailed sample description

Public Private Community Private-not-for- ALL Health for-profit Pharmacy Drug Store General Retailer Health Workers profit Facilities Outlets Facility HF Number of outlets screened (Figure 1 Box B) 493 35 5 26 123 246 4,950 5,878 Urban 157 9 4 23 121 226 3,837 4,377 Census 37 9 4 23 30 226 3,837 4,166 Booster 120 0 0 0 91 0 0 211 Rural 336 26 1 3 2 20 1,113 1,501 Census 35 26 1 3 0 20 1,113 1,198 Booster 301 0 0 0 2 0 0 303 Number of outlets eligible and interviewed (Figure 1 Box D) 490 14 3 22 116 222 109 976 Urban 155 0 2 20 114 204 81 576 Census 36 0 2 20 29 204 81 372 Booster 119 0 0 0 85 0 0 204 Rural 335 14 1 2 2 18 28 400 Census 35 14 1 2 0 18 28 98 Booster 300 0 0 0 2 0 0 302 Number of outlets eligible but not interviewed (interview non-participation) 1 0 0 1 3 2 2 9 Urban 1 0 0 1 3 2 2 9 Census 1 0 0 1 0 2 2 6 Booster 0 0 0 0 3 0 0 3 Rural 0 0 0 0 0 0 0 0 Census 0 0 0 0 0 0 0 0 Booster 0 0 0 0 0 0 0 0 Number of interviewed outlets with at least one antimalarial in stock on the day of the survey (Figure 1, Box D1) 490 14 3 22 116 222 109 976 Urban 155 0 2 20 114 204 81 576 Census 36 0 2 20 29 204 81 372 Booster 119 0 0 0 85 0 0 204 Rural 335 14 1 2 2 18 28 400 Census 35 14 1 2 0 18 28 98 Booster 300 0 0 0 2 0 0 302 www.ACTwatch.info Page 106

Table X2: Detailed sample description

Public Private Community Private-not-for- ALL Health for-profit Pharmacy Drug Store General Retailer Health Workers profit Facilities Outlets Facility HF Number of interviewed outlets with at least one antimalarial in stock on the day of the survey or at least one antimalarial reportedly in stock in the previous 3 months (Figure 1 sum of Box 1 and Box 2) 490 16 3 22 119 233 134 1,017 Urban 155 0 2 20 117 214 99 607 Census 36 0 2 20 30 214 99 401 Booster 119 0 0 0 87 0 0 206 Rural 335 16 1 2 2 19 35 410 Census 35 16 1 2 0 19 35 108 Booster 300 0 0 0 2 0 0 302 Number of interviewed outlets that provide malaria blood testing, but do not stock antimalarial medicines (Figure 1 Box D3) 1 1 0 0 0 1 0 3 Urban 0 0 0 0 0 0 0 0 Census 0 0 0 0 0 0 0 0 Booster 0 0 0 0 0 0 0 0 Rural 1 1 0 0 0 1 0 3 Census 0 1 0 0 0 1 0 2 Booster 1 0 0 0 0 0 0 1 Proportion of eligible and interviewed antimalarial-stocking outlets with at least one provider with a health-related qualification* 98.4 100 100 100 96.6 50 21.1 78.6 Urban 100 - 100 100 97.4 49.5 25.9 71.2 Census 100 - 100 100 96.6 49.5 25.9 55.9 Booster 100 - - - 97.7 - - 99.0 Rural 97.6 100 100 100 50 55.6 7.1 89.3 Census 97.1 100 100 100 - 55.6 7.1 64.3 Booster 97.7 - - - 50 - - 97.4 * Health-related qualifications include: medical doctor, pharmacist, nurse, midwife, laboratory technician, pharmacy technician, community health assistant, and community health worker Source: ACTwatch Outlet Survey, Zambia, 2014.

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Annex 6: Questionnaire ACTwatch Outlet Survey ZAMBIA 2014 Section I: Census Information Interviewer completes this section for all outlets.

Outlet ID Interviewer-District- Constituency-Ward -Outlet ID [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] C1. Today’s date (dd/mm/yyyy) [___|___]-[___|___]-[_2_|_0_|_1_|_4_] C2. Interviewer’s name C2a. Interviewer’s code

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

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

[______] [___|___|___] C5. Ward C5a. ward code

[______] [___|___|___|___] C6. Name of outlet If no name, record “no name” or owner’s name C6a. Outlet code

[______] [___|___|___] C7. Type of Outlet Public Health Facility 09 Pharmacy / Chemist 17 Kiosk 01 Health Post 10 Drug Store 18 Kantemba 02 Rural Health Centre 11 Surgery 19 Container 03 Hospital Affiliated Health Centre 12 Private Clinic 20 Mobile Providers [___|___] 04 First Level Hospital 13 Private Hospital 21 Private Diagnostic Lab (lab only) 05 Second Level Hospital 14 NGO/Mission Hospital 22 NGO/Mission Diagnostic Lab (lab only) 06 Third Level Hospital 15 Grocery Store 96 Other (specify) 07 Community Health Assistant 16 Super/mini-market/petrol stations [______] 08 Community Health Worker

C8. Is this area part of the booster sample? 1 = Yes 0 = No [___]

Hello, my name is ______, I work on behalf of Society for Family Health (SFH). We are conducting a study on the availability of antimalarial medicines and diagnostic testing services. The results will be used to improve the availability of appropriate antimalarial treatment in Zambia. I would like to ask you a few questions to see if you could be part of the survey.

Screening questions X1. Do you have any oral rehydration salts, also known as ORS? Verify with prompt card. 1 = Yes [___] 0 = No X2. Do you have any zinc tablets for treatment of diarrhea in children in stock today? Verify with prompt card. 1 = Yes [___] 0 = No S1. Do you have any medicines in stock today? 1 = Yes Go to S3 [___] 0 = No S2. Are there any medicines that are out of stock today, but that you stocked in the past 3 months? 1 = Yes Go to S4 [___] 0 = No Go to S5 8 = Don’t know Go to S5 S3. Do you have any antimalarial medicines in stock today? 1 = Yes Provide information sheet & gain consent. Record start time in C9. [___] Proceed to Section 2: Antimalarial Audit. 0 = No Go to S4 S4. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months? 1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to A16. [___] 0 = No Verify with prompt card. Go to S5 8 = Don’t know Verify with prompt card. Go to S5 108

S5. Are you offering any diagnostic services or selling any diagnostic tests here today? 1 = Yes Go to S6 [___] 0 = No Verify with prompt card. Record details in C9 then complete Sec X: Ending Interview S6. Are any of these services or tests for suspected malaria? 1 = Yes Provide information sheet & gain consent. Record start time in C9. [___] Proceed to Section 3: Diagnostic Audit 0 = No Verify with prompt card. Record details in C9 then complete Sec X: Ending Interview Before proceeding to the full interview ensure you have given the respondent a study information sheet, explained the study and obtained informed consent.

