Actwatch Study Reference Document Benin Outlet Survey 2016

Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document Benin Outlet Survey 2016

www.ACTwatch.info Copyright © Population Services International (PSI). All rights reserved. Released March 13, 2017 Suggested citation ACTwatch Group and Association Béninoise Pour le Marketing Social (ABMS). (2017). ACTwatch Study Reference Document: Benin Outlet Survey 2016. Washington DC: PSI. Contact Dr. Megan Littrell Cyprien Zinsou ACTwatch Principal Investigator Director of Research, Monitoring and Evaluation PSI | 1120 19th St NW Suit 600 Association Béninoise Pour Le Marketing Social (ABMS) Washington DC 20036 Cotonou, Benin [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). ABMS RESEARCH AGENCY : Afrikonsulting Fieldwork Interviewers Cyprien Zinsou Sethson Kassegne Carin Agnikpe Ghylsain Guedegbe Jonas Urriche Dahounto Léonce Togan Aristide Hontonou Serge Gnansounou Romaric Houessou Ella Tchiakpe Olivier Agbohouto Fieldwork Supervisors Sylvie Dahounlinton Octave Moumpala Elodiane Ahouandogbo Corrine Daga Antoinette Gbokli Phanadrique Kpogbe Epiphane Abogounrin Pierre Gandji Ministry of Health Serge Mededa Stella Aniambossou Dr. Adjibabi Bello Cherifath Rémi Ekon Marine Sossoukpe Tayéwo Chacon Colombe Agonvi Zantan Moudachirou Biaou Toussaint Tchadoukpe ACTwatch Team Mistourath Sacca Sidi Barnabé Egoudjobi Andrew Andrada Martin Hounkanrin Erick Auko Innocentia Tekobo-Padonou Dr. Katie Bates Fieldwork Quality Controllers Arthur Adoutan Dr. Paul Bouanchaud Lisette Lawson Dieu-Donné Fatoke Dr. Desmond Chavasse Gloria Agoli-Agbo Christian Hounongbe Robyn Cyr Marc Adjeran Blandine Minhinto Kevin Duff Alimi Lodjo Aurlus Zossoungbo Keith Esch Sylvie Kpadé Irène Hedji Anna Fulton Francis Dadedji Imelda Dannou Tarryn Haslam Falilatou Amadou Fidel Dotou Catharine Hurley Rachidatou Chabi Gado Damien Gbamado Whitney Isenhower Makafui Do Ebuatsi Beth Kangwana Hervé Houdjohon Gloria Kigo Franck Béhanzin Aliza Lailari Marcellin Odoulami Dr. Megan Littrell Eudes Facia Julius Ngigi Tatiana D’almeida Dr. Kate O’Connell Ben Youssouf Bio Bangana Ricki Orford M’moutoua N’tcha N’da Stephen Poyer Marc Tchiagbon Dr. Justin Rahariniaina Halik Bababodi Gomina Christina Riley Foussénatou Bio Dr. Andria Rusk Amadou Samon Yero Julianna Smith Christiane Biao Rachel Thompson Ulrich Sodanssou Cynthia Whitman

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Table of Contents

LIST OF TABLES ...... 2 LIST OF FIGURES ...... 4 DEFINITIONS ...... 7 INTRODUCTION ...... 9 SUMMARY OF METHODS AND DATA COLLECTION ...... 10 SUMMARY OF KEY FINDINGS ...... 13 RESULTS SECTION A: CORE INDICATORS ...... 37 RESULTS SECTION B: RESULTS BY URBAN/RURAL LOCATION ...... 54 RESULTS SECTION C: RESULTS BY SURVEY YEAR...... 80 ANNEX 1: ACTWATCH BACKGROUND ...... 104 ANNEX 2: COUNTRY BACKGROUND...... 107 ANNEX 3: OUTLET SURVEY METHODS ...... 112 ANNEX 4: SAMPLED CLUSTERS ...... 116 ANNEX 5: DETAILED SAMPLE DESCRIPTION ...... 118 ANNEX 6: QUESTIONNAIRE ANNEX ...... 120 ANNEX 7: ANTIMALARIAL REFERENCE ...... 138 ANNEX 8: RDT REFERENCE ...... 143 ANNEX 9. SAMPLING WEIGHTS...... 145 ANNEX 10: INDICATOR DEFINITIONS ...... 146 ANNEX 11. ADULT EQUIVALENT TREATMENT DOSE (AETD) ...... 154 ANNEX 12: ANTIMALARIAL VOLUMES ...... 156

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List of Tables

Table S1: Key results, by outlet type, 2016 ...... 13

Results Section A: Core Indicators Table A1: Availability of antimalarials, among all screened outlets, by outlet type ...... 37 Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type ...... 39 Table A3: Types of quality-assured and non-quality assured ACTs audited in the public and private sector ...... 41 Table A4: Antimalarial market composition ...... 42 Table A5a: Price of tablet formulation antimalarials, by outlet type ...... 43 Table A5b: Price of pre-packaged antimalarials, by outlet type ...... 44 Table A6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type ...... 45 Table A7: Malaria blood testing market composition ...... 46 Table A8: Price of malaria blood testing for adults, by outlet type ...... 47 Table A9: Antimalarial market share ...... 48 Table A10: Antimalarial market share within outlet type ...... 49 Table A11: Malaria blood testing market share ...... 50 Table A12: Malaria blood testing market share, within outlet type ...... 51 Table A13: Provider case management knowledge and practices, by outlet type ...... 52 Table A14: Provider antimalarial treatment knowledge and practices, by outlet type ...... 53

Results Section B: Results by Urban/Rural Location Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural location ...... 54 Table B2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across urban/rural location ...... 59 Table B4: Antimalarial market composition, across urban/rural location ...... 64 Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location ...... 65 Table B5b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location ...... 68 Table B6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location ...... 69 Table B7: Malaria blood testing market composition, across urban/rural location ...... 70 Table B8: Price of malaria blood testing for adults, by outlet type, across urban/rural location ...... 71 Table B9.1: Antimalarial market share, within urban locations ...... 72 Table B9.2: Antimalarial market share, within rural locations ...... 73 Table B10.1: Antimalarial market share within outlet type, within urban locations ...... 74 Table B10.2: Antimalarial market share within outlet type, within rural locations ...... 75 Table B13: Provider case management knowledge and practices, by outlet type, across urban/rural location ...... 76 Table B14: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location .... 78

Results Section C: Results by Survey Year Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round ...... 80

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Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round ...... 85 Table C4: Antimalarial market composition, across survey round ...... 90 Table C5a: Price of tablet formulation antimalarials, by outlet type, across survey round ...... 91 Table C5b: Price of pre-packaged antimalarials, by outlet type, across survey round ...... 93 Table C6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round ...... 94 Table C8: Price of malaria blood testing for adults, by outlet type, across survey round ...... 96 Table C9: Antimalarial market share, across survey round ...... 98 Table C10: Antimalarial market share within outlet type, across survey round ...... 100 Table C14: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round ...... 102

Annexes Table X1. Sampled Clusters ...... 116 Table X2: Detailed sample description ...... 118 Table X3: Number of antimalarials audited ...... 138 Table X4: Quality-assured (QA ACT) and Non-quality Assured ACTs Audited ...... 139 Table X5: Nationally Registered ACTs ...... 141 Table X6: Severe Malaria Treatment Audited ...... 142 Table X7: Number of RDTs audited ...... 143 Table X8: RDT Brand Names and Manufacturers* ...... 144 Table X9: Adult Equivalent Treatment Dose Definitions ...... 155 Table X10: Antimalarial volumes, by outlet type, 2016 ...... 156

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List of Figures

Figure 1. 2016 Benin Outlet Survey Study Areas ...... 10 Figure 2. Survey flow diagram, Benin, 2016 ...... 12 Figure 3. Market composition: outlet type distribution, 2009-2016 ...... 15 Figure 4. Market composition: outlet type distribution, 2016 ...... 16 Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2009-2016 ...... 17 Figure 6. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2016 ...... 17 Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2009-2016 ...... 18 Figure 8. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2016 ...... 18 Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2009- 2016 ...... 19 Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2016 ...... 19 Figure 11. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2009-2016 ...... 20 Figure 12. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2016………………………………………………………………………………………………………………………………………………………………….20 Figure 13. Types of quality-assured ACT and non-quality assured ACT audited among public- and private-sector outlets, 2016 ...... 21 Figure 14. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2009-2016 ...... 22 Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2016………………………………………………………………………………………………………………………………………………………………….22 Figure 16. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2009-2016 ...... 23 Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2016 ...... 23 Figure 18. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2009-2016 ...... 24 Figure 19. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2016 ...... 24 Figure 20. Percentage of antimalarial-stocking outlets with chloroquine in stock on the day of the survey, 2009-2016 ...... 25 Figure 21. Percentage of antimalarial-stocking outlets with chloroquine in stock on the day of the survey, 2016 ...... 25 Figure 22. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2009-2016 ...... 26 Figure 23. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2016 ...... 26 Figure 24. Antimalarial market share, 2009-2016 ...... 27 Figure 25. Antimalarial market share within sector, 2009-2016 ...... 27 Figure 26. Antimalarial market share, 2016 ...... 28 Figure 27. Antimalarial market share, 2016 ...... 28 Figure 28. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2009-2016 ...... 29 Figure 29. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2016 ...... 29 Figure 30. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2009-2016 ...... 30 Figure 31. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2016 ...... 30

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Figure 32. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2009-2016 ...... 31 Figure 33. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2016 ...... 31 Figure 34. Malaria blood testing market share, 2016 ...... 32 Figure 35. Malaria RDT market share by manufacturer, within sector, 2016 ...... 32 Figure 36. Private-sector median price of antimalarial adult equivalent treatment dosages (AETD), 2009-2016 ...... 33 Figure 37. Private-sector median price of SP and QA ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured ACT (PP pediatric QA AL), 2016 ...... 33 Figure 38. Private-sector median price of SP and QA ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL (PP pediatric QA AL), 2016...... 34 Figure 39. Median private-sector prices of pre-packaged quality-assured AL (PP QA AL) and malaria RDT testing for children and adults, 2016 ...... 34 Figure 40. Percentage of providers who correctly stated the first-line treatment for uncomplicated malaria, 2009- 2016………………………………………………………………………………………………………………………………………………………………….35 Figure 41. Percentage of providers who correctly stated the first-line treatment for uncomplicated malaria, 2016 ... 35 Figure 42. Percentage of providers who correctly stated the first-line dosing regimen for uncomplicated malaria for a two-year-old child, 2009-2016 ...... 36 Figure 43. Percentage of providers who correctly stated the first-line dosing regimen for uncomplicated malaria for a two-year-old child, 2016 ...... 36 Figure X2. Map of Study Area ...... 117

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Acronyms

ABMS Association Béninoise pour Le Marketing Social ACT Artemisinin combination therapy AETD Adult equivalent treatment dose AL Artemether Lumefantrine AMFm Affordable Medicines Facility – malaria ASAQ Artesunate amodiaquine ASF Association de Santé Familiale ASSP Artesunate Sulfadoxine/Sulfamethoxypyrazine Pyrimethamine BMGF The Bill and Melinda Gates Foundation CHW Community Health Worker DHA PPQ Dihydroartemisinin piperaquine DHS The Demographic and Health Survey EMA European Medicines Agency GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria IM Intramuscular injection ICCM Integrated community case management IPTp Intermittent preventive treatment in pregnancy IV Intravenous injection MOH Ministry of Health NGO Non-governmental Organization NMCP National Malaria Control Program Oral AMT Oral artemisinin monotherapy PMI President’s Malaria Initiative Pf Plasmodium falciparum QA ACT Quality-assured artemisinin combination therapy QA RDT Quality-assured rapid diagnostic test RDT Rapid diagnostic test SP Sulfadoxine/Sulfamethoxypyrazine Pyrimethamine UK United Kingdom USAID United States Agency for International Development WHO World Health Organization

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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) provided malaria blood testing (microscopy or rapid diagnostic tests) but did 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 Benin, they were defined as arrondissement. Census Cluster An arrondissement 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, pharmacies and drug stores. The administrative unit for these outlet types was extended beyond arrondissement to the commune level. See Annex 9 for a detailed description of the booster sampling methods.

Malaria Product Indicator Definitions

Antimalarial Any medicine recognized by the World Health Organization (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) Artemisinin An antimalarial medicine that has a single active compound, where this active compound is monotherapy artemisinin or one of its derivatives.

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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 treatment The government-recommended treatment for uncomplicated malaria. Benin’s first-line treatment for uncomplicated malaria is artemether lumefantrine. Artesunate amodiaquine is recommended for infants under six months of age. Second-line The government-recommended second-line treatment for uncomplicated malaria. Benin’s treatment second-line treatment for uncomplicated malaria is artesunate amodiaquine. Nationally ACTs registered with Benin’s national drug authority and permitted for sale or distribution in registered ACTs Benin. Each country determines its own criteria for placing a drug on its nationally registered listing. Severe malaria WHO recommends intravenous or intramuscular artesunate as first-line treatment in the treatment management of severe falciparum malaria. If artesunate is not available, artemether in preference to quinine should be used for treating severe malaria cases. Rectal artesunate is 1 suitable for pre-referral treatment in children under 6 years of age.0F Quality-assured QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Artemisinin-Based (GFATM) Quality Assurance Policy. A QA ACT is any ACT that appeared on the GFATM’s Combination indicative list of antimalarials meeting the GFATM’s quality assurance policy prior to data Therapies (QA collection (see http://www.theglobalfund.org/en/healthproducts/qualityassurance/) or that ACTs) previously had C-status in an earlier GFATM quality assurance policy. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®. Quality-assured The “green leaf” logo indicates that a quality-assured ACT was acquired through ACT with the a co-payment mechanism administered by the GFATM (Affordable Medicines “green leaf” logo, Facility, malaria – or AMFm). or “co-paid ACTs”

Quality-assured QA RDTs are RDTs that comply with the GFATM’s Quality Assurance Policy. A QA RDT is any RDT RDT that appeared on the GFATM’s indicative list of RDTs meeting the GFATM’s quality assurance policy prior to data collection (see http://www.theglobalfund.org/en/healthproducts/qualityassurance/).

1 World Health Organization. (2015). Guidelines for the treatment of malaria, 3rd edition. Geneva: WHO. www.ACTwatch.info Page 8

Introduction

This country reference document is a detailed presentation of the 2016 national ACTwatch outlet survey (OS) conducted in Benin. The 2016 OS follows previous survey rounds conducted by ACTwatch in Benin in 2008, 2009, 2011, and 2014.

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.

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

 Case management guidelines stipulating confirmatory testing (RDT or microscopy) prior to treatment. ACT treatment should only be given to people with a positive malaria blood test. Diagnosis and treatment of uncomplicated malaria should be free for children under five and pregnant women, and cases of severe malaria should be referred for inpatient care. There is a focus on improvement of diagnostic accuracy, availability of medicine, and implementation of malaria interventions.  Efforts are underway to reform the accreditation process to better align private-sector practices with national policies and strategies. Private-sector collaboration is important given the growing numbers of private clinics and practitioners and will be expanded to ensure private and public sectors are in alignment as it is related to diagnostic and therapeutic practices, according to national policy.  Scale up of malaria diagnosis and treatment provided through a national network of community health workers.

The 2016outlet survey was the fifth round of ACTwatch outlet surveys conducted in Benin. This report presents trend lines with four data points: 1) the 2009 outlet survey, 2) the 2011 outlet survey, 3) the 2014 outlet survey, and 4) the most recent 2016 survey. These surveys are designed to monitor key antimalarial market indicators at the 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.

Report notes

 This document is a complete reference for the 2016 outlet survey. Please see annexes for information about the study context, design, implementation, and data analysis.  Table numbers are consistent across all sections and are reflective of table descriptions available in Annex 10.  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 five.  Malaria testing and treatment prices are reported in US dollars. Price information is captured in local currency and converted to US dollars based on exchange rates available from www.oanda.com using the historical 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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Summary of Methods and Data Collection

A nationally representative antimalarial outlet survey was conducted in Benin between July 5th and August 6th, 2016. A full description of research design and methods is provided in Annex 3. Briefly, a representative sample of arrondissements was selected from urban and rural domains (see sampled arrondissements 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 commune 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, pharmacies, and drug stores. Figure 1 below shows the distribution of selected clusters and booster areas.

Figure 1. 2016 Benin Outlet Survey Study Areas

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 2. A detailed sample summary is provided in Annex 5.

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

Data were collected using Android phones, except in pharmacies that had a large number of antimalarial products. In these pharmacies, paper questionnaires were used so that multiple interviewers could audit antimalarial products simultaneously to shorten the time required to finish the interview. Data collected using paper questionnaires was double data entered using Microsoft Access. All data cleaning and analysis were 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 arrondissement and commune levels. Standard indicators were constructed according to definitions applied across ACTwatch project countries (see Annex 10).

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Figure 2. Survey flow diagram, Benin, 2016

A Outlets enumerated* Interview interrupted [4] [7,488]

Outlets not Respondent not available [21] screened [228] Outlet closed at time of visit [5]

B Outlet closed permanently [48] Outlets screened** [7,260] Refused [150]

Outlets that did not meet screening criteria C [4,259]

Outlets that met screening criteria [3,001] 1 = [2,770] 2 = [223] Interview interrupted [1] 3 = [8] Outlets not Respondent not available [10] interviewed [35] Outlet closed at time of visit [1]

D Refused [23] Outlets interviewed*** [2,966] 1 = [2,738] 2 = [221] 3 = [7]

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Readiness for malaria case management N=298 N=145 N=93 N=536 N=262 N=176 N=5,622 N=632 N=6,724 N=7,260 Proportion of all screened outlets outlets* with: 94.7 68.4 40.1 69.4 37.9 4.7 0.0 0.0 1.3 5.3 Availability of malaria blood testing (90.1, 97.2) (47.3, 84.0) (24.5, 58.1) (56.9, 79.6) (30.0, 46.5) (1.3, 15.3) (0.0, 0.1) - (0.9, 1.7) (3.4, 8.2) 89.9 54.8 36.0 59.4 31.2 85.2 9.8 23.1 12.0 14.9 Availability of QA ACT (83.9, 93.8) (32.2, 75.7) (19.1, 57.3) (43.6, 73.4) (19.6, 45.8) (68.5, 93.8) (6.3, 14.7) (17.3, 30.2) (8.7, 16.4) (10.6, 20.3) Availability of QA ACT and malaria 89.0 49.7 22.0 53.7 18.2 4.7 0.0 0.0 0.6 3.8 blood testing (82.7, 93.2) (28.4, 71.2) (9.2, 43.8) (39.2, 67.6) (10.8, 29.0) (1.3, 15.3) (0.0, 0.1) - (0.3, 1.1) (2.1, 6.6) Availability of QA ACT, blood testing 1.0 5.1 14.1 5.7 13.0 80.5 9.7 23.1 11.4 11.1 not available (0.2, 3.6) (2.3, 11.0) (4.0, 39.2) (3.1, 10.2) (8.0, 20.4) (64.6, 90.3) (6.3, 14.7) (17.3, 30.2) (8.3, 15.6) (8.2, 14.9) Availability of national first-line severe 5.3 0.0 1.6 1.4 1.2 37.8 0.0 0.0 0.2 0.3 malaria treatment (artesunate IV/IM) (1.6, 16.6) - (0.5, 5.1) (0.5, 4.1) (0.4, 3.7) (24.8, 52.8) - - (0.1, 0.4) (0.2, 0.5) Readiness for malaria case management N=286 N=91 N=83 N=460 N=222 N=170 N=1,388 N=468 N=2,278 N=2,738 Proportion of antimalarial-stocking outlets  with: 98.1 83.7 38.5 78.3 42.8 5.0 0.1 0.0 3.6 12.7 Availability of malaria blood testing (94.9, 99.3) (61.9, 94.2) (21.8, 58.3) (67.9, 86.0) (34.6, 51.4) (1.4, 16.0) (0.0, 0.3) - (2.6, 5.1) (8.4, 18.6) 94.7 92.3 39.5 81.8 36.4 90.0 35.4 34.2 36.1 41.7 Availability of QA ACT (90.8, 97.0) (61.5, 98.9) (21.6, 60.7) (70.3, 89.5) (23.0, 52.2) (75.0, 96.5) (27.9, 43.8) (22.3, 48.4) (27.7, 45.5) (31.9, 52.1) Availability of QA ACT and malaria 93.7 83.7 24.1 73.9 21.2 5.0 0.0 0.0 1.8 10.5 blood testing (89.1, 96.4) (61.9, 94.2) (10.2, 46.9) (62.5, 82.8) (12.8, 33.1) (1.4, 16.0) (0.0, 0.3) - (1.0, 3.3) (6.2, 17.4) Availability of QA ACT, blood testing 1.0 8.6 15.4 7.9 15.2 85.1 35.4 34.2 34.3 31.1 not available (0.3, 3.8) (3.8, 18.6) (4.5, 41.7) (4.4, 13.6) (9.4, 23.6) (70.6, 93.1) (27.8, 43.7) (22.3, 48.4) (26.3, 43.3) (24.7, 38.3) Availability of national first-line severe 5.6 0.0 1.7 2.0 1.5 40.0 0.0 0.0 0.7 0.8 malaria treatment (artesunate IV/IM) (1.7, 17.4) - (0.5, 5.6) (0.7, 5.6) (0.5, 4.3) (26.4, 55.2) - - (0.4, 1.3) (0.5, 1.4)

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Table S1: Key results, by outlet type, 2016 Public Community Private Not ALL Private General Itinerant Drug ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Retailer Vendor Private1 Outlets1 Facility Worker Facility For-Profit Facility Readiness for intermittent preventive treatment in pregnancy (IPTp) Proportion of outlets with: Availability of SP, among all screened 73.9 0.0 25.4 20.6 21.1 53.6 8.1 46.1 12.1 12.6 outlets* (63.9, 81.9) - (12.8, 44.2) (14.9, 27.7) (13.9, 30.6) (37.0, 69.4) (6.4, 10.1) (19.2, 75.5) (8.1, 17.8) (8.9, 17.6) Availability of SP, among antimalarial- 77.8 0.0 27.9 28.3 24.6 56.6 29.4 68.1 36.4 35.5 stocking outlets (67.5, 85.6) - (14.2, 47.5) (20.7, 37.5) (16.2, 35.5) (39.5, 72.3) (19.8, 41.4) (42.9, 85.8) (22.1, 53.7) (22.5, 51.0)

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

% QA ACT market share ^ 49.2 93.3 36.5 49.1 27.2 9.7 29.9 13.2 23.8 29.3 Median Median Median Median Median Median Private-sector price** Median Median Median Median [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) [IQR] (N) $1.68 $4.72 $1.35 $1.35 $1.35 Median price for one QA ACT AETD n/a n/a n/a n/a (87) [1.01- n/a (tablets) [1.35-2.02] [2.95- [1.01- [1.35- 7.53](801) 1.68](719) 2.02](197) 2.02](1,825) $0.51 $0.83 $0.34 $0.42 $0.42 Median price for one SP AETD (tablets) n/a n/a n/a n/a [0.42-0.84] (52) [0.65- [0.34- [0.34- [0.34- n/a 0.84](251) 0.42](763) 0.51](586) 0.51](1,677) $0.51 $1.97 $0.51 $0.51 $0.51 Median price for one pre-packaged n/a n/a n/a n/a (16) (26) n/a pediatric QA artemether lumefantrine # [0.42-0.67] [1.18- [0.42- [0.51-0.84] [0.42- 1.97](157) 0.59](139) 0.67](340) $0.84 $1.18 $1.68 - $0.84 Median price for an adult RDT ## n/a n/a n/a n/a n/a [0.25-0.84] (52) [1.18-1.18] (8) (1) - [0.25-1.18] (61) 1 Inclusive of 32 screened, 30 antimalarial-stocking and 0 malaria RDT-stocking drug stores. * The denominator includes 65 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. ^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by QA ACT sale/distribution within distribution by the outlet/sector. # Pre-packaged QA artemether lumefantrine for a 10kg child. ## Price inclusive of consultation / service fees. ** The numbers of antimalarials captured in audit sheets with missing price information are as follows: 15QA ACT tablets, 14SP tablets,15QA artemether lumefantrine, 8adult RDT. Source: ACTwatch Outlet Survey, Benin, 2016.

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Figure 3. Market composition: outlet type distribution, 2009-2016 Among all outlets with at least one antimalarial in stock

2014 2016 2009 2011

N=2,383 N=626 N=890 N=1,501

1,2% 1,5%

4,7% 6,1% 3,2%

6,8% 11,4% 6,0% 4,0% 15,6%

16,2% 2,6% 9,4% 10,6%

0,6% 7,2%

1,4%

2,9% 1,4%

9,5% 0,4%

7,5% 0,3% 1,4% 0,9%

67,2% 58,7% 77,7% 63,6%

Public Health Facility Community Health Worker Private Not For-Profit Facility Private For-Profit Facility Pharmacy Drug Store General Retailer Itinerant Drug Vendor

The majority of antimalarial-stocking outlets over time were general retailers. In 2016, just over one in 10 antimalarial-stocking outlets were public-sector outlets, including public health facilities (3.2%), community health workers (CHWs) (6.0%), and private not for-profit facilities (2.6%), indicating a decrease from the previous survey round in 2014, when almost one in five antimalarial- stocking outlets (18.1%) were public-sector outlets. The proportion of itinerant drug vendors in the antimalarial market composition has increased more than three-fold since the 2011 outlet survey.

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Figure 4. Market composition: outlet type distribution, 2016 Among all outlets with at least one antimalarial in stock, across urban/rural location

Urban Rural

N=1,608 N=775

Public Health Facility

2,4% 4,9% 4,9% 4,1%

Community Health Worker 2,2%

10,1% 20,7%

6,3%

Private Not For-Profit Facility

1,9% 3,5%

0,1%

Private For-Profit Facility

9,1% Pharmacy

0,3%

Drug Store 1,1%

General Retailer

66,1% Itinerant Drug Vendor

62,3%

General retailers were the most common type of antimalarial-stocking outlet in both urban and rural areas, accounting for around two in three antimalarial-stocking outlets in both urban and rural areas (62.3% and 66.1%, respectively). The public sector accounted for a greater percentage of outlets with antimalarials in rural areas as compared to urban areas. In rural areas, 18.5% of antimalarial-stocking outlets were public sector compared to 8.7% in urban areas. Itinerant drug vendors contributed to a larger portion of the market composition in urban areas compared to rural areas, accounting for over one in five antimalarial-stocking outlets in urbans areas compared to less than 5% of antimalarial-stocking outlets in rural areas.

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Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2009-2016 Among all screened outlets, across survey rounds

100 90 80 70 60 50 40

30 Percentage Percentage of outlets 20 10 0 Public Health Community Private not-for- All Public Private for-profit Pharmacy General Retailer Itinerant Drug All Private Facility Health Worker profit Health Heath Facility Vendor Facility 2009 2011 2014 2016

Antimalarial availability remained high over time in public health facilities, and in 2016, 95% of public health facilities had antimalarials in stock at the time of the survey. One in three private-sector outlets were stocking antimalarials at the time of the 2016 survey, with availability highest among pharmacies at 94.6%. Antimalarial availability in the private sector remained relatively stable across survey rounds.

Figure 6. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2016 Among all screened outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage of outlets 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Antimalarial availability was similar in urban versus rural areas for public health facilities, private for-profit health facilities, and general retailers. Other outlet types are not shown because they are located primarily in rural areas (CHWs) or urban areas (itinerant drug vendors, pharmacies).

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Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

Nearly all antimalarial-stocking public health facilities (95%) and CHWs (96.2%) had ACTs in stock in 2016. Availability was much lower among private not-for-profit health facilities (48.7%). ACT availability in the private sector has increased in recent years to 40.8% in 2016. Notable increases were observed since 2009 and 2011 among general retailers (2009, 2.7%; 2011, 18.6%; 2014, 38.1%; 2016, 38.5%) and itinerant drug vendors (2009, 1.3%; 2011, 28.8%; 2014, 28.9%; 2016, 40.8%).

Figure 8. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage of outlets 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

ACT availability was similar in urban versus rural areas among public health facilities, private for-profit health facilities, and general retailers.

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Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

Nearly all antimalarial-stocking public health facilities (94.7%) and more than 90% of CHWs (93.9%) had quality-assured ACT (QA ACT) in stock in 2016. Availability was much lower among private not-for-profit health facilities (39.5%). QA ACT availability in the private sector increased to 36.1% in 2016. Notable increases were observed since 2009 and 2011 among general retailers (2009, 2.6%; 2011, 18.4%; 2014, 37.1%; 2016, 35.4%) and itinerant drug vendors (2009, 1.3%; 2011, 28.8%; 2014, 28.9%; 2016, 34.8%).

Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage of outlets 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

QA ACT availability was similar in urban versus rural areas among public health facilities and general retailers. Data trends suggest higher availability in rural versus urban areas for private for-profit health facilities (urban, 44.9%; rural, 30.5%).

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Figure 11. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

The availability of non-quality-assured ACT (non-QA ACT) among public health facilities has decreased since 2009 and remained very low over time. In the private sector, availability of non-QA ACT has remained high over time among pharmacies (>90%), and was 100% in 2016. In other private-sector outlet types, non-QA ACT availability remained relatively low over time (<20%); however, increases were observed in 2016 from very low levels during previous rounds to greater than 10% availability among general retailers and itinerant drug vendors. Overall, 14.8% of private-sector outlets were stocking non-QA ACT in 2016.

Figure 12. Percentage of antimalarial-stocking outlets with non-quality assured ACT in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage of outlets 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Non-QA ACT availability was similar in urban versus rural areas among public health facilities, private for-profit health facilities, and general retailers.

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Figure 13. Types of quality-assured ACT and non-quality assured ACT audited among public- and private-sector outlets, 2016 Among all ACT medicines audited, across sector, 2016

Non-quality assured Public Sector Quality-assured Public Sector Quality-assured Private Sector Non-quality assured Private Sector N=47 N=886 N=1,840 N=7,349 2,7% 0,2% 5,6% 4,1% 4,7% 16,8% 19,0%

0,9% 6,0% 1,0% 6,0% 61,5% 5,6% 72,5% 2,6% 0,4% 94,4% 95,9%

Artemether lumefantrine tablet Artemisinin napthoquine tablet Artemisinin piperaquine tablet

Artesunate amodiaquine tablet Artesunate mefloquine tablet Artesunate SP tablet Dihydroartemisinin piperaquine tablet Dihydroartemisinin piperaquine trimethoprim tablet Dihydroartemisinin SP tablet

Artemether lumefantrine non-tablet Dihydroartemisinin piperaquine non-tablet Dihydroartemisinin piperaquine trimethoprim non-tablet

QA ACTs available in both the public and private sectors were primarily artemether lumefantrine (AL) tablets (94.4% and 95.9%, respectively). Most non-QA ACTs audited in the public and private sector were tablet formulation, although non-tablet formulations accounted for 22% of non-QA ACTs in the public and private sectors. Although a variety of non-QA ACT generic combinations were audited, AL was the most commonly audited non-QA ACT in both the public (72.5% AL tablets, 16.8% AL non-tablets) and private (61.5% AL tablets, 19.0% AL non-tablets) sectors.

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Figure 14. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

Non-artemisinin therapies remained widely available in the public and private sectors over time, with the exception of very low availability among CHWs. While availability has decreased from nearly 100% in 2009 in the private sector, non-artemisinin therapies remained available in more than 90% of private-sector outlets in 2016 (94%).

Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Non-artemisinin therapy availability was similar in urban versus rural areas among public health facilities, private for-profit health facilities, and general retailers.

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Figure 16. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

SP is used for intermittent preventive therapy during pregnancy (IPTp) and is dispensed for IPTp during antenatal care clinic visits. SP availability among antimalarial-stocking public health facilities increased in 2016 to 77.8%, up from 45.9% in 2014.One in three private- sector outlets were stocking SP in 2016 (36.4%), and SP availability was greater than 50% among pharmacies (56.6%) and itinerant drug vendors (68.1%).

Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

SP availability was similar in urban versus rural areas among public health facilities and private for-profit health facilities. Data trends suggest higher availability in urban versus rural areas among general retailers (urban, 35%; rural, 18.3%).

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Figure 18. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Community Private not-for- All Public Private for-profit Pharmacy General Retailer Itinerant Drug All Private Facility Health Worker profit Health Heath Facility Vendor Facility 2009 2011 2014 2016

Oral quinine availability was high among public health facilities over time and was 92.3% in 2016. In the private sector, more than 40% of antimalarial-stocking outlets had oral quinine available in 2016 (42.5%), including more than 50% of private for-profit health facilities (70.5%), pharmacies (67.6%) and itinerant drug vendors (60.1%).

Figure 19. Percentage of antimalarial-stocking outlets with oral quinine in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Data trends suggest higher availability of oral quinine in urban versus rural areas in public health facilities (urban, 97.7%; rural, 85.4%) and general retailers (urban, 39%; rural, 25%).

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Figure 20. Percentage of antimalarial-stocking outlets with chloroquine in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

Chloroquine availability has remained highest in the private sector across survey rounds (>50%) and in 2016, 59.2% of all antimalarial- stocking private-sector outlets had chloroquine available. Availability was particularly high among general retailers (71.3%) as well as itinerant drug vendors (38.4%).

Figure 21. Percentage of antimalarial-stocking outlets with chloroquine in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Data trends suggest that chloroquine availability is higher in rural areas versus urban areas among private for-profit health facilities (rural, 18.1%; urban, 6.4%); and general retailers (rural, 81.1%; urban, 66.4%).

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Figure 22. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2009-2016 Among all antimalarial-stocking outlets, across survey rounds

100 90 80 70 60 50 40

Treatments for severe malaria include artesunate IV/IM, quinine IV/IM, or artemether IV/IM. 2015 availability of severe malaria treatment among public health facilities was 83.5% in 2016, up from 76.6% in 2014, and 81.7% among private not-for-profit health facilities, up from 67.1% in 2014. In the private sector, availability in 2016 was high among private for-profit health facilities (87.1%), up from 67.2% in 2014.

Figure 23. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2016 Among antimalarial-stocking outlets, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Severe malaria treatment availability was similar in urban versus rural areas among public health facilities, private for-profit health facilities, and general retailers.

www.ACTwatch.info Page 26 Figure 24. Antimalarial market share, 2009-2016 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial type and sector, across survey round

100 90 80 70 60 50 40 30 20

Percentage Percentage of market total share 10 0 Public Private Public Private Public Private 2009 2014 2016 Non-oral artemisinin monotherapy Oral artemisinin monotherapy Other non-artemisinin therapy SP Non QA ACT QA ACT

The private sector distributed the majority of antimalarials across all survey rounds (>70%) and in 2016, private-sector market share was 78.2%. The most commonly distributed antimalarials over time were non-artemisinin therapies, including SP, oral quinine, and chloroquine. In 2016, non-artemisinin therapy accounted for 55.8% of the market share (SP, 31.3%; oral quinine, 10.4%; chloroquine, 13.4%). QA ACT market share was 12.9% in 2009, and increased to 35.4% in 2014 and 29.3% in 2016. Non-QA ACT market share was 14.3% in 2016.

Figure 25. Antimalarial market share within sector, 2009-2016 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial type within sector, across survey round

100 90 80 70 60 50 40 30 20

Percentage Percentage of market total share 10 0 Public Private Public Private Public Private Public Private 2009 2011 2014 2016 Non-oral artemisinin monotherapy Oral artemisinin monotherapy Other non-artemisinin therapy SP Non QA ACT QA ACT

Within the public sector, QA ACT market share increased from 2009 (25.9%) and 2011 (49.1%) to 61.3% in 2014 and then decreased to 49.1% in 2016. In 2016, one in five antimalarials distributed by the public sector were non-artemisinin therapies other than SP (chloroquine or quinine). Within the private sector, QA ACT market share increased from 2009 (8%) and 2011 (17.5%) to 2014 (24.7%), and 2016 (23.8%). Non-QA ACT market share in the private sector increased from 14.2% in 2009 to 18.2% in 2016. Non-artemisinin therapies dominated the private sector market share across all survey rounds, accounting for more than half of antimalarials distributed by the private sector. In 2016, one in three antimalarials distributed by the private sector were SP treatments (31.5%) and one in four were other non-artemisinin therapies (26.2%, including chloroquine and quinine).

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Figure 26. Antimalarial market share, 2016 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and outlet type

100 90 80 70 60 50 40 30 20

Percentage Percentage of market total share 10 0 Public Private Private for-profit Pharmacy Drug Store General Retailer Itinerant Drug Health Facility Vendor Non-oral artemisinin monotherapy Oral artemisinin monotherapy Other non-artemisinin therapy SP Non QA ACT QA ACT

In 2016, the private sector accounted for more than three-fourths of the antimalarial distribution (78.2%). General retailers alone accounted for nearly half of all antimalarial distribution (47.7%), and retailers most often distributed non-artemisinin therapies. Market share was 15.2% for pharmacies, and pharmacies primarily distributed non-QA ACTs. Market share was 9.1% for itinerant drug vendors, and these providers typically distributed non-artemisinin therapies.

Figure 27. Antimalarial market share, 2016 Relative market volume (sale/distribution) of antimalarial AETDs, by antimalarial class and sector, across urban/rural location

100 90 80 70 60 50 40 30 20

Percentage Percentage of sector market share 10 0 Public Private Public Private Urban Rural Non-oral artemisinin monotherapy Oral artemisinin therapy Other non-artemisinin therapy SP Non QA ACT QA ACT

The private sector accounted for approximately three-fourths of the market share in both urban (78.8%) and rural areas (75.9%). Market share for QA ACT was higher in rural (37.8%) versus urban areas (27.1%). Non-QA ACT market share was higher in urban (16.5%) versus rural areas (6.9%). In both urban and rural areas, non-artemisinin therapies were the most commonly distributed antimalarials (urban, 56%; rural, 54.8%). Notably, chloroquine accounted for nearly one in four antimalarials distributed in rural areas (22.7%) compared with 11% in urban areas.

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Figure 28. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2009-2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey rounds

100 90 80 70 60 50 40

Nearly all antimalarial-stocking public health facilities had malaria blood testing (RDT or microscopy) available in 2016 (97.9%), an increase from 89.7% in 2014. Testing availability among antimalarial-stocking CHWs increased from 12.5% in 2014 to 81.6% in 2016. Among private for-profit health facilities, availability of malaria blood testing varied over time but remained relatively low across survey rounds (<50%) and was 39.2% in 2016. Malaria blood testing was generally not available among other private-sector outlet types across survey rounds.

Figure 29. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Among antimalarial-stocking outlets, malaria blood testing (RDT or microscopy) availability was similar in urban versus rural public health facilities. Among private for-profit health facilities, data trends suggest higher availability in urban (45.2%) versus rural areas (30.1%).

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Figure 30. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2009-2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey rounds

100 90 80 70 60 50 40

Availability of malaria microscopy among antimalarial-stocking public health facilities was 29.7% in 2016, up from 12.2% in 2014. Availability was generally low in private health facilities, including not-for-profit (11.5%) and for-profit facilities (17.9%).

Figure 31. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Availability of malaria microscopy was higher in urban versus rural public health facilities (urban, 48.5%; rural, 5.1%) and private for-profit health facilities (urban, 24.6%; rural, 7.7%).

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Figure 32. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2009-2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey rounds

100 90 80 70 60 50 40

Nearly all antimalarial-stocking public health facilities had malaria RDTs available in 2016 (97.6%), an increase from 87.5% in 2014. RDT availability among antimalarial-stocking CHWs increased from 12.5% in 2014 to 81.6% in 2016. Among private for-profit health facilities, availability of malaria RDTs increased in 2016 to 26.1% from 11.6% in 2014. Malaria RDTs were generally not available among other private-sector outlet types across survey rounds.