C9. Result of Visit(s)

Date Visit 1 Visit 2 Visit 3 (dd/mm/yy) [___|___]-[___|___]-[_1_|_4_] [___|___]-[___|___]-[_1_|_4_] [___|___]-[___|___]-[_1_|_4_] Time started (use 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Time completed (use 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___]

Result [___|___] [___|___] [___|___] 01 = Outlet eligible & survey completed go to E1 02 = Outlet ineligible: does not meet any screening criteria go to E1 03 = Interview interrupted go to C11 04 = Respondent not available / Time not convenient go to C11 05 = Outlet not open at the time go to C11 06 = Outlet closed permanently go to E1 96 = Other (specify): [______] 97 = Refused go to C10

C10. If the provider refused, why?

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

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

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

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

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

THANK THE PROVIDER AND END INTERVIEW 109

Section II: Antimalarial Audit

A0. Read to the provider: Can you please show us the full range of antimalarials that you currently have in stock? Do you currently have any of the following? Prompt entire list using antimalarial prompt card; No response to be recorded.  Artemether lumefantrine, such as Lonart, Artefan, Lumartem, Coartem  Artesunate amodiaquine, such as DUAC, Coarsucam, Winthrop  Other artemisinin combination therapies, such as Asunate, Co-arinate, Arco  Artemether monotherapies, such as Artemedine, Artenam, Romether, Erither, G-vither  Artesunate monotherapies, such as Plasmotrim, Artesun, G-Sunate  SP, such as Fansidar, Pharmadar, Maladox, Malamine, Malostat, Novidar, Sulphadar  Quinine, such as Quinalin, Quinizin, QSM,  Amodiaquine, such as Amobin, Amodar, Malarid  Mefloquine, such as Mephaquin, Meflotas  Syrups or suspensions, such as Quinine-K, Quinimix ,Requin, Fantem , Co-artesiane, Co-malartem  Injectables, such as Rogoquin, Artemether, Quinax, Larither, Kwinil, Emal, Artesiane  Granules or powders, such as Artequin, Artesun

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

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

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

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

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

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

ADDITIONAL NOTES ON THE SUB-OUTLET CODE

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

SUB-OUTLET CODES X ALL outlets that have only ONE dispensing/distribution point for medicines/diagnostics A Outpatient department / dispensary/Main pharmacy (if used by all patients) B Adult outpatient department / adult dispensary / adult clinic C Child outpatient department / child dispensary / child clinic D Antenatal / maternity clinic/MCH E ART / HIV/AIDS clinic G Private dispensing unit within a public health facility (High cost) L Laboratory (for RDT audit) Z Comprehensive Clinic / Other (specify the type in the space for audit comments –TSG 13 or NT 13)

www.ACTwatch.info Copyright © Population Services International (PSI). All rights reserved. TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

Sub-outlet 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form 4. Brand name code (Include weight and age information) [__|__] [__|__|__].[__]mg [__] 1 = Tablet [_____] 1 = Yes ______[__|__] 2 = Suppository [__|__|__].[__]mg [__] 0 = No

Product [__|__] 8 = Don’t know 3 = Granule [__|__|__].[__]mg [__] number If no, specify salt: [___] [__|__] [__|__] [______] 5. Manufacturer 6. Country of 7. Package size 8. Is product 9. Does 10. Amount sold/distributed in the last 7 days to individual 11. Stocked out at manufacture a fixed-dose product consumers (Record # of packages / tins described in Q7 OR any point in the past There are a total of combination have the record the total # of tablets / suppositories / granule packs sold) 3 months? (FDC) AMFm [___|___|___|___] logo? This outlet sold [___|___|___|___] packages/ tins in the last 7 1 = Yes tablets/ suppositories/ 1 = Yes days 0 = No granule packs in each: 0 = No 1 = Yes 8 = Don’t know OR 8 = Don’t 0 = No 1 = Package know 8 = Don’t This outlet sold [___|___|___|___] tablets/ suppositories or 2 = Pot/tin know [___] granule packs in the last 7 days

[___] [__|__|__] [___] [___] Not applicable = 9995; Refused = 9997; Don’t know = 9998 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments Do not read list. For the outlet’s most recent wholesale purchase Circle ALL responses given [___|___|___] tablets, suppositories or granule [___|___|___|___] Profitable A packs tablets, suppositories or granule packs Recommended by the government B cost an individual customer cost Low price C Customer demand or preference D [___|___|___|___] . [___|___] K [___|___|___|___|___|___] . [___|___] K Positive brand reputation E Often prescribed by doctors F Most effective for treating malaria G Free = 0000.00 Free = 000000.00 Don’t know X Refused = 9997.00 Refused = 999997.00 Other Z Don’t know = 9998.00 Don’t know = 999998.00 specify [______]

111 TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub- 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form 4. Brand name outlet (Include weight and age information) code [__|__] [__|__|__].[__]mg [__] 1 = Tablet 1 = Yes [_____] [__|__] 2 = Suppository [__|__|__].[__]mg [__] 0 = No ______[__|__] 8 = Don’t know 3 = Granule [__|__|__].[__]mg [__] Product If no, specify salt: number [___]

[__|__] [__|__] [______] 5. Manufacturer 6. Country of 7. Package size 8. Is product 9. Does 10. Amount sold/distributed in the last 7 days to individual 11. Stocked out at manufacture a fixed-dose product consumers (Record # of packages / tins described in Q7 OR any point in the past There are a total of combination have the record the total # of tablets / suppositories / granule packs sold) 3 months? (FDC) AMFm [___|___|___|___] logo? This outlet sold [___|___|___|___] packages/ tins in the last 7 1 = Yes tablets/ suppositories/ 1 = Yes days 0 = No granule packs in each: 0 = No 1 = Yes 8 = Don’t know OR 8 = Don’t 0 = No 1 = Package know 8 = Don’t This outlet sold [___|___|___|___] tablets/ suppositories or 2 = Pot/tin know [___] granule packs in the last 7 days

[___] [__|__|__] [___] [___] Not applicable = 9995; Refused = 9997; Don’t know = 9998 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments Do not read list. For the outlet’s most recent wholesale purchase Circle ALL responses given [___|___|___] tablets, suppositories or granule [___|___|___|___] Profitable A packs tablets, suppositories or granule packs Recommended by the government B cost an individual customer cost Low price C Customer demand or preference D [___|___|___|___] . [___|___] K [___|___|___|___|___|___] . [___|___] K Positive brand reputation E Often prescribed by doctors F Most effective for treating malaria G Free = 0000.00 Free = 000000.00 Don’t know X Refused = 9997.00 Refused = 999997.00 Other Z Don’t know = 9998.00 Don’t know = 999998.00 specify [______] Tablet Audit Sheet [__|__] of [__|__] 112 TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub- 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form 4. Brand name outlet (Include weight and age information) code [__|__] [__|__|__].[__]mg [__] 1 = Tablet 1 = Yes [_____] [__|__] 2 = Suppository [__|__|__].[__]mg [__] 0 = No ______[__|__] 8 = Don’t know 3 = Granule [__|__|__].[__]mg [__] Product If no, specify salt: number [___]

[__|__] [__|__] [______] 5. Manufacturer 6. Country of 7. Package size 8. Is product 9. Does 10. Amount sold/distributed in the last 7 days to individual 11. Stocked out at manufacture a fixed-dose product consumers (Record # of packages / tins described in Q7 OR any point in the past There are a total of combination have the record the total # of tablets / suppositories / granule packs sold) 3 months? (FDC) AMFm [___|___|___|___] logo? This outlet sold [___|___|___|___] packages/ tins in the last 7 1 = Yes tablets/ suppositories/ 1 = Yes days 0 = No granule packs in each: 0 = No 1 = Yes 8 = Don’t OR 8 = Don’t 0 = No know 1 = Package know 8 = Don’t This outlet sold [___|___|___|___] tablets/ suppositories or 2 = Pot/tin know granule packs in the last 7 days [___] [___] [__|__|__] [___] [___] Not applicable = 9995; Refused = 9997; Don’t know = 9998 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments Do not read list. For the outlet’s most recent wholesale purchase Circle ALL responses given [___|___|___] tablets, suppositories or granule [___|___|___|___] Profitable A packs tablets, suppositories or granule packs Recommended by the government B cost an individual customer cost Low price C Customer demand or preference D [___|___|___|___] . [___|___] K [___|___|___|___|___|___] . [___|___] K Positive brand reputation E Often prescribed by doctors F Most effective for treating malaria G Free = 0000.00 Free = 000000.00 Don’t know X Refused = 9997.00 Refused = 999997.00 Other Z Don’t know = 9998.00 Don’t know = 999998.00 specify [______] Tablet Audit Sheet [__|__] of [__|__] 113 NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & OTHERS OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub- 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form outlet code [__|__] [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] 1 = Syrup 1 = Yes [_____] [__|__] 2 = Suspension [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] 0 = No ______3 = Liquid inj. 8 = Don’t know [__|__] 4 = Powder inj. [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] Product 5 = Drops number If no, specify salt: (Note: no mL recorded for powder 6 = Other (specify) [______] [__|__] injection) [______] [__|__] [___] 4. Brand name 5. Manufacturer 6. Country of 7. Package size 9. Does this 10. Amount sold/ distributed 11. Stocked out at (Include weight and age information) manufacture product have in the last 7 days to any point in the There are a total of the AMFm individual consumers past 3 months? logo? [___|___|___|___].[__] mL This outlet sold 1 = Yes (or mg for powder 1 = Yes 0 = No injections) in each: 0 = No [___|___|___|___] bottles, 8 = Don’t 1 = Bottle 8 = Don’t ampoules or vials in the know last 7 days 2 = Ampoule/vial know

Refused = 9997; Don’t know = 9998 [__|__|__] [___] [___] [___] 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments For the outlet’s most recent wholesale purchase: Do not read list. Circle ALL responses given [___|___|___] [___|___|___|___] bottles ampoules or vials bottles, ampoules or vials Profitable A

cost an individual customer cost Recommended by the government B Low price C [___|___|___|___] . [___|___] K [___|___|___|___|___|___] . [___|___] K Customer demand or preference D Positive brand reputation E Often prescribed by doctors F Free = 0000.00 Free = 000000.00 Most effective for treating malaria G Refused = 9997.00 Refused = 999997.00 Don’t know X Don’t know = 9998.00 Don’t know = 999998.00 Other Z specify [______] Non-Tablet Audit Sheet [___|___] of [___|___] www.ACTwatch.info Copyright © Population Services International (PSI). All rights reserved. NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & OTHERS OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub-outlet 1. Generic name 2. Strength 2a. Is this base strength? 3. Dosage form code [__|__] [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] 1 = Syrup [_____] 1 = Yes ______[__|__] 2 = Suspension [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] 0 = No 3 = Liquid inj. 8 = Don’t know Product [__|__] 4 = Powder inj. [__|__|__|__].[__]mg/[__|__|__].[__]mL [__] number 5 = Drops If no, specify salt: [__|__] (Note: no mL recorded for powder injection) 6 = Other (specify) [______] [______] [__|__] [___] 4. Brand name 5. Manufacturer 6. Country of 7. Package size 9. Does this 10. Amount sold/ distributed 11. Stocked out at (Include weight and age information) manufacture product have in the last 7 days to any point in the There are a total of the AMFm individual consumers past 3 months? logo? [___|___|___|___].[__] mL This outlet sold 1 = Yes (or mg for powder 1 = Yes 0 = No injections) in each: 0 = No [___|___|___|___] bottles, 8 = Don’t 1 = Bottle 8 = Don’t ampoules or vials in the know last 7 days 2 = Ampoule/vial know

Refused = 9997; Don’t know = 9998 [__|__|__] [___] [___] [___] 12. Retail selling price 13. Wholesale purchase price 14. Why do you stock this medicine [SHOW PRODUCT]? 15. Comments For the outlet’s most recent wholesale purchase: Do not read list. Circle ALL responses given [___|___|___] [___|___|___|___] bottles ampoules or vials bottles, ampoules or vials Profitable A

cost an individual customer cost Recommended by the government B Low price C [___|___|___|___] . [___|___] K [___|___|___|___|___|___] . [___|___] K Customer demand or preference D Positive brand reputation E Often prescribed by doctors F Most effective for treating malaria G Free = 0000.00 Free = 000000.00 Don’t know X Refused = 9997.00 Refused = 999997.00 Don’t know = 9998.00 Don’t know = 999998.00 Other Z specify [______] Non-Tablet Audit Sheet [___|___] of [___|___] 115 OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

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

1 = Yes go to A17 [___] 0 = No go to Section 3: Diagnostic Audit 8 = Don’t know go to Section 3: Diagnostic Audit

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

1 = Yes, specify [______] [______]

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

[______] [______]

[______] [______]

0 = No

Interviewer: Go to Section 3: Diagnostic Audit

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

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

1 = Yes [___] 0 = No 8 = Don’t know

D2. Does this outlet/facility have a sharps container, also called a sharps disposal box or safety box, available today for staff to use?

1 = Yes [___] 0 = No 8 = Don’t know

D3. Is malaria microscopic testing available here today?

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

D4. How many people were tested for malaria at this facility/outlet using microscopy within the past 7 days?

9998 = Don’t know [___|___|___|___] D5. What is the total cost for a microscopic test for malaria for an adult: [___|___|___|___] . [___|___] K

Free = 0000.00; NA =9995.00; Refused = 9997.00; Don’t know=9998.00

D6.