Figure 33. Percentage of antimalarial-stocking outlets with malaria RDTs available, 2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Availability of malaria RDTs was similar in urban versus rural areas among public health facilities and private for-profit health facilities.

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Figure 34. Malaria blood testing market share, 2016 Relative market volume (sale/distribution) of malaria blood testing using RDTs and microscopy, by type of test and outlet type

100 90 80 70 60 50 40 30

20 Percentage Percentage of market total share 10 0 Public Private Private for-profit Pharmacy Drug Store General Retailer Itinerant Drug Health Facility Vendor RDT Microscopy

In 2016, the public sector was responsible for over three-fourths of all malaria blood testing (82.2%). In the private sector, almost all tests were performed by private for-profit health facilities. The majority of blood tests were performed using malaria RDTs (78.4%).

Figure 35. Malaria RDT market share by manufacturer, within sector, 2016 Relative market volume (sale/distribution) of malaria RDTs by manufacturer and within sector

100

Percentage Percentage of withinsector market share 10

0 Public Private

Manufacturer not specified Other RDT manufacturer Access Bio ICT Diagnostics Standard Diagnostics The majority of RDT testing in the public and private sectors was performed using Standard Diagnostics RDTs. In the public sector, ICT Diagnostics RDTs composed nearly one-third of the market share (29.2%) compared with 5.4% in the private sector.

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Figure 36. Private-sector median price of antimalarial adult equivalent treatment dosages (AETD), 2009- 2016 Among all tablet formulation non-quality assured ACT (Non-QA ACT), quality-assured ACT (QA ACT), sulfadoxine pyrimethamine (SP), oral quinine, and chloroquine available in the private sector, across survey rounds, in 2009 US dollars to account for inflation

$10,50

$9,00 $8,52 $7,93 $7,50 $6,39 $6,00 $5,74

$4,69 $4,53 $4,32 $4,50 $3,96

2009 USD 2009 $3,83

$3,00 $2,06 $1,82 $1,51 $1,50 $0,65 $0,41$0,46$0,47 $0,32$0,50$0,46$0,46 $0,00 Non-QA ACT QA ACT SP Oral Quinine Chloroquine

2009 2011 2014 2016

The 2016 private-sector median price for one AETD of QA ACT was three times more expensive than one AETD of SP, but three times less expensive than one AETD of non-QA ACT. The price of one AETD has decreased over time for non-QA ACT, QA ACT, and SP. The largest decrease in price occurred with QA ACT, with the price of one AETD of QA ACT decreasing by 74% from 2009 to 2016.

Figure 37. Private-sector median price of SP and QA ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured ACT (PP pediatric QA AL), 2016 Among all tablet formulation SP, QA ACT, and PP pediatric QA AL (treatment for a two-year-old child), available in the private sector, by outlet type, in 2016 US dollars

$8,00

$7,00

$6,00

$5,00 $4,72

$4,00

2016 2016 USD $3,00 $1,97 $1,68 $2,00 $1,35 $1,35 $1,35 $0,83 $1,00 $0,51 $0,34 $0,42 $0,42 $0,51 $0,51 $0,51 $0,51 $0,00 SP AETD QA ACT AETD PP ped QA AL

Private for-profit Health Facility Pharmacy General Retailer Itinerant Drug Vendor All Private

Pre-packaged QA AL for a two-year old child was almost four times more expensive at pharmacies compared to all other private-sector outlet types. Pharmacies were also the most expensive outlet for a QA ACT AETD, at almost three times the price of the second most expensive outlet type (private for-profit health facilities). An SP AETD was less expensive at all outlet types compared to a QA ACT AETD and pre-packaged QA AL for a two-year-old child.

www.ACTwatch.info Page 33

Figure 38. Private-sector median price of SP and QA ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL (PP pediatric QA AL), 2016 Among all tablet formulation SP, QA ACT, and PP pediatric QA AL (treatment for a two-year-old child) available in the private sector, across urban/rural location, in 2016 US dollars

$2,25 $2,00 $1,75

$1,50 $1,35 $1,35 $1,25

$1,00 2016 2016 USD $0,75 $0,51 $0,42 $0,50 $0,42 $0,42 $0,25 $0,00 SP AETD QA ACT AETD PP ped QA AL

urban rural

The private-sector median price for SP AETD, QA ACT AETD, and pre-packaged pediatric QA AL was similar in urban and rural areas.

Figure 39. Median private-sector prices of pre-packaged quality-assured AL (PP QA AL) and malaria RDT testing for children and adults, 2016 Among all tablet formulation pediatric (treatment for a two-year-old child) and adult PP QA AL and malaria RDTs available in the private sector, in 2016 US dollars

$3,00

$2,50

$2,00

$1,50 $1,35 2016 2016 USD

$1,00 $0,84 $0,84

$0,51 $0,50

$0,00 Adult Child

PP QA AL RDT

For adults, the price of a pre-packaged QA AL treatment ($1.35) was higher than for RDT testing ($0.84), while for children, the price of testing ($0.84) was higher than the price of pre-packaged QA AL ($0.51).

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Figure 40. Percentage of providers who correctly stated the first-line treatment for uncomplicated malaria, 2009-2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey rounds

100 90 80 70 60 50 40

According to national policy in Benin, the first-line treatment for uncomplicated malaria is AL. Provider knowledge of the first-line treatment in public health facilities remained high over time (>90%) and was 94.2% in 2016. Nearly 90% of CHWs correctly stated the first-line treatment in 2016 (87.5%). In the private sector, fewer than half of providers stocking antimalarials could correctly name the first-line treatment in 2016 (43.3%). Knowledge was notably low among general retailers (39.8%) and itinerant drug vendors (37.9%), and higher among private for-profit health facilities (77.6%) and pharmacies (92.9%).

Figure 41. Percentage of providers who correctly stated the first-line treatment for uncomplicated malaria, 2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban/rural location

100 90 80 70 60 50 40

30 Percentage Percentage outlets of 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Provider knowledge about the first-line treatment for uncomplicated malaria was similar in urban versus rural areas among providers in public health facilities and private for-profit health facilities. Among general retailers, data trends suggest higher knowledge in urban (43.3%) versus rural areas (32.9%).

www.ACTwatch.info Page 35 Figure 42. Percentage of providers who correctly stated the first-line dosing regimen for uncomplicated malaria for a two-year-old child, 2009-2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey rounds 100 90 80 70 60 50 40 30 Percentage Percentage of outlets 20 10 0 Public Health Community Private not-for- All Public Private for-profit Pharmacy General Retailer Itinerant Drug All Private Facility Health Worker profit Health Heath Facility Vendor Facility 2009 2011 2014 2016

Provider knowledge of the first-line dosing regimen for a two-year-old child in public health facilities remained high in 2014 and 2016 (>90%) and was 91% in 2016. Among CHWs, 80.7% correctly stated the first-line dosing regimen in 2016. In the private sector, only one-third of providers stocking antimalarials could correctly name the first-line dosing regimen in 2016 (34.2%). Knowledge was notably low among general retailers (32.2%) and itinerant drug vendors (27.7%), and higher among private for-profit health facilities (60.9%) and pharmacies (65.6%).

Figure 43. Percentage of providers who correctly stated the first-line dosing regimen for uncomplicated malaria for a two-year-old child, 2016 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban/rural location 100 90 80 70 60 50 40 30 Percentage Percentage outletsof 20 10 0 Public Health Facility Private for-profit Heath Facility General Retailer

Urban Rural

Provider knowledge about the first-line dosing regimen for a two-year-old child was similar in urban versus rural areas among providers in public health facilities, private for-profit health facilities, and general retailers.

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Results Section A: Core Indicators

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=298 N=145 N=93 N=536 N=262 N=176 N=32 N=5,622 N=632 N=6,724 N=7,260 Any antimalarial at the time of survey 95.0 59.4 91.2 72.6 85.8 94.6 98.0 27.5 67.7 33.3 35.7 visit (90.3, 97.4) (40.2, 76.1) (79.8, 96.4) (58.1, 83.5) (77.6, 91.3) (76.5, 99.0) (90.5, 99.6) (21.9, 34.0) (38.8, 87.4) (30.2, 36.7) (32.1, 39.4) 90.2 57.1 44.4 62.2 40.4 94.6 91.1 10.6 27.6 13.6 16.5 Any ACT (84.2, 94.1) (36.3, 75.7) (27.4, 62.8) (47.8, 74.8) (30.4, 51.2) (76.5, 99.0) (80.2, 96.3) (7.1, 15.6) (20.5, 36.1) (10.3, 17.7) (12.4, 21.6) 89.7 57.1 41.5 61.6 39.1 94.6 88.1 10.5 27.6 13.5 16.3 Artemether lumefantrine (83.8, 93.6) (36.3, 75.7) (24.9, 60.3) (47.2, 74.3) (29.1, 50.0) (76.5, 99.0) (74.8, 94.9) (7.0, 15.5) (20.5, 36.1) (10.2, 17.6) (12.2, 21.5) 17.2 0.0 0.0 3.8 1.4 37.3 1.8 0.4 0.2 0.6 0.8 Artesunate amodiaquine (9.3, 29.6) - - (1.8, 7.7) (0.4, 4.1) (22.7, 54.6) (0.2, 12.6) (0.2, 0.8) (0.0, 2.1) (0.3, 1.0) (0.5, 1.3) 0.0 0.0 1.7 0.3 1.0 89.9 44.1 0.0 0.0 0.6 0.5 Artesunate SP - - (0.2, 11.0) (0.0, 2.0) (0.4, 2.4) (75.6, 96.2) (22.3, 68.4) (0.0, 0.1) - (0.3, 0.9) (0.3, 0.9) 0.0 0.0 1.3 0.2 1.6 93.3 43.9 0.0 0.0 0.6 0.6 Dihydroartemisinin piperaquine - - (0.3, 5.9) (0.0, 1.3) (0.6, 4.1) (78.0, 98.2) (22.2, 68.2) (0.0, 0.1) - (0.4, 1.0) (0.4, 0.9) 0.0 0.0 0.0 0.0 0.0 82.4 3.8 0.0 0.0 0.4 0.4 Other ACT β - - - - - (67.1, 91.5) (0.6, 20.7) - - (0.2, 0.7) (0.2, 0.7) 89.9 54.8 36.0 59.4 31.2 85.2 54.8 9.8 23.1 12.0 14.9 Quality-assured ACT (QA ACT) (83.9, 93.8) (32.2, 75.7) (19.1, 57.3) (43.6, 73.4) (19.6, 45.8) (68.5, 93.8) (30.4, 77.1) (6.3, 14.7) (17.3, 30.2) (8.7, 16.4) (10.6, 20.3) QA ACT with the “green leaf” 3.0 0.6 21.8 4.7 21.4 0.1 33.4 9.1 19.6 10.4 10.1 logo (0.9, 9.8) (0.1, 4.3) (8.0, 47.0) (2.0, 10.8) (13.2, 32.8) (0.0, 0.8) (13.7, 61.2) (5.8, 14.0) (14.1, 26.6) (7.3, 14.8) (7.2, 14.0) QA ACT without the “green leaf” 89.6 54.2 17.6 55.8 10.5 85.2 21.4 0.9 6.1 2.1 5.3 logo (83.6, 93.6) (31.7, 75.2) (8.9, 31.8) (40.8, 69.8) (6.2, 17.3) (68.5, 93.8) (7.0, 49.8) (0.6, 1.3) (3.4, 10.9) (1.7, 2.6) (3.6, 7.7) 89.4 54.8 36.0 59.3 30.8 84.7 54.8 9.7 23.1 12.0 14.8 QA artemether lumefantrine (83.5, 93.4) (32.2, 75.7) (19.1, 57.3) (43.5, 73.3) (19.3, 45.2) (68.3, 93.4) (30.4, 77.1) (6.3, 14.6) (17.3, 30.2) (8.7, 16.3) (10.6, 20.2) Non-quality assured ACT (non-QA 0.3 2.3 11.1 3.3 16.6 94.6 71.9 3.5 8.8 4.9 4.8 ACT) (0.1, 1.1) (0.4, 11.7) (5.2, 22.0) (1.4, 7.6) (11.4, 23.4) (76.5, 99.0) (42.7, 89.8) (2.0, 5.9) (5.2, 14.5) (3.3, 7.2) (3.4, 6.9) 89.4 55.7 26.2 58.1 27.8 94.3 70.2 5.6 16.1 7.7 10.7 Nationally registered ACT (83.5, 93.3) (35.4, 74.2) (15.0, 41.7) (44.7, 70.4) (20.7, 36.3) (77.0, 98.8) (41.4, 88.7) (3.7, 8.4) (10.9, 23.2) (5.9, 10.1) (8.0, 14.2)

www.ACTwatch.info Page 37

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=298 N=145 N=93 N=536 N=262 N=176 N=32 N=5,622 N=632 N=6,724 N=7,260 94.2 4.5 83.5 37.7 83.2 75.6 83.5 25.6 66.3 31.3 31.7 Any non-artemisinin therapy (89.5, 96.9) (0.8, 22.1) (63.3, 93.7) (28.5, 47.9) (74.6, 89.3) (54.0, 89.2) (58.1, 94.9) (20.7, 31.2) (37.0, 86.9) (28.7, 34.1) (29.0, 34.5) 73.9 0.0 25.4 20.6 21.1 53.6 61.5 8.1 46.1 12.1 12.6 SP (63.9, 81.9) - (12.8, 44.2) (14.9, 27.7) (13.9, 30.6) (37.0, 69.4) (38.6, 80.2) (6.4, 10.1) (19.2, 75.5) (8.1, 17.8) (8.9, 17.6) 87.7 2.3 73.9 33.2 60.5 63.9 62.3 9.4 40.7 14.1 15.3 Oral quinine (82.7, 91.3) (0.4, 11.7) (56.6, 86.0) (25.0, 42.6) (53.2, 67.4) (44.0, 80.0) (35.3, 83.3) (7.3, 12.2) (16.7, 70.1) (9.7, 20.2) (11.2, 20.4) 0.4 0.0 7.2 1.3 9.6 0.0 1.6 19.6 26.0 19.7 18.6 Chloroquine (0.1, 1.6) - (2.4, 19.6) (0.5, 3.5) (4.4, 19.4) - (0.2, 11.6) (12.7, 29.0) (17.0, 37.6) (13.2, 28.5) (12.8, 26.4) 0.2 0.0 3.3 0.6 2.9 14.7 5.5 0.6 5.8 1.2 1.2 Other non-artemisinin therapy ^ (0.0, 1.7) - (0.5, 18.0) (0.1, 3.1) (1.1, 7.3) (8.0, 25.4) (1.4, 18.5) (0.4, 0.9) (2.9, 11.4) (0.7, 1.9) (0.7, 1.8) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Oral artemisinin monotherapy ------6.8 0.0 30.0 6.6 25.4 72.9 29.9 0.2 0.0 1.4 1.7 Non-oral artemisinin monotherapy (2.5, 16.7) - (17.2, 46.8) (3.3, 12.8) (17.6, 35.1) (56.5, 84.7) (12.8, 55.5) (0.1, 0.7) - (1.0, 2.1) (1.2, 2.5) 79.3 4.5 74.5 32.9 74.7 73.0 66.0 0.5 0.0 3.3 5.0 Any treatment for severe malaria (69.5, 86.5) (0.8, 22.1) (56.1, 87.0) (24.3, 42.7) (65.4, 82.2) (56.9, 84.7) (42.2, 83.8) (0.2, 1.2) - (2.4, 4.5) (3.7, 6.9) 5.3 0.0 1.0 1.3 1.2 22.6 0.0 0.0 0.0 0.2 0.2 Artesunate IV/IM # (1.6, 16.6) - (0.2, 5.3) (0.4, 4.1) (0.4, 3.7) (13.6, 35.1) - - - (0.1, 0.3) (0.1, 0.4) 6.2 0.0 24.6 5.5 24.7 66.5 29.9 0.2 0.0 1.4 1.6 Artemether IV/IM (2.1, 16.7) - (12.7, 42.2) (2.5, 11.8) (17.1, 34.3) (51.5, 78.8) (12.8, 55.5) (0.1, 0.7) - (0.9, 2.0) (1.1, 2.4) 79.3 4.5 70.9 32.2 70.9 28.8 57.1 0.5 0.0 2.9 4.7 Quinine IV/IM (69.5, 86.5) (0.8, 22.1) (52.8, 84.2) (23.9, 41.9) (61.5, 78.9) (17.8, 42.9) (33.0, 78.3) (0.2, 1.2) - (2.1, 4.0) (3.4, 6.4) * The denominator includes 65 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other types of non-artemisinin therapy include amodiaquine, atovaquone proguanil, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria.

Source: ACTwatch Outlet Survey, Benin, 2016.

www.ACTwatch.info Page 38

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=286 N=91 N=83 N=460 N=222 N=170 N=1,388 N=468 N=2,278 N=2,738 95.0 96.2 48.7 85.7 47.1 100.0 38.5 40.8 40.8 46.2 Any ACT (91.1, 97.2) (78.3, 99.4) (31.0, 66.7) (77.7, 91.2) (35.9, 58.6) - (31.0, 46.6) (27.9, 55.2) (32.8, 49.2) (37.1, 55.5) 94.4 96.2 45.5 84.9 45.6 100.0 38.2 40.8 40.4 45.8 Artemether lumefantrine (90.7, 96.7) (78.3, 99.4) (28.1, 64.1) (76.6, 90.6) (34.3, 57.3) - (30.7, 46.4) (27.9, 55.2) (32.5, 48.9) (36.7, 55.2) 18.1 0.0 0.0 5.2 1.6 39.4 1.4 0.4 1.8 2.2 Artesunate amodiaquine (9.9, 30.8) - - (2.5, 10.4) (0.5, 4.7) (24.2, 57.0) (0.7, 2.7) (0.0, 3.5) (1.0, 3.0) (1.3, 3.6) 0.0 0.0 1.9 0.4 1.1 95.0 0.1 0.0 1.7 1.5 Artesunate SP - - (0.3, 12.0) (0.1, 2.8) (0.4, 2.8) (86.4, 98.3) (0.0, 0.5) - (1.1, 2.7) (1.0, 2.3) 0.0 0.0 1.5 0.3 1.9 98.7 0.1 0.0 1.8 1.6 Dihydroartemisinin piperaquine - - (0.3, 6.4) (0.1, 1.7) (0.7, 4.8) (96.7, 99.5) (0.0, 0.5) - (1.1, 2.9) (1.1, 2.4) 0.0 0.0 0.0 0.0 0.0 87.1 0.0 0.0 1.2 1.1 Other ACT β - - - - - (74.0, 94.2) - - (0.7, 2.1) (0.7, 1.8) 94.7 92.3 39.5 81.8 36.4 90.0 35.4 34.2 36.1 41.7 Quality-assured ACT (QA ACT) (90.8, 97.0) (61.5, 98.9) (21.6, 60.7) (70.3, 89.5) (23.0, 52.2) (75.0, 96.5) (27.9, 43.8) (22.3, 48.4) (27.7, 45.5) (31.9, 52.1) 3.2 1.0 23.9 6.5 25.0 0.1 33.2 28.9 31.3 28.3 QA ACT with the “green leaf” logo (0.9, 10.3) (0.1, 7.2) (9.0, 49.9) (2.8, 14.3) (15.5, 37.6) (0.0, 0.8) (25.7, 41.7) (17.1, 44.6) (23.0, 41.0) (21.6, 36.2) QA ACT without the “green leaf” 94.4 91.3 19.3 76.9 12.3 90.0 3.3 9.0 6.4 14.9 logo (90.3, 96.8) (63.0, 98.5) (9.9, 34.1) (64.8, 85.7) (7.3, 19.9) (75.0, 96.5) (2.3, 4.9) (6.9, 11.8) (5.0, 8.1) (10.6, 20.5) 94.2 92.3 39.5 81.6 35.9 89.5 35.1 34.2 35.9 41.4 QA artemether lumefantrine (90.4, 96.5) (61.5, 98.9) (21.6, 60.7) (70.2, 89.4) (22.7, 51.6) (74.9, 96.1) (27.5, 43.6) (22.3, 48.4) (27.5, 45.3) (31.7, 51.9) 0.3 3.8 12.1 4.6 19.3 100.0 12.7 13.0 14.8 13.6 Non-quality assured ACT (non-QA ACT) (0.1, 1.2) (0.6, 21.7) (5.6, 24.3) (1.8, 11.2) (13.3, 27.2) - (8.4, 18.9) (7.5, 21.6) (10.6, 20.3) (10.0, 18.2) 94.1 93.8 28.7 80.0 32.4 99.6 20.2 23.8 23.2 30.1 Nationally registered ACT (90.4, 96.5) (80.3, 98.2) (16.7, 44.7) (71.2, 86.7) (24.2, 41.9) (97.8, 99.9) (15.4, 26.2) (18.0, 30.8) (18.7, 28.4) (24.1, 36.9) 99.3 7.7 91.6 51.9 97.0 80.0 93.0 98.0 94.0 88.9 Any non-artemisinin therapy (97.8, 99.8) (1.1, 38.5) (76.5, 97.3) (37.6, 65.9) (91.1, 99.0) (56.9, 92.3) (89.6, 95.3) (91.4, 99.6) (90.1, 96.4) (82.2, 93.3) 77.8 0.0 27.9 28.3 24.6 56.6 29.4 68.1 36.4 35.5 SP (67.5, 85.6) - (14.2, 47.5) (20.7, 37.5) (16.2, 35.5) (39.5, 72.3) (19.8, 41.4) (42.9, 85.8) (22.1, 53.7) (22.5, 51.0) 92.3 3.8 81.1 45.7 70.5 67.6 34.3 60.1 42.5 42.9 Oral quinine (88.5, 94.9) (0.6, 21.7) (67.6, 89.8) (34.2, 57.7) (64.0, 76.3) (46.7, 83.2) (21.1, 50.5) (36.1, 80.1) (26.1, 60.7) (28.1, 59.0) 0.4 0.0 7.9 1.8 11.1 0.0 71.3 38.4 59.2 52.3 Chloroquine (0.1, 1.7) - (2.7, 21.0) (0.7, 4.6) (5.1, 22.6) - (54.7, 83.6) (19.0, 62.4) (39.9, 76.1) (37.8, 66.4) www.ACTwatch.info Page 39

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets* stocking: N=286 N=91 N=83 N=460 N=222 N=170 N=1,388 N=468 N=2,278 N=2,738 0.3 0.0 3.7 0.9 3.4 15.6 2.1 8.6 3.6 3.2 Other non-artemisinin therapy ^ (0.0, 1.8) - (0.6, 19.3) (0.2, 4.0) (1.3, 8.4) (8.6, 26.6) (1.3, 3.4) (5.7, 12.8) (2.1, 6.0) (1.9, 5.5) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Oral artemisinin monotherapy ------7.1 0.0 32.9 9.0 29.6 77.0 0.8 0.0 4.3 4.8 Non-oral artemisinin monotherapy (2.7, 17.5) - (18.1, 52.1) (4.3, 17.9) (20.5, 40.6) (61.0, 87.8) (0.3, 2.2) - (3.0, 6.0) (3.5, 6.6) 83.5 7.7 81.7 45.3 87.1 77.2 1.7 0.0 9.8 14.1 Any treatment for severe malaria (73.7, 90.1) (1.1, 38.5) (66.2, 91.1) (32.2, 59.0) (80.9, 91.5) (61.3, 87.8) (0.8, 3.7) - (7.3, 13.1) (10.8, 18.2) 5.6 0.0 1.1 1.9 1.5 23.9 0.0 0.0 0.5 0.6 Artesunate IV/IM # (1.7, 17.4) - (0.2, 5.8) (0.6, 5.6) (0.5, 4.3) (14.5, 36.8) - - (0.2, 0.9) (0.4, 1.1) 6.5 0.0 27.0 7.6 28.8 70.3 0.8 0.0 4.1 4.5 Artemether IV/IM (2.3, 17.4) - (14.0, 45.7) (3.4, 16.0) (19.9, 39.7) (55.5, 81.8) (0.3, 2.2) - (2.9, 5.8) (3.3, 6.2) 83.5 7.7 77.8 44.4 82.7 30.4 1.7 0.0 8.7 13.0 Quinine IV/IM (73.7, 90.1) (1.1, 38.5) (62.3, 88.1) (31.7, 57.9) (75.7, 88.0) (19.0, 44.9) (0.8, 3.7) - (6.4, 11.8) (9.9, 17.0) * 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 23 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other types of non-artemisinin therapy include amodiaquine, atovaquone proguanil, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A3: Types of quality-assured and non-quality assured ACTs audited in the public and private sector Quality-assured ACT Non-Quality Assured ACT ACT generic name and formulation Public Sector Private sector Public Sector Private Sector % (95% CI) % (95% CI) % (95% CI) % (95% CI) Proportion of all audited antimalarials: N audited=886 N audited=1,840 N audited=47 N audited=7,349 Tablet formulation: 94.4 95.9 72.5 61.4 Artemether lumefantrine (89.9, 96.9) (93.5, 97.4) (50.7, 87.2) (55.2, 67.2) 0.0 0.0 0.0 0.1 Artemisinin naphthoquine - - - (0.0, 0.3) 0.0 0.0 0.0 <0.1 Artemisinin piperaquine - - - (<0.1, <0.1) 5.6 4.1 0.0 0.4 Artesunate amodiaquine (3.1, 10.1) (2.6, 6.5) - (0.2, 0.7) 0.0 0.0 0.0 2.6 Artesunate mefloquine - - - (2.1, 3.3) 0.0 0.0 6.0 5.6 Artesunate SP - - (0.8, 34.9) (4.6, 7.0) 0.0 0.0 0.0 6.0 Dihydroartemisinin piperaquine - - - (4.9, 7.3) Dihydroartemisinin piperaquine 0.0 0.0 0.0 1.0 trimethoprim - - - (0.7, 1.4) 0.0 0.0 0.0 0.9 Dihydroartemisinin SP - - - (0.6, 1.4) Non-tablet formulation*: 0.0 0.0 16.8 19.0 Artemether lumefantrine - - (7.4, 33.7) (16.5, 21.8) 0.0 0.0 0.0 0.1 Artesunate amodiaquine - - - (0.0, 0.5) 0.0 0.0 0.0 0.0 Artesunate mefloquine - - - (0.0, 0.1) 0.0 0.0 4.7 2.7 Dihydroartemisinin piperaquine - - (1.1, 17.8) (2.1, 3.6) Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.2 trimethoprim - - - (0.1, 0.3) * Non-tablet ACTs were most commonly suspensions but also granules, syrups and suppositories. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A4: Antimalarial market composition Public Community Private Not ALL Private General Itinerant Drug ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Retailer Vendor Private Facility Worker Facility For-Profit Facility antimalarial in stock on the day of the survey:* % % % % % % % % % % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 3.2 6.0 2.6 11.8 7.2 1.4 0.4 63.6 15.6 88.2 N=2,383 outlets (2.4, 4.2) (3.4, 10.6) (1.8, 3.7) (8.3, 16.5) (5.4, 9.7) (0.9, 2.1) (0.2, 0.8) (55.5, 71.0) (9.3, 25.0) (83.5, 91.7) *Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A5a: Price of tablet formulation antimalarials, by outlet type Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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) $1.80 $4.92 $1.35 $1.35 $2.02 Any ACT [1.35-3.37] (168) [3.93-6.49] (5,772) [1.01-1.68] (928) [1.35-2.02] (249) [1.35-4.23] (7,205) $1.68 $4.33 $1.35 $1.35 $1.68 Artemether lumefantrine [1.35-3.03] (155) [3.90-5.90] (4,171) [1.01-1.68] (902) [1.35-2.02] (248) [1.18-3.89] (5,536) $2.02 $4.52 $2.70 $13.48 $4.04 Artesunate amodiaquine [1.68-4.04] (4) [2.56-7.88] (184) [1.01-4.72] (24) (1) [2.02-5.39] (214) $7.75 $6.00 $8.42 - $6.00 Artesunate SP [5.90-8.42] (4) [4.23-7.87] (493) (1) - [4.23-7.87] (511) $7.58 $6.69 $5.90 - $6.69 Dihydroartemisinin piperaquine [4.21-7.58] (5) [5.41-7.85] (516) (1) - [5.42-7.58] (534) $1.68 $4.72 $1.35 $1.35 $1.35 Quality-assured ACT (QA ACT) [1.35-2.02] (87) [2.95-7.53] (801) [1.01-1.68] (719) [1.35-2.02] (197) [1.01-2.02] (1,825) $1.68 $3.83 $1.35 $1.35 $1.35 QA ACT with the “green leaf” logo [1.35-1.80] (56) (1) [1.01-1.68] (667) [1.35-2.02] (155) [1.01-1.68] (892) $1.68 $4.72 $1.52 $1.35 $2.95 QA ACT without the “green leaf” logo [1.12-2.70] (31) [2.95-7.53] (800) [1.01-2.02] (52) [1.35-1.68] (42) [1.35-4.72] (933) $1.68 $4.72 $1.35 $1.35 $1.35 QA artemether lumefantrine [1.35-2.02] (83) [3.15-5.90] (677) [1.01-1.68] (695) [1.35-2.02] (196) [1.01-2.02] (1,671) $3.37 $4.92 $1.35 $1.68 $4.19 Non-quality assured ACT (Non-QA ACT) [2.36-4.72] (81) [4.07-6.49] (4,971) [1.01-2.02] (209) [1.35-3.37] (52) [2.36-6.01] (5,380) $0.51 $0.83 $0.34 $0.42 $0.42 SP [0.42-0.84] (52) [0.65-0.84] (251) [0.34-0.42] (763) [0.34-0.51] (586) [0.34-0.51] (1,677) $4.25 $19.10 $3.54 $3.54 $3.54 Quinine [3.54-5.31] (248) [5.83-25.78] (326) [2.83-4.25] (901) [3.18-4.25] (532) [2.83-4.25] (2,045) $0.42 - $0.41 $0.41 $0.41 Chloroquine [0.41-1.05] (13) - [0.41-0.42] (887) [0.41-0.42] (135) [0.41-0.42] (1,035) * AETD - adult equivalent treatment dose - is the number of milligrams required to treat a 60-kg 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. The numbers of tablet antimalarials captured in audit sheets with missing price and/ or product information are as follows: 36 any ACT, 32 artemether lumefantrine, one artesunate amodiaquine, 15 QA ACT, 13 QA ACT with the “green leaf” logo, 2 QA ACT without the “green leaf” logo, 14 QA artemether lumefantrine, 21 non-QA ACT, 15 SP, 25 quinine, 9 chloroquine. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A5b: Price of pre-packaged antimalarials, by outlet type Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of one pre-packaged therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) $1.68 $3.83 $1.18 $1.35 $1.35 Adult first-line quality-assured ACT (QA ACT)  [1.35-1.68] (42) [2.95-5.10] (448) [1.01-1.35] (317) [1.18-1.35] (128) [1.01-1.68] (948) $0.51 $1.97 $0.51 $0.51 $0.51 Pediatric first-line quality-assured ACT (QA ACT)  [0.42-0.67] (16) [1.18-1.97] (157) [0.42-0.59] (139) [0.51-0.84] (26) [0.42-0.67] (340)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and pediatric children. Adult pre-packaged therapy is the package size intended for a 60-kg adult. Pediatric pre-packaged therapy is the package size intended for a 10-kg 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: 9 adult first-line QA ACT and one pediatric first-line QA ACT. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A6: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type Public Private Not ALL Private Community General Itinerant Drug ALL ALL Health For-Profit Public / Not- For-Profit Pharmacy Health Worker Retailer Vendor Private Outlets Facility Facility For-Profit Facility % % % % % % % % % %

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of outlets** stocking N=290 N=120 N=85 N=495 N=233 N=170 N=1,530 N=496 N=2,459 N=2,954 97.9 81.6 38.0 77.8 39.2 5.0 0.1 0.0 3.3 13.1 Any malaria blood testing (94.7, 99.2) (67.0, 90.6) (21.6, 57.7) (69.2, 84.5) (30.6, 48.5) (1.4, 16.0) (0.0, 0.3) - (2.3, 4.7) (8.8, 19.0) N=290 N=120 N=85 N=495 N=233 N=170 N=1,530 N=496 N=2,459 N=2,954 29.7 1.0 11.5 9.8 17.9 0.0 0.0 0.0 1.5 2.6 Malaria microscopy (22.5, 38.0) (0.2, 6.0) (4.9, 24.8) (6.6, 14.5) (8.7, 33.2) - - - (0.8, 2.8) (1.9, 3.5) N=290 N=120 N=85 N=495 N=232 N=170 N=1,530 N=496 N=2,458 N=2,953 97.6 81.6 31.4 76.5 26.1 5.0 0.1 0.0 2.2 12.0 Rapid diagnostic tests (RDTs) (94.5, 99.0) (67.0, 90.6) (16.2, 52.1) (67.5, 83.6) (16.8, 38.3) (1.4, 16.0) (0.0, 0.3) - (1.3, 3.8) (7.4, 18.8) N=290 N=120 N=85 N=495 N=232 N=170 N=1,530 N=496 N=2,458 N=2,953

Quality-assured rapid 88.9 78.1 29.4 72.1 23.1 4.4 0.1 0.0 2.0 11.2 diagnostic tests (QA RDT)*** (77.0, 95.1) (58.4, 90.0) (14.3, 50.9) (60.6, 81.2) (13.9, 35.8) (1.1, 16.6) (0.0, 0.3) - (1.1, 3.6) (6.7, 18.1) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. Five antimalarial-stocking outlets were missing information about both availability of microscopy and availability of RDTs. Seven antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.” *** QA RDT status could not be determined for 28 RDTs because of missing product information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A7: Malaria blood testing market composition Public Community Private Not ALL Private General Itinerant Drug ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with malaria blood Retailer Vendor Private Facility Worker Facility For-Profit Facility testing available on the day of the survey:* % % % % % % % % % % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 21.1 48.4 7.9 77.4 22.2 0.1 - 0.4 - 22.6 N=308 outlets (13.5, 31.3) (35.2, 61.9) (4.7, 13.0) (68.5, 84.3) (15.3, 31.0) (0.0, 0.5) - (0.1, 1.6) - (15.7, 31.5)

* 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, Benin, 2016.