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

Free = 0000.00; NA = 9995.00; Refused = 9997.00; Don’t know=9998.00

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

Are malaria RDTs available here today?

[___] 1 = Yes go to D8 0 = No go to D9 Don’t know ask to speak with a respondent who has this information

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

 SD Bioline, SD Malaria Antigen, U-Test Malaria  Wondfo One Step, Nova Test  First Response, ParaCheck, CareStart

Proceed to the RDT audit.

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

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

In health facilities complete the Sub-outlet Code as well as the Product Number for each RDT audited. Sub-outlet codes are listed on page 3.

117 RAPID DIAGNOSTIC TEST AUDIT SHEET (RDT) OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___] Sub-outlet 1. Brand name 2. Antigen test 3. Parasite species 4. Manufacturer 5. Country of 6. Lot Number code Manufacture (circle ALL that apply) (circle ALL that apply)

[_____] Not indicated Z Not indicated Z

HRP2 A Pf A Product number pLDH B Pv B

Aldolase C Po C [__|__] pm D

pan E vom/Pvom F other G Specify [______] Not indicated = 998 7. Number of tests 8. Has this test been 9a. Do you or other staff use this brand 10a. Does this facility/outlet 11. Wholesale purchase price 12. Comments sold/ distributed stocked out at any of RDT to test clients here at this provide this brand of RDT for For the outlet’s most recent wholesale /used in the last 7 point in the past 3 facility/outlet? clients to take away for testing purchase: days to individual months? somewhere else? consumers 1 = Yes (Record total # of 1 = Yes 0 = No go to 10a 1 = Yes [___|___|___|___] tests tests) 0 = No 8 = Don’t know go to 10a 0 = No go to 11 This outlet sold or 8 = Don’t know 8 = Don’t know go to 11 cost distributed [___] [___] [___|___|___|___|___]. [___|___] K

9b. If yes, what is the total cost for an [___|___|___] tests [___] adult to have a test conducted with this 10b. If yes, what is cost of this in the last 7 days RDT, including RDT cost and service fee? RDT for an adult? Free = 00000.00 Refused = 997 ; [___|___|___|___] . [___|___] K [___|___|___|___] . [___|___] K NA = 99995.00 Don’t know=998 Refused = 99997.00 9c. If yes, what is the total cost for a 10c. If yes, what is the cost of this Don’t know=99998.00 child under the age of five to have a test RDT for a child under the age of conducted with this RDT, including RDT five? cost and service fee? [___|____|___|___] . [___|___] K [___|___|___|___] . [___|___] K Free = 0000.00; NA = 9995.00; Refused = 9997.00; Don’t know=9998.00

RDT Audit Sheet [___|___] of [___|___]

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

Sub-outlet 1. Brand name 2. Antigen test 3. Parasite species 4. Manufacturer 5. Country of 6. Lot Number code Manufacture (circle ALL that apply) (circle ALL that apply)

[_____] Not indicated Z Not indicated Z

HRP2 A Pf A Product number pLDH B Pv B

Aldolase C Po C [__|__] pm D

pan E vom/Pvom F other G Specify [______] Not indicated = 998 7. Number of tests 8. Has this test been 9a. Do you or other staff use this brand 10a. Does this facility/outlet 11. Wholesale purchase price 12. Comments sold/ distributed stocked out at any of RDT to test clients here at this provide this brand of RDT for For the outlet’s most recent wholesale /used in the last 7 point in the past 3 facility/outlet? clients to take away for testing purchase: days to individual months? somewhere else? consumers 1 = Yes (Record total # of 1 = Yes 0 = No go to 10a 1 = Yes [___|___|___|___] tests tests) 0 = No 8 = Don’t know go to 10a 0 = No go to 11 This outlet sold or 8 = Don’t know 8 = Don’t know go to 11 cost distributed [___] [___] [___|___|___|___|___]. [___|___] K

9b. If yes, what is the total cost for an [___|___|___] tests [___] adult to have a test conducted with this 10b. If yes, what is cost of this in the last 7 days RDT, including RDT cost and service fee? RDT for an adult? Free = 00000.00 Refused = 997 ; [___|___|___|___] . [___|___] K [___|___|___|___] . [___|___] K NA = 99995.00 Don’t know=998 Refused = 99997.00 9c. If yes, what is the total cost for a 10c. If yes, what is the cost of this Don’t know=99998.00 child under the age of five to have a test RDT for a child under the age of conducted with this RDT, including RDT five? cost and service fee? [___|____|___|___] . [___|___] K [___|___|___|___] . [___|___] K Free = 0000.00; NA = 9995.00; Refused = 9997.00; Don’t know=9998.00

RDT Audit Sheet [___|___] of [___|___]

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RDT stock outs

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

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

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

1 = Yes, specify [______] [___] [______] [______] 0 = No D11. Does this facility/outlet provide medicines or prescription for medicines?

1 = Yes go to Section 4: Provider Module 0 = No Confirm response in S3 and S4 is not equal to 1 and outlet type recorded in [___] C7 is 21 or 22 ( “lab only”). Go to Section X: Ending the interview

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Section IV: Provider Module

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

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

1 = Yes |___] No ask to speak with the senior-most person at the outlet with 1 or more of these responsibilities

P2. For how many years have you worked in this outlet/facility? If less than 1 year, enter 01 [___|___] P3. What age are you today? Write age in years Don’t know=997 ; Refuse=998 [___|___|___]

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

1 = Male [___|___] 2 = Female

P5. What is the highest level of education you completed?

1 = No formal education 2 = Some primary school 3 = Completed primary school [___] 4 = Some secondary school 5 = Completed secondary school 6 = Some university/college 7 = Completed a university/college degree or diploma P6. Have you received any training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy? Include pre-service training and stand-alone workshops. [___] 1 = Yes 0 = No 8 = Don’t know P7. Have you received any training in the last 12 months on the national treatment guidelines for malaria? Include pre-service training and stand-alone workshops.

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

I. Pharmacist [___] II. Medical doctor [___] III. Clinical Officer [___] IV. Nurse / Nursing Officer [___] V. Midwife [___] VI. Laboratory technician / Lab assistant [___] VII. Pharmacy technician / Pharmacy assistant [___] VIII. Environmental Health Technician [___] IX. Medical assistant / Nursing Assistant / Nursing Aid [___] X. Community Health Assistant [___] XI. Community based distributor/Community Health Worker [___] XII. Other 1: specify [______] [___] 121

P9. Not including yourself, do any other people working in this outlet or facility have the following health qualifications? Read list. Record 1 for yes, 0 for no, 8 for don’t know I. Pharmacist [___] II. Medical doctor [___] III. Clinical Officer [___] IV. Nurse / Nursing Officer [___] V. Midwife [___] VI. Laboratory technician / Lab assistant [___] VII. Pharmacy technician / Pharmacy assistant [___] VIII. Environmental Health Technician [___] IX. Medical assistant / Nursing Assistant / Nursing Aid [___] X. Community Health Assistant [___] XI. Community based distributor/Community Health Worker [___] XII. Other 1: specify [______] [___] XIII. Other 2: specify [______] [___] XIV. Other 3: specify [______] [___]

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

P10. In your opinion, for treating uncomplicated malaria in adults, what is the most effective antimalarial medicine?