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Table A8: Price of malaria blood testing for adults, by outlet type Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Total median price to consumers:* (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) Malaria microscopy $2.53 - - - $2.53 Adult [2.02-3.37] (63) - - - [2.02-3.37] (63) $2.53 - - - $2.53 Child under 5 years [2.02-3.37] (63) - - - [2.02-3.37] (63) Rapid diagnostic tests (RDTs) $0.84 $1.18 $1.68 - $0.84 Adult [0.25-0.84] (52) [1.18-1.18] (8) (1) - [0.25-1.18] (61) $0.84 $1.18 $1.68 - $0.84 Child under 5 years [0.25-0.84] (52) [1.18-1.18] (7) (1) - [0.25-1.18] (60) * Total price to the consumer including consultation and/or service fees. Microscopic blood testing price information was not available (missing or “don’t know” response) for:4 adult microscopy tests, 4 child microscopy tests, 8 adult RDTs, and 9 child RDTs. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A9: Antimalarial market share Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL** distributed:* % % % % % % % % % % % 1. Any ACT 8.8 0.8 1.4 11.0 2.5 11.2 0.2 17.5 1.5 32.8 43.9 Artemether lumefantrine 8.8 0.8 1.4 11.0 2.4 9.0 0.2 17.4 1.5 30.4 41.4 Artesunate amodiaquine 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.0 0.3 0.3 Artesunate SP 0.0 0.0 0.0 0.0 0.0 0.7 0.0 0.0 0.0 0.7 0.7 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.0 1.1 0.0 0.0 0.0 1.1 1.1 Other ACT β 0.0 0.0 0.0 0.0 0.0 0.3 0.0 0.0 0.0 0.3 0.3 Quality-assured ACT (QA ACT) 8.8 0.8 1.1 10.7 1.6 1.5 0.1 14.2 1.2 18.6 29.3 QA ACT with the “green leaf” logo 0.1 0.1 0.7 0.8 1.1 0.0 0.0 13.4 1.0 15.6 16.4 QA ACT without the “green leaf” logo 8.7 0.7 0.4 9.9 0.4 1.5 0.1 0.8 0.2 3.0 12.9 QA artemether lumefantrine 8.8 0.8 1.1 10.7 1.6 1.4 0.1 14.1 1.2 18.4 29.0 Non-quality assured ACT (non-QA ACT) 0.0 0.0 0.3 0.3 0.9 9.7 0.1 3.2 0.3 14.3 14.6 Nationally registered ACT 8.7 0.7 0.8 10.3 1.5 6.3 0.1 8.0 0.8 16.8 27.0 2. Any non-artemisinin therapy 9.1 0.0 1.6 10.7 3.1 3.9 0.3 30.2 7.6 45.1 55.8 Sulfadoxine pyrimethamine 5.9 0.0 0.6 6.5 0.9 3.7 0.1 14.7 5.2 24.7 31.1 Oral quinine 3.0 0.0 0.9 3.9 1.7 0.2 0.2 3.3 1.1 6.5 10.4 Quinine IV/IM 0.2 0.0 0.1 0.3 0.3 0.0 0.0 0.1 0.0 0.5 0.7 Chloroquine 0.0 0.0 0.0 0.0 0.2 0.0 0.0 12.0 1.1 13.3 13.4 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.1 0.1 0.2 0.1 0.0 0.0 0.0 0.3 0.3 Artesunate IV/IM # 0.0 0.0 0.1 0.1 0.2 0.0 0.0 0.0 0.0 0.2 0.3 Artemether IV/IM 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 0.2 0.0 0.1 0.3 0.5 0.1 0.0 0.2 0.0 0.7 1.1 OUTLET TYPE TOTAL*** 17.9 0.8 3.1 21.8 5.8 15.2 0.5 47.7 9.1 78.2 100.0 * A total of 25,427.4AETDs were reportedly sold or distributed in the previous 7 days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 10,577antimalarials (in the census sample) were audited. Of these, 1,449 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A10: Antimalarial market share within outlet type Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL distributed:* % % % % % % % % % % % 1. Any ACT 49.2 97.5 46.8 50.7 42.6 73.8 39.0 36.6 16.8 42.0 43.9 Artemether lumefantrine 49.0 97.5 46.0 50.4 41.9 59.2 33.1 36.4 16.7 38.9 41.4 Artesunate amodiaquine 0.2 0.0 0.0 0.2 0.5 0.8 0.0 0.2 0.0 0.3 0.3 Artesunate SP 0.0 0.0 0.8 0.1 0.1 4.5 2.6 0.0 0.0 0.9 0.7 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.2 7.3 3.3 0.0 0.0 1.4 1.1 Other ACT β 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 0.0 0.4 0.3 Quality-assured ACT (QA ACT) 49.2 93.3 36.5 49.1 27.2 9.7 17.6 29.9 13.2 23.8 29.3 QA ACT with the “green leaf” logo 0.5 6.3 22.1 3.7 19.5 0.0 6.4 28.2 11.0 19.9 16.4 QA ACT without the “green leaf” logo 48.7 87.1 14.4 45.3 7.7 9.7 11.1 1.7 2.2 3.8 12.9 QA artemether lumefantrine 49.0 93.3 36.5 48.9 26.8 9.2 17.6 29.6 13.2 23.5 29.0 Non-quality assured ACT (non-QA ACT) 0.0 4.1 10.3 1.6 15.4 64.0 21.4 6.8 3.6 18.2 14.6 Nationally registered ACT 48.8 90.0 25.3 47.1 25.6 41.8 20.7 16.9 9.0 21.5 27.0 2. Any non-artemisinin therapy 50.7 2.5 51.5 49.0 54.3 25.9 59.9 63.3 83.2 57.7 55.8 Sulfadoxine pyrimethamine 32.9 0.0 18.7 29.7 15.2 24.6 27.8 30.8 57.6 31.5 31.1 Oral quinine 16.9 2.0 28.1 17.9 30.1 1.1 30.3 6.8 12.5 8.3 10.4 Quinine IV/IM 0.9 0.6 3.2 1.2 5.1 0.1 1.1 0.3 0.0 0.6 0.7 Chloroquine 0.0 0.0 1.4 0.2 3.5 0.0 0.7 25.2 12.4 17.0 13.4 Other non-artemisinin therapy ^ 0.0 0.0 0.2 0.0 0.4 0.1 0.0 0.2 0.7 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 1.7 0.3 3.1 0.4 1.2 0.1 0.0 0.4 0.3 Artesunate IV/IM # 0.1 0.0 1.7 0.3 2.9 0.2 1.2 0.1 0.0 0.3 0.3 Artemether IV/IM 0.0 0.0 0.0 0.0 0.2 0.1 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 1.0 0.6 4.9 1.5 8.2 0.4 2.3 0.4 0.0 0.9 1.1 * A total of 25,427.4 AETDs were reportedly sold or distributed in the previous 7 days: 3,542.7public health facilities; 120.4 community health workers; 748.7 private not for-profit health facilities; 1,563.7 private for-profit health facilities; 6,132.6 pharmacies; 122.9 drug stores; 10,265.2 general retailers; and 2,931.2 itinerant drug vendors. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% within each column. A total of 10,577antimalarials were audited. Of these, 1,449 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 49 public health facilities; 0 community health workers; 75 private not for-profit health facilities; 100 private for-profit health facilities; 1,045 pharmacies; 0 drug stores; 162 general retailers; 9 itinerant drug vendors; and 9 unknown outlet types. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A11: Malaria blood testing market share Public Community Private Not TOTAL Private Number of malaria blood tests provided General Itinerant TOTAL BLOOD TEST Health Health For-Profit Public / Not For-Profit Pharmacy Drug Store in the previous week by outlet type and Retailer Drug Vendor Private TOTAL** blood test type as a percentage of all Facility Worker Facility For-Profit Facility blood tests provided:* % % % % % % % % % % % 1. Malaria microscopy 8.7 0.1 6.0 14.8 6.8 0.0 0.0 0.0 0.0 6.8 21.6 2. RDT 51.5 8.9 7.0 67.4 10.9 0.0 0.0 0.0 0.0 11.0 78.4 OUTLET TYPE TOTAL*** 60.2 9.1 12.9 82.2 17.8 0.0 0.0 0.0 0.0 17.8 100.0 * A total of 6,712 malaria blood tests were reportedly administered in the previous 7 days. ** Row sum – market share for the specified type of blood testing medicine. *** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 359 malaria blood tests were audited. Of these, 30 audited tests were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A12: Malaria blood testing market share, within outlet type Public Community Private Not TOTAL Private Number of malaria blood tests provided General Itinerant TOTAL BLOOD TEST Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store in the previous week by blood test type Retailer Drug Vendor Private TOTAL** as a percentage of all blood tests Facility Worker Facility For-Profit Facility provided within each outlet type:* % % % % % % % % % % % Total blood testing market 1. Malaria microscopy 14.5 1.5 46.1 18.0 38.4 0.0 0.0 0.0 0.0 38.4 21.6 2. RDT 85.5 98.5 53.9 82.0 61.6 0.0 0.0 100.0 0.0 61.6 78.4 Malaria RDT market Manufacturer  Standard Diagnostics Inc. 65.3 71.1 69.0 66.5 82.9 0.0 0.0 100.0 0.0 82.9 68.8 ICT Diagnostics 33.2 21.4 9.4 29.2 5.4 0.0 0.0 0.0 0.0 5.4 25.9 Access Bio Inc. 0.0 1.2 4.0 0.6 11.6 0.0 0.0 0.0 0.0 11.6 2.1 Other 0.0 0.0 17.3 1.8 0.0 0.0 0.0 0.0 0.0 0.0 1.5 Unknown 1.4 6.4 0.3 2.0 0.1 0.0 0.0 0.0 0.0 0.1 1.7 Quality-assured RDT (QA RDT) ** 90.6 94.3 95.5 91.6 96.5 0.0 0.0 100.0 0.0 96.5 92.3 * 6,712malaria blood tests reportedly administered in the previous 7 days: 3,683 public health facilities; 381 community health workers; 1,054 private not for-profit health facilities; 1,591 private for-profit health facilities; 0 pharmacies;0 drug stores; 3 general retailers; and 0 itinerant drug vendors. Categories 1 through 2 sum to 100% within each column. A total of 359 malaria blood tests were audited. Of these, 30 audited tests were not included in market share calculations due to incomplete or inconsistent information.  Manufacturer was not captured for 11 RDTs audited. ** QA RDT status could not be determined for 28 RDTs because of missing product information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table A13: Provider case management knowledge and practices, by outlet type Public Community Private Not ALL Private General Itinerant Drug ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Retailer Vendor Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2-year-old child with symptoms of severe malaria to a - N=120 - N=120 - N=169 N=1,528 N=493 N=2,220 N=2,340 health facility 99.5 99.5 97.7 95.5 95.1 95.4 95.8 Yes, would refer to health facility N/A N/A N/A (97.0, 99.9) (97.0, 99.9) (93.1, 99.3) (93.2, 97.0) (87.3, 98.2) (93.1, 97.0) (93.8, 97.2) Would recommend that a client with a negative malaria blood test take an N=286 N=119 N=65 N=470 N=181 N=135 N=344 N=145 N=826 N=1,296 antimalarial 16.5 3.3 36.8 12.0 39.3 31.1 4.7 16.2 14.4 13.6 Yes – sometimes (11.1, 23.9) (0.7, 14.7) (21.0, 56.0) (7.8, 17.9) (32.0, 47.0) (19.4, 46.0) (2.3, 9.6) (11.1, 23.0) (9.7, 20.8) (10.6, 17.4) 2.2 0.0 4.4 1.3 10.0 0.8 0.5 2.0 2.6 2.2 Yes – always (0.5, 9.8) - (1.1, 16.7) (0.4, 3.7) (5.5, 17.5) (0.2, 2.3) (0.1, 2.9) (0.9, 4.2) (1.3, 5.1) (1.2, 3.9) Circumstances cited for recommending antimalarial treatment N=62 N=2 N=21 N=85 N=84 N=49 N=23 N=29 N=187 N=272 to a client who tested negative for malaria:* Patient has signs and symptoms of 87.6 100.0 96.7 94.0 91.7 0.0 71.9 53.2 76.0 80.8 malaria (71.8, 95.1) - (78.2, 99.6) (86.3, 97.5) (80.1, 96.8) - (31.3, 93.5) (31.1, 74.2) (60.6, 86.7) (66.9, 89.7) When the patient asks for 9.5 0.0 14.6 10.7 16.5 0.0 40.6 14.3 20.6 18.0 antimalarial treatment (3.9, 21.3) - (5.3, 34.2) (4.8, 22.0) (8.9, 28.5) - (19.5, 65.8) (3.1, 46.3) (12.7, 31.7) (12.2, 25.7) 5.6 0.0 8.9 6.5 22.9 0.0 8.5 0.0 14.6 12.5 Provider doesn’t trust test result (2.6, 11.6) - (2.6, 26.6) (2.6, 15.4) (13.0, 37.0) - (2.8, 23.3) - (9.4, 22.0) (8.0, 18.9) 6.5 0.0 17.7 11.2 23.0 1.5 19.5 13.9 19.1 17.0 Other (all other reasons) (2.3, 16.7) - (6.5, 40.2) (4.8, 24.1) (13.7, 35.8) (0.2, 9.1) (6.8, 44.6) (2.3, 53.0) (13.4, 26.6) (12.3, 23.2) 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). * 10 providers were missing information on referring 2-year-old child with symptoms of severe malaria to a health facility. Two providers were missing information on recommending that a client with a negative blood test take an antimalarial. No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. Source: ACTwatch Outlet Survey, Benin, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Proportion of providers who: N=290 N=120 N=85 N=495 N=234 N=170 N=1,533 N=497 N=2,464 N=2,959 Correctly state the national first-line 94.2 87.5 81.6 88.1 77.6 92.9 39.8 37.9 43.3 49.2 treatment for uncomplicated malaria  (87.2, 97.5) (78.5, 93.0) (61.0, 92.6) (81.4, 92.6) (70.9, 83.1) (85.0, 96.8) (32.2, 47.9) (32.7, 43.4) (37.2, 49.6) (42.7, 55.6) Correctly state the first-line dosing

regimen for: 93.3 45.6 68.6 61.2 61.3 77.7 32.5 25.8 34.3 37.9 An adult (86.7, 96.7) (26.9, 65.6) (47.9, 83.9) (48.4, 72.7) (50.6, 71.0) (61.7, 88.3) (24.1, 42.2) (19.0, 33.9) (26.4, 43.2) (29.7, 46.8) 91.0 80.7 72.3 81.7 60.9 65.6 32.2 27.7 34.2 40.4 A 2-year-old child (85.0, 94.7) (67.0, 89.6) (50.6, 86.9) (72.2, 88.5) (49.1, 71.5) (46.2, 80.9) (24.0, 41.6) (21.2, 35.3) (26.7, 42.7) (31.9, 49.6) Report an ACT as the most effective

antimalarial medicine for: 94.6 59.8 73.1 70.6 62.7 93.0 32.0 20.2 33.4 38.3 An adult (90.6, 97.0) (38.0, 78.3) (56.5, 85.1) (55.9, 82.0) (54.7, 70.1) (78.9, 97.9) (23.0, 42.5) (8.2, 41.9) (23.1, 45.6) (27.6, 50.2) 96.4 97.1 78.3 93.6 73.4 94.9 35.4 21.3 37.0 44.4 A child (93.0, 98.1) (91.8, 99.0) (61.3, 89.1) (89.9, 96.0) (66.6, 79.3) (77.9, 99.0) (25.7, 46.5) (7.4, 47.7) (25.4, 50.3) (31.7, 57.9) Report an ACT as the antimalarial he/she most commonly recommends for: 92.8 53.3 67.1 65.4 65.5 94.4 27.2 20.2 30.2 34.8 An adult (85.2, 96.7) (31.8, 73.7) (48.2, 81.7) (49.4, 78.5) (56.9, 73.1) (78.6, 98.7) (19.5, 36.7) (7.6, 43.6) (21.3, 40.8) (25.4, 45.5) 95.8 96.2 68.6 91.2 70.2 98.5 31.7 20.3 33.9 41.4 A child (89.6, 98.4) (86.6, 99.0) (51.0, 82.0) (85.6, 94.7) (60.7, 78.3) (95.4, 99.5) (23.2, 41.5) (6.6, 47.8) (23.8, 45.7) (30.0, 53.8)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and in 2-year-old children. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. The number of providers with missing information include: 11 providers were missing information on the national first-line treatment; 11 were missing information on the first-line dosing regimen for both adults and children;9 and 10 providers were missing information on the most effective antimalarial medicine for adults and children, respectively; and 12 were missing information on the most recommended antimalarial medicine for both adults and children. Source: ACTwatch Outlet Survey, Benin, 2016.

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Results Section B: Results by urban/rural location

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

visit 93.6 72.6 93.8 82.9 84.4 94.5 26.4 68.5 33.1 35.0 Urban (85.0, 97.4) (31.7, 93.8) (84.4, 97.7) (54.6, 95.1) (71.3, 92.2) (74.2, 99.1) (19.2, 35.0) (35.5, 89.6) (29.2, 37.2) (30.7, 39.6) 96.8 51.4 88.0 64.2 87.8 95.9 30.1 60.9 33.9 37.1 Rural (92.9, 98.6) (30.0, 72.2) (62.4, 97.0) (45.9, 79.1) (75.6, 94.3) (85.2, 98.9) (24.4, 36.5) (48.2, 72.3) (28.5, 39.8) (31.9, 42.7) Any ACT 91.0 66.6 39.0 67.7 36.9 94.5 9.7 26.4 12.9 15.0 Urban (80.7, 96.1) (22.0, 93.4) (23.0, 57.7) (43.6, 85.1) (25.2, 50.4) (74.2, 99.1) (5.5, 16.4) (18.9, 35.5) (9.0, 18.1) (10.2, 21.6) 89.0 51.4 51.1 57.7 45.6 95.9 12.8 37.8 15.3 19.8 Rural (80.9, 93.9) (30.0, 72.2) (20.6, 80.8) (38.9, 74.6) (29.6, 62.6) (85.2, 98.9) (8.7, 18.4) (20.4, 59.0) (11.1, 20.6) (16.1, 24.2) Artemether lumefantrine 91.0 66.6 33.7 66.6 35.5 94.5 9.5 26.4 12.7 14.8 Urban (80.7, 96.1) (22.0, 93.4) (19.2, 52.1) (42.7, 84.2) (24.0, 49.1) (74.2, 99.1) (5.4, 16.3) (18.9, 35.5) (8.9, 18.0) (10.0, 21.4) 87.8 51.4 51.1 57.6 44.4 95.9 12.8 37.8 15.2 19.7 Rural (80.1, 92.8) (30.0, 72.2) (20.6, 80.8) (38.8, 74.4) (28.5, 61.6) (85.2, 98.9) (8.7, 18.3) (20.4, 59.0) (11.0, 20.6) (16.0, 24.1) Artesunate amodiaquine 16.2 0.0 0.0 4.6 0.7 35.8 0.3 0.0 0.5 0.7 Urban (6.3, 36.0) - - (1.4, 14.1) (0.1, 5.2) (20.4, 54.8) (0.1, 0.7) - (0.3, 1.0) (0.3, 1.4) 18.5 0.0 0.0 3.2 2.4 66.0 0.6 2.2 0.8 1.0 Rural (8.1, 37.1) - - (1.3, 7.5) (0.6, 8.2) (34.1, 87.9) (0.2, 1.8) (0.3, 14.5) (0.3, 1.8) (0.6, 1.8) Artesunate SP 0.0 0.0 3.1 0.7 1.6 89.7 0.0 0.0 0.7 0.7 Urban - - (0.4, 20.4) (0.1, 4.9) (0.6, 3.8) (74.0, 96.4) (0.0, 0.2) - (0.4, 1.4) (0.4, 1.4)

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logo 91.0 59.0 21.8 60.2 10.3 84.6 0.6 6.9 2.1 4.3 Urban (80.6, 96.1) (14.3, 92.5) (9.9, 41.5) (33.6, 81.9) (4.7, 21.2) (66.4, 93.9) (0.4, 0.8) (4.0, 11.6) (1.6, 2.7) (2.6, 7.1) 87.8 51.4 12.4 52.2 10.9 95.9 1.8 0.2 2.2 7.6 Rural (79.4, 93.1) (30.0, 72.2) (3.2, 37.5) (34.7, 69.2) (5.4, 20.6) (85.2, 98.9) (1.1, 2.9) (0.0, 1.2) (1.5, 3.2) (5.2, 10.8) QA artemether lumefantrine 91.0 60.6 25.7 61.9 25.0 84.1 8.8 22.0 11.2 13.1 Urban (80.6, 96.1) (14.7, 93.2) (10.7, 49.8) (34.3, 83.5) (12.1, 44.7) (66.2, 93.5) (4.7, 15.8) (16.0, 29.5) (7.2, 16.9) (8.3, 20.3) www.ACTwatch.info Page 55

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=96 Urban N=45 Urban N=41 Urban N=182 Urban N=154 Urban N=151 Urban N=3,877 Urban N=532 Urban N=4,722 Urban N=4,904 Proportion of outlets* stocking: Rural N=202 Rural N=100 Rural N=52 Rural N=354 Rural N=108 Rural N=25 Rural N=1,745 Rural N=100 Rural N=2,002 Rural N=2,356 87.3 51.4 48.8 57.2 39.4 95.9 11.7 31.7 13.8 18.4 Rural (79.5, 92.4) (30.0, 72.2) (18.8, 79.7) (38.4, 74.0) (23.4, 58.0) (85.2, 98.9) (8.4, 16.1) (17.4, 50.7) (10.4, 18.1) (15.3, 22.1) Non-quality assured ACT (non-QA ACT) 0.2 6.0 17.4 6.7 17.1 94.5 2.9 7.4 4.5 4.6 Urban (0.0, 1.2) (1.3, 23.6) (7.9, 34.1) (2.8, 15.3) (10.6, 26.3) (74.2, 99.1) (1.6, 5.5) (4.3, 12.6) (2.9, 6.9) (3.1, 6.8) 0.5 0.0 3.2 0.5 15.8 95.9 4.8 19.7 6.0 5.4 Rural (0.1, 2.8) - (0.4, 21.0) (0.1, 3.5) (8.2, 28.3) (85.2, 98.9) (2.0, 10.9) (5.4, 51.4) (2.9, 12.0) (2.6, 10.9) Nationally registered ACT 91.0 65.0 25.4 64.1 27.5 94.2 4.8 15.5 7.3 9.5 Urban (80.7, 96.1) (21.7, 92.6) (13.0, 43.9) (41.4, 81.8) (18.4, 38.9) (74.9, 98.9) (2.8, 8.1) (10.1, 23.2) (5.4, 9.8) (6.6, 13.5) 87.2 50.0 27.1 53.2 28.4 95.9 7.2 20.6 8.8 13.6 Rural (79.4, 92.3) (29.7, 70.3) (9.8, 55.8) (36.2, 69.5) (17.5, 42.5) (85.2, 98.9) (4.0, 12.6) (5.4, 54.0) (5.4, 14.1) (10.1, 17.9) Any non-artemisinin therapy 93.6 12.1 90.9 51.3 83.5 74.7 24.7 67.5 31.3 32.1 Urban (85.0, 97.4) (2.5, 42.4) (79.2, 96.4) (34.5, 67.9) (70.5, 91.5) (51.4, 89.1) (18.5, 32.0) (34.1, 89.3) (28.3, 34.5) (28.8, 35.6) 95.1 0.0 74.3 26.5 82.6 93.8 27.7 57.3 31.3 30.8 Rural (89.8, 97.7) - (35.7, 93.8) (16.3, 40.1) (70.0, 90.7) (78.5, 98.4) (22.1, 34.1) (44.5, 69.2) (25.9, 37.3) (25.8, 36.3) SP 73.4 0.0 35.2 27.9 22.7 54.5 9.2 48.8 14.3 14.8 Urban (55.5, 85.9) - (15.6, 61.4) (16.2, 43.6) (13.7, 35.3) (36.6, 71.3) (7.5, 11.3) (19.2, 79.2) (9.6, 20.7) (10.5, 20.5) 74.6 0.0 13.3 14.6 18.6 37.0 5.5 24.8 6.9 7.7 Rural (67.7, 80.5) - (3.7, 37.8) (9.9, 21.0) (8.1, 37.5) (14.0, 67.9) (3.5, 8.7) (13.2, 41.7) (4.8, 9.8) (5.7, 10.3) Oral quinine 91.4 6.0 83.1 46.0 59.2 63.4 10.3 43.8 15.7 16.8 Urban (83.0, 95.9) (1.3, 23.6) (66.6, 92.4) (30.2, 62.6) (49.9, 67.8) (42.0, 80.6) (7.7, 13.6) (17.8, 73.8) (10.2, 23.3) (11.8, 23.4) 82.6 0.0 62.5 22.7 62.5 73.7 7.5 15.8 10.4 11.8 Rural (76.1, 87.6) - (32.9, 85.1) (13.9, 34.9) (49.2, 74.2) (44.6, 90.7) (5.3, 10.7) (7.5, 30.2) (8.1, 13.4) (9.2, 14.9) Chloroquine 0.0 0.0 6.0 1.3 5.4 0.0 17.5 25.8 17.9 17.3 Urban - - (1.0, 29.5) (0.2, 6.6) (1.4, 18.5) - (9.3, 30.6) (15.9, 39.0) (10.1, 29.8) (10.0, 28.2)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=96 Urban N=45 Urban N=41 Urban N=182 Urban N=154 Urban N=151 Urban N=3,877 Urban N=532 Urban N=4,722 Urban N=4,904 Proportion of outlets* stocking: Rural N=202 Rural N=100 Rural N=52 Rural N=354 Rural N=108 Rural N=25 Rural N=1,745 Rural N=100 Rural N=2,002 Rural N=2,356 1.0 0.0 8.6 1.3 15.9 0.0 24.5 28.1 24.1 21.7 Rural (0.2, 4.0) - (2.0, 30.1) (0.4, 4.7) (6.8, 32.6) - (19.0, 30.9) (15.6, 45.2) (18.8, 30.4) (16.8, 27.5) Other non-artemisinin therapy ^ 0.0 0.0 6.0 1.3 2.4 14.7 0.5 6.1 1.2 1.2 Urban - - (1.0, 29.5) (0.2, 6.6) (0.6, 9.4) (7.7, 26.4) (0.3, 0.8) (3.0, 12.2) (0.7, 2.3) (0.7, 2.2) 0.6 0.0 0.0 0.1 3.5 14.5 0.9 3.4 1.1 1.0 Rural (0.1, 4.3) - - (0.0, 0.8) (0.9, 12.8) (3.5, 44.6) (0.5, 1.6) (0.6, 16.9) (0.7, 1.8) (0.6, 1.6) Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Non-oral artemisinin monotherapy 10.1 0.0 32.6 9.6 24.6 71.8 0.3 0.0 1.4 1.7 Urban (3.1, 28.3) - (13.5, 60.0) (3.2, 25.6) (18.1, 32.6) (54.2, 84.6) (0.1, 1.1) - (0.9, 2.3) (1.0, 2.9) 2.3 0.0 26.8 4.1 26.6 91.7 0.1 0.0 1.4 1.7 Rural (0.9, 5.6) - (13.4, 46.5) (1.9, 8.7) (11.6, 50.1) (72.2, 97.9) (0.0, 0.8) - (0.8, 2.5) (1.0, 2.8) Any treatment for severe malaria 79.3 12.1 83.9 45.9 74.6 72.0 0.6 0.0 3.1 4.8 Urban (62.2, 89.9) (2.5, 42.4) (65.6, 93.4) (31.9, 60.4) (62.0, 84.1) (54.7, 84.6) (0.2, 1.7) - (2.0, 4.8) (3.0, 7.4) 79.2 0.0 63.0 22.2 75.0 91.7 0.2 0.0 3.7 5.6 Rural (69.6, 86.4) - (32.9, 85.5) (12.8, 35.8) (58.8, 86.3) (72.2, 97.9) (0.1, 0.7) - (2.8, 4.7) (4.5, 7.1) Artesunate IV/IM # 8.9 0.0 1.8 2.9 2.1 21.8 0.0 0.0 0.2 0.3 Urban (2.4, 28.4) - (0.4, 8.5) (0.8, 9.9) (0.7, 6.3) (12.4, 35.5) - - (0.1, 0.5) (0.1, 0.6) 0.5 0.0 0.0 0.1 0.0 37.0 0.0 0.0 0.0 0.0 Rural (0.1, 4.0) - - (0.0, 0.7) - (14.0, 67.9) - - (0.0, 0.1) (0.0, 0.1) Artemether IV/IM 9.1 0.0 29.7 8.7 23.5 65.2 0.3 0.0 1.3 1.6 Urban (2.4, 28.5) - (11.4, 58.1) (2.7, 24.6) (17.5, 30.8) (49.0, 78.4) (0.1, 1.1) - (0.8, 2.2) (1.0, 2.7)

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Source: ACTwatch Outlet Survey, Benin, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=90 Urban N=39 Urban N=37 Urban N=166 Urban N=133 Urban N=147 Urban N=903 Urban N=416 Urban N=1,606 Urban N=1,772 Proportion of outlets* stocking: Rural N=196 Rural N=52 Rural N=46 Rural N=294 Rural N=89 Rural N=23 Rural N=485 Rural N=52 Rural N=672 Rural N=966 Any ACT 97.2 91.7 41.6 81.7 43.7 100.0 36.6 38.5 39.0 42.8 Urban (91.1, 99.2) (56.9, 98.9) (24.5, 60.9) (68.7, 90.0) (30.2, 58.3) - (27.6, 46.6) (26.8, 51.7) (29.5, 49.3) (31.8, 54.6) 92.0 100.0 58.1 90.0 52.0 100.0 42.4 62.0 45.1 53.3 Rural (84.9, 95.9) - (26.2, 84.4) (78.9, 95.6) (34.9, 68.6) - (29.8, 56.1) (35.5, 82.9) (33.6, 57.1) (44.1, 62.3) Artemether lumefantrine 97.2 91.7 35.9 80.4 42.1 100.0 36.2 38.5 38.5 42.3 Urban (91.1, 99.2) (56.9, 98.9) (20.5, 55.0) (66.6, 89.4) (28.7, 56.8) - (27.2, 46.2) (26.8, 51.7) (29.2, 48.8) (31.3, 54.1) 90.8 100.0 58.1 89.7 50.6 100.0 42.4 62.0 44.9 53.2 Rural (84.0, 94.8) - (26.2, 84.4) (78.7, 95.3) (33.3, 67.7) - (29.8, 56.0) (35.5, 82.9) (33.4, 57.0) (43.9, 62.2) Artesunate amodiaquine 17.3 0.0 0.0 5.5 0.8 37.8 1.2 0.0 1.6 1.9 Urban (6.8, 37.7) - - (1.7, 16.7) (0.1, 6.1) (21.7, 57.1) (0.5, 2.5) - (0.8, 3.0) (1.0, 3.8) 19.2 0.0 0.0 4.9 2.7 68.9 1.9 3.6 2.3 2.7 Rural (8.4, 38.0) - - (2.1, 10.9) (0.8, 9.0) (37.1, 89.3) (0.6, 5.7) (0.5, 21.5) (1.0, 5.2) (1.5, 5.0) Artesunate SP 0.0 0.0 3.3 0.8 1.9 94.9 0.1 0.0 2.2 2.1 Urban - - (0.4, 21.5) (0.1, 5.8) (0.8, 4.6) (85.4, 98.3) (0.0, 0.8) - (1.2, 4.2) (1.1, 3.8) 0.0 0.0 0.0 0.0 0.0 97.8 0.0 0.0 0.5 0.4 Rural - - - - - (91.6, 99.5) - - (0.2, 0.9) (0.2, 0.7) Dihydroartemisinin piperaquine 0.0 0.0 2.3 0.5 1.9 98.6 0.1 0.0 2.3 2.1 Urban - - (0.5, 10.8) (0.1, 3.8) (0.5, 6.7) (96.4, 99.5) (0.0, 0.8) - (1.2, 4.3) (1.2, 3.7) 0.0 0.0 0.4 0.1 1.9 100.0 0.0 0.0 0.7 0.6 Rural - - (0.0, 2.7) (0.0, 0.6) (0.4, 8.4) - - - (0.4, 1.5) (0.3, 1.3) www.ACTwatch.info Page 59

logo 97.2 81.2 23.2 72.6 12.2 89.5 2.1 10.0 6.3 12.4 Urban (91.1, 99.1) (32.9, 97.4) (10.8, 43.0) (53.2, 86.1) (5.6, 24.5) (73.1, 96.4) (1.2, 3.6) (8.2, 12.3) (4.7, 8.4) (7.8, 19.0) 90.8 100.0 14.1 81.4 12.4 100.0 5.8 0.3 6.6 20.3 Rural (83.0, 95.2) - (3.6, 41.5) (64.7, 91.3) (6.3, 23.0) - (3.2, 10.2) (0.0, 2.0) (4.2, 10.2) (14.1, 28.4) QA artemether lumefantrine 97.2 83.4 27.4 74.6 29.7 89.0 33.2 32.2 33.9 37.6 Urban (25.7, 51.2) (91.1, 99.1) (32.7, 98.1) (11.7, 51.7) (54.5, 87.8) (14.5, 51.2) (73.0, 96.0) (23.5, 44.6) (21.2, 45.5) (23.6, 45.9)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=90 Urban N=39 Urban N=37 Urban N=166 Urban N=133 Urban N=147 Urban N=903 Urban N=416 Urban N=1,606 Urban N=1,772 Proportion of outlets* stocking: Rural N=196 Rural N=52 Rural N=46 Rural N=294 Rural N=89 Rural N=23 Rural N=485 Rural N=52 Rural N=672 Rural N=966 90.3 100.0 55.5 89.1 44.9 100.0 38.9 52.1 40.7 49.6 Rural (83.3, 94.5) - (23.7, 83.4) (77.6, 95.1) (27.3, 63.9) - (28.6, 50.4) (30.9, 72.6) (31.3, 50.9) (41.7, 57.6) Non-quality assured ACT (non-QA ACT) 0.2 8.3 18.6 8.1 20.2 100.0 11.1 10.8 13.6 13.1 Urban (0.0, 1.3) (1.1, 43.1) (8.0, 37.2) (2.8, 21.7) (12.2, 31.6) - (7.0, 17.2) (6.9, 16.6) (9.5, 19.0) (9.6, 17.7) 0.5 0.0 3.7 0.8 18.0 100.0 15.9 32.3 17.7 14.6 Rural (0.1, 2.9) - (0.5, 23.5) (0.1, 5.3) (9.7, 30.8) - (7.2, 31.5) (8.8, 70.2) (9.1, 31.8) (7.3, 27.1) Nationally registered ACT 97.2 89.5 27.1 77.3 32.5 99.6 18.3 22.7 22.0 27.1 Urban (91.1, 99.2) (57.3, 98.2) (13.9, 46.3) (63.0, 87.2) (21.5, 45.9) (97.6, 99.9) (13.6, 24.3) (18.2, 27.9) (17.7, 27.1) (20.5, 34.8) 90.1 97.4 30.8 82.9 32.3 100.0 24.0 33.8 26.0 36.5 Rural (83.2, 94.4) (87.0, 99.5) (11.8, 59.6) (70.7, 90.7) (20.5, 46.9) - (14.0, 37.9) (9.0, 72.6) (16.4, 38.6) (28.4, 45.5) Any non-artemisinin therapy 100.0 16.6 97.0 61.9 99.0 79.0 93.5 98.4 94.6 91.7 Urban - (1.9, 67.3) (91.2, 99.0) (35.3, 82.9) (97.4, 99.6) (54.3, 92.3) (88.8, 96.3) (90.9, 99.8) (89.4, 97.4) (82.4, 96.3) 98.3 0.0 84.5 41.3 94.1 97.8 92.0 94.1 92.4 83.0 Rural (94.9, 99.4) - (50.0, 96.7) (25.6, 58.9) (78.2, 98.6) (91.6, 99.5) (86.3, 95.4) (79.4, 98.5) (86.6, 95.8) (77.2, 87.6) SP 78.4 0.0 37.5 33.7 26.9 57.6 35.0 71.2 43.2 42.3 Urban (59.1, 90.1) - (16.9, 63.9) (20.0, 50.7) (15.8, 41.8) (39.1, 74.2) (22.5, 50.0) (45.9, 87.8) (25.5, 62.9) (25.9, 60.7) 77.1 0.0 15.2 22.7 21.2 38.6 18.3 40.8 20.2 20.7 Rural (70.1, 82.9) - (4.2, 41.9) (15.4, 32.3) (9.1, 42.0) (14.0, 70.8) (11.2, 28.5) (23.3, 60.9) (13.4, 29.3) (14.9, 28.1) Oral quinine 97.7 8.3 88.7 55.5 70.1 67.1 39.0 64.0 47.3 48.1 Urban (90.0, 99.5) (1.1, 43.1) (73.7, 95.6) (34.7, 74.6) (63.3, 76.0) (44.6, 83.7) (20.6, 61.1) (40.6, 82.2) (26.0, 69.7) (28.3, 68.5) www.ACTwatch.info Page 61

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=90 Urban N=39 Urban N=37 Urban N=166 Urban N=133 Urban N=147 Urban N=903 Urban N=416 Urban N=1,606 Urban N=1,772 Proportion of outlets* stocking: Rural N=196 Rural N=52 Rural N=46 Rural N=294 Rural N=89 Rural N=23 Rural N=485 Rural N=52 Rural N=672 Rural N=966 85.4 0.0 71.1 35.4 71.2 76.8 25.0 25.9 30.8 31.7 Rural (79.1, 90.0) - (45.4, 87.9) (22.3, 51.2) (57.4, 82.0) (46.1, 92.8) (17.8, 34.0) (11.1, 49.4) (23.8, 38.9) (24.8, 39.4) Chloroquine 0.0 0.0 6.4 1.5 6.4 0.0 66.4 37.6 54.2 49.4 Urban - - (1.1, 30.6) (0.3, 7.2) (1.7, 21.5) - (43.6, 83.4) (17.1, 63.8) (30.4, 76.2) (30.1, 68.9) 1.0 0.0 9.8 2.1 18.1 0.0 81.1 46.1 71.2 58.4 Rural (0.2, 4.2) - (2.3, 33.0) (0.6, 7.3) (7.6, 37.2) - (71.9, 87.9) (26.3, 67.1) (62.7, 78.4) (49.9, 66.5) Other non-artemisinin therapy ^ 0.0 0.0 6.4 1.5 2.9 15.6 1.7 8.9 3.7 3.5 Urban - - (1.1, 30.6) (0.3, 7.2) (0.7, 10.8) (8.2, 27.6) (0.8, 3.8) (6.0, 13.1) (1.8, 7.3) (1.7, 6.9) 0.6 0.0 0.0 0.1 4.0 15.1 2.9 5.6 3.3 2.7 Rural (0.1, 4.5) - - (0.0, 1.2) (1.1, 14.1) (3.4, 47.8) (1.7, 4.8) (1.0, 26.9) (2.1, 5.1) (1.7, 4.2) Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Urban ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Rural ------Non-oral artemisinin monotherapy 10.8 0.0 34.7 11.6 29.2 76.0 1.1 0.0 4.3 5.0 Urban (3.3, 29.8) - (14.0, 63.5) (3.9, 29.8) (21.0, 38.9) (58.7, 87.6) (0.4, 3.2) - (2.8, 6.6) (3.3, 7.4) 2.4 0.0 30.5 6.4 30.3 95.7 0.3 0.0 4.2 4.6 Rural (1.0, 5.8) - (12.9, 56.4) (2.5, 15.1) (13.2, 55.3) (83.8, 99.0) (0.0, 2.3) - (2.3, 7.5) (2.7, 7.6) Any treatment for severe malaria 84.7 16.6 89.5 55.3 88.3 76.2 2.3 0.0 9.4 13.6 Urban (65.9, 94.1) (1.9, 67.3) (72.6, 96.5) (33.0, 75.7) (79.4, 93.7) (59.1, 87.6) (1.0, 5.4) - (6.2, 14.0) (9.3, 19.4)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=90 Urban N=39 Urban N=37 Urban N=166 Urban N=133 Urban N=147 Urban N=903 Urban N=416 Urban N=1,606 Urban N=1,772 Proportion of outlets* stocking: Rural N=196 Rural N=52 Rural N=46 Rural N=294 Rural N=89 Rural N=23 Rural N=485 Rural N=52 Rural N=672 Rural N=966 81.9 0.0 71.6 34.6 85.4 95.7 0.7 0.0 10.8 15.2 Rural (73.4, 88.1) - (44.0, 89.0) (19.9, 53.0) (73.6, 92.5) (83.8, 99.0) (0.2, 1.9) - (8.2, 14.1) (11.7, 19.5) Artesunate IV/IM # 9.5 0.0 1.9 3.5 2.5 23.1 0.0 0.0 0.6 0.9 Urban (2.5, 29.9) - (0.4, 9.2) (1.0, 11.6) (0.8, 7.6) (13.2, 37.2) - - (0.3, 1.4) (0.4, 1.7) 0.5 0.0 0.0 0.1 0.0 38.6 0.0 0.0 0.1 0.1 Rural (0.1, 4.2) - - (0.0, 1.1) - (14.0, 70.8) - - (0.0, 0.4) (0.0, 0.3) Artemether IV/IM 9.7 0.0 31.7 10.5 27.8 68.9 1.1 0.0 4.1 4.7 Urban (2.6, 29.9) - (11.9, 61.3) (3.3, 28.7) (20.4, 36.7) (53.1, 81.3) (0.4, 3.2) - (2.6, 6.2) (3.0, 7.1) 2.4 0.0 20.8 4.5 30.3 95.7 0.3 0.0 4.2 4.2 Rural (1.0, 5.8) - (8.4, 42.9) (1.8, 11.2) (13.2, 55.3) (83.8, 99.0) (0.0, 2.3) - (2.3, 7.5) (2.5, 7.1) Quinine IV/IM 84.7 16.6 87.2 54.8 84.9 30.4 2.3 0.0 8.3 12.5 Urban (65.9, 94.1) (1.9, 67.3) (71.0, 95.0) (32.8, 75.0) (74.0, 91.7) (18.3, 46.1) (1.0, 5.4) - (5.4, 12.5) (8.5, 18.0) 81.9 0.0 65.4 33.4 79.5 29.7 0.7 0.0 9.9 14.2 Rural (73.4, 88.1) - (38.6, 85.0) (19.3, 51.4) (67.5, 88.0) (10.3, 60.8) (0.2, 1.9) - (7.2, 13.5) (10.7, 18.7) * Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by the presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes 23 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other types of non-artemisinin therapy include amodiaquine, atovaquone proguanil, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B4: Antimalarial market composition, across urban/rural location Public Community Private Not ALL Private General Itinerant Drug ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Retailer Vendor Private Facility Worker Facility For-Profit Facility antimalarial in stock on the day of the survey:* % % % % % % % % % % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2.4 4.1 2.2 8.6 6.3 1.9 0.1 62.4 20.7 91.4 Urban, N=1,608 outlets (1.6, 3.4) (1.4, 11.1) (1.3, 3.5) (4.7, 15.3) (3.9, 10.0) (1.2, 3.1) (0.0, 0.4) (50.6, 72.9) (11.6, 34.1) (84.7, 95.3) 4.9 10.1 3.5 18.4 9.1 0.3 1.1 66.2 4.9 81.6 Rural, N=775 outlets (3.2, 7.4) (5.3, 18.5) (1.8, 6.5) (12.8, 25.9) (6.7, 12.4) (0.1, 1.2) (0.5, 2.3) (57.4, 74.0) (2.9, 8.1) (74.1, 87.2) *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, Benin, 2016.