Generic or brand name Dosage form 01 = Tablet 04 = Syrup 95 = No preference 02 = Suppository 05 = Suspension 96 = Other (specify) 03 = Granule 06 = Liquid inj. 98 = Don’t know 07 = Powder inj.

[______] [___|___]

Don’t know = 98 If Other, specify [______]

P11. In your opinion, for treating uncomplicated malaria in children under five, what is the most effective antimalarial medicine?

Generic or brand name Dosage form 01 = Tablet 04 = Syrup 95 = No preference 02 = Suppository 05 = Suspension 96 = Other (specify) 03 = Granule 06 = Liquid inj. 98 = Don’t know 07 = Powder inj.

[______] [___|___]

Don’t know = 98 If Other, specify [______]

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P12. What antimalarial medicine for treating uncomplicated malaria in adults do you most often recommend to customers?

Generic or brand name Dosage form 01 = Tablet 04 = Syrup 95 = No preference 02 = Suppository 05 = Suspension 96 = Other (specify) 03 = Granule 06 = Liquid inj. 98 = Don’t know 07 = Powder inj.

[______] [___|___]

Don’t know = 98 If Other, specify [______]

P13. What antimalarial medicine for treating uncomplicated malaria in children under five do you most often recommend to customers?

Generic or brand name Dosage form 01 = Tablet 04 = Syrup 95 = No preference 02 = Suppository 05 = Suspension 96 = Other (specify) 03 = Granule 06 = Liquid inj. 98 = Don’t know 07 = Powder inj.

[______] [___|___]

Don’t know = 98 If Other, specify [______]

P14. Please name the first line medicine recommended by the government to treat uncomplicated malaria fever. Do not read list. Only one response allowed.

01 = Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem)……………… go to P15 02 = ACT...... go to P15 03 = ACTm...... go to P15 04 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop) 05 = Dihydroartemisinin Piperaquine 06 = Amodiaquine [___|___] 07 = Artemether 08 = Artemisinin 09 = Artesunate go to P17 10 = Chloroquine 11 = Quinine 12 = Sulfadoxine Pyrimethamine (Fansidar, SP, ) 96 = Other specify: [______] 98 = Don’t know

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P15. Please explain the government recommended treatment regimen for this drug for an adult (60kg) Read the following 3 questions to the provider

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___] If respondent has the medicine available use the package to complete the table below. Don’t know = 98 If the medicine is not available ask respondent to identify from prompt card. NA = 95 If identification not possible, ask respondent to recall medicine details.

Generic name Strength Brand name Manufacturer

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

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

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

[___|___] Is this drug a fixed-dose combination 1 = Yes 0 = No [___] 8 = Don’t know

P16. Please explain the government recommended treatment regimen for this drug for a 2-year old child (10kg) Read the following 3 questions to the provider

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___] If respondent has the medicine available use the package to complete the table below. Don’t know = 98 If the medicine is not available ask respondent to identify from prompt card. NA = 95 If identification not possible, ask respondent to recall medicine details. Generic name Strength Brand name Manufacturer Syrup/Suspension=94

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

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

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

[___|___] Is this drug a fixed-dose combination 1 = Yes 0 = No [___] 8 = Don’t know

P17. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

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

[___] 1 = Yes go to P18 0 = No go to P20 8 = Don’t know go to P20

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P18. Would you ever recommend a patient/customer take an antimalarial if a blood test using a rapid diagnostic test produced a negative test result for malaria? Read list. Record only one response.

1 = Yes, Sometimes [___] 2 = Yes, Always 3 = No, Never go to P20 8 = Don’t know go to P20

P19. Under what circumstances would you recommend a patient/customer take an antimalarial following a negative RDT test for malaria? Do not read list. Prompt “anything else” until the respondent is finished. Circle ALL responses given When they have signs/symptoms of malaria A

When they ask for antimalarial treatment B

When they are a child C

When they are an adult D

When they are a pregnant woman E

When I do not trust/believe the test F

When I know the patient/customer G

Other X Other (specify) [______] P20. What are the danger signs of severe illness in a child under 5? Do not read list. Prompt “anything else” until the respondent is finished.

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

Vomits everything B

Convulsions C

Lethargic or unconscious D

Aneamia/Paleness/lack of enough blood E

Body aches and pains/Joint pains F

Difficulty in breathing, Abnormal breathing G

Fever, Hot body, High temperature H

Don’t know Z

Other X Other (specify) [______]

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P21. What would you do if a 2-year old child was brought to this outlet with the danger signs of severe illness? Do not read list. Only one response allowed.

01 = Seek advice/help from someone in this facility 02 = Treat the child in this facility 03 = Refer to a health facility (clinic, hospital) with or without treating here [___|___] 04 = Refer to a non health facility outlet (not a clinic or hospital) with or without treating here 05 = Send them away/home without medicine 06 = Send them away/home with medicine 96 = Other – specify: [______] 98 = Don’t know

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

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Section V: Audit Tracking Sheet

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

THANK THE PROVIDER FOR THEIR PARTICIPATION

Return to C9 and record the final status of the interview and time completed. Then complete Section X: Ending

the Interview.

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Annex 7: Antimalarial Reference Table X3: Number of antimalarials audited Public Community ALL Private Private-not- General ALL Health Health Public / Not for-profit Pharmacy Drug Store Total Private for-profit retailer Outlets Facility Worker for-profit HF Urban 1,110 0 12 1122 100 962 321 93 1,476 2,598 Census 257 0 12 269 100 232 321 93 746 1,015 Booster 853 0 0 853 0 730 0 0 730 1,583 Rural 2,334 28 11 2373 6 10 43 34 93 2,466 Census 217 28 11 256 6 0 43 34 83 339 Booster 2,117 0 0 2117 0 10 0 0 10 2,127 TOTAL 3,444 28 23 3495 106 972 364 127 1,569 5,064 Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table X4: Quality-Assured (QAACT) and Non-Quality Assured ACTs Quality-Assured ACT (QAACT) QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Quality Assurance Policy. A QAACT is any ACT that appeared on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy* prior to data collection, or that previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. QAACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA)** – specifically Eurartesim® and Pyramax®. Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets Coarsucam Infant 2-11 Months# Artefan 20/120 35+ Kg Adults# Coarsucam Toddler 1-5 Years# Artemether + Lumefantrine <3 Years# Coarsucam Adult +14 Years# Artemether + Lumefantrine 3-8 Years# Winthrop Toddler 1-5 Years# Artemether + Lumefantrine 9-14 Years#^ Winthrop Adult +14 Years# Artemether + Lumefantrine >14 Years# Coartem 20/120 5-15 kg#^ Coartem 20/120 15-25 kg#^ Coartem 20/120 25-35 kg#^ Coartem 20/120#^ Coartem Dispersible 5-15 kg#^ Coartem Dispersible 15-25 kg#^ Combiart 20/120# Lumartem 5kg To <15 kg# Lumartem 35kg And Above# Lumerax#^ Non-Quality-Assured ACT ACTs that do not meet the definition of being quality-assured. Artemether Lumefantrine Tablets Artesunate Sulfadoxine Pyrimethamine Tablets Artefan 40/240#^ Asu-Denk Fixed Dose# Artefan 80/480# Asunate Denk 100 Plus Junior# Artemether 20mg Lumefantrine 120mg 5kg To <15kg (S Kant Healthcare)#^ Asunate Denk 200 Plus# Artemether 20mg Lumefantrine 120mg 15kg To <25kg (S Kant Healthcare)#^ Co-Arinate FDC Junior#^ Artemether 20mg Lumefantrine 120mg 25kg To <35kg (S Kant Healthcare)#^ Co-Arinate FDC Adult# Artemether 20mg Lumefantrine 120mg 35kg and above Novidar Plus Adult^ (S Kant Healthcare)#^ Artiglen Max#^ Artesunate Amodiaquine Suspension Co-Max Artemether 20mg Lumefantrine 120mg# Sunat-A# Lonart Dispersible#^ Dihydroartemisinin Piperaquine Trimethoprim Lonart Forte# D-Artepp# Lonart Tablets#^ Ridmal 40/320# Luma# Artemether Lumefantrine Suspension Lumet Forte# Artefan Suspension# Lumether 20mg/120mg#^ Artiglen Max# Shikarthem-L# Co-Artesiane Pediatric#^ Artemisinin Napthoquine Tablets L-Artem Dry Syrup# Arco# Lonart 20/120 Pediatric#^ Lumether# * http://www.theglobalfund.org/en/procurement/quality/pharmaceutical **http://www.ema.europa.eu/ ^ Product audited in the public sector # Product audited in the private sector

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Table X5: Nationally Registered ACTs

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

Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets Coarsucam Infant 2-11 Months# Artefan 20/120# Coarsucam Toddler 1-5 Years# Artefan 40/240#^ Coarsucam Adult +14 Years# Artemether + Lumefantrine <3 Years# Artesunate Sulfadoxine Pyrimethamine Tablets Artemether + Lumefantrine 3-8 Years# Asu-Denk Fixed Dose# Artemether + Lumefantrine 9-14 Years#^ Asunate Denk 100 Plus Junior# Artemether + Lumefantrine >14 Years# Co-Arinate FDC Junior#^ Artiglen Max#^ Co-Arinate FDC Adult# Co-Max Artemether 20mg Lumefantrine 120mg# Novidar Plus Adult^ Coartem 20/120 5-15 Kg#^

Dihydroartemisinin Piperaquine Tablets Coartem 20/120 15-25 Kg#^ Ridmal 40/320# Coartem 20/120 25-35 Kg#^ Artemisinin Napthoquine Tablets Coartem 20/120#^ Arco# Coartem Dispersible 5-15kg#^ Artemether Lumefantrine Suspensions Coartem Dispersible 15-25kg#^ Artefan Suspension# Lonart Dispersible#^ Artiglen Max# Lonart Forte# Lonart 20/120 Pediatric#^ Lonart Tablets#^ Lumether# Luma# Lumartem 5kg To <15kg# Lumartem 35kg And Above# Lumerax#^ Lumet Forte# Lumether 20mg/120mg#^ ^ Product audited in the public sector # Product audited in the private sector

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Table X6: Severe Malaria Treatment WHO recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria, with artemether or quinine injections as acceptable alternatives if parenteral artesunate is not available*. If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate, injectable artemether, and injectable arteether/artemotil. Quinine Liquid Injection (Manufacturer) Artemether Liquid Injection (Manufacturer) Linquine-F (Lincoln Pharmaceuticals LTD)#^ Armether Injection (Shalina Laboratories Pvt LTD)# Quinine Dihydrochloride (Wuhan Grand Pharmaceutical CO LTD)^ Artem Artemether Injection (Kunming Pharmaceutical Corp)#^ Quinine Dihydrochloride (Baxy Pharmaceuticals Mfg CO LTD)# Artemal-M (Plethico Pharmaceuticals LTD)# Quinine Dihydrochloride (Tejay Pharmaceuticals LTD)# Artemether Injectable (Syncom Formulations LTD)# Arteether/Artemotil Liquid Injection (Manufacturer) Artemether Injection (Anhui Chengshi Pharmaceutical CO LTD)# Betamotil (Ipca Laboratories LTD)# Artesiane 20 (Dafra Pharma GmbH)# Emal Injection (Themis Medicare Limited)# Artesiane 80 (Dafra Pharma GmbH)# Artesunate Powder Injection (Manufacturer) Gvither Forte Injection (Bliss GVS Pharma LTD)#^ S Kapaluartem Artemether Injection (Anhui Chengshi Artesun 30mg (Guilin Pharmaceutical CO LTD)^ Pharmaceutical CO LTD)# Artesun 60mg (Guilin Pharmaceutical CO LTD)#^ Artesun 120mg (Guilin Pharmaceutical CO LTD)#^ * Guidelines for the treatment of malaria, 2nd edition – revision 1.WHO. Geneva: 2010. ^ Product audited in the public sector # Product audited in the private sector

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Annex 8: RDT Reference

Table X7: Number of RDTs audited

Public Private Community Private Not-for- ALL Health for-profit Pharmacy Drug Store General retailer Health Worker Profit Facility Outlets Facility HF Urban 150 0 3 14 80 10 1 258 Census 30 0 3 14 19 10 1 77 Booster 120 0 0 0 61 0 0 181 Rural 361 15 2 2 0 11 0 391 Census 42 15 2 2 0 11 0 72 Booster 319 0 0 0 0 0 0 319 TOTAL 511 15 5 16 80 21 1 649 Source: ACTwatch Outlet Survey, Zambia, 2014.