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Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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 $2.02 $4.92 $1.35 $1.35 $2.70 Urban [1.68-4.04] (95) [3.93-6.49] (5,059) [1.01-2.02] (589) [1.35-2.02] (208) [1.35-4.85] (5,968) $1.68 $4.72 $1.18 $1.35 $1.35 Rural [1.35-2.02] (73) [3.93-6.50] (713) [1.01-1.57] (339) [1.35-2.02] (41) [1.01-1.68] (1,237) Artemether lumefantrine $2.02 $4.33 $1.35 $1.35 $2.02 Urban [1.68-3.87] (88) [3.90-5.90] (3,653) [1.01-2.02] (572) [1.35-2.02] (208) [1.35-4.07] (4,531) $1.68 $4.30 $1.18 $1.35 $1.35 Rural [1.35-2.02] (67) [3.92-5.33] (518) [1.01-1.35] (330) [1.35-2.02] (40) [1.01-1.68] (1,005) Artesunate amodiaquine $1.68 $4.52 $1.35 - $4.04 Urban (1) [2.56-7.88] (159) [0.84-4.04] (15) - [1.57-4.72] (175) $4.04 $4.52 $4.04 $13.48 $4.04 Rural [2.02-4.04] (3) [2.56-7.88] (25) [2.02-8.09] (9) (1) [2.02-8.09] (39) Artesunate SP $7.75 $5.99 $8.42 - $6.00 Urban [5.90-8.42] (4) [4.23-7.87] (435) (1) - [4.23-7.87] (444) - $6.89 - - $6.40 Rural - [5.90-7.87] (58) - - [5.63-7.87] (67) Dihydroartemisinin piperaquine $7.58 $6.69 $5.90 - $6.69 Urban [4.21-7.58] (2) [5.41-7.85] (448) (1) - [5.41-7.58] (454) $5.90 $6.69 - - $6.69 Rural [5.90-6.40] (3) [5.70-7.85] (68) - - [6.39-7.47] (80)

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Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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) Quality-assured ACT (QA ACT) $1.68 $4.72 $1.35 $1.35 $1.35 Urban [1.35-2.02] (47) [2.95-7.87] (702) [1.01-1.68] (459) [1.35-2.02] (165) [1.18-2.02] (1,376) $1.68 $4.58 $1.18 $1.35 $1.35 Rural [1.35-2.02] (40) [2.95-5.33] (99) [1.01-1.68] (260) [1.12-1.68] (32) [1.01-1.68] (449) QA ACT with the “green leaf” logo $1.68 $3.83 $1.35 $1.35 $1.35 Urban [1.68-2.02] (29) (1) [1.01-1.68] (430) [1.35-2.02] (124) [1.01-1.68] (585) $1.68 - $1.18 $1.35 $1.35 Rural [1.35-1.68] (27) - [1.01-1.68] (237) [1.12-1.68] (31) [1.01-1.68] (307) QA ACT without the “green leaf” logo $1.35 $4.72 $2.02 $1.35 $3.15 Urban [1.12-2.70] (18) [2.95-7.87] (701) [1.35-2.36] (29) [1.35-1.68] (41) [1.68-5.21] (791) $2.02 $4.58 $1.35 $1.68 $1.52 Rural [1.35-2.70] (13) [2.95-5.33] (99) [0.84-1.57] (23) (1) [1.01-2.70] (142) QA artemether lumefantrine $1.68 $4.72 $1.35 $1.35 $1.35 Urban [1.35-2.02] (46) [3.15-6.00] (594) [1.01-1.68] (444) [1.35-2.02] (165) [1.12-2.02] (1,252) $1.68 $4.07 $1.18 $1.35 $1.35 Rural [1.35-2.02] (37) [3.15-5.33] (83) [1.01-1.52] (251) [1.12-1.68] (31) [1.01-1.68] (419) Non-quality assured ACT (Non-QA ACT) $4.04 $4.92 $1.68 $2.02 $4.33 Urban [3.03-5.05] (48) [4.07-6.49] (4,357) [1.18-4.04] (130) [1.35-3.37] (43) [3.38-6.10] (4,592) $2.36 $4.85 $1.12 $1.68 $1.35 Rural [1.35-3.03] (33) [4.07-6.51] (614) [1.01-1.35] (79) [1.35-2.02] (9) [1.01-3.34] (788)

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Table B5a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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) SP $0.51 $0.83 $0.34 $0.42 $0.42 Urban [0.42-0.84] (35) [0.65-0.84] (222) [0.34-0.42] (561) [0.34-0.51] (556) [0.34-0.51] (1,382) $0.51 $0.83 $0.34 $0.42 $0.42 Rural [0.51-0.51] (17) [0.34-0.84] (29) [0.34-0.42] (202) [0.34-0.51] (30) [0.34-0.51] (295) Quinine $3.71 $19.10 $3.54 $3.54 $3.54 Urban [3.54-5.31] (152) [5.83-25.78] (292) [2.83-4.25] (677) [3.18-4.25] (484) [2.83-4.25] (1,613) $4.25 $9.19 $3.54 $3.54 $3.54 Rural [3.54-6.37] (96) [4.85-20.24] (34) [2.83-4.25] (224) [2.83-4.25] (48) [2.83-4.25] (432) Chloroquine $0.41 - $0.41 $0.41 $0.41 Urban [0.41-0.42] (5) - [0.41-0.42] (524) [0.41-0.42] (121) [0.41-0.42] (650) $0.42 - $0.41 $0.41 $0.41 Rural [0.41-1.05] (8) - [0.41-0.42] (363) [0.41-0.42] (14) [0.41-0.42] (385) * AETD - adult equivalent treatment dose - is the number of milligrams required to treat a 60-kg 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. The numbers of tablet antimalarials captured in audit sheets with missing price and/ or product information are as follows: 36 any ACT, 32 artemether lumefantrine, 1 artesunate amodiaquine, 15 QA ACT, 13 QA ACT with the “green leaf” logo, 2 QA ACT without the “green leaf” logo, 14 QA artemether lumefantrine, 21 non-QA ACT, 15 SP, 25 quinine, 9 chloroquine. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B5b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of one pre-packaged therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials)

Adult first-line quality-assured ACT (QA ACT) 

$1.68 $3.83 $1.18 $1.35 $1.35 Urban [1.35-2.02] (27) [2.95-5.10] (391) [1.01-1.35] (205) [1.18-1.35] (109) [1.01-1.68] (733) $1.35 $3.83 $1.01 $1.35 $1.18 Rural [1.35-1.68] (15) [2.95-5.33] (57) [0.84-1.35] (112) [1.01-1.35] (19) [1.01-1.35] (215)

Pediatric first-line quality-assured ACT (QA ACT) 

$0.67 $1.97 $0.51 $0.51 $0.51 Urban [0.51-0.67] (8) [1.18-1.97] (140) [0.42-0.67] (94) [0.51-0.84] (22) [0.51-0.84] (264) $0.51 $1.18 $0.42 $0.84 $0.42 Rural [0.42-0.67] (8) [1.18-1.69] (17) [0.34-0.51] (45) [0.51-0.84] (4) [0.42-0.51] (76)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and pediatric children. Adult pre-packaged therapy is the package size intended for a 60-kg adult. Pediatric pre-packaged therapy is the package size intended for a 10-kg 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: 9 adult first-line QA ACT and one pediatric first-line QA ACT. Source: ACTwatch Outlet Survey, Benin, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=91 Urban N=40 Urban N=39 Urban N=170 Urban N=140 Urban N=147 Urban N=990 Urban N=439 Urban N=1,723 Urban N=1,893 Proportion of outlets** stocking Rural N=199 Rural N=80 Rural N=46 Rural N=325 Rural N=93 Rural N=23 Rural N=540 Rural N=57 Rural N=736 Rural N=1,061 Any malaria blood testing 100.0 79.1 37.8 76.1 45.2 4.9 0.1 0.0 3.3 9.7 Urban - (41.1, 95.3) (19.0, 61.2) (62.1, 86.0) (36.8, 53.9) (1.2, 17.5) (0.0, 0.3) - (2.1, 5.2) (5.4, 16.6) 95.3 82.9 38.2 79.1 30.1 6.5 0.1 0.0 3.4 19.9 Rural (87.5, 98.3) (69.9, 91.1) (12.7, 72.4) (66.9, 87.7) (15.8, 49.6) (1.5, 23.4) (0.0, 0.9) - (1.8, 6.1) (13.9, 27.6) Urban N=91 Urban N=40 Urban N=39 Urban N=170 Urban N=140 Urban N=147 Urban N=990 Urban N=439 Urban N=1,723 Urban N=1,893

Rural N=199 Rural N=80 Rural N=46 Rural N=325 Rural N=93 Rural N=23 Rural N=540 Rural N=57 Rural N=736 Rural N=1,061 Malaria microscopy 48.5 2.9 16.5 20.1 24.6 0.0 0.0 0.0 1.7 3.3 Urban (34.8, 62.4) (0.5, 14.2) (6.5, 36.0) (11.7, 32.2) (11.5, 45.1) - - - (0.8, 3.5) (2.4, 4.6) 5.1 0.0 4.8 1.6 7.7 0.0 0.0 0.0 0.8 1.0 Rural (2.2, 11.6) - (0.6, 29.2) (0.5, 5.0) (2.4, 21.8) - - - (0.3, 2.7) (0.4, 2.6) Urban N=91 Urban N=40 Urban N=39 Urban N=170 Urban N=139 Urban N=147 Urban N=990 Urban N=439 Urban N=1,722 Urban N=1,892

Rural N=199 Rural N=80 Rural N=46 Rural N=325 Rural N=93 Rural N=23 Rural N=540 Rural N=57 Rural N=736 Rural N=1,061 Rapid diagnostic tests (RDTs) 99.5 79.1 29.1 73.9 25.8 4.9 0.1 0.0 1.9 8.2 Urban (98.1, 99.9) (41.1, 95.3) (12.6, 54.0) (59.0, 84.8) (14.1, 42.5) (1.2, 17.5) (0.0, 0.3) - (0.9, 4.1) (3.9, 16.7) 95.2 82.9 34.5 78.6 26.6 6.5 0.1 0.0 3.0 19.5 Rural (87.4, 98.2) (69.9, 91.1) (10.4, 70.4) (66.2, 87.3) (12.9, 46.9) (1.5, 23.4) (0.0, 0.9) - (1.6, 5.6) (13.5, 27.2) Urban N=91 Urban N=40 Urban N=39 Urban N=170 Urban N=139 Urban N=147 Urban N=990 Urban N=439 Urban N=1,722 Urban N=1,892

Rural N=199 Rural N=80 Rural N=46 Rural N=325 Rural N=93 Rural N=23 Rural N=540 Rural N=57 Rural N=736 Rural N=1,061 Quality-assured Rapid

diagnostic tests (QA RDT)*** 85.9 69.4 26.1 64.5 22.3 4.5 0.1 0.0 1.7 7.2 Urban (63.9, 95.4) (24.0, 94.2) (10.1, 52.8) (43.5, 81.1) (11.2, 39.5) (1.0, 18.2) (0.0, 0.3) - (0.7, 3.7) (3.1, 15.8) 93.0 82.9 33.7 78.1 24.4 4.3 0.1 0.0 2.7 19.2 Rural (85.6, 96.7) (69.9, 91.1) (9.9, 70.3) (65.7, 86.9) (10.9, 45.9) (1.0, 16.2) (0.0, 0.9) - (1.3, 5.6) (13.1, 27.1) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. Five antimalarial-stocking outlets were missing information about both availability of microscopy and availability of RDTs. Seven antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.” *** QA RDT status could not be determined for 28 RDTs because of missing product information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B7: Malaria blood testing market composition, across urban/rural location Public Community Private Not ALL Private General Itinerant Drug ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with malaria blood Retailer Vendor Private Facility Worker Facility For-Profit Facility testing available on the day of the survey:* % % % % % % % % % % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 24.0 34.5 8.7 67.2 32.4 - - 0.4 - 32.8 Urban, N=159 outlets (12.8, 40.4) (15.2, 60.8) (4.5, 16.1) (50.8, 80.2) (19.5, 48.7) - - (0.0, 3.3) - (19.8, 49.2) 18.4 61.4 7.1 86.9 12.7 0.1 - 0.4 - 13.1 Rural, N=149 outlets (8.9, 34.2) (43.8, 76.4) (2.9, 16.5) (75.7, 93.4) (6.3, 23.7) (0.0, 1.0) - (0.0, 3.2) - (6.6, 24.3) * 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, Benin, 2016.

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Table B8: Price of malaria blood testing for adults, by outlet type, across urban/rural location Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Total median price to consumers:* (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) Malaria microscopy Adult $2.53 - - - $2.53 Urban [2.02-3.37] (46) - - - [2.02-3.37] (46) $2.53 - - - $2.53 Rural [1.68-2.53] (17) - - - [1.68-2.53] (17) Child under 5 years $2.53 - - - $2.53 Urban [2.02-3.37] (46) - - - [2.02-3.37] (46) $2.53 - - - $2.53 Rural [1.68-2.53] (17) - - - [1.68-2.53] (17) Rapid diagnostic tests (RDTs) Adult $0.84 $1.18 $1.68 - $0.84 Urban [0.34-1.68] (33) [1.18-1.18] (6) (1) - [0.34-1.68] (40) $0.51 $1.68 - - $0.51 Rural [0.17-0.84] (19) [0.84-2.53] (2) - - [0.17-0.84] (21) Child under 5 years $0.84 $1.18 $1.68 - $0.84 Urban [0.34-1.68] (33) [1.18-1.18] (5) (1) - [0.34-1.68] (39) $0.51 $1.68 - - $0.51 Rural [0.17-0.84] (19) [0.84-2.53] (2) - - [0.17-0.84] (21) * Total price to the consumer including consultation and/or service fees. Microscopic blood testing price information was not available (missing or “don’t know” response) for:4 adult microscopy tests, 4 child microscopy tests, 8 adult RDTs, and 9 child RDTs. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B9.1: Antimalarial market share, within urban locations Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL** distributed:* % % % % % % % % % % % 1. Any ACT 8.3 0.6 1.1 10.0 2.5 13.5 0.1 16.2 1.5 33.7 43.7 Artemether lumefantrine 8.3 0.6 1.0 9.9 2.4 10.9 0.0 16.1 1.5 30.9 40.8 Artesunate amodiaquine 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.1 0.0 0.3 0.3 Artesunate SP 0.0 0.0 0.0 0.0 0.0 0.8 0.0 0.0 0.0 0.8 0.9 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.0 1.3 0.0 0.0 0.0 1.3 1.3 Other ACT β 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.4 0.4 Quality-assured ACT (QA ACT) 8.3 0.5 0.7 9.5 1.6 1.8 0.0 13.0 1.2 17.6 27.1 QA ACT with the “green leaf” logo 0.0 0.1 0.3 0.4 1.1 0.0 0.0 12.7 1.0 14.8 15.2 QA ACT without the “green leaf” logo 8.3 0.5 0.3 9.1 0.5 1.8 0.0 0.3 0.3 2.8 11.9 QA artemether lumefantrine 8.3 0.5 0.7 9.5 1.6 1.7 0.0 12.9 1.2 17.3 26.9 Non-quality assured ACT (non-QA ACT) 0.0 0.0 0.4 0.4 0.9 11.7 0.1 3.2 0.3 16.1 16.5 Nationally registered ACT 8.3 0.5 0.6 9.4 1.5 7.7 0.0 7.8 0.7 17.7 27.1 2. Any non-artemisinin therapy 9.5 0.0 1.7 11.2 2.3 4.7 0.3 28.6 8.9 44.9 56.0 Sulfadoxine pyrimethamine 6.3 0.0 0.6 6.9 0.7 4.5 0.2 15.5 6.4 27.2 34.1 Oral quinine 3.0 0.0 0.9 3.9 1.3 0.2 0.1 3.3 1.2 6.2 10.1 Quinine IV/IM 0.1 0.0 0.1 0.2 0.2 0.0 0.0 0.1 0.0 0.3 0.6 Chloroquine 0.0 0.0 0.0 0.0 0.2 0.0 0.0 9.6 1.2 11.0 11.0 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.1 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.1 0.1 0.1 0.1 0.0 0.0 0.0 0.2 0.3 Artesunate IV/IM # 0.0 0.0 0.1 0.1 0.1 0.0 0.0 0.0 0.0 0.2 0.3 Artemether IV/IM 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 0.2 0.0 0.1 0.3 0.3 0.1 0.0 0.2 0.0 0.6 0.9 OUTLET TYPE TOTAL*** 17.8 0.6 2.8 21.2 4.9 18.3 0.3 44.9 10.4 78.8 100.0 * A total of 19,599.2AETDs were reportedly sold or distributed in the previous 7 days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 7,623antimalarials (in the census sample) were audited. Of these, 846 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B9.2: Antimalarial market share, within rural locations Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL** distributed:* % % % % % % % % % % % 1. Any ACT 10.6 1.7 2.9 15.3 2.5 2.1 0.8 22.5 1.6 29.4 44.7 Artemether lumefantrine 10.6 1.7 2.9 15.2 2.4 1.5 0.8 22.4 1.5 28.7 43.9 Artesunate amodiaquine 0.1 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.2 0.2 Artesunate SP 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.2 0.2 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.0 0.0 0.4 0.4 Other ACT β 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Quality-assured ACT (QA ACT) 10.6 1.7 2.8 15.2 1.5 0.3 0.5 19.2 1.1 22.6 37.8 QA ACT with the “green leaf” logo 0.4 0.0 2.0 2.4 1.1 0.0 0.2 16.5 1.1 18.8 21.2 QA ACT without the “green leaf” logo 10.2 1.7 0.9 12.8 0.4 0.3 0.3 2.8 0.0 3.7 16.6 QA artemether lumefantrine 10.6 1.7 2.8 15.1 1.4 0.3 0.5 19.1 1.1 22.4 37.6 Non-quality assured ACT (non-QA ACT) 0.0 0.0 0.1 0.1 1.0 1.7 0.3 3.3 0.5 6.8 6.9 Nationally registered ACT 10.6 1.7 1.5 13.8 1.3 1.0 0.4 9.2 1.3 13.1 26.9 2. Any non-artemisinin therapy 7.5 0.0 1.2 8.7 6.3 0.7 0.5 36.2 2.3 46.1 54.8 Sulfadoxine pyrimethamine 4.2 0.0 0.4 4.6 1.7 0.7 0.0 11.7 0.7 14.8 19.4 Oral quinine 3.2 0.0 0.6 3.7 3.5 0.0 0.4 3.0 0.7 7.6 11.4 Quinine IV/IM 0.2 0.0 0.1 0.3 0.7 0.0 0.0 0.1 0.0 0.9 1.2 Chloroquine 0.0 0.0 0.1 0.1 0.3 0.0 0.0 21.4 0.9 22.6 22.7 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.1 0.1 0.4 0.0 0.0 0.0 0.0 0.5 0.5 Artesunate IV/IM # 0.0 0.0 0.1 0.1 0.4 0.0 0.0 0.0 0.0 0.4 0.5 Artemether IV/IM 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 0.2 0.0 0.2 0.4 1.1 0.0 0.1 0.1 0.0 1.3 1.7 OUTLET TYPE TOTAL*** 18.2 1.7 4.1 24.1 9.2 2.9 1.3 58.8 3.9 75.9 100.0 * A total of 5,828.2 AETDs were reportedly sold or distributed in the previous 7 days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. ** Row sum – market share for the specified antimalarial medicine. *** Column sum – market share for the specified outlet type. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 2,954 antimalarials (in the census sample) were audited. Of these, 602 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B10.1: Antimalarial market share within outlet type, within urban locations Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL distributed:* % % % % % % % % % % % 1. Any ACT 46.8 95.6 38.1 47.0 50.0 73.8 17.9 36.1 14.6 42.8 43.7 Artemether lumefantrine 46.6 95.6 37.0 46.7 49.2 59.4 6.4 35.8 14.6 39.2 40.8 Artesunate amodiaquine 0.1 0.0 0.0 0.1 0.4 0.8 0.0 0.3 0.0 0.4 0.3 Artesunate SP 0.0 0.0 1.1 0.1 0.2 4.4 5.2 0.0 0.0 1.1 0.9 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.2 7.1 6.4 0.0 0.0 1.7 1.3 Other ACT β 0.0 0.0 0.0 0.0 0.0 2.0 0.0 0.0 0.0 0.5 0.4 Quality-assured ACT (QA ACT) 46.8 88.4 24.6 45.0 32.4 9.6 0.0 28.9 11.9 22.3 27.1 QA ACT with the “green leaf” logo 0.0 10.9 12.5 2.0 22.9 0.0 0.0 28.2 9.4 18.8 15.2 QA ACT without the “green leaf” logo 46.8 77.5 12.0 43.1 9.5 9.6 0.0 0.7 2.4 3.5 11.9 QA artemether lumefantrine 46.6 88.4 24.6 44.9 32.0 9.1 0.0 28.7 11.9 22.0 26.9 Non-quality assured ACT (non-QA ACT) 0.0 7.2 13.5 2.0 17.5 64.1 17.9 7.1 2.7 20.5 16.5 Nationally registered ACT 46.4 84.7 20.8 44.1 31.0 42.0 11.5 17.3 6.8 22.5 27.1 2. Any non-artemisinin therapy 53.1 4.4 60.0 52.6 47.5 25.9 81.9 63.8 85.4 56.9 56.0 Sulfadoxine pyrimethamine 35.5 0.0 21.9 32.7 13.8 24.6 51.6 34.5 61.3 34.5 34.1 Oral quinine 16.8 3.4 33.4 18.6 26.2 1.2 30.3 7.4 11.9 7.8 10.1 Quinine IV/IM 0.8 1.0 3.3 1.1 3.7 0.1 0.0 0.3 0.0 0.4 0.6 Chloroquine 0.0 0.0 1.2 0.2 3.5 0.0 0.0 21.5 11.5 14.0 11.0 Other non-artemisinin therapy ^ 0.0 0.0 0.3 0.0 0.3 0.1 0.0 0.2 0.7 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 1.9 0.4 2.5 0.3 0.2 0.1 0.0 0.3 0.3 Artesunate IV/IM # 0.1 0.0 1.9 0.4 2.3 0.2 0.2 0.1 0.0 0.2 0.3 Artemether IV/IM 0.0 0.0 0.0 0.0 0.3 0.1 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 0.9 1.0 5.2 1.5 6.2 0.4 0.2 0.4 0.0 0.7 0.9 * A total of 19,599.2 AETDs were reportedly sold or distributed in the previous 7 days: 2,628.8 public health facilities; 64.7 community health workers; 521.4 private not for-profit health facilities; 1,089.9 private for-profit health facilities; 5,278.3 pharmacies; 81.5 drug stores; 7,329.0 general retailers; and12,605.6 itinerant drug vendors. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% within each column. A total of 7,623 antimalarials were audited. Of these, 846 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 18 public health facilities; 0 community health workers, 25 private not for-profit health facilities; 43 private for-profit health facilities; 685 pharmacies; 0 drug stores;59 general retailers;7 itinerant drug vendors; and 9 unknown outlet types. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B10.2: Antimalarial market share within outlet type, within rural locations Public Community Private Not TOTAL Private ANTI- AETDs sold or distributed in the previous General Itinerant TOTAL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL week by outlet type and antimalarial type Retailer Drug Vendor Private as a percentage of all AETDs sold / Facility Worker Facility For-Profit Facility TOTAL distributed:* % % % % % % % % % % % 1. Any ACT 58.5 100.0 69.9 63.4 26.9 73.2 60.8 38.3 39.9 38.7 44.7 Artemether lumefantrine 58.1 100.0 69.9 63.1 26.3 53.0 60.8 38.2 39.7 37.8 43.9 Artesunate amodiaquine 0.4 0.0 0.0 0.3 0.5 0.9 0.0 0.2 0.3 0.2 0.2 Artesunate SP 0.0 0.0 0.0 0.0 0.0 5.3 0.0 0.0 0.0 0.2 0.2 Dihydroartemisinin piperaquine 0.0 0.0 0.0 0.0 0.2 13.0 0.0 0.0 0.0 0.5 0.4 Other ACT β 0.0 0.0 0.0 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.0 Quality-assured ACT (QA ACT) 58.5 100.0 68.2 63.1 15.9 12.0 35.9 32.7 27.5 29.7 37.8 QA ACT with the “green leaf” logo 2.2 0.0 47.6 9.9 12.0 0.0 13.1 28.1 27.4 24.8 21.2 QA ACT without the “green leaf” logo 56.3 100.0 20.6 53.3 3.9 12.0 22.7 4.7 0.1 4.9 16.6 QA artemether lumefantrine 58.1 100.0 68.2 62.8 15.8 11.3 35.9 32.6 27.2 29.5 37.6 Non-quality assured ACT (non-QA ACT) 0.0 0.0 1.7 0.3 11.0 61.2 25.0 5.6 12.5 9.0 6.9 Nationally registered ACT 58.1 97.1 37.2 57.3 14.2 35.6 30.2 15.6 32.2 17.3 26.9 2. Any non-artemisinin therapy 41.5 0.0 28.9 36.3 68.8 25.5 37.0 61.7 60.1 60.7 54.8 Sulfadoxine pyrimethamine 22.9 0.0 10.0 19.0 18.3 24.7 3.0 19.8 18.9 19.5 19.4 Oral quinine 17.4 0.0 13.9 15.6 38.4 0.5 30.3 5.0 19.0 10.0 11.4 Quinine IV/IM 1.1 0.0 2.9 1.3 8.2 0.3 2.3 0.2 0.0 1.2 1.2 Chloroquine 0.1 0.0 2.0 0.4 3.3 0.0 1.4 36.4 22.2 29.7 22.7 Other non-artemisinin therapy ^ 0.0 0.0 0.0 0.0 0.5 0.1 0.0 0.2 0.0 0.2 0.2 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 1.2 0.3 4.2 1.3 2.1 0.0 0.0 0.6 0.5 Artesunate IV/IM # 0.0 0.0 1.2 0.2 4.2 0.5 2.1 0.0 0.0 0.6 0.5 Artemether IV/IM 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 Any severe malaria treatment 1.1 0.0 4.2 1.6 12.4 1.3 4.4 0.2 0.0 1.8 1.7 * A total of 5,828.2 AETDs were reportedly sold or distributed in the previous 7 days: 914.0 public health facilities; 55.8 community health workers; 227.2 private not for-profit health facilities; 473.8 private for- profit health facilities; 854.3 pharmacies; 41.4 drug stores; 2,936.2 general retailers; and325.6 itinerant drug vendors. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% within each column. A total of 2,954 antimalarials were audited. Of these, 602 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 31 public health facilities; 0 community health workers, 50 private not for-profit health facilities; 57 private for-profit health facilities; 360 pharmacies; 0 drug stores;102 general retailers; and 2 itinerant drug vendors. Source: ACTwatch Outlet Survey, Benin, 2016.

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Table B13: Provider case management knowledge and practices, by outlet type, across urban/rural location Public Community Private Not ALL Private General Itinerant Drug ALL ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Retailer Vendor Private Outlets Facility Worker Facility For-Profit Facility % % % % % % % % % % Proportion of providers who: (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Would refer a 2-year old child with Urban N=40 Urban N=40 Urban N=146 Urban N=987 Urban N=436 Urban N=1, 576 Urban N=1,616 symptoms of severe malaria to a - - - Rural N=80 Rural N=80 Rural N=23 Rural N=541 Rural N=57 Rural N=644 Rural N=724 health facility Yes, would refer to health facility 98.5 98.5 97.8 95.1 96.8 95.6 95.7 Urban N/A N/A N/A (92.6, 99.7) (92.6, 99.7) (92.4, 99.4) (91.9, 97.0) (91.4, 98.9) (92.4, 97.5) (92.9, 97.4) 100.0 100.0 95.7 96.2 81.2 95.1 96.0 Rural N/A N/A N/A - - (83.8, 99.0) (91.8, 98.3) (58.8, 92.9) (91.3, 97.3) (92.4, 97.9) Would recommend that a client with a Urban N=89 Urban N=40 Urban N=32 Urban N=161 Urban N=108 Urban N=114 Urban N=219 Urban N=124 Urban N=570 Urban N=731 negative malaria blood test take an Rural N=197 Rural N=79 Rural N=33 Rural N=309 Rural N=73 Rural N=21 Rural N=125 Rural N=21 Rural N=256 Rural N=565 antimalarial Yes – sometimes 14.4 7.7 49.4 18.6 41.5 32.2 2.9 18.7 14.0 15.1 Urban (7.7, 25.3) (1.2, 36.8) (28.4, 70.6) (11.3, 29.3) (32.4, 51.2) (19.4, 48.4) (0.9, 9.2) (14.4, 23.9) (8.0, 23.3) (10.9, 20.5) 19.3 0.8 19.1 6.6 36.2 13.6 8.4 1.2 15.2 11.3 Rural (11.2, 31.1) (0.1, 7.0) (4.9, 51.9) (3.4, 12.5) (24.8, 49.3) (2.8, 45.7) (3.4, 19.1) (0.1, 9.3) (9.3, 23.9) (7.9, 16.1) Yes – always 3.0 0.0 4.6 1.9 11.3 0.7 0.7 2.3 2.8 2.6 Urban (0.4, 19.1) - (0.6, 29.0) (0.4, 8.1) (5.0, 23.7) (0.2, 2.5) (0.1, 4.5) (1.3, 4.1) (1.1, 6.6) (1.3, 5.2) 1.3 0.0 4.2 0.8 8.2 2.3 0.0 0.0 2.3 1.6 Rural (0.2, 9.3) - (0.6, 24.1) (0.2, 3.4) (3.4, 18.5) (0.5, 9.3) - - (0.9, 5.6) (0.7, 3.8) Circumstances cited for recommending antimalarial treatment Urban N=22 Urban N=1 Urban N=13 Urban N=36 Urban N=50 Urban N=42 Urban N=14 Urban N=27 Urban N=134 Urban N=170 to a client who tested negative for Rural N=40 Rural N=1 Rural N=8 Rural N=49 Rural N=34 Rural N=7 Rural N=9 Rural N=2 Rural N=53 Rural N=102 malaria:* Patient has signs and symptoms of

malaria 95.7 100.0 100.0 98.9 87.2 0.0 87.3 52.8 71.2 78.7 Urban (81.9, 99.1) - - (94.6, 99.8) (72.1, 94.7) - (74.4, 94.2) (30.5, 74.1) (55.1, 83.3) (61.1, 89.7) 78.6 100.0 85.9 83.0 98.9 0.0 58.8 100.0 86.0 85.2 Rural (50.1, 93.1) - (35.3, 98.5) (64.8, 92.9) (91.5, 99.9) - (11.2, 94.2) - (48.3, 97.6) (60.0, 95.7)

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Provider doesn’t trust test result

1.4 0.0 10.5 6.3 14.9 0.0 18.5 0.0 10.1 9.0 Urban (0.2, 8.8) - (2.6, 34.4) (1.6, 21.8) (5.0, 36.9) - (6.6, 42.2) - (5.4, 18.1) (4.3, 18.2) 10.3 0.0 3.6 7.0 35.7 0.0 0.0 0.0 24.2 19.8 Rural (4.9, 20.4) - (0.4, 27.2) (3.2, 14.3) (18.7, 57.2) - - - (11.7, 43.4) (10.3, 34.5)

Other (all other reasons)

1.4 0.0 10.5 6.3 28.5 1.5 23.5 14.0 21.3 17.3 Urban (0.2, 8.8) - (2.6, 34.4) (1.6, 21.8) (16.2, 45.0) (0.2, 9.8) (12.1, 40.6) (2.1, 54.8) (15.5, 28.7) (11.7, 24.7) 12.1 0.0 41.1 22.4 14.2 0.0 16.1 0.0 14.6 16.6 Rural (3.4, 35.3) - (8.1, 84.7) (8.0, 48.9) (5.0, 34.2) - (1.6, 69.1) - (5.2, 34.5) (8.4, 30.1) 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). * 10 providers were missing information on referring 2-year-old child with symptoms of severe malaria to a health facility. Two providers were missing information on recommending that a client with a negative blood test take an antimalarial. No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria. Source: ACTwatch Outlet Survey, Benin, 2016.

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

treatment for uncomplicated malaria  91.8 88.8 92.6 90.6 78.1 93.7 43.3 37.3 45.3 49.3 Urban (79.5, 97.0) (66.6, 96.9) (79.7, 97.5) (80.5, 95.7) (69.7, 84.7) (85.0, 97.5) (33.0, 54.3) (32.6, 42.3) (36.9, 54.1) (40.5, 58.2) 97.4 86.7 66.8 86.0 76.7 78.7 32.9 42.7 38.5 48.9 Rural (92.8, 99.1) (75.9, 93.1) (31.0, 90.0) (75.3, 92.6) (63.7, 86.1) (36.0, 96.0) (23.7, 43.6) (21.8, 66.6) (30.2, 47.6) (40.0, 57.9) Correctly state the first-line dosing regimen for: An adult 91.4 18.4 75.7 54.1 59.0 78.0 34.7 24.8 35.0 36.6 Urban (79.4, 96.7) (8.1, 36.7) (47.2, 91.6) (37.0, 70.3) (45.5, 71.3) (60.5, 89.2) (22.8, 48.8) (18.4, 32.4) (24.0, 47.8) (25.7, 49.1) 95.7 60.6 59.0 67.0 64.7 72.2 28.3 34.0 32.8 40.3 Rural (90.8, 98.0) (39.3, 78.4) (26.6, 85.1) (51.2, 79.7) (47.7, 78.7) (37.4, 91.9) (19.4, 39.3) (16.8, 56.9) (24.6, 42.3) (31.1, 50.2) A 2-year-old child 90.6 77.6 82.5 82.7 59.3 66.3 34.1 26.2 34.7 38.9 Urban (79.3, 96.0) (41.9, 94.3) (54.9, 94.8) (64.5, 92.7) (43.5, 73.4) (45.2, 82.4) (22.5, 48.0) (20.9, 32.3) (24.4, 46.7) (27.7, 51.4) 91.6 82.4 58.6 80.9 63.2 54.1 28.3 40.1 33.1 43.5 Rural (86.1, 95.0) (70.2, 90.3) (24.1, 86.3) (68.6, 89.1) (45.6, 77.9) (24.8, 80.8) (19.7, 38.9) (18.3, 66.7) (24.6, 42.8) (33.9, 53.6) Report an ACT as the most effective antimalarial medicine for: An adult 95.6 35.2 75.5 63.1 64.5 92.7 31.7 14.9 31.5 34.3 Urban (87.5, 98.6) (9.1, 74.7) (60.6, 86.1) (38.1, 82.6) (53.5, 74.2) (77.2, 97.9) (19.1, 47.6) (6.2, 31.7) (18.3, 48.5) (20.9, 50.7) 93.3 73.4 69.9 76.7 60.0 97.8 32.6 63.3 37.9 46.4 Rural (88.4, 96.3) (56.1, 85.7) (35.0, 90.9) (63.8, 86.0) (47.1, 71.7) (91.6, 99.5) (24.6, 41.8) (42.3, 80.2) (31.1, 45.3) (39.4, 53.5) A child 97.3 95.6 83.0 93.2 76.9 94.7 34.3 16.5 34.5 39.7 Urban (89.5, 99.4) (79.4, 99.2) (68.9, 91.4) (88.6, 96.1) (68.6, 83.5) (76.0, 99.0) (20.7, 51.0) (5.4, 41.0) (19.8, 53.0) (23.6, 58.3) 95.1 98.0 72.0 93.9 68.3 100.0 37.7 60.0 42.8 53.9 Rural (90.9, 97.4) (93.2, 99.4) (35.8, 92.2) (87.1, 97.2) (53.8, 80.0) - (30.0, 46.0) (41.6, 76.0) (36.1, 49.9) (47.1, 60.6)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) Urban N=91 Urban N=40 Urban N=39 Urban N=170 Urban N=140 Urban N=147 Urban N=991 Urban N=440 Urban N=1,725 Urban N=1,895 Proportion of providers who: Rural N=199 Rural N=80 Rural N=46 Rural N=325 Rural N=94 Rural N=23 Rural N=542 Rural N=57 Rural N=739 Rural N=1,064 Report an ACT as the antimalarial he/she most commonly recommends for: An adult 89.9 32.1 68.1 58.2 69.0 94.1 26.0 14.9 27.9 30.6 Urban (75.6, 96.2) (6.7, 75.8) (44.9, 84.8) (31.8, 80.6) (57.7, 78.4) (76.9, 98.7) (15.7, 39.9) (5.6, 34.0) (17.0, 42.2) (19.3, 44.8) 96.6 65.1 65.8 71.1 60.2 100.0 29.6 63.5 35.5 43.3 Rural (93.1, 98.4) (45.2, 80.8) (32.2, 88.6) (55.6, 82.9) (47.8, 71.5) - (20.9, 40.1) (42.7, 80.3) (27.8, 44.0) (35.4, 51.5) A child 95.1 89.2 71.5 87.0 76.1 98.4 30.1 16.1 31.6 36.4 Urban (82.1, 98.8) (69.8, 96.7) (51.5, 85.5) (78.4, 92.4) (65.8, 84.0) (95.1, 99.5) (18.6, 44.7) (4.6, 43.4) (18.9, 47.8) (22.6, 53.0) 96.7 100.0 64.7 94.5 61.5 100.0 34.9 53.8 39.3 51.4 Rural (92.1, 98.6) - (31.5, 87.9) (87.4, 97.7) (45.0, 75.8) - (26.4, 44.4) (37.3, 69.5) (31.3, 48.0) (43.2, 59.5)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and in 2-year-old children. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. The number of providers with missing information include: 11 providers were missing information on the national first-line treatment; 11 were missing information on the first-line dosing regimen for both adults and children; 9 and 10 providers were missing information on the most effective antimalarial medicine for adults and children, respectively; and 12 were missing information on the most recommended antimalarial medicine for both adults and children. Source: ACTwatch Outlet Survey, Benin, 2016.