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Table X8: RDT Brand Names and Manufacturers* Brand Name Manufacturer

Care Start#^ Access Bio Inc First Response#^ Premier Medical Corporation LTD Hexagon Malaria Combi# Human GmbH ICT Malaria Cassette Test#^ ICT Diagnostics Malaria (Pf/Pv) Poct# Intec Products Inc One Step Malaria (P.F.) Test# Blue Cross Bio-Medical (Beijing) CO LTD Paracheck#^ Orchid Biomedical Systems Parahit^ Span Diagnostics LTD Rapitest# Orem Access Bio Inc Sd Bioline#^ Standard Diagnostics Inc U-Test# Humor Diagnostics Vision Biotech# Vision Biotech (Pty) LTD Wondfo# Wondfo Biotech CO LTD * 649 RDTs were audited. No RDTs was missing brand name information (missing or don’t know) or were missing manufacturer name (missing or don’t know). ^ Product audited in the public sector # Product audited in the private sector

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Annex 9. Sampling Weights

Sampling weights were applied for analysis of the Zambia 2014 outlet survey data to account for variations in probability of selection as a result of the sampling design:

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

2) One-stage cluster sampling: Wards were selected from sampling frames within each domain with probability proportional to size. Within each ward, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted.

3) Booster sample – public health facilities (PHFs): The geographic area for the outlet census was extended to the constituency level for public health facilities. All public health facilities within constituencies in which the selected wards were located were included in the study.

4) Booster sample – pharmacies: The booster strategy for pharmacies consisted of a national census of all pharmacies.

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

1 푊푖 = M a × α ∑ Mα

Where:

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

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

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

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

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The ward sampling weights were applied to all other indicators in the report for all outlet types with the exception of:

1. Public health facilities: Given that PHFs were included in the sample through a constituency-wide census, the weights applied to PHFs for all indicators other than market share were calculated using the sampling weight

formula (Wi), where:

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

2. Pharmacies: All pharmacies were included in the study at national level. For consistency with a weighting approach tied to cluster population size, the weight applied to pharmacies for all indicators other than market share were

calculated using the sampling weight formula (Wi), where:

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

The population estimates used to select wards with PPS and to create sampling weights were obtained from the 2010 census of population and housing conducted by the Central Statistical Office of Zambia31. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size.

31CSO. (2011). 2010 Census Populuation and Housing Report (pp. 1-71). 135

Annex 10: Indicator Definitions

Table 1: Availability of antialarials, among all screened outlets

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

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

Denominator Number of outlets screened.

Calculation Numerator divided by denominator.

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

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

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

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

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

Denominator Number of outlets with at least 1 antimalarial audited.

Calculation Numerator divided by denominator.

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

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

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Table 3: Antimalarial market composition

Table 3 reports the distribution of outlet types among outlets with at least one antimalarial in stock on the day of the survey.

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

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

Calculation Numerator for each outlet type divided by the denominator.

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

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

Table 4: Price of antimalarials

Table 4a provides the median price of an adult equivalent treatment dose (AETD, see Annex 11) for select tablet formulation types of antimalarials across outlet types. The inter-quartile range (IQR) is provided as a measure of dispersion.

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

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

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

A. Table 4b reports the median price of one injection of an antimalarial that should be used for severe malaria treatment only (artemether injection, quinine injection). The inter-quartile range (IQR) is provided as a measure of dispersion. B. Table 4b also provides the median price of two pre-packaged QAACT therapies: pediatric appropriate for a 10kg child (2 years of age), and adult appropriate for a 60kg adult. The inter-quartile range (IQR) is provided as a measure of dispersion.

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

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

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

Table 5: Availability of malaria blood testing among antimalarial-stocking outlets

Table 5 reports the proportion of antimalarial-stocking outlets that had malaria blood testing available. Testing availability is reported among all outlets as well as among individual outlet types, all public outlets, and all private outlets. Availability is reported for any blood test as well as specific test types: microscopy and rapid diagnostic test (RDT).

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

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

Calculation Numerator divided by denominator.

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

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

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Table 6: Malaria blood testing market composition

Table 6 reports the distribution of outlet types among outlets with malaria blood testing available on the day of the survey.

Numerator By outlet type, the number of outlets with malaria blood testing available at the time of the survey visit, as confirmed by presence of at least one RDT recorded in the RDT audit section and/or reported availability of malaria microscopy services.

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

Calculation Numerator for each outlet type divided by the denominator.

Handling All outlets with non-missing values for the RDT audit or malaria microscopy availability questions missing values are included in the indicators. This includes outlets where the interview was not fully completed (partial interview).

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

Table 7: Price of malaria blood testing

A. Table 7 reports the median price of blood testing to consumers including any consultation or service fees. The inter-quartile range (IQR) is provided as a measure of dispersion.

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

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

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

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Table 8: Antimalarial market share

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

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

Denominator Total number of AETDs sold/distributed.

Calculation Numerator divided by denominator.

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

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

Table 9: Antimalarial market share across outlet type

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

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

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

Calculation Numerator divided by denominator.

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

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

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Table 10: Malaria blood testing market share

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

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

Denominator Total number of malaria blood tests sold/distributed.

Calculation Numerator divided by denominator.

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

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

Table 11: Malaria blood testing market share across outlet type

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

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

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

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

Calculation Numerator divided by denominator.

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

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

Table 12: Provider case management knowledge and practices

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Table 12 reports key indicators of provider case management knowledge and practices. These include referral practices for severe malaria; and self-reported practices for managing clients who test negative for malaria.

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

Denominator A. Referral: respondents who provided a response to this question, including “don’t know.” Note this denominator excludes providers located in a public or private health facility. B. Recommends antimalarials to test-negative clients: respondents who provided a response to this question, including “don’t know.” C. Circumstances for recommending an antimalarial: respondents who provided at least 1 response to this question, including “don’t know” (i.e. at least 1 variable in this series is non- missing). Note this denominator excludes providers who did not respond to the previous question about recommending antimalarials to test-negative clients with “yes always” or “yes sometimes.”

Calculation Numerator divided by denominator.

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

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

Table 13: Provider antimalarial treatment knowledge and practices

Table 13 reports key indicators of provider antimalarial treatment knowledge and practices. These include knowledge of the first-line treatment; knowledge of the first-line treatment dosing regimen for adults and children; citing ACT as most effective to treat malaria in adults and children; and citing ACT as most commonly recommended by the provider to manage malaria in adults and children.

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

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

Calculation Numerator divided by denominator.

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

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Annex 11. Adult Equivalent Treatment Dose (AETD)

Definition

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

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

Additional considerations:

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

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

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

Calculation

Information collected on drug strength and unit size as listed on the product packaging was used to calculate the total amount of each active ingredient found in the package. The number of AETDs in a unit was calculated.32 The number of AETDs in a monotherapy is calculated by dividing the total amount of active ingredient contained in the unit by the AETD (i.e. the total number of mg required to treat a 60kg adult). The number of AETDs for a combination therapy was calculated by dividing the total amount of the active ingredient that was used as the basis for the AETD by the AETD.

32 The unit is dependent on the drug dosage form. The unit for antimalarials in tablet, suppository, or granule form is the package. The unit for injectable antimalarials is the ampoule. The unit for syrup and suspension antimalarials is the bottle. 144

Table X9: Adult Equivalent Treatment Dose Definitions

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

Amodiaquine 1800mg WHO Model Formulary, 2008 Arteether / Artemotil 1050mg WHO Use of Antimalarials, 2001 Artemether 960mg WHO Use of Antimalarials, 2001 Artemether-Lumefantrine 480mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 [Artemether] Artemisinin-Naphthoquine 2400mg WHO Use of Antimalarials, 2001 [Artemisinin] Artesunate 960mg WHO Use of Antimalarials, 2001 Artesunate-Amodiaquine 600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 [Artesunate] Artesunate- Sulfadoxine- Pyrimethamine 600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 [Artesunate] Atovaquone-Proguanil 3000mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 [Atovaquone] Dihydroartemisinin- Piperaquine 360mg WHO Guidelines for the treatment of malaria 2nd edition, 2010 [Dihydroartemisinin] Manufacturer Guidelines Halofantrine 1398mg (Plaquenil – Sanofi Aventis) 1000mg Mefloquine WHO Model Formulary, 2008

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

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Annex 12: Antimalarial Volumes

Table X10: Antimalarial volumes, by outlet type Public ALL Private TOTAL AETDs sold or distributed in the Health Public / Not for- for-profit Pharmacy Drug Store General retailer ALL Outlets previous week by outlet type and Private Facility profit HF antimalarial type:* % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) 55904.3 64690.5 760.9 1320.6 1749.7 576.4 4407.5 69098.0 1. Any ACT (28524.5, 83284.0) (35400.0, 93981.0) - (556.7, 2084.6) (0.0, 3730.2) (160.7, 992.1) (2064.8, 6750.3) (39645.8, 98550.2) Artemether Lumefantrine (AL) 0.0 0.0 90.1 337.8 0.0 0.0 427.9 427.9  - - (0.0, 350.3) (72.3, 603.3) - - (125.4, 730.4) (125.4, 730.4) Artesunate Sulfadoxine 0.0 0.0 8.6 0.0 0.0 0.0 8.6 8.6 Pyrimethamine (ASSP) - - (0.0, 83.2) - - - (0.0, 83.2) (0.0, 83.2) 0.0 0.0 90.1 337.8 0.0 0.0 427.9 427.9 DHA PPQ - - (0.0, 350.3) (72.3, 603.3) - - (125.4, 730.4) (125.4, 730.4) 28139.0 33731.9 321.0 638.1 1496.4 554.3 3009.8 36741.7 Quality Assured ACT (QAACT) (6760.3, 49517.7) (11238.7, 56225.0) - (300.7, 975.5) (0.0, 3457.9) (80.7, 1027.9) (934.5, 5085.1) (14364.1, 59119.3) 28139.0 33731.9 308.3 621.6 1495.1 554.3 2979.4 36711.2 QA AL (6760.3, 49517.7) (11238.7, 56225.0) - (292.3, 950.9) (0.0, 3329.3) (80.7, 1027.9) (977.4, 4981.4) (14450.8, 58971.7) Non-quality-assured ACT 27765.3 30958.6 565.2 1036.8 254.5 22.1 1878.6 32837.2 (non-QA ACT) (13114.8, 42415.8) (15218.3, 46699.0) - (335.6, 1738.0) (70.1, 438.9) - (936.2, 2821.0) (17048.8, 48625.6) 28139.0 34980.7 656.2 1525.1 1689.8 510.8 4381.9 39362.6 Nationally Registered ACT (6760.3, 49517.7) (12332.9, 57628.5) - (746.7, 2303.5) (0.0, 3577.5) (98.1, 923.5) (2170.3, 6593.5) (16887.0, 61838.3) 2. Any non-artemisinin 32701.7 32819.9 749.8 1288.3 10382.3 5929.0 18349.4 51169.3 therapy (17244.1, 48159.3) (17324.5, 48315.2) - (353.6, 2222.9) (6497.3, 14267.2) (1274.0, 10584.0) (11967.4, 24731.4) (35315.7, 67022.8) 30133.2 30133.2 668.7 1195.3 10011.9 5865.6 17741.5 47874.8 Sulfadoxine-Pyrimethamine (15629.4, 44637.0) (15629.4, 44637.0) - (284.6, 2106.0) (6144.7, 13879.1) (1328.3, 10402.9) (11556.6, 23926.5) (32819.9, 62929.7) 2381.3 2473.4 25.0 1.5 0.0 0.0 26.6 2499.9 Oral Quinine (699.4, 4063.3) (753.8, 4192.9) (0.0, 81.4) (0.0, 5.5) - - - (774.6, 4225.2) 187.2 213.3 8.2 0.0 0.0 0.0 8.2 221.5 Quinine IV/IM (0.0, 382.8) (16.2, 410.4) (0.0, 33.3) - - - (0.0, 30.1) (24.4, 418.6) 3. Oral artemisinin 51.8 51.8 7.7 3.6 14.4 0.0 25.7 77.6 monotherapy (0.0, 148.2) (0.0, 148.2) (0.0, 20.1) (0.0, 14.6) - - (0.0, 65.4) (0.0, 169.5) 4. Non-oral artemisinin 331.3 331.3 55.2 0.0 0.0 0.0 55.2 386.5 monotherapy (0.0, 4372.5) (0.0, 4372.5) - - - - - (0.0, 5101.3) 331.3 331.3 55.2 0.0 0.0 0.0 55.2 386.5 Injectable artesunate (0.0, 4372.5) (0.0, 4372.5) - - - - - (0.0, 5101.3) 51.8 51.8 7.7 3.6 14.4 0.0 25.7 77.6 Injectable artemether (0.0, 148.2) (0.0, 148.2) (0.0, 20.1) (0.0, 14.6) - - (0.0, 65.4) (0.0, 169.5)

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Table X10: Antimalarial volumes, by outlet type Public ALL Private TOTAL AETDs sold or distributed in the Health Public / Not for- for-profit Pharmacy Drug Store General retailer ALL Outlets previous week by outlet type and Private Facility profit HF antimalarial type:* % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Injectable artemotil ------5. Any treatment for severe 570.3 596.4 71.1 3.6 14.4 0.0 89.2 685.6 malaria (0.0, 1230.8) (0.0, 1251.2) (0.0, 199.2) (0.0, 14.6) - - (0.0, 213.5) (0.0, 1453.6) 88989.1 97893.5 1698.9 2966.8 12147.7 6505.4 23318.8 121212.3 OUTLET TYPE TOTAL*** (54898.9, 123079.4) (61398.1, 134388.9) - (1482.6, 4451.0) (7341.5, 16953.8) (1817.3, 11193.6) (15854.6, 30783.0) (84386.1, 158038.5) * A total of 18,804 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation.  At the time of the 2014 ACTwatch outlet survey artemether lumefantrine was Zambia's first line treatment for uncomplicated malaria. A total of 1,354 antimalarials were audited in the census clusters. Of these, 245 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Zambia, 2014.

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