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Results Section C: Results by survey year

Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=182 2009 N=0 2009 N=47 2009 N=229 2009 N=118 2009 N=118 2009 N=0 2009 N=1,124 2009 N=81 2009 N=1,441 2009 N=1,670 2011 N=199 2011 N=51 2011 N=80 2011 N=330 2011 N=152 2011 N=230 2011 N=0 2011 N=2,051 2011 N=128 2011 N=2,561 2011 N=2,891 Proportion of outlets* stocking: 2014 N=229 2014 N=78 2014 N=45 2014 N=352 2014 N=167 2014 N=184 2014 N=20 2014 N=3,178 2014 N=431 2014 N=3,980 2014 N=4,332 2016 N=298 2016 N=145 2016 N=93 2016 N=536 2016 N=262 2016 N=176 2016 N=32 2016 N=5,622 2016 N=632 2016 N=6,724 2016 N=7,260 Any antimalarial at the time of survey visit 95.4 - 91.2 94.0 84.2 96.7 - 33.1 42.7 36.3 39.0 2009 (87.8, 98.4) - (67.5, 98.1) (86.7, 97.4) (70.2, 92.3) (92.0, 98.7) - (24.7, 42.7) (19.9, 69.2) (27.1, 46.6) (30.1, 48.7) 93.5 83.3 83.0 85.8 78.3 97.0 - 29.9 52.4 33.2 39.1 2011 (80.2, 98.1) (62.3, 93.8) (66.1, 92.5) (72.3, 93.4) (62.9, 88.4) (94.9, 98.2) - (24.3, 36.2) (31.2, 72.7) (28.1, 38.7) (32.6, 46.0) 97.2 53.2 88.2 64.3 86.4 90.7 96.7 33.4 68.3 39.6 42.5 2014 (94.4, 98.6) (30.9, 74.3) (78.1, 94.0) (45.4, 79.6) (72.3, 93.9) (73.2, 97.2) (83.8, 99.4) (25.8, 41.9) (58.3, 76.8) (32.6, 47.1) (35.6, 49.7) 95.0 59.4 91.2 72.6 85.8 94.6 98.0 27.5 67.7 33.3 35.7 2016 (90.3, 97.4) (40.2, 76.1) (79.8, 96.4) (58.1, 83.5) (77.6, 91.3) (76.5, 99.0) (90.5, 99.6) (21.9, 34.0) (38.8, 87.4) (30.2, 36.7) (32.1, 39.4) Any ACT 81.8 - 38.2 67.1 18.4 96.7 - 0.9 0.5 2.3 5.4 2009 (71.6, 88.8) - (12.8, 72.3) (51.8, 79.5) (7.3, 39.4) (92.0, 98.7) - (0.2, 3.2) (0.1, 4.6) (1.0, 5.1) (3.8, 7.5) 74.3 83.3 51.2 77.4 37.8 94.8 - 5.6 15.1 7.9 15.6 2011 (62.2, 83.6) (62.3, 93.8) (27.1, 74.8) (63.3, 87.1) (21.8, 57.0) (92.2, 96.5) - (4.0, 7.6) (6.9, 29.7) (5.9, 10.6) (11.6, 20.8) 87.4 50.0 60.9 58.3 44.6 84.0 67.9 12.7 19.7 15.6 20.6 2014 (77.6, 93.3) (28.9, 71.1) (34.5, 82.2) (40.4, 74.2) (29.6, 60.8) (66.9, 93.1) (37.3, 88.2) (8.4, 18.8) (12.0, 30.8) (10.7, 22.3) (15.0, 27.6) 90.2 57.1 44.4 62.2 40.4 94.6 91.1 10.6 27.6 13.6 16.5 2016 (84.2, 94.1) (36.3, 75.7) (27.4, 62.8) (47.8, 74.8) (30.4, 51.2) (76.5, 99.0) (80.2, 96.3) (7.1, 15.6) (20.5, 36.1) (10.3, 17.7) (12.4, 21.6) Artemether lumefantrine 81.3 - 26.5 62.9 16 95.9 - 0.9 0.5 2.2 5.0 2009 (70.9, 88.6) - (4.9, 71.6) (45.8, 77.2) (5.3, 39.2) (89.9, 98.4) - (0.2, 3.2) (0.1, 4.6) (1.0, 4.9) (3.5, 7.1) 64.9 83.3 42.4 74.0 36.4 93.5 - 5.5 15.1 7.9 15.2 2011 (50.8, 76.8) (62.3, 93.8) (21.0, 67.1) (60.9, 83.8) (20.0, 56.6) (89.3, 96.1) - (4.0, 7.6) (6.9, 29.7) (5.8, 10.5) (11.2, 20.3) 86.9 50.0 59.7 58.1 44.1 84.0 57.4 12.7 19.7 15.5 20.5 2014 (77.3, 92.8) (28.9, 71.1) (33.5, 81.4) (40.3, 74.0) (29.0, 60.3) (66.9, 93.1) (27.1, 83.0) (8.4, 18.8) (12.0, 30.8) (10.6, 22.2) (14.9, 27.5) 89.7 57.1 41.5 61.6 39.1 94.6 88.1 10.5 27.6 13.5 16.3 2016 (83.8, 93.6) (36.3, 75.7) (24.9, 60.3) (47.2, 74.3) (29.1, 50.0) (76.5, 99.0) (74.8, 94.9) (7.0, 15.5) (20.5, 36.1) (10.2, 17.6) (12.2, 21.5) www.ACTwatch.info Page 80

Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=182 2009 N=0 2009 N=47 2009 N=229 2009 N=118 2009 N=118 2009 N=0 2009 N=1,124 2009 N=81 2009 N=1,441 2009 N=1,670 2011 N=199 2011 N=51 2011 N=80 2011 N=330 2011 N=152 2011 N=230 2011 N=0 2011 N=2,051 2011 N=128 2011 N=2,561 2011 N=2,891 Proportion of outlets* stocking: 2014 N=229 2014 N=78 2014 N=45 2014 N=352 2014 N=167 2014 N=184 2014 N=20 2014 N=3,178 2014 N=431 2014 N=3,980 2014 N=4,332 2016 N=298 2016 N=145 2016 N=93 2016 N=536 2016 N=262 2016 N=176 2016 N=32 2016 N=5,622 2016 N=632 2016 N=6,724 2016 N=7,260 Artesunate amodiaquine 13.9 - 0.0 9.2 0.8 71.4 - 0.0 0.0 0.6 1.0 2009 (6.3, 27.7) - - (3.9, 20.1) (0.2, 2.5) (64.3, 77.6) - - - (0.2, 1.5) (0.5, 1.7) 43.1 0.0 0.0 10.9 0.6 67.8 - 0.0 0.0 0.6 1.8 2011 (29.7, 57.7) - - (5.9, 19.1) (0.1, 3.4) (62.2, 73.0) - - - (0.4, 1.1) (1.2, 2.5) 6.5 0.0 2.4 1.5 0.6 59.3 0.0 0.1 0.0 0.4 0.6 2014 (3.2, 12.8) - (0.4, 12.1) (0.7, 3.2) (0.1, 3.1) (45.6, 71.7) - (0.0, 0.1) - (0.3, 0.8) (0.3, 0.9) 17.2 0.0 0.0 3.8 1.4 37.3 1.8 0.4 0.2 0.6 0.8 2016 (9.3, 29.6) - - (1.8, 7.7) (0.4, 4.1) (22.7, 54.6) (0.2, 12.6) (0.2, 0.8) (0.0, 2.1) (0.3, 1.0) (0.5, 1.3) Quality-assured ACT (QA ACT) 80.5 - 26.5 62.4 15.9 89.0 - 0.9 0.5 2.1 5.0 2009 (69.8, 88.0) - (4.9, 71.6) (44.9, 77.1) (5.3, 39.2) (83.7, 92.7) - (0.2, 3.2) (0.1, 4.6) (0.9, 4.9) (3.5, 7.0) 74.3 83.3 41.2 76.2 34.8 84.8 - 5.5 15.1 7.7 15.3 2011 (62.1, 83.6) (62.3, 93.8) (19.9, 66.4) (62.1, 86.2) (18.1, 56.3) (80.2, 88.4) - (4.0, 7.5) (6.9, 29.7) (5.7, 10.3) (11.2, 20.6) 87.2 50.0 58.7 58.1 39.3 79.9 49.0 12.4 19.7 15.0 20.0 2014 (77.5, 93.1) (28.9, 71.1) (31.9, 81.2) (40.3, 74.1) (26.2, 54.2) (64.7, 89.6) (22.7, 75.9) (8.2, 18.3) (12.0, 30.8) (10.2, 21.4) (14.5, 26.8) 89.9 54.8 36.0 59.4 31.2 85.2 54.8 9.8 23.1 12.0 14.9 2016 (83.9, 93.8) (32.2, 75.7) (19.1, 57.3) (43.6, 73.4) (19.6, 45.8) (68.5, 93.8) (30.4, 77.1) (6.3, 14.7) (17.3, 30.2) (8.7, 16.4) (10.6, 20.3) QA ACT with the “green leaf” logo 0.0 - 0.0 0.0 0.0 0.0 - 0.0 0.0 0.0 0.0 2009 ------0.3 0.0 6.8 0.9 0.9 2.2 - 0.6 5.7 0.8 0.8 2011 (0.1, 1.7) - (3.3, 13.6) (0.3, 2.9) (0.3, 2.8) (0.7, 6.9) - (0.3, 1.3) (1.1, 24.4) (0.4, 1.5) (0.4, 1.6) 1.2 0.0 29.0 2.0 32.5 10.6 28.9 11.4 17.7 13.1 11.8 2014 (0.4, 3.8) - (9.0, 62.9) (0.7, 5.8) (17.9, 51.4) (4.1, 24.7) (11.0, 57.2) (7.5, 16.8) (10.0, 29.5) (8.7, 19.1) (8.1, 16.8) 3.0 0.6 21.8 4.7 21.4 0.1 33.4 9.1 19.6 10.4 10.1 2016 (0.9, 9.8) (0.1, 4.3) (8.0, 47.0) (2.0, 10.8) (13.2, 32.8) (0.0, 0.8) (13.7, 61.2) (5.8, 14.0) (14.1, 26.6) (7.3, 14.8) (7.2, 14.0)

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Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=182 2009 N=0 2009 N=47 2009 N=229 2009 N=118 2009 N=118 2009 N=0 2009 N=1,124 2009 N=81 2009 N=1,441 2009 N=1,670 2011 N=199 2011 N=51 2011 N=80 2011 N=330 2011 N=152 2011 N=230 2011 N=0 2011 N=2,051 2011 N=128 2011 N=2,561 2011 N=2,891 Proportion of outlets* stocking: 2014 N=229 2014 N=78 2014 N=45 2014 N=352 2014 N=167 2014 N=184 2014 N=20 2014 N=3,178 2014 N=431 2014 N=3,980 2014 N=4,332 2016 N=298 2016 N=145 2016 N=93 2016 N=536 2016 N=262 2016 N=176 2016 N=32 2016 N=5,622 2016 N=632 2016 N=6,724 2016 N=7,260 Non-quality assured ACT (non-QA ACT) 5.2 - 38.2 16.3 3.8 96.7 - 0.0 0.0 0.9 1.6 2009 (2.7, 10.0) - (12.8, 72.3) (6.5, 35.5) (1.5, 9.1) (92.0, 98.7) - (0.0, 0.3) - (0.4, 2.3) (0.8, 3.3) 1.9 0.0 10.0 1.6 5.7 94.3 - 0.4 0.6 1.4 1.4 2011 (0.7, 4.8) - (1.8, 40.3) (0.4, 5.8) (1.9, 15.9) (91.5, 96.3) - (0.1, 1.0) (0.1, 3.0) (0.9, 2.2) (1.0, 2.1) 0.3 0.0 4.3 0.3 9.2 84 47.9 0.4 0.0 1.5 1.4 2014 (0.1, 1.1) - (1.5, 11.7) (0.1, 0.9) (3.9, 20.2) (66.9, 93.1) (28.0, 68.4) (0.1, 1.1) - (0.9, 2.4) (0.8, 2.2) 0.3 2.3 11.1 3.3 16.6 94.6 71.9 3.5 8.8 4.9 4.8 2016 (0.1, 1.1) (0.4, 11.7) (5.2, 22.0) (1.4, 7.6) (11.4, 23.4) (76.5, 99.0) (42.7, 89.8) (2.0, 5.9) (5.2, 14.5) (3.3, 7.2) (3.4, 6.9) Any non-artemisinin therapy 90.8 - 91.2 90.9 83.6 90.7 - 33 42.7 36.2 38.8 2009 (82.2, 95.5) - (67.5, 98.1) (82.3, 95.6) (68.9, 92.1) (79.3, 96.2) - (24.7, 42.6) (19.9, 69.2) (27.0, 46.5) (29.9, 48.4) 91.8 0.0 78.5 32.1 73.6 88.3 - 28.9 52.2 32.0 32.0 2011 (80.0, 96.9) - (61.3, 89.4) (18.6, 49.4) (60.9, 83.3) (83.4, 91.9) - (23.3, 35.2) (30.9, 72.7) (26.9, 37.5) (27.2, 37.2) 93.6 3.3 84 26.6 82.3 88.3 84.9 30.2 66.4 36.5 35.3 2014 (86.0, 97.2) (0.9, 11.2) (72.0, 91.5) (17.4, 38.3) (67.0, 91.4) (72.8, 95.6) (61.2, 95.2) (23.7, 37.5) (55.7, 75.7) (30.1, 43.4) (29.6, 41.5) 94.2 4.5 83.5 37.7 83.2 75.6 83.5 25.6 66.3 31.3 31.7 2016 (89.5, 96.9) (0.8, 22.1) (63.3, 93.7) (28.5, 47.9) (74.6, 89.3) (54.0, 89.2) (58.1, 94.9) (20.7, 31.2) (37.0, 86.9) (28.7, 34.1) (29.0, 34.5) SP 49.7 - 45 48.1 28.9 81.6 - 3.3 14.7 5.7 7.7 2009 (32.9, 66.5) - (19.3, 73.8) (31.5, 65.1) (14.3, 49.9) (75.6, 86.4) - (1.6, 7.0) (6.2, 31.0) (2.9, 10.8) (4.7, 12.2) 17.2 0.0 20.0 6.6 15.3 72.6 - 7.2 12.8 8.3 8.2 2011 (13.1, 22.3) - (9.3, 37.8) (3.5, 12.3) (5.3, 36.9) (64.8, 79.2) - (5.1, 10.1) (6.4, 24.1) (6.5, 10.7) (6.3, 10.4) 44.7 1.7 53.7 13.6 16.6 78.8 53.7 6.1 36.5 9.7 10.2 2014 (37.6, 51.9) (0.2, 11.7) (29.9, 75.9) (8.3, 21.4) (8.4, 30.0) (64.3, 88.5) (39.0, 67.8) (4.1, 9.0) (18.0, 60.1) (6.4, 14.5) (7.0, 14.5) 73.9 0.0 25.4 20.6 21.1 53.6 61.5 8.1 46.1 12.1 12.6 2016 (63.9, 81.9) - (12.8, 44.2) (14.9, 27.7) (13.9, 30.6) (37.0, 69.4) (38.6, 80.2) (6.4, 10.1) (19.2, 75.5) (8.1, 17.8) (8.9, 17.6)

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Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=182 2009 N=0 2009 N=47 2009 N=229 2009 N=118 2009 N=118 2009 N=0 2009 N=1,124 2009 N=81 2009 N=1,441 2009 N=1,670 2011 N=199 2011 N=51 2011 N=80 2011 N=330 2011 N=152 2011 N=230 2011 N=0 2011 N=2,051 2011 N=128 2011 N=2,561 2011 N=2,891 Proportion of outlets* stocking: 2014 N=229 2014 N=78 2014 N=45 2014 N=352 2014 N=167 2014 N=184 2014 N=20 2014 N=3,178 2014 N=431 2014 N=3,980 2014 N=4,332 2016 N=298 2016 N=145 2016 N=93 2016 N=536 2016 N=262 2016 N=176 2016 N=32 2016 N=5,622 2016 N=632 2016 N=6,724 2016 N=7,260 Oral quinine 75.0 - 78.1 76.1 45.9 36.3 - 4.7 11.5 7.1 10.4 2009 (65.6, 82.6) - (54.1, 91.5) (68.4, 82.4) (24.5, 69.0) (23.3, 51.6) - (2.1, 10.4) (2.0, 44.7) (3.2, 15.1) (6.1, 16.9) 89.2 0.0 73.2 30.8 60.5 49.6 - 8.7 17.7 11.4 13.6 2011 (78.1, 95.0) - (52.4, 87.2) (18.1, 47.4) (49.6, 70.4) (41.4, 57.8) - (6.2, 12.2) (5.4, 44.7) (8.2, 15.8) (10.7, 17.1) 82.3 1.5 75.5 22.5 59.5 66.2 77.8 11.5 44.6 17.3 17.9 2014 (72.5, 89.1) (0.3, 8.7) (57.9, 87.4) (15.1, 32.0) (41.8, 75.0) (52.6, 77.6) (54.7, 91.0) (7.7, 16.9) (33.8, 56.0) (11.5, 25.3) (12.4, 25.2) 87.7 2.3 73.9 33.2 60.5 63.9 62.3 9.4 40.7 14.1 15.3 2016 (82.7, 91.3) (0.4, 11.7) (56.6, 86.0) (25.0, 42.6) (53.2, 67.4) (44.0, 80.0) (35.3, 83.3) (7.3, 12.2) (16.7, 70.1) (9.7, 20.2) (11.2, 20.4) Chloroquine 1.4 - 23.2 8.7 14.1 13.8 - 30.0 36.8 29.7 28.7 2009 (0.5, 4.3) - (8.3, 50.0) (3.6, 19.6) (7.5, 25.2) (10.8, 17.5) - (22.1, 39.4) (15.0, 65.6) (21.9, 38.8) (21.3, 37.3) 0.4 0.0 5.4 0.7 1.9 4.8 - 23.3 38.1 22.9 20.4 2011 (0.1, 3.0) - (2.1, 13.2) (0.2, 2.9) (0.6, 5.8) (2.5, 8.9) - (17.0, 31.0) (17.6, 63.9) (16.6, 30.6) (15.4, 26.6) 0.6 0.0 2.6 0.3 7.7 12.8 3.1 22.0 23.0 21.2 18.7 2014 (0.1, 3.1) - (0.9, 7.0) (0.1, 0.8) (2.7, 20.1) (2.6, 44.8) (0.5, 18.1) (15.5, 30.2) (16.6, 30.9) (15.3, 28.6) (14.0, 24.6) 0.4 0.0 7.2 1.3 9.6 0.0 1.6 19.6 26.0 19.7 18.6 2016 (0.1, 1.6) - (2.4, 19.6) (0.5, 3.5) (4.4, 19.4) - (0.2, 11.6) (12.7, 29.0) (17.0, 37.6) (13.2, 28.5) (12.8, 26.4) Oral artemisinin monotherapy 1.1 - 8.4 3.6 0.0 35.5 - 0.0 0.0 0.3 0.4 2009 (0.3, 4.4) - (1.2, 40.7) (0.8, 14.7) - (26.9, 45.2) - - - (0.1, 0.7) (0.2, 0.9) 0.0 0.0 0.0 0.0 0.2 3.0 - 0.0 0.0 0.0 0.0 2011 - - - - (0.0, 1.2) (1.1, 7.9) - - - (0.0, 0.1) (0.0, 0.1) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2014 ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2016 ------

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Table C1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=182 2009 N=0 2009 N=47 2009 N=229 2009 N=118 2009 N=118 2009 N=0 2009 N=1,124 2009 N=81 2009 N=1,441 2009 N=1,670 2011 N=199 2011 N=51 2011 N=80 2011 N=330 2011 N=152 2011 N=230 2011 N=0 2011 N=2,051 2011 N=128 2011 N=2,561 2011 N=2,891 Proportion of outlets* stocking: 2014 N=229 2014 N=78 2014 N=45 2014 N=352 2014 N=167 2014 N=184 2014 N=20 2014 N=3,178 2014 N=431 2014 N=3,980 2014 N=4,332 2016 N=298 2016 N=145 2016 N=93 2016 N=536 2016 N=262 2016 N=176 2016 N=32 2016 N=5,622 2016 N=632 2016 N=6,724 2016 N=7,260 Non-oral artemisinin monotherapy 4.3 - 26.0 11.6 1.5 61.9 - 0.0 0.0 0.5 1.0 2009 (1.8, 10.2) - (4.6, 71.9) (3.2, 34.5) (0.5, 4.7) (54.5, 68.8) - - - (0.2, 1.3) (0.5, 2.3) 16.8 0.0 1.7 4.4 15.0 60.4 - 0.2 0.0 1.3 1.6 2011 (9.6, 27.7) - (0.4, 7.1) (2.1, 9.2) (6.6, 30.5) (54.7, 65.9) - (0.0, 1.2) - (0.7, 2.4) (1.0, 2.6) 24.4 0.0 3.5 5.2 15.7 55.4 19.8 0.0 0.0 1.3 1.7 2014 (17.2, 33.4) - (1.2, 9.5) (2.9, 9.2) (9.3, 25.4) (38.1, 71.5) (7.0, 44.9) (0.0, 0.1) - (0.7, 2.2) (1.1, 2.7) 6.8 0.0 30.0 6.6 25.4 72.9 29.9 0.2 0.0 1.4 1.7 2016 (2.5, 16.7) - (17.2, 46.8) (3.3, 12.8) (17.6, 35.1) (56.5, 84.7) (12.8, 55.5) (0.1, 0.7) - (1.0, 2.1) (1.2, 2.5) Any treatment for severe malaria 62.2 - 61.4 62 36.9 52.7 - 0.5 0.0 2.4 5.2 2009 (50.7, 72.6) - (33.6, 83.3) (51.0, 71.8) (23.8, 52.2) (41.7, 63.5) - (0.2, 1.6) - (1.3, 4.4) (3.5, 7.7) 80.9 0.0 65.2 27.8 44.4 55.7 - 0.4 0.0 2.6 5.4 2011 (69.8, 88.6) - (42.4, 82.7) (16.3, 43.4) (34.6, 54.8) (49.9, 61.2) - (0.1, 2.3) - (1.7, 4.0) (4.0, 7.1) 74.5 0.0 59.2 18.8 58.0 67.8 26.2 0.3 0.0 3.9 5.6 2014 (66.6, 81.0) - (31.2, 82.3) (12.0, 28.2) (44.4, 70.5) (52.8, 79.9) (10.4, 52.0) (0.1, 0.8) - (2.6, 5.8) (4.2, 7.5) 79.3 4.5 74.5 32.9 74.7 73.0 66.0 0.5 0.0 3.3 5.0 2016 (69.5, 86.5) (0.8, 22.1) (56.1, 87.0) (24.3, 42.7) (65.4, 82.2) (56.9, 84.7) (42.2, 83.8) (0.2, 1.2) - (2.4, 4.5) (3.7, 6.9) * The denominator includes outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview). Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=173 2009 N=0 2009 N=39 2009 N=212 2009 N=94 2009 N=114 2009 N=372 2009 N=52 2009 N=632 2009 N=844 2011 N=189 2011 N=42 2011 N=62 2011 N=293 2011 N=127 2011 N=223 2011 N=537 2011 N=57 2011 N=944 2011 N=1,237 Proportion of outlets* stocking: 2014 N=222 2014 N=42 2014 N=37 2014 N=301 2014 N=132 2014 N=177 2014 N=889 2014 N=288 2014 N=1,505 2014 N=1,806 2016 N=286 2016 N=91 2016 N=83 2016 N=460 2016 N=222 2016 N=170 2016 N=1,388 2016 N=468 2016 N=2,278 2016 N=2,738 Any ACT 85.7 - 41.9 71.4 21.9 100.0 2.7 1.3 6.4 13.7 2009 (78.3, 90.9) - (14.3, 75.7) (55.6, 83.3) (7.8, 48.0) - (0.8, 8.9) (0.1, 11.9) (3.1, 12.8) (9.9, 18.7) 79.5 100.0 61.7 90.1 48.7 97.8 18.6 28.8 24.0 40.1 2011 (66.9, 88.1) - (34.8, 82.9) (80.6, 95.2) (25.7, 72.4) (94.6, 99.1) (14.2, 24.0) (17.5, 43.6) (18.2, 30.9) (33.2, 47.5) 90.0 93.9 69.0 90.6 51.7 92.6 38.1 28.9 39.4 48.4 2014 (80.6, 95.1) (80.4, 98.3) (41.0, 87.7) (82.1, 95.3) (35.7, 67.3) (73.5, 98.3) (29.4, 47.7) (16.4, 45.7) (30.6, 49.0) (39.9, 57.1) 95.0 96.2 48.7 85.7 47.1 100.0 38.5 40.8 40.8 46.2 2016 (91.1, 97.2) (78.3, 99.4) (31.0, 66.7) (77.7, 91.2) (35.9, 58.6) - (31.0, 46.6) (27.9, 55.2) (32.8, 49.2) (37.1, 55.5) Artemether lumefantrine 85.2 - 29.1 66.9 19.0 99.2 2.6 1.3 6.0 12.9 2009 (77.6, 90.5) - (5.4, 74.6) (48.8, 81.1) (5.9, 47.0) (92.2, 99.9) (0.7, 9.0) (0.1, 11.9) (2.8, 12.4) (9.2, 17.8) 69.4 100.0 51.0 86.2 46.5 96.4 18.5 28.8 23.7 38.9 2011 (54.0, 81.4) - (26.1, 75.4) (76.0, 92.4) (23.2, 71.4) (90.7, 98.7) (14.1, 23.9) (17.5, 43.6) (18.0, 30.5) (31.8, 46.5) 89.4 93.9 67.7 90.4 51.0 92.6 38.1 28.9 39.2 48.2 2014 (80.3, 94.6) (80.4, 98.3) (39.9, 86.9) (81.6, 95.2) (35.1, 66.7) (73.5, 98.3) (29.3, 47.6) (16.4, 45.7) (30.4, 48.8) (39.7, 56.9) 94.4 96.2 45.5 84.9 45.6 100.0 38.2 40.8 40.4 45.8 2016 (90.7, 96.7) (78.3, 99.4) (28.1, 64.1) (76.6, 90.6) (34.3, 57.3) - (30.7, 46.4) (27.9, 55.2) (32.5, 48.9) (36.7, 55.2) Artesunate amodiaquine 14.5 - 0.0 9.8 0.9 73.9 0.0 0.0 1.6 2.5 2009 (6.7, 28.6) - - (4.2, 21.3) (0.3, 3.2) (67.0, 79.8) - - (0.6, 4.0) (1.3, 4.7) 46.1 0.0 0.0 12.6 0.7 70.0 0.0 0.0 1.9 4.5 2011 (32.1, 60.8) - - (7.2, 21.4) (0.1, 4.1) (63.8, 75.4) - - (1.0, 3.5) (3.2, 6.2) 6.7 0.0 2.7 2.3 0.7 65.4 0.2 0.0 1.1 1.3 2014 (3.3, 13.3) - (0.5, 13.8) (1.0, 5.3) (0.1, 3.7) (51.3, 77.2) (0.1, 0.4) - (0.6, 1.9) (0.8, 2.1) 18.1 0.0 0.0 5.2 1.6 39.4 1.4 0.4 1.8 2.2 2016 (9.9, 30.8) - - (2.5, 10.4) (0.5, 4.7) (24.2, 57.0) (0.7, 2.7) (0.0, 3.5) (1.0, 3.0) (1.3, 3.6)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=173 2009 N=0 2009 N=39 2009 N=212 2009 N=94 2009 N=114 2009 N=372 2009 N=52 2009 N=632 2009 N=844 2011 N=189 2011 N=42 2011 N=62 2011 N=293 2011 N=127 2011 N=223 2011 N=537 2011 N=57 2011 N=944 2011 N=1,237 Proportion of outlets* stocking: 2014 N=222 2014 N=42 2014 N=37 2014 N=301 2014 N=132 2014 N=177 2014 N=889 2014 N=288 2014 N=1,505 2014 N=1,806 2016 N=286 2016 N=91 2016 N=83 2016 N=460 2016 N=222 2016 N=170 2016 N=1,388 2016 N=468 2016 N=2,278 2016 N=2,738 Quality-assured ACT (QA ACT) 84.4 - 29.1 66.4 18.9 92.0 2.6 1.3 5.9 12.7 2009 (76.4, 90.0) - (5.4, 74.6) (47.8, 80.9) (5.8, 47.0) (87.4, 95.1) (0.7, 9.0) (0.1, 11.9) (2.7, 12.3) (9.0, 17.6) 79.4 100.0 49.6 88.8 44.9 87.4 18.4 28.8 23.2 39.2 2011 (66.8, 88.1) - (24.8, 74.6) (78.5, 94.5) (21.0, 71.3) (82.3, 91.2) (14.0, 23.8) (17.5, 43.6) (17.5, 30.0) (31.9, 47.1) 89.7 93.9 66.6 90.4 45.5 88.1 37.1 28.9 37.8 47.0 2014 (80.5, 94.8) (80.4, 98.3) (37.9, 86.7) (81.7, 95.1) (31.7, 60.1) (73.6, 95.2) (28.4, 46.7) (16.4, 45.7) (29.2, 47.1) (38.5, 55.7) 94.7 92.3 39.5 81.8 36.4 90.0 35.4 34.2 36.1 41.7 2016 (90.8, 97.0) (61.5, 98.9) (21.6, 60.7) (70.3, 89.5) (23.0, 52.2) (75.0, 96.5) (27.9, 43.8) (22.3, 48.4) (27.7, 45.5) (31.9, 52.1) QA ACT with the “green leaf” logo 0.0 - 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2009 ------0.3 0.0 8.2 1.0 1.2 2.2 2.0 10.9 2.4 2.1 2011 (0.1, 1.8) - (3.6, 17.6) (0.3, 3.4) (0.4, 3.2) (0.7, 7.1) (0.8, 4.5) (2.8, 34.3) (1.3, 4.6) (1.0, 4.2) 1.2 0.0 32.9 3.1 37.6 11.7 34.1 26.0 33.0 27.8 2014 (0.4, 3.9) - (10.3, 67.8) (1.1, 8.1) (21.5, 57.0) (4.6, 26.7) (26.3, 43.0) (13.8, 43.5) (25.0, 42.2) (20.9, 35.8) 3.2 1.0 23.9 6.5 25.0 0.1 33.2 28.9 31.3 28.3 2016 (0.9, 10.3) (0.1, 7.2) (9.0, 49.9) (2.8, 14.3) (15.5, 37.6) (0.0, 0.8) (25.7, 41.7) (17.1, 44.6) (23.0, 41.0) (21.6, 36.2) Non-quality assured ACT (non-QA ACT) 5.5 - 41.9 17.4 4.5 100.0 0.1 0.0 2.5 4.2 2009 (2.8, 10.5) - (14.3, 75.7) (6.9, 37.4) (1.6, 11.7) - (0.0, 0.8) - (1.0, 6.2) (2.2, 7.9) 2.0 0.0 12.0 1.9 7.3 97.3 1.2 1.2 4.2 3.7 2011 (0.8, 5.0) - (2.2, 45.4) (0.5, 6.6) (2.6, 18.9) (93.7, 98.9) (0.4, 3.2) (0.2, 5.7) (2.5, 6.9) (2.2, 5.9) 0.3 0.0 4.9 0.5 10.6 92.6 1.2 0.0 3.8 3.2 2014 (0.1, 1.2) - (1.6, 13.6) (0.2, 1.4) (4.7, 22.5) (73.5, 98.3) (0.5, 3.0) - (2.5, 5.7) (2.1, 4.9) 0.3 3.8 12.1 4.6 19.3 100.0 12.7 13.0 14.8 13.6 2016 (0.1, 1.2) (0.6, 21.7) (5.6, 24.3) (1.8, 11.2) (13.3, 27.2) - (8.4, 18.9) (7.5, 21.6) (10.6, 20.3) (10.0, 18.2)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=173 2009 N=0 2009 N=39 2009 N=212 2009 N=94 2009 N=114 2009 N=372 2009 N=52 2009 N=632 2009 N=844 2011 N=189 2011 N=42 2011 N=62 2011 N=293 2011 N=127 2011 N=223 2011 N=537 2011 N=57 2011 N=944 2011 N=1,237 Proportion of outlets* stocking: 2014 N=222 2014 N=42 2014 N=37 2014 N=301 2014 N=132 2014 N=177 2014 N=889 2014 N=288 2014 N=1,505 2014 N=1,806 2016 N=286 2016 N=91 2016 N=83 2016 N=460 2016 N=222 2016 N=170 2016 N=1,388 2016 N=468 2016 N=2,278 2016 N=2,738 Any non-artemisinin therapy 95.2 - 100.0 96.7 99.3 93.8 99.9 100.0 99.7 99.4 2009 (83.5, 98.7) - - (87.7, 99.2) (95.8, 99.9) (82.0, 98.1) (99.2, 100.0) - (99.3, 99.9) (98.4, 99.8) 98.1 0.0 94.6 37.4 94.0 91.4 96.6 99.6 96.4 82.0 2011 (94.0, 99.4) - (72.4, 99.1) (21.7, 56.2) (76.5, 98.7) (85.5, 95.1) (92.3, 98.5) (96.8, 99.9) (93.1, 98.2) (69.4, 90.1) 96.3 6.1 95.3 41.3 95.3 97.4 90.5 97.2 92.0 83.1 2014 (88.2, 98.9) (1.7, 19.6) (83.2, 98.8) (26.1, 58.4) (76.0, 99.2) (93.2, 99.1) (84.2, 94.4) (91.8, 99.1) (86.4, 95.5) (74.1, 89.4) 99.3 7.7 91.6 51.9 97.0 80.0 93.0 98.0 94.0 88.9 2016 (97.8, 99.8) (1.1, 38.5) (76.5, 97.3) (37.6, 65.9) (91.1, 99.0) (56.9, 92.3) (89.6, 95.3) (91.4, 99.6) (90.1, 96.4) (82.2, 93.3) SP 52.1 - 49.4 51.2 34.3 84.4 10.1 34.4 15.7 19.7 2009 (35.3, 68.4) - (20.5, 78.7) (34.0, 68.1) (18.4, 54.8) (79.0, 88.6) (4.7, 20.5) (17.4, 56.6) (8.6, 27.0) (12.4, 29.9) 18.4 0.0 24.1 7.7 19.8 75.9 24.3 24.5 25.2 20.9 2011 (14.2, 23.5) - (9.7, 48.3) (4.0, 14.3) (7.3, 43.7) (68.4, 82.1) (17.8, 32.1) (16.5, 34.7) (19.8, 31.4) (15.5, 27.6) 45.9 3.2 60.9 21.2 19.2 87.0 18.1 53.4 24.5 23.9 2014 (38.9, 53.2) (0.5, 19.4) (35.8, 81.3) (13.3, 32.0) (10.3, 32.9) (75.6, 93.5) (10.7, 29.0) (24.8, 79.9) (14.5, 38.2) (15.0, 35.9) 77.8 0.0 27.9 28.3 24.6 56.6 29.4 68.1 36.4 35.5 2016 (67.5, 85.6) - (14.2, 47.5) (20.7, 37.5) (16.2, 35.5) (39.5, 72.3) (19.8, 41.4) (42.9, 85.8) (22.1, 53.7) (22.5, 51.0) Oral quinine 78.7 - 85.6 80.9 54.6 37.5 14.3 26.8 19.6 26.5 2009 (67.8, 86.6) - (60.5, 95.8) (73.0, 86.9) (25.5, 80.8) (23.8, 53.6) (6.2, 29.6) (3.7, 77.9) (8.9, 37.9) (15.9, 40.9) 95.3 0.0 88.2 35.9 77.3 51.1 29.2 33.9 34.4 34.8 2011 (90.1, 97.9) - (72.0, 95.6) (21.1, 54.0) (56.9, 89.7) (42.6, 59.6) (19.1, 41.8) (8.5, 73.9) (22.7, 48.4) (24.8, 46.3) 84.6 2.9 85.6 34.9 68.9 73.0 34.5 65.3 43.7 42.2 2014 (74.4, 91.3) (0.5, 16.2) (69.2, 94.0) (22.1, 50.3) (51.3, 82.3) (59.9, 83.1) (22.0, 49.5) (53.3, 75.7) (29.6, 59.0) (29.3, 56.3) 92.3 3.8 81.1 45.7 70.5 67.6 34.3 60.1 42.5 42.9 2016 (88.5, 94.9) (0.6, 21.7) (67.6, 89.8) (34.2, 57.7) (64.0, 76.3) (46.7, 83.2) (21.1, 50.5) (36.1, 80.1) (26.1, 60.7) (28.1, 59.0)

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(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=173 2009 N=0 2009 N=39 2009 N=212 2009 N=94 2009 N=114 2009 N=372 2009 N=52 2009 N=632 2009 N=844 2011 N=189 2011 N=42 2011 N=62 2011 N=293 2011 N=127 2011 N=223 2011 N=537 2011 N=57 2011 N=944 2011 N=1,237 Proportion of outlets* stocking: 2014 N=222 2014 N=42 2014 N=37 2014 N=301 2014 N=132 2014 N=177 2014 N=889 2014 N=288 2014 N=1,505 2014 N=1,806 2016 N=286 2016 N=91 2016 N=83 2016 N=460 2016 N=222 2016 N=170 2016 N=1,388 2016 N=468 2016 N=2,278 2016 N=2,738 Chloroquine 1.5 - 25.4 9.3 16.8 14.3 90.8 86.0 81.7 73.5 2009 (0.5, 4.6) - (9.0, 53.9) (3.9, 20.6) (8.1, 31.7) (11.1, 18.2) (81.5, 95.7) (52.9, 97.1) (70.0, 89.5) (63.4, 81.7) 0.5 0.0 6.5 0.9 2.4 4.9 77.9 72.7 68.8 52.2 2011 (0.1, 3.2) - (2.4, 16.9) (0.2, 3.3) (0.8, 7.0) (2.6, 9.2) (66.0, 86.5) (40.6, 91.2) (54.7, 80.1) (43.7, 60.6) 0.6 0.0 2.9 0.4 8.9 14.1 65.8 33.6 53.4 44.1 2014 (0.1, 3.2) - (1.0, 8.3) (0.2, 1.2) (3.3, 22.1) (2.9, 47.7) (53.5, 76.3) (23.2, 46.0) (41.1, 65.3) (35.5, 53.0) 0.4 0.0 7.9 1.8 11.1 0.0 71.3 38.4 59.2 52.3 2016 (0.1, 1.7) - (2.7, 21.0) (0.7, 4.6) (5.1, 22.6) - (54.7, 83.6) (19.0, 62.4) (39.9, 76.1) (37.8, 66.4) Oral artemisinin monotherapy 1.2 - 9.2 3.8 0.0 36.8 0.0 0.0 0.7 1.1 2009 (0.3, 4.6) - (1.3, 43.1) (0.8, 15.4) - (27.7, 46.9) - - (0.3, 1.8) (0.5, 2.4) 0.0 0.0 0.0 0.0 0.3 3.2 0.0 0.0 0.1 0.1 2011 - - - - (0.0, 1.5) (1.2, 8.3) - - (0.0, 0.2) (0.0, 0.2) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2014 ------0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2016 ------Non-oral artemisinin monotherapy 4.5 - 28.5 12.3 1.7 64 0.0 0.0 1.5 2.7 2009 (1.9, 10.5) - (5.1, 74.8) (3.4, 36.2) (0.5, 5.7) (55.9, 71.5) - - (0.6, 3.4) (1.3, 5.4) 17.9 0.0 2.1 5.1 19.4 63.2 0.6 0.0 3.8 4.1 2011 (10.6, 28.8) - (0.5, 8.6) (2.4, 10.7) (7.9, 40.1) (57.1, 68.8) (0.1, 3.6) - (2.0, 7.0) (2.6, 6.6) 25.1 0.0 4.0 8.1 18.2 61.1 0.0 0.0 3.2 4.1 2014 (17.6, 34.5) - (1.4, 11.0) (4.1, 15.2) (10.3, 30.0) (42.0, 77.3) (0.0, 0.2) - (2.0, 4.9) (2.8, 5.8) 7.1 0.0 32.9 9.0 29.6 77.0 0.8 0.0 4.3 4.8 2016 (2.7, 17.5) - (18.1, 52.1) (4.3, 17.9) (20.5, 40.6) (61.0, 87.8) (0.3, 2.2) - (3.0, 6.0) (3.5, 6.6)

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Table C4: Antimalarial market composition, across survey round Public Community Private Not ALL Private General Itinerant Drug ALL Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store Outlet type, among outlets with at least 1 Retailer Vendor Private Facility Worker Facility For-Profit Facility antimalarial in stock on the day of the survey:* % % % % % % % % % % (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 1.5 - 4.0 5.5 9.4 0.6 - 77.7 6.8 94.5 2009, N=626 outlets (0.9, 2.6) - (1.9, 8.2) (3.2, 9.3) (5.5, 15.5) (0.2, 1.6) - (62.1, 88.1) (2.3, 18.9) (90.7, 96.8) 1.2 16.2 2.9 20.3 7.5 0.3 - 67.2 4.7 79.7 2011, N=890 outlets (0.8, 1.9) (7.6, 31.1) (1.4, 6.1) (11.3, 33.6) (4.1, 13.4) (0.1, 0.8) - (58.1, 75.1) (2.4, 9.3) (66.4, 88.7) 6.1 10.6 1.4 18.1 9.5 1.4 0.9 58.6 11.4 81.9 2014, N=1,501 outlets (4.2, 8.8) (5.6, 19.0) (0.7, 2.9) (12.0, 26.4) (5.5, 15.8) (0.8, 2.5) (0.2, 3.7) (51.4, 65.5) (6.4, 19.5) (73.6, 88.0) 3.2 6.0 2.6 11.8 7.2 1.4 0.4 63.6 15.6 88.2 2016, N=2,383 outlets (2.4, 4.2) (3.4, 10.6) (1.8, 3.7) (8.3, 16.5) (5.4, 9.7) (0.9, 2.1) (0.2, 0.8) (55.5, 71.0) (9.3, 25.0) (83.5, 91.7) *Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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Table C5a: Price of tablet formulation antimalarials, by outlet type, across survey round Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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 $2.59 $8.62 $3.02 $3.24 $8.27 2009 [1.94-5.18] (28) [7.31-10.73] (1,443) [1.73-3.02] (11) (1) [5.87-10.51] (1,483) $1.23 $8.11 $2.06 $2.26 $5.47 2011 [1.23-3.29] (89) [7.21-9.19] (3,268) [1.44-2.47] (186) [2.06-3.29] (29) [2.06-8.17] (3,572) $2.19 $5.96 $1.46 $1.46 $2.19 2014 [1.82-3.64] (100) [4.54-7.44] (5,632) [1.09-2.19] (568) [1.46-2.19] (116) [1.46-5.19] (6,466) $2.01 $5.51 $1.51 $1.51 $2.26 2016 [1.51-3.77] (168) [4.41-7.27] (5,772) [1.13-1.89] (928) [1.51-2.26] (249) [1.51-4.74] (7,205) Quality-assured ACT (QA ACT) $2.59 $8.82 $3.02 $3.24 $5.74 2009 [1.94-2.59] (16) [5.77-16.80] (327) [1.73-3.02] (9) (1) [2.59-8.82] (353) $1.23 $8.40 $2.06 $2.26 $2.06 2011 [1.23-2.47] (67) [8.00-11.44] (575) [1.44-2.47] (183) [2.06-3.29] (29) [1.44-3.29] (854) $2.19 $5.10 $1.46 $1.46 $1.82 2014 [1.82-3.64] (61) [3.41-7.44] (1,050) [1.09-2.19] (556) [1.46-2.19] (116) [1.28-2.55] (1,802) $1.89 $5.28 $1.51 $1.51 $1.51 2016 [1.51-2.26] (87) [3.30-8.43] (801) [1.13-1.89] (719) [1.51-2.26] (197) [1.13-2.26] (1,825) Non-quality assured ACT (Non-QA ACT) $6.48 $8.52 $8.04 - $8.52 2009 [5.29-8.27] (12) [7.57-10.51] (1,116) [6.91-9.18] (2) - [7.50-10.51] (1,130) $7.21 $7.93 $4.94 - $7.93 2011 [5.41-8.10] (22) [7.21-8.89] (2,693) [3.50-4.94] (3) - [7.21-8.89] (2,718) $5.90 $6.39 $2.19 - $6.39 2014 [3.64-7.29] (39) [4.54-7.24] (4,582) [1.09-2.19] (12) - [4.53-7.24] (4,664) $3.77 $5.51 $1.51 $1.89 $4.69 2016 [2.64-5.28] (81) [4.56-7.27] (4,971) [1.13-2.26] (209) [1.51-3.77] (52) [2.64-6.73] (5,380)

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Table C5a: Price of tablet formulation antimalarials, by outlet type, across survey round Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor 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) SP $0.43 $1.04 $0.43 $1.08 $0.65 2009 [0.43-2.14] (34) [0.94-1.19] (284) [0.43-0.65] (108) [0.54-1.94] (36) [0.43-1.08] (462) $0.62 $1.01 $0.41 $0.51 $0.41 2011 [0.41-0.82] (52) [0.96-2.11] (341) [0.31-0.51] (190) [0.41-0.62] (17) [0.41-0.62] (600) $0.46 $0.91 $0.46 $0.46 $0.46 2014 [0.36-0.55] (30) [0.70-0.96] (420) [0.36-0.55] (548) [0.36-0.55] (346) [0.36-0.55] (1,363) $0.57 $0.92 $0.38 $0.47 $0.47 2016 [0.47-0.94] (52) [0.73-0.94] (251) [0.38-0.47] (763) [0.38-0.57] (586) [0.38-0.57] (1,677) Oral quinine $4.53 $7.33 $4.53 $4.53 $4.53 2009 [3.63-5.44] (128) [5.76-11.89] (68) [3.17-4.76] (153) [4.08-6.80] (48) [3.17-5.44] (397) $4.32 $6.48 $4.32 $4.32 $4.32 2011 [2.59-6.48] (150) [5.49-11.23] (161) [3.46-4.32] (279) [3.46-6.48] (56) [3.46-5.18] (646) $3.83 $9.95 $3.83 $3.83 $3.83 2014 [3.06-4.59] (154) [4.86-21.71] (395) [3.06-4.59] (675) [3.06-4.59] (294) [3.06-4.59] (1,540) $4.75 $21.39 $3.96 $3.96 $3.96 2016 [3.96-5.94] (248) [6.53-28.88] (326) [3.17-4.75] (901) [3.57-4.75] (532) [3.17-4.75] (2,045) Chloroquine $0.32 $0.58 $0.32 $0.27 $0.32 2009 [0.27-0.32] (20) [0.28-0.97] (4) [0.24-0.40] (294) [0.22-0.27] (28) [0.24-0.40] (346) $0.75 $0.93 $0.50 $0.50 $0.50 2011 [0.50-1.00] (4) [0.75-1.00] (6) [0.50-0.62] (406) [0.50-0.50] (21) [0.50-0.62] (437) $0.44 $0.44 $0.46 $0.46 $0.46 2014 [0.44-0.91] (4) [0.33-0.46] (3) [0.44-0.57] (550) [0.44-0.57] (91) [0.44-0.57] (649) $0.47 - $0.46 $0.46 $0.46 2016 [0.46-1.18] (13) - [0.46-0.47] (887) [0.46-0.47] (135) [0.46-0.47] (1,035) * AETD - adult equivalent treatment dose - is the number of milligrams required to treat a 60-kg 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. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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Table C5b: Price of pre-packaged antimalarials, by outlet type, across survey round Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median price of one pre-packaged therapy: (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials) (N of Antimalarials)

Adult quality-assured Artemether Lumefantrine 

$5.40 $8.82 $1.73 $3.24 $5.74 2009 [5.18-5.61] (6) [5.74-8.82] (138) [1.73-1.73] (3) (1) [5.42-8.82] (148) $2.47 $8.40 $1.65 $2.06 $2.06 2011 [2.06-3.09] (26) [3.60-8.40] (282) [1.23-2.06] (62) [2.06-2.26] (11) [1.44-3.09] (381) $1.82 $5.64 $1.46 $1.46 $1.46 2014 [1.09-2.19] (28) [3.41-5.97] (546) [1.28-1.46] (140) [1.28-1.46] (37) [1.28-3.19] (761) $1.89 $4.29 $1.32 $1.51 $1.51 2016 [1.51-1.89] (42) [3.30-5.71] (448) [1.13-1.51] (317) [1.32-1.51] (128) [1.13-1.89] (948)

Pediatric quality-assured Artemether Lumefantrine 

$2.59 $8.47 $3.02 - $3.02 2009 [2.59-2.59] (2) [8.38-8.82] (5) [3.02-3.02] (2) - [2.59-3.02] (9) $1.23 $9.63 $2.47 $4.94 $2.06 2011 [1.23-1.23] (14) [4.94-9.67] (31) [1.23-2.88] (59) [2.88-4.94] (11) [1.23-2.88] (115) $3.64 $5.10 $1.82 $2.19 $2.19 2014 [2.19-3.64] (15) [5.10-5.10] (155) [1.46-2.19] (212) [1.46-2.19] (31) [1.46-2.92] (419) $0.57 $2.21 $0.57 $0.57 $0.57 2016 [0.47-0.75] (16) [1.32-2.21] (157) [0.47-0.66] (139) [0.57-0.94] (26) [0.47-0.75] (340)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and pediatric children. Adult pre-packaged therapy is the package size intended for a 60-kg adult. Pediatric pre-packaged therapy is the package size intended for a 10-kg child. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=175 2009 N=0 2009 N=42 2009 N=217 2009 N=97 2009 N=113 2010 N=522 2009 N=59 2009 N=791 2009 N=1,008 2011 N=191 2011 N=49 2011 N=66 2011 N=306 2011 N=134 2011 N=223 2011 N=674 2011 N=63 2011 N=1,094 2011 N=1,400 Proportion of outlets** stocking 2014 N=220 2014 N=58 2014 N=39 2014 N=317 2014 N=139 2014 N=175 2014 N=962 2014 N=306 2014 N=1,600 2014 N=1,917 2016 N=290 2016 N=120 2016 N=85 2016 N=495 2016 N=233 2016 N=170 2016 N=1,530 2016 N=496 2016 N=2,459 2016 N=2,954 Any malaria blood testing 86.1 - 51.8 74.8 21.3 1.0 0.0 0.0 1.6 7.7 2009 (76.7, 92.1) - (18.7, 83.3) (58.4, 86.3) (9.5, 41.0) (0.3, 3.3) - - (0.6, 4.2) (4.9, 12.1) 40.1 0.0 36.7 13.2 33.3 2.3 0.0 0.0 3.0 5.3 2011 (28.5, 53.1) - (18.1, 60.3) (8.3, 20.2) (23.7, 44.6) (1.0, 5.2) - - (1.4, 6.0) (3.5, 8.0) 89.7 12.5 69.3 35.1 20.7 0.2 0.6 0.0 2.7 9.1 2014 (84.1, 93.5) (2.0, 50.5) (46.0, 85.7) (18.1, 56.9) (11.5, 34.3) (0.0, 1.1) (0.1, 2.4) - (1.6, 4.5) (5.7, 14.1) 97.9 81.6 38.0 77.8 39.2 5.0 0.1 0.0 3.3 13.1 2016 (94.7, 99.2) (67.0, 90.6) (21.6, 57.7) (69.2, 84.5) (30.6, 48.5) (1.4, 16.0) (0.0, 0.3) - (2.3, 4.7) (8.8, 19.0) 2009 N=175 2009 N=0 2009 N=42 2009 N=217 2009 N=97 2009 N=113 2009 N=521 2009 N=59 2009 N=790 2009 N=1,007 2011 N=191 2011 N=49 2011 N=66 2011 N=306 2011 N=134 2011 N=221 2011 N=669 2011 N=63 2011 N=1,087 2011 N=1,393 2014 N=218 2014 N=58 2014 N=39 2014 N=315 2014 N=139 2014 N=174 2014 N=957 2014 N=304 2014 N=1,592 2014 N=1,907 2016 N=290 2016 N=120 2016 N=85 2016 N=495 2016 N=233 2016 N=170 2016 N=1,530 2016 N=496 2016 N=2,459 2016 N=2,954 Malaria microscopy 14.5 - 32 20.2 10.9 0.0 0.0 0.0 0.8 2.4 2009 (9.3, 21.8) - (7.3, 73.8) (9.1, 39.0) (3.8, 27.2) - - - (0.3, 2.4) (1.4, 4.3) 7.2 0.0 12.6 3.1 22.5 0.0 0.0 0.0 1.9 2.2 2011 (4.4, 11.7) - (4.9, 28.7) (1.5, 6.4) (14.4, 33.4) - - - (0.8, 4.5) (1.1, 4.3) 12.2 0.0 37.2 5.6 10.5 0.1 0.5 0.0 1.5 2.3 2014 (8.8, 16.8) - (14.3, 67.9) (3.0, 10.0) (4.0, 24.6) (0.0, 0.6) (0.1, 2.6) - (0.7, 3.0) (1.4, 3.8) 29.7 1.0 11.5 9.8 17.9 0.0 0.0 0.0 1.5 2.6 2016 (22.5, 38.0) (0.2, 6.0) (4.9, 24.8) (6.6, 14.5) (8.7, 33.2) - - - (0.8, 2.8) (1.9, 3.5) www.ACTwatch.info Page 94

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=175 2009 N=0 2009 N=42 2009 N=217 2009 N=97 2009 N=112 2009 N=520 2009 N=59 2009 N=788 2009 N=1,005 2011 N=186 2011 N=49 2011 N=64 2011 N=299 2011 N=129 2011 N=219 2011 N=667 2011 N=63 2011 N=1,078 2011 N=1,377 2014 N=221 2014 N=60 2014 N=39 2014 N=320 2014 N=139 2014 N=175 2014 N=960 2014 N=306 2014 N=1,598 2014 N=1,918 2016 N=290 2016 N=120 2016 N=85 2016 N=495 2016 N=232 2016 N=170 2016 N=1,530 2016 N=496 2016 N=2,458 2016 N=2,953 Rapid diagnostic tests (RDTs) 84.4 - 45.4 71.6 10.7 1.0 0.0 0.0 0.8 6.8 2009 (73.9, 91.2) - (13.0, 82.2) (53.1, 84.9) (1.9, 42.8) (0.3, 3.3) - - (0.1, 4.7) (3.9, 11.4) 37.2 0.0 21.8 11.2 11.4 2.3 0.0 0.0 1.0 3.4 2011 (25.7, 50.4) - (5.5, 57.2) (7.3, 16.7) (2.5, 39.5) (1.0, 5.1) - - (0.2, 4.3) (1.9, 5.8) 87.5 12.5 32.0 32.0 11.6 0.1 0.2 0.0 1.4 7.4 2014 (81.5, 91.7) (2.0, 50.5) (9.5, 67.9) (15.7, 54.2) (5.2, 23.8) (0.0, 0.5) (0.1, 0.5) - (0.6, 3.2) (4.3, 12.5) 97.6 81.6 31.4 76.5 26.1 5.0 0.1 0.0 2.2 12.0 2016 (94.5, 99.0) (67.0, 90.6) (16.2, 52.1) (67.5, 83.6) (16.8, 38.3) (1.4, 16.0) (0.0, 0.3) - (1.3, 3.8) (7.4, 18.8) * Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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Table C8: Price of malaria blood testing for adults, by outlet type, across survey round Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Total median price to consumers:* (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) Malaria microscopy $3.24 - - - $3.24 2009 [2.16-3.24] (20) - - - [2.16-3.24] (20) Adult $4.11 - - - $4.11 2011 [2.67-4.11] (27) - - - [2.67-4.11] (27) $2.73 - $5.47 - $2.73 2014 [2.19-3.64] (54) - (1) - [2.19-4.19] (55)

2016

Child under 5 years $4.11 - - - $4.11 2011 [2.67-4.11] (28) - - - [2.67-4.11] (28) $2.73 - $5.47 - $2.73 2014 [2.19-3.64] (55) - (1) - [2.19-4.19] (56)

2016

Rapid diagnostic tests (RDTs) $2.70 - - - $2.70 2009 [2.16-3.24] (2) - - - [2.16-3.24] (2) Adult $2.47 $2.96 - - $2.47 2011 [0.00-3.09] (11) [2.06-2.98] (5) - - [0.00-3.09] (16) $0.00 - $0.00 - $0.00 2014 [0.00-2.73] (15) - [0.00-5.47] (2) - [0.00-2.73] (17)

2016

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Table C8: Price of malaria blood testing for adults, by outlet type, across survey round Private ALL For-Profit Pharmacy General Retailer Itinerant Drug Vendor Private Facility Median [IQR] Median [IQR] Median [IQR] Median [IQR] Median [IQR] Total median price to consumers:* (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) (N of Blood Tests) Child under 5 years $1.65 $2.52 - - $1.65 2011 [0.00-1.65] (10) [1.03-3.03] (4) - - [0.00-1.65] (14) $0.00 - $0.00 - $0.00 2014 [0.00-2.73] (15) - [0.00-5.47] (2) - [0.00-2.73] (17)

2016

* Total price to the consumer including consultation and/or service fees. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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Table C9: Antimalarial market share, across survey round Public Community Private Not TOTAL Private Itinerant ANTI- AETDs sold or distributed in the previous General TOTAL Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Drug MALARIAL week by outlet type and antimalarial type Retailer Private as a percentage of all AETDs sold/ Facility Worker Facility For-Profit Facility Vendor TOTAL*** distributed:* % % % % % % % % % % % 2009 1. Any ACT 6.5 0.0 0.8 7.3 0.5 15.1 0.0 0.5 0.0 16.1 23.4 Quality-assured (QA ACT) 6.4 0.0 0.6 7.1 0.4 4.9 0.0 0.5 0.0 5.8 12.9 QA ACT with the “green leaf” logo 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 QA ACT without the “green leaf” logo 6.4 0.0 0.6 7.1 0.4 4.9 0.0 0.5 0.0 5.8 12.9 Non-quality assured ACT (non-QA ACT) 0.0 0.0 0.2 0.2 0.1 10.2 0.0 0.0 0.0 10.3 10.5 2. Any non-artemisinin therapy 15.9 0.0 4.2 20.1 4.4 21.4 0.0 26.6 3.8 56.3 76.4 SP 10.2 0.0 1.4 11.6 1.7 20.7 0.0 4.8 1.2 28.5 40.1 Oral quinine 4.8 0.0 1.4 6.2 1.2 0.2 0.0 1.4 0.2 2.9 9.2 Chloroquine 0.7 0.0 1.2 1.9 1.0 0.1 0.0 19.9 2.4 23.4 25.3 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.1 4. Non-oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.1 Any treatment for severe malaria 0.2 0.0 0.1 0.3 0.5 0.1 0.0 0.0 0.0 0.7 1.0 OUTLET TYPE TOTAL** 22.4 0.0 5.0 27.4 5.0 36.7 0.0 27.1 3.8 72.6 100.0 2014 1. Any ACT 14.8 2.5 0.8 18.1 5.9 14.3 0.1 9.2 1.2 30.7 48.9 Quality-assured (QA ACT) 14.7 2.5 0.7 17.9 4.9 2.2 0.1 9.1 1.2 17.5 35.4 QA ACT with the “green leaf” logo 0.3 0.0 0.5 0.8 4.1 0.0 0.0 8.4 0.8 13.3 14.2 QA ACT without the “green leaf” logo 14.4 2.5 0.2 17.1 0.8 2.2 0.0 0.7 0.4 4.2 21.3 Non-quality assured ACT (non-QA ACT) 0.1 0.0 0.1 0.2 1.0 12.1 0.1 0.1 0.0 13.2 13.4 2. Any non-artemisinin therapy 8.3 1.3 1.5 11.0 5.5 4.2 0.3 23.2 6.5 39.7 50.8 SP 4.5 1.3 0.8 6.5 1.2 3.5 0.2 7.5 4.1 16.5 23.0 Oral quinine 3.6 0.0 0.6 4.3 3.3 0.5 0.1 2.8 0.8 7.5 11.8 Chloroquine 0.0 0.0 0.0 0.0 0.6 0.0 0.0 12.5 1.6 14.7 14.7 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 0.0 0.1 0.1 0.2 0.0 0.0 0.0 0.3 0.4 Any treatment for severe malaria 0.3 0.0 0.0 0.3 0.4 0.2 0.0 0.2 0.0 0.8 1.2 OUTLET TYPE TOTAL** 23.2 3.8 2.3 29.2 11.5 18.8 0.4 32.4 7.7 70.8 100.0

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Table C9: Antimalarial market share, across survey round Public Community Private Not TOTAL Private Itinerant ANTI- AETDs sold or distributed in the previous General TOTAL Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Drug MALARIAL week by outlet type and antimalarial type Retailer Private as a percentage of all AETDs sold/ Facility Worker Facility For-Profit Facility Vendor TOTAL*** distributed:* % % % % % % % % % % % 2016 1. Any ACT 8.8 0.8 1.4 11.0 2.5 11.2 0.2 17.5 1.5 32.8 43.9 Quality-assured (QA ACT) 8.8 0.8 1.1 10.7 1.6 1.5 0.1 14.2 1.2 18.6 29.3 QA ACT with the “green leaf” logo 0.1 0.1 0.7 0.8 1.1 0.0 0.0 13.4 1.0 15.6 16.4 QA ACT without the “green leaf” logo 8.7 0.7 0.4 9.9 0.4 1.5 0.1 0.8 0.2 3.0 12.9 Non-quality assured ACT (non-QA ACT) 0.0 0.0 0.3 0.3 0.9 9.7 0.1 3.2 0.3 14.3 14.6 2. Any non-artemisinin therapy 9.1 0.0 1.6 10.7 3.1 3.9 0.3 30.2 7.6 45.1 55.8 SP 5.9 0.0 0.6 6.5 0.9 3.7 0.1 14.7 5.2 24.7 31.1 Oral quinine 3.0 0.0 0.9 3.9 1.7 0.2 0.2 3.3 1.1 6.5 10.4 Chloroquine 0.0 0.0 0.0 0.0 0.2 0.0 0.0 12.0 1.1 13.3 13.4 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.0 0.0 0.1 0.1 0.2 0.1 0.0 0.0 0.0 0.3 0.3 Any treatment for severe malaria 0.2 0.0 0.1 0.3 0.5 0.1 0.0 0.2 0.0 0.7 1.1 OUTLET TYPE TOTAL** 17.9 0.8 3.1 21.8 5.8 15.2 0.5 47.7 9.1 78.2 100.0 * * Row sum – market share for the specified antimalarial medicine. ** ** Column sum (within each survey round) – market share for the specified outlet type. *** Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column (within survey round). Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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Table C10: Antimalarial market share within outlet type, across survey round Public Community Private Not TOTAL Private General Itinerant TOTAL AETDs sold or distributed in the previous Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Retailer Drug Vendor Private week by outlet type and antimalarial type as Facility Worker Facility For-Profit Facility a percentage of all AETDs sold/ distributed:* % % % % % % % % % % 2009 1. Any ACT 29.0 0.0 16.3 26.7 11.1 41.1 0.0 1.7 0.2 22.2 Quality-assured (QA ACT) 28.8 0.0 12.8 25.9 8.2 13.4 0.0 1.7 0.2 8.0 QA ACT with the “green leaf” logo 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 QA ACT without the “green leaf” logo 28.8 0.0 12.8 25.9 8.2 13.4 0.0 1.7 0.2 8.0 Non-quality assured ACT (non-QA ACT) 0.2 0.0 3.5 0.8 2.9 27.7 0.0 0.0 0.0 14.2 2. Any non-artemisinin therapy 71.0 0.0 83.5 73.3 88.9 58.4 0.0 98.3 99.8 77.5 SP 45.4 0.0 28.7 42.3 34.3 56.4 0.0 17.9 32.1 39.2 Oral quinine 21.6 0.0 27.7 22.7 24.2 0.4 0.0 5.0 5.4 4.0 Chloroquine 3.2 0.0 24.1 7.1 20.4 0.2 0.0 73.5 62.3 32.2 3. Oral artemisinin monotherapy 0.0 0.0 0.2 0.0 0.0 0.2 0.0 0.0 0.0 0.1 4. Non-oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.1 0.3 0.0 0.0 0.0 0.1 Any treatment for severe malaria 0.8 0.0 3.0 1.2 10.0 0.3 0.0 0.1 0.0 0.9 2011 1. Any ACT 43.2 100.0 43.4 49.3 30.2 73.5 0.0 11.7 33.1 25.0 Quality-assured (QA ACT) 43.2 100.0 41.7 49.1 28.1 21.1 0.0 11.6 33.1 17.5 QA ACT with the “green leaf” logo 0.0 0.0 7.7 0.9 0.5 4.6 0.0 0.8 5.5 1.5 QA ACT without the “green leaf” logo 43.2 100.0 34.0 48.2 27.6 16.6 0.0 10.7 27.6 16.0 Non-quality assured ACT (non-QA ACT) 0.0 0.0 1.7 0.2 2.1 52.4 0.0 0.2 0.0 7.5 2. Any non-artemisinin therapy 56.7 0.0 56.5 50.7 69.7 25.5 0.0 88.3 66.9 74.8 SP 9.3 0.0 17.4 9.2 46.1 21.8 0.0 34.0 21.2 34.2 Oral quinine 46.1 0.0 30.7 39.5 17.9 2.0 0.0 7.8 15.3 9.5 Chloroquine 0.0 0.0 2.5 0.3 0.1 0.7 0.0 44.8 30.4 28.8 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 0.0 0.1 0.1 1.0 0.0 0.0 0.0 0.1 Any treatment for severe malaria 1.4 0.0 6.0 1.7 2.3 0.9 0.0 0.1 0.0 0.7

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Table C10: Antimalarial market share within outlet type, across survey round Public Community Private Not TOTAL Private General Itinerant TOTAL AETDs sold or distributed in the previous Health Health For-Profit Public/Not For-Profit Pharmacy Drug Store Retailer Drug Vendor Private week by outlet type and antimalarial type as Facility Worker Facility For-Profit Facility a percentage of all AETDs sold/ distributed:* % % % % % % % % % % 2014 1. Any ACT 64.0 66.3 34.2 62.0 51.3 76.4 34.6 28.4 15.2 43.4 Quality-assured (QA ACT) 63.5 66.3 31.1 61.3 42.8 11.7 15.0 28.2 15.2 24.7 QA ACT with the “green leaf” logo 1.5 0.0 21.4 2.9 35.6 0.0 9.4 25.9 10.3 18.8 QA ACT without the “green leaf” logo 62.0 66.3 9.7 58.5 7.2 11.7 5.6 2.3 4.9 5.9 Non-quality assured ACT (non-QA ACT) 0.5 0.0 3.1 0.7 8.5 64.7 19.6 0.2 0.0 18.7 2. Any non-artemisinin therapy 35.7 33.7 65.7 37.7 48.0 22.6 65.4 71.5 84.8 56.1 SP 19.2 33.2 35.1 22.3 10.6 18.7 40.4 23.0 53.1 23.3 Oral quinine 15.5 0.5 28.1 14.5 28.8 2.8 22.9 8.6 10.9 10.7 Chloroquine 0.0 0.0 0.8 0.1 5.1 0.0 0.0 38.5 20.6 20.7 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.3 0.0 0.1 0.3 0.7 1.0 0.0 0.1 0.0 0.4 Any treatment for severe malaria 1.2 0.0 1.6 1.1 3.7 1.0 0.0 0.7 0.0 1.2 2016 1. Any ACT 49.2 97.5 46.8 50.7 42.6 73.8 39.0 36.6 16.8 42.0 Quality-assured (QA ACT) 49.2 93.3 36.5 49.1 27.2 9.7 17.6 29.9 13.2 23.8 QA ACT with the “green leaf” logo 0.5 6.3 22.1 3.7 19.5 0.0 6.4 28.2 11.0 19.9 QA ACT without the “green leaf” logo 48.7 87.1 14.4 45.3 7.7 9.7 11.1 1.7 2.2 3.8 Non-quality assured ACT (non-QA ACT) 0.0 4.1 10.3 1.6 15.4 64.0 21.4 6.8 3.6 18.2 2. Any non-artemisinin therapy 50.7 2.5 51.5 49.0 54.3 25.9 59.9 63.3 83.2 57.7 SP 32.9 0.0 18.7 29.7 15.2 24.6 27.8 30.8 57.6 31.5 Oral quinine 16.9 2.0 28.1 17.9 30.1 1.1 30.3 6.8 12.5 8.3 Chloroquine 0.0 0.0 1.4 0.2 3.5 0.0 0.7 25.2 12.4 17.0 3. Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4. Non-oral artemisinin monotherapy 0.1 0.0 1.7 0.3 3.1 0.4 1.2 0.1 0.0 0.4 Any treatment for severe malaria 1.0 0.6 4.9 1.5 8.2 0.4 2.3 0.4 0.0 0.9 * * Categories 1 through 4 sum to 100% within each column. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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

(95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 2009 N=175 2009 N=0 2009 N=42 2009 N=217 2009 N=100 2009 N=116 2009 N=538 2009 N=62 2009 N=816 2009 N=1,033 2011 N=193 2011 N=49 2011 N=66 2011 N=308 2011 N=135 2011 N=223 2011 N=683 2011 N=63 2011 N=1,104 2011 N=1,412 Proportion of providers who: 2014 N=223 2014 N=60 2014 N=39 2014 N=322 2014 N=141 2014 N=177 2014 N=974 2014 N=306 2014 N=1,617 2014 N=1,939 2016 N=290 2016 N=120 2016 N=85 2016 N=495 2016 N=234 2016 N=170 2016 N=1,533 2016 N=497 2016 N=2,464 2016 N=2,959 Correctly state the national first-line

treatment for uncomplicated malaria  91.4 - 30.5 72.8 55.4 66.6 14.1 12.6 18.0 22.8 2009 (84.8, 95.3) - (7.7, 69.7) (53.8, 85.9) (41.3, 68.8) (55.6, 76.1) (6.3, 28.7) (7.1, 21.4) (10.3, 29.7) (15.0, 33.2) 93.8 96.2 71.6 93.1 83.6 87.4 39.2 55.8 44.8 55.8 2011 (88.0, 96.9) (83.8, 99.2) (34.5, 92.3) (84.3, 97.1) (66.6, 92.9) (82.8, 90.9) (30.3, 48.8) (28.7, 79.9) (36.6, 53.3) (45.8, 65.4) 97.4 93.7 89.0 94.3 66.8 83.1 31.3 29.9 35.9 47.4 2014 (94.2, 98.8) (83.2, 97.8) (72.8, 96.1) (87.3, 97.5) (49.2, 80.7) (63.1, 93.4) (23.6, 40.2) (19.2, 43.5) (30.2, 42.1) (40.7, 54.2) 94.2 87.5 81.6 88.1 77.6 92.9 39.8 37.9 43.3 49.2 2016 (87.2, 97.5) (78.5, 93.0) (61.0, 92.6) (81.4, 92.6) (70.9, 83.1) (85.0, 96.8) (32.2, 47.9) (32.7, 43.4) (37.2, 49.6) (42.7, 55.6) Correctly state the first-line dosing regimen for: An adult 88.3 - 29.1 70.2 46.7 61.8 4.5 2.1 8.5 13.9 2009 (81.5, 92.9) - (7.0, 69.0) (51.6, 83.9) (32.2, 61.8) (48.9, 73.2) (1.6, 11.9) (0.3, 13.0) (4.5, 15.3) (8.9, 21.0) 88.0 54.8 53.3 63.1 77.2 82.4 22.9 42.0 29.7 37.3 2011 (77.1, 94.1) (35.2, 73.0) (23.3, 81.1) (47.8, 76.1) (54.9, 90.4) (78.4, 85.7) (18.5, 27.9) (25.1, 60.9) (23.4, 36.9) (30.8, 44.3) 93.0 49.9 84.1 62.7 56.4 59.6 22.7 20.9 26.9 34.0 2014 (88.4, 95.8) (43.2, 56.6) (66.1, 93.4) (55.4, 69.4) (38.7, 72.6) (44.5, 73.1) (17.2, 29.4) (13.6, 30.8) (22.7, 31.6) (29.5, 38.7) 93.3 45.6 68.6 61.2 61.3 77.7 32.5 25.8 34.3 37.9 2016 (86.7, 96.7) (26.9, 65.6) (47.9, 83.9) (48.4, 72.7) (50.6, 71.0) (61.7, 88.3) (24.1, 42.2) (19.0, 33.9) (26.4, 43.2) (29.7, 46.8) A 2-year-old child 87.7 - 28.4 69.5 46.9 57.3 3.6 2.1 7.6 13.0 2009 (81.0, 92.2) - (6.7, 68.8) (51.0, 83.3) (31.7, 62.6) (44.1, 69.6) (1.3, 9.3) (0.3, 13.0) (4.0, 14.0) (8.4, 19.6) 72.6 89.6 42.8 80.6 65.4 71.8 23.8 33.7 28.8 40.6 2011 (62.0, 81.2) (65.9, 97.4) (20.6, 68.4) (63.2, 90.9) (41.4, 83.5) (65.7, 77.2) (16.5, 33.1) (19.4, 51.8) (21.3, 37.7) (29.9, 52.3) 94.6 83.6 83.4 86.3 59.4 73.2 24.0 25.2 28.9 40.2 2014 (90.9, 96.9) (72.1, 91.0) (67.2, 92.5) (77.9, 91.8) (41.0, 75.5) (54.9, 86.0) (18.5, 30.5) (16.9, 35.8) (24.8, 33.4) (34.8, 45.8) 91.0 80.7 72.3 81.7 60.9 65.6 32.2 27.7 34.2 40.4 2016 (85.0, 94.7) (67.0, 89.6) (50.6, 86.9) (72.2, 88.5) (49.1, 71.5) (46.2, 80.9) (24.0, 41.6) (21.2, 35.3) (26.7, 42.7) (31.9, 49.6) www.ACTwatch.info Page 102

antimalarial medicine 68.5 - 27.6 55.1 38.8 62.7 4.2 1.0 7.6 11.9 2009 (58.0, 77.4) - (4.7, 74.5) (37.7, 71.4) (14.7, 69.9) (57.4, 67.7) (1.2, 13.4) (0.1, 9.5) (3.4, 16.0) (7.1, 19.2) For an adult 90.4 81.0 56.2 80.9 67.7 83.8 17.3 39.8 24.1 37.0 2011 (85.5, 93.8) (58.4, 92.8) (31.2, 78.4) (65.9, 90.2) (43.8, 85.0) (78.6, 87.9) (12.8, 23.0) (23.1, 59.3) (18.3, 31.1) (28.9, 46.0) 89.4 76.9 70.6 79.6 58.6 86.6 26.7 17.1 30.0 39.8 2014 (83.7, 93.3) (56.1, 89.7) (47.7, 86.4) (64.4, 89.3) (41.8, 73.6) (79.1, 91.7) (20.3, 34.2) (11.0, 25.7) (24.3, 36.5) (33.1, 46.9) 94.6 59.8 73.1 70.6 62.7 93.0 32.0 20.2 33.4 38.3 2016 (90.6, 97.0) (38.0, 78.3) (56.5, 85.1) (55.9, 82.0) (54.7, 70.1) (78.9, 97.9) (23.0, 42.5) (8.2, 41.9) (23.1, 45.6) (27.6, 50.2) For a child 89.2 100.0 54.4 92.6 63.6 81.1 26.8 38.0 31.6 45.5 2011 (85.5, 92.0) - (30.4, 76.5) (85.6, 96.3) (49.2, 75.9) (74.5, 86.3) (19.5, 35.7) (21.6, 57.6) (24.0, 40.3) (35.0, 56.5) 93.8 93.6 75.4 92.4 70.7 86.1 34.5 19.1 37.3 48.2 2014 (89.9, 96.2) (86.9, 97.0) (53.0, 89.3) (87.7, 95.5) (57.9, 80.8) (69.9, 94.3) (26.3, 43.7) (12.6, 27.9) (29.8, 45.5) (39.1, 57.3) 96.4 97.1 78.3 93.6 73.4 94.9 35.4 21.3 37.0 44.4 2016 (93.0, 98.1) (91.8, 99.0) (61.3, 89.1) (89.9, 96.0) (66.6, 79.3) (77.9, 99.0) (25.7, 46.5) (7.4, 47.7) (25.4, 50.3) (31.7, 57.9)  At the time of the 2016 Benin ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria in adults and in 2-year-old children. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. Source: ACTwatch Outlet Survey, Benin, 2009, 2011, 2014, 2016.

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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, 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.

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

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

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

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

ACTwatch research tools for malaria market monitoring include:

1. Outlet surveys

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

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

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5 From 2008 through 2016, ACTwatch conducted 50 national outlet surveys across the 12 project countries.4F Reports are available at www.actwatch.info, and peer-reviewed publications have appeared in Malaria Journal and TheLancet.5F, 6 ,7 7 ,77

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 eight national supply chain studies. Reports are available at 8 www.actwatch.info, and a peer-reviewed publication has appeared in PLoS One.6F

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

3. Population-based surveys

Population-based surveys are conducted among consumers to document fever treatment-seeking behavior. A representative sample of the target population (caregivers of children and/or adults according to burden and risk) is identified, and a screening tool is used to identify individuals who have recently experienced fever. The surveys investigate the extent to which health care was sought, as well as common sources of care received. Respondent reports of malaria blood testing and antimalarials acquired are documented and summarized. The survey includes measures of demographic and other individual, household/family, and community characteristics that can be used to develop consumer profiles as well as monitor equity in access to malaria case management. From 2008 through 2012, ACTwatch conducted 14 household surveys focused on fever treatment-seeking behavior. Reports are available at 9 www.actwatch.info, and a peer-reviewed publication has appeared in Malaria Journal.7F

4. Fever case management quality of care

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

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

5 Surveys in the DRC (2) and Myanmar (3) were sub-national. 6 O’Connell K, Gatakaa H, Poyer S, et al. 2011. Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries. Malaria Journal, 10: 326. 7Tougher 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. 8 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). 9Littrell M, Gatakaa H, Evance I, et al. (2011). Monitoring fever treatment behavior and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries. Malaria Journal, 10: 327.

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

ACTwatch in Benin

ACTwatch baseline surveys were conducted in Benin in 2008-2009, including an outlet survey (2008), a household survey (2009), and a supply chain study (2009). Follow-up outlet surveys were conducted in 2011, 2014, and 2016. A follow-up household survey was conducted in 2011. All reports are available at www.actwatch.info.

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Annex 2: Country Background

Benin is a stable and democratic country, located in the West Africa region, and it is bordered by Niger and Burkina Faso to the north, Nigeria to the east, and Togo to the west.10 Benin is characterized by two distinct climates. In the south, it is humid and has an alternating dry season from November to March and mid-July to mid-September. The rainy season is from April to mid-July and from mid-September to October. The north is characterized by a tropical climate with a dry season from November to April and a rainy season from June to September.The terrain is mostly flat, rising from coastal plains in the south to a hilly landscape in the north.11 Administratively, Benin is divided into 12 departments, 77 communes, and 546 arrondissements.12 There are three metropolitan areas: Cotonou, Porto Novo, and Parakou.

In 2015, the population was estimated to be 10.6 million, with a median age of 18.6 years and children under 15 years of age accounting for approximately 44% of the population. Cotonou and Porto-Novo, both located in the south of the country, are the major urban areas; approximately 44% of the population was estimated to reside in an urban area in 2015.13 Benin is classified as a low-income country by the World Bank, with an average per capita income of $860 (USD) in 2015.14 The 2015 Human Development Index ranked Benin 166th out of 188 countries, a rank associated with Low Human Development.15 Life expectancy at birth is among the lowest in the world, estimated at 59 years.16 The total fertility rate in 2012 was 4.9 children per woman17, and the infant mortality rate in 2015 was 54.2 per 1,000 live births.18 64.2% of the population is considered to live in multidimensional poverty.19

Benin is currently experiencing a ‘double burden’ of communicable and non-communicable diseases, with malaria being a major cause of mortality and morbidity (see below), but other infectious diseases also contribute substantially to the burden of ill health, including respiratory infections, tuberculosis, schistosomiasis, and a stable but generalized HIV epidemic (1.1% prevalence20, similar to other countries in the region). These are accompanied by the threat of non-communicable diseases to public health21, which are estimated to account for 36% of all mortality in the country.22

10 Benin Government. (n.d.). Géographie du Bénin. Retrieved July 27, 2015 from http://www.gouv.bj/tout-sur-le-benin/geographie 11 Ibid 12 Benin Government. (n.d.). Les communes du Bénin. Retrieved October 28, 2016 fromhttp://gouv.bj/communes/ 13 Central Intelligence Agency. (2013). The World Factbook, 2013 - 2014. Washington, DC: Central Intelligence Agency. 14 The World Bank. (2016). Benin. Retrieved August 30, 2016 from http://data.worldbank.org/country/benin 15 UNDP. (2015). Human Development Report 2015: Work for Human Development. Retrieved from http://hdr.undp.org/sites/default/files/2015_human_development_report.pdf 16 WHO. (2015). Benin WHO Statistical Profile. Retrieved October 28, 2016 from http://www.who.int/gho/countries/ben.pdf?ua=1 17 UNICEF. (2013). Benin Statistics. Retrieved August 30, 2016 from http://www.unicef.org/infobycountry/benin_statistics.html 18 Central Intelligence Agency. (2013). The World Factbook, 2013 - 2014. Washington, DC: Central Intelligence Agency. 19 UNDP. (2015). Human Development Report 2015: Work for Human Development. Retrieved from http://hdr.undp.org/sites/default/files/2015_human_development_report.pdf 20 UNAIDS. (2015). HIV and AIDS estimates. Retrieved October 28, 2016 from http://www.unaids.org/en/regionscountries/countries/benin 21 Direction Nationale de la Protection Sanitaire, Programme National de Lutte contre les Maladies Non Transmissibles, MoH. (2007). Rapport final de l’enquete STEPS au Benin. Retrieved from http://www.who.int/chp/steps/2007_STEPS_Report_Benin.pdf 22 WHO. (2014). Noncommunicable Diseases (NCD) Country Profiles, 2014. Retrieved from http://www.who.int/nmh/countries/ben_en.pdf?ua=1 www.ACTwatch.info Page 107

Healthcare System

Benin’s health system receives substantial levels of donor support, with a large number of bilateral and multilateral agencies involved in the sector.23,24 The WHO reported that Benin was off track for all health-related Millennium Development Goals.25 Benin’s national health system’s organization parallels its administrative structure. Each administrative department is paired to a health department, composed of health zones.26 Two to three communes with a population ranging between approximately 84,000 – 492,000 are grouped to create these health zones. In terms of service provision, the health system has three distinct levels: central, intermediate, and peripheral, which include:27  Central: One National Referral Hospital (Centre National Hospitalier Universitaire).  Intermediate: Six Departmental Health Directorates with six corresponding Departmental Referral Hospitals (Centres Hospitaliers Départementaux).  Peripheral: 34 health zones comprising Zonal Hospitals (Hôpitaux de Zone); Commune Health Centers (Centre de Santé de la Commune); accredited private health facilities; Community Health Centers (Centres de Santé d’Arrondissement); and village health units, including Community Health Workers (CHWs).

There are approximately 12,500 CHWs in Benin. National policy requires these CHWs to have, at minimum, a primary education, and to live in the community they serve. The CHWs’ role has been expanded in recent years in order to bolster the provision of primary care in the country. Since 2014, the majority of CHWs have been trained on appropriate use of malaria RDTs and integrated management of malaria, pneumonia, diarrhea, and malnutrition.28 Several other policy initiatives have been carried out by the Government of Benin in order to increase health service utilization, such as waiving user fees for children under five in the public sector, the creation of a fund to provide free healthcare to the extremely poor, and reinforcing health financing schemes.29

In the public sector, the main supplier of medications, Central d’achat des Médicaments Essentiels (CAME), is the only authorized supplier of ACTs in Benin.30 CAME ships inventory to distribution depots in the health zones, which then ship the inventory to health facilities where it will reach patients.31

Several issues in managing the supply of antimalarial medications exist: 1) There are frequent stock outs, 2) Antimalarial medications nearing expiration are not used first and therefore facilities have many expired products, 3) Drug use data are neither accurate nor always available, and 4) Sometimes diagnostic tests are available but there is no treatment to provide to patients.32

23 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 24 WHO. (2014). Country Cooperation Strategy – Benin. Retrieved from http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_ben_en.pdf 25 Ibid 26 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 27 Ibid 28 Ibid 29 DOS, USAID, CDC, Peace Corps, USDA, USADF, DOD. (2011). Global Health Initiative: Benin Country Strategy. Retrieved from https://www.ghi.gov/wherewework/docs/BeninStrategy.pdf 30Torres Rueda, S., Tougher, S., Palafox, B., Patouillard, E., Goodman, C., Hanson, K., Tassiba, M.E., O’Connell, K. & the ACTwatch Group. (2009). A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Benin, 2009. Nairobi: ACTwatch project, Population Services International. 31 Ibid 32 Ibid

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The private sector is diverse and expanding rapidly in Benin. An estimated half of the country’s population seeks healthcare in the private sector, including traditional practitioners, licensed pharmacists, and informal drug vendors.33 It is estimated that 77% of these providers are unlicensed, mainly because the accreditation process is perceived to be difficult and convey few benefits.34 It has been difficult to get the private sector to comply with current malaria treatment policies, largely due to reimbursement issues for free services.35

Malaria Risk and Burden

Malaria is endemic in Benin, and transmission is influenced by vector species, geography, climate, and hydrography.36 The primary malaria vector is Anopheles gambiae s.s., but to a large extent, secondary vectors drive the regional differences in malaria (A. melas and A. gambiae s.l. in the coastal region, A. gambiae s.l. in the central region, and the seasonal breeding of A. gambiae s.l. in the north). In the south of the country, A. gambiae has a year-round breeding pattern, while in the north it follows a more seasonal pattern. As such, transmission is continuous in the south and seasonal in the north (highest in the July to October rainy season), with holoendemic levels of malaria in the central region that is north of the coastal region. There is also evidence of carbamate insecticide resistance having developed in recent monitoring of one area in the east of the country.37 The first month of the malaria transmission season is around April in the south, May in the central region, and June for most of the north. In 2014, 100% of the population lived in high-transmission areas.38 The majority of malaria cases are caused by the P. falciparum parasite.39

The WHO estimates that, at a national level, malaria incidence was 303 per 1,000 inhabitants in 2013, and in 2012, it was the second most common cause of death.40 In 2014, the WHO reported over 1 million confirmed cases and over 1,800 deaths.41 Among children under five years of age, malaria led to 56.1% of visits to a health care provider, 29.2% of hospitalizations, and 26% of deaths.42 Pregnant women are another particularly vulnerable group: the most recent Demographic Health Survey (DHS) found that 68% of pregnant women had taken antimalarials, while 25% had used intermittent treatment as prevention during pregnancy (ITPp).43

The Ministry of Health (MOH) outlines three key areas of intervention that its malaria control policy targets: 1) the use of ACTs for the treatment of simple malaria; 2) the use of long-term insecticide-treated nets, indoor residual spraying, and larvicide use for vector control; and 3) the use of ITPp.44

33 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 34 Ibid 35 Ibid 36 PMI. (2016). Benin Country Profile. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/country- profiles/benin_profile.pdf?sfvrsn=28 37 Ibid 38 WHO. (2015). World Malaria Report, 2015. Retrieved from http://apps.who.int/iris/bitstream/10665/200018/1/9789241565158_eng.pdf 39 Ibid 40 WHO. (2016). World Health Statistics 2016: Monitoring health for the SDGs. Retrieved from http://www.who.int/gho/publications/world_health_statistics/2016/en/ 41 WHO. (2015). World Malaria Report, 2015. Retrieved from http://apps.who.int/iris/bitstream/10665/200018/1/9789241565158_eng.pdf 42 Government of Benin. (2015). Rapport annuel d'activités 2014 du Programme National de Lutte contre le Paludisme. Retrieved from http://www.sante.gouv.bj/documents/PNLP/Rapport_annuel_PNLP_2014%20final.pdf 43 Institut National de la Statistique et de l’Analyse Économique (INSAE) et ICF International, 2013. Enquête Démographique et de Santé du Bénin 2011-2012. Calverton, Maryland, USA : INSAE et ICF International. 44 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5

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Malaria case management guidelines

National case management guidelines include universal malaria testing by all health workers and the provision of free testing and treatment for children under five years old and pregnant women. Furthermore, in 2014, updates to national policy brought case management guidelines in line with WHO recommendations for ITPp and the treatment of severe malaria. Scale-up of private-sector health care provider training and increased access to malaria commodities is ongoing.45

The national strategy objectives for Benin target the provision of microscopy or RDT diagnosis to public health units, selected private health clinics, and trained CHWs.46 The government also implemented a free malaria treatment policy in government health facilities, the formal private sector (both for-profit and not-for-profit), and appropriately trained CHWs.47

Diagnosis

The malaria National Strategic Plan (2011-2018) recommends free universal diagnostic testing using microscopy or RDT for 100% of suspected cases of malaria at every level of care and, specifically, prior to treatment with an ACT.48 Access to RDTs continues to be a challenge throughout the health system, especially at the peripheral level. In addition to increasing awareness of the policies among health care providers, priority strategies for increasing diagnostic testing include training more CHWs in the use of RDTs, increasing the proportion of health facilities with an adequate stock of RDTs, and building laboratory capacity.49

Treatment

In 2004, Benin adopted artemether-lumefantrine (AL) as the first-line treatment for uncomplicated malaria. In cases of intolerance to AL, where AL is not available, or in children less than five months of age, artesunate-amodiaquine (ASAQ) is recommended.50 The second-line treatment is quinine (QN).51 For the treatment of uncomplicated malaria in pregnancy, oral quinine is recommended during the first trimester, while ACTs are recommended beginning with the second trimester through the pregnancy term.52 Severe malaria in pregnant women should be treated with quinine regardless of the term of pregnancy. In other cases of severe malaria, parenteral artesunate is the first-choice treatment option; if artesunate is not available, parenteral quinine is recommended.53 Once the patient is stabilized, it is recommended that treatment continue orally. According to national policy, supervised administration of sulfadoxine pyrimethamine (SP) between the 16th and 36th week of gestation is used for intermittent preventative treatment in pregnancy (IPTp).54 Oral artemisinin monotherapies have been banned in Benin since 2008.55

45 Ibid 46 République du Bénin, Ministère de la Santé. (2011). Directives Nationales de Prise en Charge des cas de Paludismes. Retrieved from http://www.remed.org/Directives_de_PEC_des_cas.pdf 47 Ibid 48 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 49 Ibid 50 République du Bénin, Ministère de la Santé. (2011). Directives Nationales de Prise en Charge des cas de Paludismes. Retrieved from http://www.remed.org/Directives_de_PEC_des_cas.pdf 51 Ibid 52 Ibid 53 Ibid 54 Ibid 55 WHO. (2009). Malaria Country Profiles: Benin. Retrieved from http://www.who.int/malaria/publications/country- profiles/2009/mal2009_ben_en.pdf

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Financing and Major Initiatives to Improve Malaria Case Management

Malaria control activities and financing in Benin come from several sources—including the Benin MOH, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the World Bank, USAID/President’s Malaria Initiative (PMI), and the WHO/UNICEF—and are coordinated by the National Malaria Control Program (NMCP).56 PMI and the GFATM are the main donors to the NMCP, while the African Development Bank and World Bank provide district-focused financing. Meanwhile, several civil society organizations act at the local level or in remote areas as the NMCP’s implementing partners.57 A major MOH priority launched at the end of 2011 was the Free Malaria Care Initiative.58 With this initiative, malaria case management became free to children under five years of age and pregnant women. The implementation of this policy has been successful in public clinics and some hospitals. It has been more challenging to implement in the private sector, as private providers rely on revenue generated from malaria treatment. In 2012, the World Bank awarded a $10 million supplemental grant to the Government of Benin to ramp up activities related to malaria control.59

In the 2016 fiscal year, PMI estimated funding for Benin was approximately $16.5 million.60 During the 2015 fiscal year, PMI funds were used to procure nearly 740,000 insecticide-treated nets for routine services, two million RDTs, and over two million ACT treatments, as well as to train health workers in treatment with ACTs, malaria diagnosis, and IPTp.61

There were two malaria grants from the GFATM, and both were scheduled to end in late 2015. A grant launched in November 2004 committed $66.8 million to support malaria control activities in the Mono and Couffo regions. The grant activities focused on promoting the use of insecticide-treated bed nets through women’s groups and health facilities, and by increasing access to early diagnosis and treatment with ACTs. In addition, the program aimed to increase awareness about malaria prevention and treatment.62 The second GFATM grant was initiated in July 2008 and committed a sum of $21 million. This program supported community-level malaria care for children under five years of age in 14 health zones.63

56 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 57 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 58 The World Bank. (2012). Health Sector in Benin: Additional Financing to Improve Access to and the Quality of Malaria Treatment for the Most Vulnerable. Retrieved November 17, 2015 from http://www.worldbank.org/en/news/press-release/2012/03/15/health-sector-in-benin- additional-financing-to-improve-access-to-and-the-quality-of-malaria-treatment-for-the-most-vulnerable 59 Ibid 60 USAID, PMI. (n.d.). President’s Malaria Initiative Benin Malaria Operational Plan FY 2016. Retrieved from https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy16/fy-2016-benin-malaria-operational- plan.pdf?sfvrsn=5 61 Ibid 62 The Global Fund (n.d.). Grant Portfolio. Retrieved July 9, 2015 from http://portfolio.theglobalfund.org/en/Grant/Index/BEN-304-G04-M 63 Ibid www.ACTwatch.info Page 111

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 Benin, this includes the following outlet types:

Public health facilities Health facilities operated by the government including hospitals, health centers, and village health units. A fee for service is generally charged.

Community health worker Trained volunteers operating in rural areas providing malaria blood testing using RDTs and providing medicines, including ACTs. Treatment is provided free of charge.

Private not-for-profit health NGO/faith-based hospitals or clinics operated by trained health professionals and facilities registered with the Ministry of Health. A fee for service is generally charged.

Private for profit health Private hospitals, clinics, and diagnostic laboratories operated by trained health facilities facilities professionals and registered with the Ministry of Health. Medical consultations, diagnosis, and treatment are provided at cost.

Pharmacies Pharmacies are licensed and regulated by the Director of Pharmacies to sell (Pharmacies agréées) prescription medicines at a commercial rate. They are managed by pharmacists and qualified health professionals and are typically located in urban areas.

Drug stores (Depôts Drug stores located primarily in rural areas that do not have access to pharmacies. pharmaceutiques) They are tied to pharmacies from which they receive drug supplies.

General retailers Grocery stores, shops, minimarkets, kiosks and market stalls selling fast-moving consumer products.

Itinerant drug vendors Mobile providers typically working within urban markets. They are not registered with any national regulatory authority.

Eligibility Criteria

Outlets were eligible for a provider interview and malaria product audit if they meet 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).

Stratification

The Benin outlet survey was stratified to deliver estimates for urban and rural areas.

Sampling

The primary sampling approach taken for ACTwatch outlet surveys entails sampling a set of administrative units (geographic clusters) with a population of approximately 10,000 to 15,000 inhabitants. Clusters are selected with cluster probability of selection proportionate to size (PPS). The most appropriate administrative unit in Benin matching this desired population size is arrondissement. Within each arrondissement, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted.

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Booster Sample

A ‘booster’ sample was selected to increase the sample size for public health facilities, pharmacies and drug shops (dépôt de medicament). Within the communes in which the 30 selected arrondissements are located, all public health facilities, pharmacies, and drug shops were included in the sample.

Sample Size

A series of calculations was completed to identify minimum sample size requirements to detect an increase or decrease in the availability of QA ACT and of malaria blood testing between 2014 and 2016. Calculations examined the sample size required to detect a 20 percentage point change among all outlets, the public sector, the private sector, public health facilities, pharmacies, and retail outlets.

The required sample size for each research domain (urban and rural areas) 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 antimalarial-stocking outlets

The number of antimalarial-stocking outlets required to detect a change over time is given by:

2 deff Z1 2P1 P  Z1 P11 P1  P2 1 P2  n  2 P2  P1  Where: n = desired sample size P1= the proportion of antimalarial-stocking outlets with QA ACT/malaria blood testing available in stock in 2014 P2= the expected proportion of antimalarial-stocking outlets with QA ACT/malaria blood testing available in stock in 2016 (20 percentage point increase or decrease) P = (P1+P2)/2 Z= the standard normal deviation value for an  type I error (two-sided) Z1-= the standard normal deviation value for a type II error Deff = the design effect in case of multi-stage cluster sample design. Deff figures from the 2014 dataset were used in sample size calculations.

Required number of outlets

The estimated number of outlets enumerated needed for the QA ACT availability indicator was determined by the following formula for outlets within urban and rural domains: N = n/Pam where Pam is the proportion of outlets having antimalarial stocks at the time of the survey among all outlets enumerated. In this equation, the assumptions are as follows: N = desired sample size of all outlets for monitoring availability indicators, n is the number of outlets with antimalarial stocks at the time of the survey. Pam is the proportion of outlets having antimalarials in stock at the time of the survey among outlets enumerated in 2014 within urban and rural areas. The Pam values documented in the 2014 outlet survey and used for 2016 sample size calculations are summarized in the table below.

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Proportion of enumerated outlets with antimalarials in stock, 2014 ACTwatch outlet survey (data not weighted) In stock on the day of In stock on the day of the survey the survey or within the past 3 months Urban All outlets 39% 42% Public sector 86% 90% Public health facilities 93% 94% Private sector 37% 39% Pharmacies 96% 96% Retail 27% 29% Rural All outlets 59% 65% Public sector 82% 90% Public health facilities 97% 97% Private sector 46% 52% Pharmacies n/a n/a Retail 39% 45%

Required number of clusters (arrondissements)

The average numbers of outlets by outlet type in arrondissements within urban and rural areas screened during the 2014 outlet survey were used to estimate the number of clusters required in 2016 to achieve the desired sample sizes. In 2014, the numbers of outlets per arrondissement enumerated were as follows: all outlets: urban, 260.1 and rural, 46.1; public sector: urban, 7.4 and rural, 9.1; public health facilities: urban, 3.1 and rural, 2.0; private sector: urban, 252.7 and rural, 37.0; pharmacy: urban, 4.3 and rural, 0; general retail (shops and stalls): urban, 207.8 and rural, 32.0. Considering sample size requirements to detect change over time and average numbers of outlets across each outlet type, the optimal minimum number of localities required to reach desired numbers of outlets is 30 arrondissements (15 urban, 15 rural) plus a booster sample of public health facilities, pharmacies, and drug shops at the commune 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 5thtoAugust6th, 2016.

A series of screening questions was 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 Annexes 7 and 8. In addition to the product audit, a series of questions was administered to the senior-most provider regarding malaria case management knowledge and practices, as well as provider training and qualifications. Geo-coordinates were recorded for each outlet using a handheld Global Positioning System (GPS) unit.

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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 collected with paper questionnaires were double entered and verified in Nairobi, Kenya using a Microsoft Access database. All data cleaning and analysis were 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 arrondissement and commune levels. Indicator definitions are provided in Annex 10.

Protection of Human Subjects

The 2016outlet survey protocol received ethical approval from the Benin National Research Ethics Committee (Comité National d’Ethique Pour La Recherche En Santé) and from the PSI Research Ethics Board. Provider interviews and product audits were completed only after the administration of a standard informed consent form and the 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 Clusters

Table X1. Sampled Clusters URBAN/RURAL DEPARTMENT COMMUNE ARRONDISSEMENT POPULATION RURAL ALIBORI KANDI SONSORO 22,920 RURAL ATACORA KOUANDE GUILMARO 27,319 RURAL ATLANTIQUE ABOMEY-CALAVI GODOMEY 253,262 RURAL ATLANTIQUE ALLADA AYOU 7,897 RURAL ATLANTIQUE TORI-BOSSITO AVAME 5,351 RURAL BORGOU N'DALI SIRAROU 28,365 RURAL COLLINES BANTE ATOKOLIGBE 12,863 RURAL COLLINES SAVALOU LEMA 9,666 RURAL COUFFO KLOUEKANME ADJAHONME 23,368 RURAL DONGA DJOUGOU BARIENOU 36,738 RURAL MONO HOUEYOGBE DOUTOU 32,597 RURAL OUEME AVRANKOU KOUTY 18,312 RURAL PLATEAU ADJA-OUERE TATONNOUKON 14,445 RURAL ZOU BOHICON AGONGOINTO 8,982 RURAL ZOU ZOGBODOMEY MASSI 12,382 URBAIN ALIBORI KANDI KANDI I 20,537 URBAIN ATACORA KEROU KEROU 54,276 URBAIN ATLANTIQUE ABOMEY-CALAVI ABOMEY-CALAVI 117,824 URBAIN BORGOU BEMBEREKE BEMBEREKE 31,176 URBAIN BORGOU PARAKOU 1ER ARRONDISSEMENT 114,558 URBAIN BORGOU TCHAOUROU TCHAOUROU 43,862 URBAIN COUFFO DJAKOTOME DJAKOTOMEY II 8,366 URBAIN DONGA DJOUGOU DJOUGOU II 30,892 URBAIN LITTORAL COTONOU 13ÈME ARRONDISSEMENT 68,486 URBAIN LITTORAL COTONOU 3ÈME ARRONDISSEMENT 69,991 URBAIN LITTORAL COTONOU 9ÈME ARRONDISSEMENT 57,691 URBAIN OUEME ADJOHOUN ADJOHOUN 10,423 URBAIN OUEME PORTO-NOVO 4ÈME ARRONDISSEMENT 63,306 URBAIN PLATEAU KETOU KETOU 39,626 URBAIN ZOU BOHICON BOHICON II 53,701

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Figure X2. Map of Study Area

All outlet types were screened for eligibility within the selected arrondissement (dark blue/purple). A “booster sample” (light blue/purple) was collected for public health facilities, pharmacies, and drug stores. The administrative unit for these outlet types was extended beyond arrondissement to the commune level. See Annex 9 for a detailed description of the booster sampling methods. Source: ACTwatch Outlet Survey, Benin, 2016.

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Annex 5: Detailed Sample Description

Table X2: Detailed sample description

Public Community Private Not Private Itinerant General ALL Health Health For-Profit ALL Public For-Profit Pharmacy Drug Store Drug ALL Private Retailer Outlets Facility Worker Facility Facility Vendor Number of outlets screened (Figure 2 Box B) Urban 96 45 41 182 154 151 8 3,877 532 4,722 4,904 Census 36 45 41 122 154 45 3 3,877 532 4,611 4,733 Booster 60 0 0 60 0 106 5 0 0 111 171 Rural 202 100 52 354 108 25 24 1,745 100 2,002 2,356 Census 36 100 52 188 108 15 6 1,745 100 1,974 2,162 Booster 166 0 0 166 0 10 18 0 0 28 194 TOTAL 298 145 93 536 262 176 32 5,622 632 6,724 7,260 Number of outlets eligible and interviewed (Figure

2 Box D) Urban 91 40 40 171 144 147 7 991 440 1,729 1,900 Census 34 40 40 114 144 45 2 991 440 1,622 1,736 Booster 57 0 0 57 0 102 5 0 0 107 164 Rural 199 81 47 327 94 23 23 542 57 739 1,066 Census 34 81 47 162 94 13 6 542 57 712 874 Booster 165 0 0 165 0 10 17 0 0 27 192 TOTAL 290 121 87 498 238 170 30 1,533 497 2,468 2,966 Number of outlets eligible but not interviewed

(interview non-participation) Urban 1 0 0 1 5 4 0 11 0 20 21 Census 0 0 0 0 5 0 0 11 0 16 16 Booster 1 0 0 1 0 4 0 0 0 4 5 Rural 0 1 0 1 5 2 1 4 1 13 14 Census 0 1 0 1 5 2 0 4 1 12 13 Booster 0 0 0 0 0 0 1 0 0 1 1 TOTAL 1 1 0 2 10 6 1 15 1 33 35 Number of interviewed outlets with at least one antimalarial in stock on the day of the survey (Figure 2, Box D1) Urban 90 39 37 166 133 147 7 903 416 1,606 1,772 Census 33 39 37 109 133 45 2 903 416 1,499 1,608 Booster 57 0 0 57 0 102 5 0 0 107 164 Rural 196 52 46 294 89 23 23 485 52 672 966 Census 32 52 46 130 89 13 6 485 52 645 775

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Table X2: Detailed sample description

Public Community Private Not Private Itinerant General ALL Health Health For-Profit ALL Public For-Profit Pharmacy Drug Store Drug ALL Private Retailer Outlets Facility Worker Facility Facility Vendor Booster 164 0 0 164 0 10 17 0 0 27 191 TOTAL 286 91 83 460 222 170 30 1,388 468 2,278 2,738 Number of interviewed outlets with at least 1 antimalarial in stock on the day of the survey or at least 1 antimalarial reportedly in stock in the previous 3 months (Figure 2 sum of Box 1 and Box 2) Urban 91 40 39 170 140 147 7 991 440 1,725 1,895 Census 34 40 39 113 140 45 2 991 440 1,618 1,731 Booster 57 0 0 57 0 102 5 0 0 107 164 Rural 199 80 46 325 94 23 23 542 57 739 1,064 Census 34 80 46 160 94 13 6 542 57 712 872 Booster 165 0 0 165 0 10 17 0 0 27 192 TOTAL 290 120 85 495 234 170 30 1,533 497 2,464 2,959 Number of interviewed outlets that provide malaria blood testing, but do not stock antimalarial medicines (Figure 2 Box D3) Urban 0 0 1 1 4 0 0 0 0 4 5 Census 0 0 1 1 4 0 0 0 0 4 5 Booster 0 0 0 0 0 0 0 0 0 0 0 Rural 0 1 1 2 0 0 0 0 0 0 2 Census 0 1 1 2 0 0 0 0 0 0 2 Booster 0 0 0 0 0 0 0 0 0 0 0 TOTAL 0 1 2 3 4 0 0 0 0 4 7 Proportion of eligible and interviewed antimalarial- stocking outlets with at least 1 provider with a health-related qualification* Urban 97.8 100.0 97.3 98.2 98.5 100.0 85.7 1.9 0.7 18.8 26.3 Census 97.0 100.0 97.3 98.2 98.5 100.0 100.0 1.9 0.7 13.1 18.8 Booster 98.3 - - 98.3 - 100.0 80.0 - - 99.1 98.8 Rural 99.0 94.2 97.8 98.0 98.9 95.7 43.5 2.7 5.8 20.2 43.9 Census 96.9 94.2 97.8 96.2 98.9 92.3 33.3 2.7 5.8 18.2 31.3 Booster 99.4 - - 99.4 - 100.0 47.1 - - 66.7 94.8 TOTAL 98.6 96.7 97.6 98.0 98.6 99.4 53.3 2.2 1.3 19.2 32.5 * Health-related qualifications include pharmacist, medical doctor, nurse, midwife, lab assistant, pharmacist assistant/technician, health assistant, counselor, and community health worker. Source: ACTwatch Outlet Survey, Benin, 2016.

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Annex 6: Questionnaire Annex ACTwatch : Enquête de points de vente Bénin 2016 Section 1 : Informations de recensement L’enquêteur doit remplir cette partie pour tous les points de vente. PDVID Enquêteur – Commune – Arrondissement – Code PDV [___|___]-[___|___|-[___|___|___|___|-[___|___|___] C1. Date d’aujourd’hui (jj/mm/aaaa) [___|___]-[___|___]-[___|___|___|___] C2. Nom de l’enquêteur [_C22_a.|_ Code0_|_1 de_|_6 l’enquêteur_] [______] [___|___] C3. Commune C3a. Code de la commune [______] [___|___] C4. Arrondissement C4a. Code de l’arrondissement [______] [___|___|___|___] C5. Quartier/Village [______] C6. Nom de PDV Si sans nom, écrire “sans nom” ou le nom du propriétaire C6a. Code PDV [______] [___|___|___]

C7. Type de point de vente

Formation sanitaire publique Formation sanitaire privée but lucratif 17 Supermarché / superette 01 Centre National Hospitalier Universitaire 10 Clinique privée 18 Boutique dans marché 02 Centre Hospitalier Départemental 11 Laboratoire privé but lucratif 19 Boutique hors marché 03 Hôpital de zone Formation sanitaire privée but non-lucratif 20 Etalage dans marché 04 Centre de santé communal 12 Hôpital missionnaire 21 Etalage hors marché [___|___] 05 Centre de santé d’arrondissement 13 ONG centre sanitaire 22 Vendeur ambulant 06 Dispensaire 14 Laboratoire privé but non-lucratif 96 Autre (spécifiez) 07 Maternité Autres PDV privé but lucratif 08 Unité villageoises de santé [______] 15 Pharmacie formelle ou officine 09 Relais communautaire 16 Dépôt pharmaceutique

C8. Cet arrondissement fait-il partie de l’échantillon boosté ? 1 = Oui 0=Non [___]

Section 2 : Questions de sélection S1. Avez-vous des médicaments en stock aujourd’hui ? 1 = Oui Aller à S3 [___] 0 = Non S2. Y a-t-il des médicaments qui sont épuisés aujourd’hui, mais que vous avez présentés à la vente ces 3 derniers mois ? 1 = Oui Aller à S4 [___] 0 = Non Aller à S5 8 = Ne sait pas Aller à S5 S3. Avez-vous des antipaludiques en stock aujourd’hui ? 1 = Oui Donnez des informations sur l’étude et obtenez son accord. Enregistrer l’heure du début de [___] l’entretien à C9. Aller à la Section 3 (Audit des antipaludiques) 0 = Non Vérifier en utilisant la fiche illustrative. Aller à S4 S4. Y a-t-il des antipaludiques qui sont épuisés aujourd’hui, mais que vous avez présentés à la vente ces 3 derniers mois ? 1 = Oui Donnez des informations sur l’étude et obtenez son accord. Enregistrez l’heure à C9. Aller à A16. [___] 0 = Non Vérifier en utilisant la fiche illustrative. Aller à S5 8 = Ne sait pas Vérifier en utilisant la fiche illustrative. Aller à S5 S5. Offrez-vous les services de dépistage en générale ou vendez-vous des tests diagnostiques ? 1 = Oui Aller à S6 [___] 0 = Non Vérifier en utilisant la fiche illustrative. Enregistrer les détails à C9 et remplir Sec 7: ORS & Zinc, Amoxicilline puis la Section X : Fin S6. Y a-t-il un de ces services ou tests pour diagnostiquer le paludisme ? 1 = Oui Donnez des informations sur l’étude et obtenez son accord. Enregistrez l’heure du début de l’entretien à C9. Aller à la Section 3: Audit de diagnostiques [___] 0 = Non Vérifier en utilisant la fiche illustrative. Enregistrer les détails à C9 et remplir Sec 7: ORS & Zinc, Amoxicilline puis la Section X : Fin Avant de procéder à l’entretien, assurez-vous que vous avez donné au participant la fiche d’information sur l’étude, que vous lui avez expliqué l’étude et que vous avez obtenu son consentement éclairé.

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C9. Résultat de visite(s)

Date Visite1 Visite2 Visite3 (jj/mm/aa) [___|___]-[___|___]-[_1_|_6_] [___|___]-[___|___]-[_1_|_6_] [___|___]-[___|___]-[_1_|_6_]

Heure du début de l’entretien (Format : 24 heures) 95:95 = N/A [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Heure de fin de l’entretien (Format : 24 heures) 95:95 = N/A [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___]

Résultat [___|___] [___|___] [___|___] 01= PDV éligible et entretien terminé Aller à E1 02 = PDV inéligible : ne satisfait pas aux critères de sélection Aller à E1 03= Entretien interrompu Aller à C11 04= Prestataire éligible non disponible / L’heure ne convient pas Aller à C11 05 =Point de vente pas ouvert au moment de la visite Aller à C11 06=Point de vente fermé définitivement Aller à E1 96=Autre(préciser): [______] 97 = Refus Aller à C10

C10. Si le prestataire a refusé de répondre, pourquoi ?

1=Affluence de clients Demandez à quelle heure il/elle préfère être interrogé et notez-le en C11 2 =Pense que c’est une inspection / a peur pour son autorisation Aller à E1 3 =Pas intéressé Aller à E1 [___] 6 =Autre (préciser): [______] 7 =Refuse de donner une raison Aller à E1 C11. Utilisez cet espace pour noter l’heure du rendez-vous. Si ce n’est pas possible de revenir, allez à E1 dans la Section X.

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Section 7 : SRO, Zinc & Amoxicilline Lisez au prestataire : Je voudrais vous poser quelques questions pour savoir si vous disposez de traitements pour la diarrhée et la pneumonie. ORS1. Avez-vous en stock aujourd’hui des sels de réhydratation orale, aussi connus comme SRO (ORS) Vérifiez avec une fiche illustrative [___] 1 = Oui 0 = Non ORS2. Avez-vous en stock aujourd’hui des comprimés de zinc pour le traitement de la diarrhée chez les enfants ? Vérifiez avec une fiche illustrative [___] 1 = Oui 0 = Non Allez à AB1 ORS3. Quel dosage de comprimés de zinc pour le traitement de la diarrhée chez les enfants avez-vous en stock

aujourd’hui ? Lisez la liste, encerclez TOUT ceux qui s’applique A A = 10mg B B = 20mg Z Z = Autre (à préciser): [______] ORS4. Avez-vous en stock aujourd’hui des SRO qui sont emballés avec un traitement de zinc pour la diarrhée chez les enfants ? Vérifiez avec une fiche illustrative [___] 1 = Oui 0 = Non AB1. Avez-vous des antibiotiques en stock aujourd’hui ? 1 = Oui [___] 0 = Non AB2. Avez-vous des comprimés d’amoxicilline dispersible, aussi connus comme Amox DT ? Montrez la fiche illustrative. Intervieweur: demandez à voir le produit et vérifiez qu’il s’agit d’amoxicilline dispersible [___] 1 = Oui 0 = Non Allez à la Section X AB3. Quel dosage de comprimés d’amoxicilline dispersible, aussi connus comme Amox DT, avez-vous en stock aujourd’hui ? Lisez la liste, encerclez TOUT ce qui s’applique A = 125mg A B = 250mg B Z = Autre (à préciser): [______] Z

Section X : Fin de l’entretien E1. Nom du participant:

5 = Non-applicable, pas de participant ; 7 = Refus [___] E2. Adresse physique ou identifiants du lieu (n’enregistrez pas la boite E3. Numéro de téléphone postale). Donnez une description détaillée qui permettra au contrôleur 99999995 = Non-applicable: pas de de retrouver le point de vente plus tard. participant ou pas de téléphone 99999997 = Refus

[___|___|___|___|___|___|___|___| GPS : E4. Nord/sud : Latitude E5. Est : Longitude

[_N_]-[___|___|___]-[___|___|___|___|___] [_E_]-[___|___|___]-[___|___|___|___|___] E7. Observations/remarques supplémentaires de l’enquêteur (s’il y en a)

REMERCIEZ LE PRESTATAIRE OU LE VENDEUR ET TERMINEZ L’ENTRETIEN Retournez à la question C9 (page 2) pour enregistrer le statut final de l’entretien et l’heure.

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Section 3 : Fiches d’audit du médicament

A0. Lisez au prestataire : Pourriez-vous nous montrer la gamme complète de médicaments modernes antipaludéens que vous avez en stock ? Avez-vous un ou plusieurs des médicaments modernes antipaludéens suivants : Lisez la liste entière en utilisant le catalogue photos. Aucune réponse ne sera rapportée.  Artémether + lumefantrine, par exemple, Arco, Artefan, Artif, Artiz, Artluf, Artrim, Artrin, Bimalaril, Cachart, Cether-L, Chinther, Co-Artesiane, Gvither Plus, Coartem, Co-Artesiane, Cofantrine, Colart, Combiart, Combisunate, Falciter, Lufanter, Luther, Lumartem, L-Artem, Lonart, Lumiter, Sharlum, Tarlum, Tonlum  Artésunate amodiaquine, par exemple, Amonat, Apoxin, Arsuamoon, Arsucam, Artediam, Camoquin Plus, Coarsucam, Falcimon, Larimal, Macsunate Plus, Malmed, Winthrop  Des autres combinaisons thérapeutiques à base d’artémisinine, par exemple, Arco, Artecure, Arte-Plus, Artequin, Artedar, AsunateDenk, Co-Arinate, Darte-Q, Duo-cotecxin, Malacur, P-Alaxin, Artecom, Alaxin Plus  Artémether monothérapies, par exemple, Artesiane, Artenam, Malather  Artésunate monothérapies, par exemple, Plasmotrim, Arinate  Quinine, par exemple, Arsiquinoform, Quinimax, Quinine Phosphate, Surquina  Sulfadoxine pyriméthamine (SP), par exemple, Combimal, SP, Fansidar, Maloxine, Falcidox, Malafan, Maladox, Malastop, Suprim, Metakelfin  Amodiaquine, par exemple, Amoquin, Malaridose, Exoquin, Malarkite, Malarid, Zendiq, Malaritab, Camoquin  Chloroquine, par exemple, Letaquine, Nivaquine, Quinnox  Sirops ou suspensions, par exemple, Artrim, Co-Artesiane, Flavoquine, Malacur, Lufanter, Halfan, Prosol  Injectables, par exemple, Quinine injectable, Artesiane, Quinine Résorcine, Malather, Malarix  Granules ou poudres, par exemple, Artequin pédiatrique, Darte-Q pédiatrique  Gouttes, par exemple, quinine gouttes

Si le point de vente n’a aucun médicament moderne antipaludique en stock, revérifier les résultats et aller à A16.

Procédez à l’audit de médicaments antipaludiques. Différentes fiches d’audit de médicaments seront utilisées, pour décrire les informations des antipaludiques selon la forme sous laquelle ils se présentent.

Triez tous les médicaments modernes antipaludiques dans 2 groupes :  Dans le premier groupe, rassemblez tous les médicaments antipaludiques qui se présentent sous la forme de comprimés, suppositoires ou granulés. Utilisez la “Fiche d’audit de médicaments en comprimés, suppositoires et granulés” pour noter leurs informations.

 Dans le deuxième groupe, rassemblez tous les médicaments antipaludiques qui se présentent sous autre forme que comprimés, suppositoires ou granulés. Utilisez la “Fiche d’audit de médicaments autre que comprimés” pour noter leurs informations.

Joignez des fiches additionnelles et agrafer au bon endroit à l'intérieur du questionnaire, si nécessaire. Vérifiez que toutes les pages sont au bon endroit avant d’aller au prochain PDV.

Assigner à chaque produit un Numéro de Produit (chronologique). (Commencer à partir de 1 pour les médicaments CSG et aussi à partir de 1 pour les médicaments NC.) Numéroter chaque fiche utilisée au bas de la page.

NOTES SUPPLÉMENTAIRES CODE SOUS-PDV EN LETTRE Dans tous les PDVs, remplir le code sous-PDV en lettre ainsi que le numéro de produit pour chaque médicament audité. CODE SOUS-PDV EN LETTRE PDV indépendant n’abritant pas un autre PDV (ex : pharmacies et dépôts pharmaceutiques, boutiques, étalages, les X vendeurs ambulants, etc.) A Pharmacie dans une formation sanitaire B Formation sanitaire : Clinique général, dispensaire C Formation sanitaire : Dispensaire ou clinique pour adulte seulement D Formation sanitaire : Clinique/centre de santé pédiatrique (enfants) E Formation sanitaire : Consultation prénatale / Maternité F Formation sanitaire : Clinique de traitement ARV / prise en charge des PVV L Laboratoire (pour l’audit de diagnostic)–pour les labos dans les formations sanitaires et les labos indépendants Z Autre (notez le type dans l’espace de commentaires – CSG 15 ou NC 15)

www.ACTwatch.info Page 123 FICHE D’AUDIT DU MEDICAMENT EN COMPRIME, SUPPOSITOIRE OU GRANULE (CSG) Code 1. Nom générique 2. Dosage 2a. Est-ce un dosage base? 3. Présentation 4. Nom de marque SOUS-PDV (Inclus les informations sur le poids et l’âge)

[___|___|___],[___]mg [__] 1 = Comprimé [_____] [___|___] ______1 = Oui 2 = Suppositoire No de [___|___|___],[___]mg [__] 0 = Non [___|___] 3 = Granule produit 8 = Ne sait pas

[___|___|___],[___]mg [__]

[___|___] [___|___] [___] Si non, précisez le sel : [___|___] [______] 5. Fabricant 6. Pays de fabrication 7. Taille de l’emballage 8. Est-ce une 9. Ce produit 10. Quantité vendue/distribuée au cours des 7 derniers jours à des 11. Rupture de stock dose fixe a-t-il le logo clients individuels (Ecrire le nombre de plaquettes/boîtes décrits à la au cours des 3 derniers Il y a un total de combinée ? feuille verte Q7 OU écrire le nombre total de comprimés / suppositoires / sachets de mois? (AMFm) ? granules vendus) [___|___|___|___] Ce PDV a vendu/distribué [___|___|___] plaquettes / boîtes au cours 1 = Oui comprimés / suppositoires / 1 = Oui 1 = Oui des 7 derniers jours. 0 = Non sachets de granules dans 0 = Non 0 = Non 8 = Ne sait pas chaque : 8 = Ne sait pas 8 = Ne sais OU pas 1 = Plaquette/Paquet Ce PDV a vendu/distribué [___|___|___|___] comprimés / 2 = Boîte/Bocal/Pot [___] suppositoires / sachets de granules au cours des 7 derniers jrs [___] [___] [___] Non applicable = 9995; Refusé = 9997; Ne sait pas = 9998 12. Prix de vente au détail 13. Prix d’achat en gros 14. Quelle raison vous amène à vous approvisionner de ce 15. Commentaires médicament ? [MONTRER LE PRODUIT] Achat de gros le plus récent du point de vente : Ne pas lire la liste. [___|___] Encercler TOUTES les réponses données Comprimés / suppositoires / sachets de granules coûtent au client individuel [___|___|___|___] Génère du profit A Comprimés / suppositoires / sachets de granules pour Recommandé par le gouvernement B un coût de Bas prix C La demande ou préférence des clients D [___|___|___|___|___|___] CFA [___|___|___|___|___|___] CFA Bonne réputation de la marque E Souvent prescrit par les docteurs F Plus efficace pour traiter le paludisme G Ne sait pas X Autres Z Gratuit = 000000; Refus = 999997; Ne sait pas = 999998 précisez [______]

Fiche d’audit du médicament en CSG [___|___] sur [___|___]

www.ACTwatch.info Page 124 FICHE D’AUDIT DU MEDICAMENT AUTRE QUE COMPRIME (NC) (sirops, suspensions, injectables & autres)

Code 1. Nom générique 2. Dosage 2a. Est-ce un dosage base ? 3. Présentation SOUS-PDV [___|___] [___|___|___|___],[___]mg/[___|___|___],[___]mL [___] 1 = Sirop [_____] ______[___|___] 1 = Oui 2 = Suspension [___|___|___|___],[___]mg/[___|___|___],[___]mL [___] 0 = Non 3 = Liquide injectable. o N de [___|___] 8 = Ne sait pas 4 = Poudre injectable. produit [___|___|___|___],[___]mg/[___|___|___],[___]mL [___] 5 = Gouttes

Si non, précisez le sel : 6 = Autre (préciser) [______] [___|___] (Note: ne pas renseigner mL pour les poudres injectables) [______] [___] [___|___] 4. Nom de marque 5. Fabricant 6. Pays de fabrication 7. Taille de l’emballage 9. Ce produit a- 10. Quantité vendu/distribuée 11. Rupture de stock (Inclus les informations sur le poids et t-il le logo au cours des 7 derniers jours à au cours des 3 l’âge) Il y a un total de feuille verte des clients individuels derniers mois ? (AMFm) ? Ce PDV a vendu/distribué 1 = Oui [___|___|___|___],[___] mL 1 = Oui 0 = Non (ou mg pour poudre injections) 0 = Non [___|___|___|___] bouteilles / 8 = Ne sait pas dans chaque: 8 = Ne sait pas ampoules au cours des 7 derniers jours 1 = Bouteille 2 = Ampoule/fiole Refusé = 9997 Ne sait pas = 9998 [___] [___] [___] 12. Prix de vente au détail 13. Prix d’achat en gros 14. Quelle raison vous amène à vous approvisionner de ce 15. Commentaires Achat de gros le plus récent du point de vente : médicament ? [MONTRER LE PRODUIT] Ne pas lire la liste. Encercler TOUTES les réponses données [___|___] [___|___|___|___] Bouteilles ou ampoules Bouteilles ou ampoules Génère du profit A coûte au client individuel coûte Recommandé par le gouvernement B Bas prix C La demande ou préférence des clients D [___|___|___|___|___|___] CFA [___|___|___|___|___|___] CFA Bonne réputation de la marque E Souvent prescrit par les médecins F Plus efficace pour traiter le paludisme G Ne sait pas X Autres Z Gratuit = 000000; Refus = 999997; Ne sait pas = 999998 précisez [______]

Fiche d’audit du médicament en NC [___|___] sur [___|___]

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Ruptures de stock des antipaludiques A16. Y a-t-il des antipaludiques qui sont épuisés aujourd’hui, mais que vous avez eus en stock ces 3 derniers mois ?

1 = Oui [___] 0 = Non Aller à Section 4: Audit de diagnostiques 8 = Ne sait pas Aller à Section 4: Audit de diagnostiques

A17.Est-ce que vous vous rappelez du nom de ces antipaludiques ? Nous acceptons les noms génériques ou les noms de marque. Enregistrez un médicament par ligne.

1 = Oui, préciser 0 = Non [______]

[______]

[______] [___] [______]

[______]

Aller à la Section 4 : Audit de diagnostiques

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Section 4 : Audit de diagnostiques Cette section renseigne sur la disponibilité des tests de diagnostic du paludisme. Renseigner les questions peut nécessiter de parler à plus d’une personne de ce point de vente. Si le participant ne connait pas la réponse à une question de cette section, demandez à parler avec une autre personne qui peut fournir l’information.

D1. Est-ce que ce point de vente/formation sanitaire dispose de gants à usage unique aujourd’hui que le personnel utilise pour consulter les clients/patients ?

[___] 1 = Oui 0 = Non 8 = Ne sait pas D2. Est-ce que ce point de vente/ formation sanitaire dispose de poubelle pour collecter les aiguilles aussi appelé boîte d’élimination des objets tranchants ou boîte de sécurité disponible aujourd’hui pour le personnel ? [___] 1 = Oui 0 = Non 8 = Ne sait pas D3. Le dépistage par microscopie du paludisme est-il disponible ici aujourd’hui?

1= Oui [___] 0= Non Aller à D7

D4. Combien de tests à la microscopie du paludisme avez-vous réalisés au cours des 7 derniers jours ? [___|___|___|___]

9998 = Ne sait pas D5. Quel est le coût total pour cet examen microscopique pour un adulte: [___|___|___|___|___] CFA Gratuit = 00000; Non-applicable = 99995; Refus = 99997; Ne sait pas=99998 D6. Quel est le coût total pour un examen microscopique pour un enfant de moins de 5 ans: [___|___|___|___|___] CFA Gratuit = 00000; Non-applicable = 99995; Refus = 99997; Ne sait pas=99998 D7. Un test de diagnostic rapide du paludisme, aussi connu comme un TDR, est un petit test de sang, emballé individuellement, qui rapidement diagnostique si une personne a le paludisme. Montrer les photos de TDR dans les fiches illustratives. Les TDR sont-ils disponibles ici aujourd’hui ? [___]

1 = Oui Aller à D8 0 = Non Aller à D9 8 = Ne sait pas Demander à parler avec quelqu’un qui détient l’information D8. SVP, montrez-nous toute la variété des tests que vous avez  SD Bioline (Standard Diagnostic Bioline) actuellement en stock. Avez-vous présentement un des  DiaSpot tests suivant ?  ParaCheck Lire la liste entière ; pas de réponse à enregistrer.  Parasight  Care star malaria  First response malaria  Star combo Procéder à l’audit de diagnostiques. Si vous utilisez des fiches supplémentaires, joignez les et agrafez au bon endroit à l’intérieur du questionnaire. Vérifiez que toutes les pages sont au bon endroit avant d’aller au prochain PDV. Assigner à chaque TDR un Numéro de Produit (chronologique). Dans les formations sanitaires, remplir le Code sous-PDV en lettre ainsi que le Numéro de Produit. Trouver les Codes sous-PDV en lettre sur la page 3. Numéroter chaque fiche d’audit utilisée au bas de la page. Dans les formations sanitaires, remplir le code PDV en lettre de ainsi que le numéro de produit pour chaque TDR audité.

www.ACTwatch.info Page 127 FICHE D’AUDIT DE TDR Code 1. Nom de marque 2. Test d’antigène 3. Type de parasites 4. Fabricant 5. Pays de 5b. Numéro de 6. No. du lot 7. Est-ce un kit de SOUS-PDV (Encercler tous ceux (Encercler tous ceux qui fabrication catalogue du test pour auto-

qui s’appliquent) s’appliquent) produit administration avec

[_____] HRP2 A Pf A son tampon, sa Pv B pipette et sa pLDH B Po C lancette ? Aldolase C pm D No de pan E 1 = Oui produit Pas indiqué Z vom/Pvom F 0 = Non

Autre G 8 = Ne sait pas [___|___] Préciser [______] Pas indiqué Z [___]

13. Quantité 14. 15a. Est-ce que vous ou les 16a. Est-ce que ce centre/point de 17. Prix d’achat en gros 18. Quelle raison vous amène à vous 19. Commentaires vendue, distribuée Rupture de autres employés utilisent cette vente fournit cette marque de TDR Pour l’achat le plus récent : approvisionner de ce TDR? ? [Montrer le ou utilisée au cours stock de ce marque de TDR pour tester des à des clients qui l’emportent pour TDR] des 7 derniers jours TDR au clients dans ce centre/point de faire des tests ailleurs? Ne lisez pas la liste à des clients cours des 3 vente? 1 = Oui [___|___|___|___] tests Encercler toutes les réponses données individuels derniers 1 = Oui 0 = Non Aller à 17 (Ecrivez le nombre mois? 0 = Non Aller à 16a 8 = Ne sait pas Aller à 17 Prestation gratuite A total de TDR) 8 = Ne sait pas Aller à 16a coût 1 = Oui [___] [___] Profitable B Ce point de vente a 0 = Non 15b. Quel est le coût total 16b. Quel est le coût spécifique du vendu ou distribué 8 = Ne sait d’un TDR pour un adulte (y test pour un adulte? [___|___|___|___|___|___] Recommandé par le gouvernement C pas compris le coût du TDR et les CFA [___|___|___|___] frais de services) ? [___|___|___|___|___] CFA Prix bas D tests au cours des 7 Gratuit = 000000; [___] derniers jours [___|___|___|___|___] CFA 16c. Quel est le coût spécifique du Refus = 999997; Préférence du client E 15c. Quel est le coût total d’un test pour un enfant de moins de 5 Ne sait pas = 999998 Refus = 9997; TDR pour un enfant de moins ans ? Réputation positive de la marque F Ne sait pas=9998 de 5 ans (y compris le coût du

TDR et les frais de services) ? [___|___|___|___|___] CFA Ne sait pas X

[___|___|___|___|___] CFA Autre Z

préciser [______] Gratuit = 00000 ; Non-applicable = 99995; Refus = 99997; Ne sait pas = 99998

Fiche d’audit des TDR [___|___] sur [___|___]

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Ruptures de stock de TDR D9. Y a-t-il des kits de Test Diagnostic Rapide (TDR) du paludisme qui sont épuisés aujourd’hui, mais que vous avez eus en stock ces 3 derniers mois ?

1 = Oui [___] 0 = Non Aller à D11 8 = Ne sait pas Aller à D11

D10. Connaissez-vous le nom de marque de ces TDR qui sont en rupture de stock ? Enregistrer une marque par ligne.

1 = Oui, préciser [______] [___] [______] [______] 0 = Non D11. Est-ce que ce centre/point de vente fournit des médicaments ou prescrit des ordonnances médicales ?

1 = Oui Aller à la section 5 Questionnaire Prestataire

0 = Non Vérifier que S1 est non et S2 est non (Le PDV n’a pas de médicament [___] actuellement/ ou n’a pas de médicament récemment) et aussi C7 est 11 ou 14. Aller à Section 7 : ORS, ZINC et amoxicilline.

Aller à la Section 5 : Questionnaire pour le prestataire

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Section 5 : Questionnaire pour le prestataire

Cette section est pour les responsables ayant en charge la prescription des ordonnances, la fourniture des soins ou médicaments aux clients/patients.

P1. Vos responsabilités dans ce centre/point de vente incluent : la prescription des ordonnances, la fourniture des soins ou médicaments aux clients/patients ?

1 = Oui [___] 0= Non demander à parler avec un responsable du point de vente qui assume une ou plusieurs de ces responsabilités

P2. Depuis combien d’années travaillez-vous dans ce point de vente ? (Si moins d’un an, écrivez 01.) [___|___] ans P3. Quel âge avez-vous aujourd’hui ? Ecrire l’âge en année 997 = Refus 998 = Ne sait pas [___|___|___] ans P4. Ne lisez pas : Le participant est-il un homme ou une femme?

1= Homme 2= Femme [___]

P5. Quel est votre niveau d’instruction ?

1 = N’a pas fréquenté 2 = Niveau primaire 3 = A terminé le niveau primaire 4 = Niveau secondaire [___|___] 5 = A terminé le niveau secondaire 6 = Niveau universitaire 7 = A terminé l’université 97 = Refus

P6. Avez-vous déjà participé à une formation organisée dans le domaine du diagnostic du paludisme incluant le diagnostic microscopique ou le test de diagnostic rapide au cours des 12 derniers mois ? Y compris stage et atelier. [___] 1 = Oui 0 = Non 8 = Ne sait pas P7. Avez-vous déjà participé au cours des 12 derniers mois à une formation sur le protocole utilisé au plan national sur le traitement du paludisme ? Y compris stage et atelier. [___] 1 = Oui 0 = Non 8 = Ne sait pas P8. Avez-vous une des qualifications suivantes en santé ? Lire la liste. Enregistrer 1 pour oui, 0 pour non I. Pharmacien [___] II. Médecin [___] III. Infirmier (ère) [___]

IV. Sage-femme [___] V. Laborantin / Assistant en laboratoire [___]

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VI. Technicien en pharmacie / Assistant en pharmacie [___] VII. Aide-soignante [___] VIII. Conseiller (ère) (VIH, TB, Planification familiale, etc.) [___] IX. Relais communautaire [___]

P9. En dehors de vous, est-ce qu’il y a des personnes qui travaillent dans ce point de vente et qui ont les types de qualifications suivantes liées à la santé ?

Lire la liste. Enregistrer 1 pour oui, 0 pour non, 8 pour ne sait pas I. Pharmacien [___] II. Médecin [___] III. Infirmier (ère) [___] IV. Sage-femme [___] V. Laborantin / Assistant en laboratoire [___] VI. Technicien en pharmacie / Assistant en pharmacie [___] VII. Aide-soignante [___] VIII. Conseiller (ère) (VIH, TB, Planification familiale, etc.) [___] IX. Relais communautaire [___]

Enquêteur : Pour les quatre prochaines questions, enregistrez le nom de la marque ou le nom générique, et la présentation. Demandez au prestataire de vous montrer les médicaments s’ils sont en stock pour vérifier le nom et la présentation.

P10. A votre avis, quel est le médicament antipaludique le plus efficace pour le paludisme simple des adultes? Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[___|___] [______] Ne sait pas = 98

P11. A votre avis, quel est le médicament antipaludique le plus efficace pour le paludisme simple des enfants de moins de cinq ans? Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[______] [___|___] Ne sait pas = 98

P12. Quel médicament antipaludique pour traiter le paludisme simple des adultes recommandez-vous le plus souvent à vos clients ?

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Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[___|___] [______] Ne sait pas = 98

P13. Quel médicament antipaludique pour traiter le paludisme simple des enfants de moins de cinq ans recommandez-vous le plus souvent à vos clients ? Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[___|___] [______] Ne sait pas = 98

P14. Selon votre opinion, quel est médicament antipaludique le plus efficace pour traiter le paludisme grave chez les adultes? Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[___|___] [______] Ne sait pas = 98

P15. Selon votre opinion, quel est médicament antipaludique le plus efficace pour traiter le paludisme grave chez les enfants de moins de cinq ans? Demandez au prestataire de vous montrer le médicament s’il est en stock Nom de la marque ou nom générique Présentation

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié 03 = Granule 06 = Injection IM/IV 98 = Ne sait pas (liquide ou poudre)

[___|___] [______] Ne sait pas = 98

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P16. Veuillez citer le médicament de première intention recommandé par le gouvernement pour traiter le paludisme simple. Ne pas lire la liste. Enregistrer seulement une réponse.

01 = Artemether-lumefantrine (ex. Coartem, Luther, L-Artem, Lonart, Co-Rimetar, Co-Artluf, Lumartem) ……...... Aller à P17 02 = CTA...... Aller à P17 03 = ACTm...... Aller à P17 04 = Dihydroartemisinin Piperaquine [___|___] 05 = Amodiaquine 06 = Artémether 07 = Artémisinin 08 = Artésunate Aller àP19 09 = Chloroquine 10 = Quinine 11 = Sulfadoxine Pyrimethamine (ex. Fansidar, SP) 96 = Autre (préciser) [______] 98 = Ne sait pas P17.Veuillez spécifier le schéma de traitement de première intention recommandé par le gouvernement pour un adulte (60 kg) pour ce médicament.

Quelle est la présentation?

01 = Comprimé 04 = Sirop 07 = Gouttes 02 = Suppositoire 05 = Suspension 95 = Pas préférence/Non spécifié [___|___] 03 = Granules 06 = Injection (IM/IV) 96 = Non Applicable 98 = Ne sait pas Si le prestataire répond une présentation qui n’est pas comprimé, allez à la question P18

Lire les 3 questions qui suivent : I. Combien des comprimés par prise ?

II. Combien de fois par jour ? [___|___],[___|___] III. Pendant combien de jours ? [___|___] [___|___] Si le médicament est disponible, utiliser l’emballage pour remplir le tableau ci-dessous. Ne sait pas = 98 Si le médicament n’est pas disponible, demander au participant de l’identifier de la fiche illustrative. Si l’identification n’est pas possible, demander au participant de se rappeler des détails du médicament.

Nom générique Dosage Nom de la marque

[__|__] ______[__|__|__],[__]mg

[___|___] Ne sait pas = 999,8

Fabricant Le médicament est-il une dose fixe combinée ? 1 = Oui 0 = Non [___] Ne sait pas = 98 8 = Ne sait pas

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P18. Veuillez spécifier le schéma de traitement de première intention recommandé par le gouvernement pour un enfant de deux ans (10 kg) pour le paludisme simple pour ce médicament.

Quelle est la présentation?

01 = Comprimé 04 = Sirop 07 = Gouttes 02 = Suppositoire 05 = Suspension 95 = Pas préférence/Non spécifié [___|___] 03 = Granules 06 = Injection (IM/IV) 96 = Non Applicable 98 = Ne sait pas

Si le prestataire répond une présentation qui n’est pas comprimé, allez à la question P19

Lire les 3 questions qui suivent :

I. Combien des comprimés par prise ?

II. Combien de fois par jour ? [___|___],[___|___] III. Pendant combien de jours ? [___|___] Si le médicament est disponible, utiliser l’emballage pour remplir le tableau ci-dessous. [___|___] Si le médicament n’est pas disponible, demander au participant de l’identifier de la fiche Ne sait pas = 98 illustrative.

Si l’identification n’est pas possible, demander au participant de se rappeler des détails du

médicament.

Nom générique Dosage Nom de la marque

[__|__] ______[__|__|__],[__]mg

[___|___] Ne sait pas = 999,8

Fabricant Le médicament est-il une dose fixe combinée ? 1 = Oui 0 = Non [___] 8 = Ne sait pas Ne sait pas = 98

P19. Veuillez citer le médicament de première intention recommandé par le gouvernement pour traiter le paludisme grave. Ne pas lire la liste. Enregistrer seulement une réponse

01 = Artesunate (Artesun, Larinate, Plasmotrim) ………………………………………………………………… Aller à P20 02 = Artemether (Anamether, Artefan, Artem, Artenam, Artesiane, Gviter, Lariter-40, Malather, Philomether, Nemether, Talimether)...... Aller à P20 03 = Quinine (Mediquin, Paluject, Pecgina, Penine, Philco, Quinimax, Rindoquine, ...... Aller à P20 04 = ACT/ACTm 05 = Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem) [___|___] 06 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop) 07 = Dihydroartemisinin Piperaquine (Duo-cotecxin, P-alaxin) Aller à P21 08 = Chloroquine (Sugarquin) 09 = Sulfadoxine Pyrimethamine (Fansidar, SP, Orodar, Ekelfin, Metakelfin) 96 = Autre (préciser): [______] 98 = Ne sait pas

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P20. Quelle est la présentation de ce médicament recommandé par le gouvernement pour traiter le paludisme grave? Ne pas lire les options de présentations

01 = Comprimé 04 = Sirop 07 = Goutte 02 = Suppositoire 05 = Suspension 95 = Non spécifié [___|___] 03 = Granule 06 = IM/IV Injection (Liquide ou 98 = Ne sait pas poudre) P21. Un test de diagnostic rapide du paludisme, aussi connu comme un TDR, est un petit test de sang, emballé individuellement, qui rapidement diagnostique si une personne a le paludisme. Montrer les photos des TDR dans les fiches illustratives. En avez-vous déjà vu ou entendu parler ? [___]

1 = Oui Aller à P22 0 = Non Aller à P29 8 = Ne sait pas Aller à P29 P22. Avez-vous déjà testé un client pour le paludisme en utilisant un TDR ?

1 = Oui

0 = Non [___] 8 = Ne sait pas P23. Recommanderiez-vous à un patient/client de prendre un antipaludique si le test de diagnostic rapide donne un résultat négatif pour le paludisme? Lire la liste. Enregistrer une seule réponse

1 = Oui, parfois [___] 2 = Oui, toujours 3 = Non, jamais Aller à P29 8 = Ne sait pas Aller à P29 P24. Dans quelles circonstances recommanderez-vous à un patient/client de prendre un antipaludique après un test négatif avec le TDR du paludisme? Ne pas lire la liste. Demander “à part ça ?” jusqu’à ce que le participant ne finisse. Encercler TOUTES les réponses données Quand ils ont des signes/symptômes du paludisme A

Quand ils demandent un traitement antipaludique B

Quand ce sont des enfants C

Quand ce sont des adultes D

Quand ce sont des femmes enceintes E

Quand je ne fais pas confiance au test F

Quand je connais le patient/client G

Autre X Autre (spécifier) [______]

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P29. Quels sont les signes de danger d’une maladie grave chez un enfant de moins de 5 ans? Ne pas lire la liste. Demander “à part ça ?” jusqu’à ce que le participant ne finisse.

Encercler TOUTES les réponses données Ne peut pas boire / Refuse de prendre le sein A

Vomissement B

Convulsions C

Un état léthargique ou inconscient D

Ne sait pas Z

Autre X Autre (spécifier) [______]

P30. Que feriez-vous si on vous amène un enfant de deux ans avec les signes de danger d’une maladie grave ? Ne pas lire, ni proposer les réponses. Enregistrer seulement une réponse.

01 = Demander de l’aide/conseils à quelqu’un dans cette structure 02 =Traiter l’enfant dans cette structure 03 = Référer à une structure de santé (hôpital/clinique) après ou sans avoir traité ici [___|___] 04 = Référer à une structure non-sanitaire (pas hôpital/clinique) après ou sans avoir traité ici 05 = Renvoyer à la maison sans médicaments 06 = Renvoyer à la maison avec médicament 96 = Autre préciser : [______] 98 = Ne sait pas

Remplir fiche de synthèse sur la prochaine page et suivre les instructions pour la fin de l’entretien. Pour le remplissage de la fiche de synthèse, vous ne devriez plus poser de questions à l’enquêté. Compléter les réponses à partir des informations précédemment obtenues

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Section 6 : Fiche de Synthèse

T1. Y a-t-il des antipaludiques COMPRIMES/SUPOSITOIRES/GRANULES en stock dans ce point de vente ? 1 = Oui 0 = Non Aller à T4 [___] 8 = Ne sait pas Aller à T4

T2. Nombre total de fiches d’audit du médicament en comprimés, suppositoires et granules [___|___] T3. Avez-vous rempli des fiches d’audits pour tous les antipaludiques COMPRIMES/SUPOSITOIRES/GRANULES disponibles?

[___] 1 = Oui, audit complet 0 = Non, audit non complet

T4. Y a-t-il des antipaludiques NON COMPRIMES en stock dans ce point de vente ?

1 = Oui [___] 0 = Non Aller à T7 8 = Ne sait pas Aller à T7

T5. Nombre total de fiches d’audit du médicament en non comprimés [___|___] T6. Avez-vous rempli des fiches d’audits pour tous les antipaludiques NON COMPRIMES disponibles?

1 = Oui, audit complet [___] 0 = Non, audit non complet

T7. Y a-t-il des TDR en stock dans ce point de vente ? 1 = Oui 0 = Non Aller à T10 [___] 8 = Ne sait pas Aller à T10

T8. Nombre total de fiches d’audit TDR complété [___|___] T9. Avez-vous rempli des fiches d’audits pour tous TDR disponibles?

1 = Oui, audit complet [___] 0 = Non, audit non complet

T10. COMMENTAIRES : Raison de l’audit incomplet (si réponse est non pour T3, T6, or T9) :

Assurez-vous de compléter la Section 7 : SRO, Zinc & Amoxicilline. Et dans C9, enregistrer le statut final de l’interview et l’heure de fin. Puis procéder à la Section X : Fin de l’entretien.

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Annex 7: Antimalarial Reference

Table X3: Number of antimalarials audited

Public Community Private Not Private General Itinerant Drug ALL Health Health For-Profit ALL Public for-Profit Pharmacy Drug Store Total Private Retailer Vendor Outlets Facility Worker Facility Facility Urban 645 42 162 849 528 7,749 48 2,521 1,437 12,283 13,132 Census 250 42 162 454 528 2,639 16 2,521 1,437 7,141 7,595 Booster 395 0 0 395 0 5,110 32 0 0 5,142 5,537 Rural 1,164 56 199 1,419 370 1,137 164 1,231 143 3,045 4,464 Census 174 56 199 429 370 718 58 1,231 143 2,520 2,949 Booster 990 0 0 990 0 419 106 0 0 525 1,515 TOTAL 1,809 98 361 2,268 898 8,886 212 3,752 1,580 15,328 17,596 Source: ACTwatch Outlet Survey, Benin, 2016.

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

QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s (GFATM) Quality Assurance Policy. A QA ACT is any ACT that appeared on the GFATM’s indicative list of antimalarials meeting the GFATM’s quality assurance policy* prior to data collection, or that previously had C-status in an earlier GFATM quality assurance policy and was used in a program supplying subsidized ACTs. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and Pyramax®. Artemether Lumefantrine ARTEFAN 20/120 5-15 KG ^# COMBISUNATE 5-15 KG ^# ARTEFAN 20/120 15-25 KG ^# COMBISUNATE 15-25 KG ^# ARTEFAN 20/120 35+ KG # COMBISUNATE 25-35 KG ^# ARTEMEF 5-15 KG # COMBISUNATE 35+ KG ^# ARTEMETHER LUMEFANTRINE - IPCA ^# LARITEM 20/120 ^# COARTEM 20/120 5-15 KG # LUMARTEM 5-15 KG ^# COARTEM 20/120 15-25 KG ^# LUMARTEM 15-25 KG ^# COARTEM 20/120 25-35 KG ^# LUMARTEM 25-35 KG ^# COARTEM 20/120 35+ KG ^# LUMARTEM 35+ KG ^# COARTEM 80/480 35+ KG # LUMITER 20/120 ADULT # COLART - IPCA # MACALUM 5-15 KG # COMBIART 20/120 35+ KG ^# MACALUM 35+ KG # Artesunate Amodiaquine APMOD 25/67.5 # ARTESUNATE AMODIAQUINE 14+ YEARS - IPCA# APMOD 50/135 # ASAQ WINTHROP INFANT 2-11 MONTHS ^# ARTESUNATE AMODIAQUINE - CIPLA # ASAQ WINTHROP TODDLER 1-5 YEARS ^# ARTESUNATE AMODIAQUINE 1-5 years - IPCA # ASAQ WINTHROP CHILD 6-13 YEARS # ARTESUNATE AMODIAQUINE 6-13 years - IPCA# ASAQ WINTHROP ADULT 14+ YEARS # Non-Quality-Assured ACT ACTs that do not meet the definition of being quality-assured. Artemether Lumefantrine Tablets ARMETRINE # COMBIART 20/120 5-15 KG # ARTEFAN 40/240 15-25 KG COMBIART 20/120 15-25 KG ^# ARTEFAN 40/240 25-35 KG ^# COMBIART 20/120 25-35 KG # ARTEFAN 60/360 25-35 KG # COMBIART 80/480 35+ KG ^# ARTEFAN 80/480 35+ KG ^# LUFANTER 20/120 INFANT & CHILD ^# ARTEMETHER LUMEFANTRINE - TONGMEI # LUFANTER 40/240 ADULT ^# ARTIZ 40/240 ^# LUFANTER 80/480 ADULT # ARTIZ 80/480 ^# LUFEMAX 20/120 # ARTLUF-FORTE # LUFEMAX 80/480 # ARTRIM ^# LUFENART 20/120 # ARTRIN # LUFENART 40/240 # ARTRINE 20/120 ^# LUFENART 80/480 # ARTRINE 40/240 ^# LUMA ^# ARTRINE 80/480 ^# LUMART # BIMALARIL 20/120 # LUMATE ^# BIMALARIL 40/240 # LUMITER 80/480 ADULT ^# BIMALARIL 60/360 # MALAR 2 # BIMALARIL 80/480 ^# POMEX 20/120 ^# CACHART # POMEX 40/240 # CETHER-L # R-LUME 40/240 # CHINTER # R-LUME 80/480 # COFANTRINE 20/120 INFANT & CHILD # TARLUM ^# COFANTRINE 20/120 ADULT # TONLUM 20/120 5-15 KG # COFANTRINE 80/480 ADULT ^# TONLUM 20/120 35+ KG # COLART - GLAXOSMITHKLINE# TONLUM 80/480 #

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Table X4: Quality-assured (QA ACT) and Non-quality Assured ACTs Audited Non-Quality-Assured ACT Artemether Lumefantrine Suspension ARH-L # CO-ARTESIANE 180/1080 60ML^# ARTEFAN ^# CO-ARTESIANE 360/2160, 120ML ^# ARTEMETHER LUMEFANTRINE - MEDOPHERM # COFANTRINE # ARTIZ # FALCIART # ARTLUF-FORTE # FANTEM # ARTOME ^# L-ARTEM # ARTRIM ^# LUFANTER # BIMALARIL 20/120, 30ML ^# LUMITER # BIMALARIL 40/240, 30ML# R-LUME # BIMALARIL 60/360, 30ML# TARLUM ^# CETHER-L # Artemisinin Naphthoquine Tablets ARCO # Artemisinin Piperaquine Tablets ARTEQUICK # Artesunate Amodiaquine Tablets ARTEDIAM # ASAQ DENK # Artesunate Amodiaquine Suspension MD ARTESUNATE PLUS # Artesunate Mefloquine Tablets ARTEQUIN 300/375 # ARTEQUIN 600/750 # Artesunate Mefloquine Granule ARTEQUIN 50/125 # Artesunate SP Tablets ARTEDAR ADULT # CO-ARINATE ADULT # ASUNATE DENK 100 # CO-ARINATE JUNIOR ^# ASUNATE DENK 200 # Dihydroartemisinin Piperaquine Tablets D-ARTEPP # MALACUR # DARTE-Q ADULT # P-ALAXIN # DUO-COTECXIN # RIDMAL # Dihydroartemisinin Piperaquine Granule DARTE-Q PEDIATRIC # Dihydroartemisinin Piperaquine Suspension MALACUR ^# P-ALAXIN # Dihydroartemisinin Piperaquine Trimethoprim Tablets ARTECOM # Dihydroartemisinin Piperaquine Trimethoprim Suspension ARTECOM # Dihydroartemisinin Sulfadoxine Pyrimethamine Tablets ALAXIN PLUS # * http://www.theglobalfund.org/en/procurement/quality/pharmaceutical ^ Product audited in the public sector # Product audited in the private sector Source: ACTwatch Outlet Survey, Benin, 2016.

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Table X5: Nationally Registered ACTs

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

Artemether Lumefantrine Tablets ARMETRINE # FALCIART 20/120 ^# ARTEMETHER LUMEFANTRINE - IPCA ^# FALCIART 80/480 ^# ARTLUF-FORTE # LARITEM 20/120 ^# ARTRIM ^# LARITEM 40/240 # ARTRIN # LARITEM 80/480 ^# BIMALARIL 20/120 # LUFANTER 20/120 INFANT & CHILD ^# BIMALARIL 40/240 # LUFANTER 40/240 ADULT ^# BIMALARIL 60/360 # LUFANTER 80/480 ADULT # BIMALARIL 80/480 ^# LUFEMAX 20/120 # COARTEM 20/120 5-15 KG ^# LUFEMAX 80/480 # COARTEM 20/120 15-25 KG ^# LUFENART 20/120 # COARTEM 20/120 25-35 KG ^# LUFENART 40/240 # COARTEM 20/120 35+ KG ^# LUFENART 80/480 # COARTEM 80/480 35+ KG # LUMITER 20/120 ADULT # COFANTRINE 20/120 INFANT & CHILD # LUMITER 80/480 ADULT ^# COFANTRINE 20/120 ADULT # POMEX 40/240 # COFANTRINE 80/480 ADULT ^# R-LUME 40/240 # COLART - GLAXOSMITHKLINE# R-LUME 80/480 # COMBIART 20/120 5-15 KG # TARLUM ^# COMBIART 20/120 15-25 KG ^# TONLUM 20/120 5-15 KG # COMBIART 20/120 25-35 KG # TONLUM 20/120 35+ KG # COMBIART 20/120 35+ KG ^# TONLUM 80/480 # COMBIART 80/480 35+ KG ^# Artemether Lumefantrine Suspension ARH-L # CO-ARTESIANE 360/2160, 120ML^# ARTOME ^# COFANTRINE # ARTRIM ^# FANTEM # BIMALARIL 20/120, 30ML# R-LUME # BIMALARIL 40/240, 30ML# TARLUM ^# BIMALARIL 420, 30ML# Artesunate Amodiaquine Tablets ARTEDIAM # ARTESUNATE AMODIAQUINE - IPCA # Artemisinin Mefloquine Tablets ARTEQUIN 300/375 # ARTEQUIN 600/750 # Artesunate SP Tablets CO-ARINATE ADULT # CO-ARINATE JUNIOR ^# Dihydroartemisinin Piperaquine Tablets DUO-COTECXIN # Dihydroartemisinin Piperaquine Suspension P-ALAXIN # Dihydroartemisinin Piperaquine Trimethoprim Tablets ARTECOM # ^ Product audited in the public/private-not-for-profit sector # Product audited in the private sector

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Table X6: Severe Malaria Treatment Audited

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, and injectable artemether. Rectal artesunate PLASMOTRIM 50 ^# PLASMOTRIM 200 ^# Artesunate powder injection ARTESUN 30 # ARTESUN 120 # ARTESUN 60 ^# MALAVAN # Artemether injection ARTEM ^# GVITHER FORTE # ARTEMAL ^# ARTEMETHER (KINGLION)# ARTEMETHER - NORTH CHINA PHARMACEUTICAL GROUP CORPORATION LARITHER 80 # ^# ARTEMETHER - TONGMEI ^# NEMETHER ^# ARTENAM # PALMATHER # ARTESIANE 20 # PARALINE # ARTESIANE 40 ^# PHILOMETHER ^# ARTESIANE 80 ^# R-LUME # Quinine injection # HAMEXQUINE ^# QUINIDO ^ # LIZOQUIN # QUINIMAX # NELBPHARQUINE ^# QUININE - COMPAGNIE PHARMACEUTIQUE AFRICAINE ^ # PALUJECT # QUININE - WUHAN GRAND PHARMACEUTICAL GROUP CO. LTD ^ # PENINE ^# QUININE - XINGHUA PHARM ^ # PHILCO-QUININE # QUININE RESORCINE - SANOFI AVENTIS ^ # PHILOQUIN ^# RINDOQUINE ^ QUIDOX ^# * Guidelines for the treatment of malaria, 3rd edition. WHO. Geneva: 2015. ^ Product audited in the public sector # Product audited in the private sector Source: ACTwatch Outlet Survey, Benin, 2016.

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Annex 8: RDT Reference

Table X7: Number of RDTs audited Public Community Private Not Private Private General Itinerant Drug Health Health For-Profit ALL Public for-Profit Pharmacy Drug Store ALL Private for-Profit Retailer Vendor Facility Worker Facility Facility Facility Urban 101 35 13 149 36 7 0 1 0 44 193 Census 40 35 13 88 36 0 0 1 0 37 125 Booster 61 0 0 61 0 7 0 0 0 7 68 Rural 202 62 12 276 21 3 0 1 0 25 301 Census 31 62 12 105 21 2 0 1 0 24 129 Booster 171 0 0 171 0 1 0 0 0 1 172 TOTAL 303 97 25 425 57 10 0 2 0 69 494 Source: ACTwatch Outlet Survey, Benin, 2016.

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Table X8: RDT Brand Names and Manufacturers*

Brand Name, Manufacturer CARESTART, ACCESS BIO INC ^# FIRST RESPONSE, PREMIER MEDICAL CORPORATION LIMITED ^ ICT DIAGNOSTICS, ICT DIAGNOSTICS ^# MAKESURE, HLL LIFECARE LIMITED # SD BIOLINE, STANDARD DIAGNOSTICS INC ^# * 494 RDTs were audited. Four RDTs were missing brand name information (missing or don’t know) and 11 were missing manufacturer name (missing or don’t know). ^ Product audited in the public/private-not-for-profit sector. # Product audited in the private sector. Source: ACTwatch Outlet Survey, Benin, 2016.

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Annex 9. Sampling Weights

Sampling weights were applied for analysis of the Benin 2016 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 arrondissements. A representative sample was selected within each domain. 2) One-stage cluster sampling: Arrondissements were selected from sampling frames within each domain with probability proportional to size. Within each arrondissement, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was conducted. 3) Booster sample: The geographic area for the outlet census was extended to the commune level for public health facilities, pharmacies, and drug stores. All public health facilities, pharmacies, and drug stores within communes in which the selected arrondissements were located were included in the study.

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 arrondissement level only (i.e. the booster sample was not included in market share calculations). Arrondissement sampling weights were created using the sampling weight formula (Wi), where:

Mα = estimated arrondissement population size ΣMα = sum of estimated arrondissement population size in the entire stratum a = number of arrondissements selected within the stratum

The arrondissement sampling weights were applied to all other indicators in the report for all outlet types, with the exception of public health facilities, pharmacies, and drug stores. Given that these outlet types were included in the sample through a commune-wide census, the weights applied to these outlet types for all indicators other than market share were calculated using the sampling weight formula (Wi), where:

Mα = estimated commune population size ΣMα = sum of estimated commune population size in the entire stratum a = number of communes selected within the stratum

The population estimates used to select arrondissements with PPS and to create sampling weights were obtained from the 2013 Benin Population and Housing Census. A sampling frame with population sizes was used for selecting the sample because accurate estimates on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets and/or distribution of medicines moving through outlets in a given cluster is correlated with population size.

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Annex 10: Indicator Definitions

Table 1: Availability of antimalarials, among all screened outlets

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

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

Denominator Number of outlets screened.

Calculation Numerator divided by denominator.

Handling 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.

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: Types of quality-assured and Non-quality assured ACTs

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

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

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

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

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

Notes and considerations

Table 4: Antimalarial market composition

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

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

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

Calculation Numerator for each outlet type divided by the denominator.

Handling 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.

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Table 5: Price of antimalarials

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

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.

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

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

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

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

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

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

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

Calculation Numerator divided by denominator.

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

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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.

Table 7: Malaria blood testing market composition

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

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

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

Calculation Numerator for each outlet type divided by the denominator.

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

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

Table 8: Price of malaria blood testing

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

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

Handling 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.

Table 9: Antimalarial market share

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

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

Denominator Total number of AETDs sold/distributed.

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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 10: Antimalarial market share across outlet type

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

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

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

Calculation Numerator divided by denominator.

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

Table 11: Malaria blood testing market share

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

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

Denominator Total number of malaria blood tests sold/distributed.

Calculation Numerator divided by denominator.

Handling 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.

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

Table 12: Malaria blood testing market share across outlet type

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

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

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

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

Calculation Numerator divided by denominator.

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

Table 13: Provider case management knowledge and practices

Table 13 reports key indicators of provider case management knowledge and practices. These include 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 one response to this question, including “don’t know” (i.e. at least one 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.” www.ACTwatch.info Page 151

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 A and B in Table 13), while a different provider responsible for prescribing and/or dispensing medicines may have responded to questions about government- recommended malaria first-line treatment and dosing regimen (indicators A and B in Table 14). In all cases, the questions assessing provider knowledge and practices were administered only one time per outlet. As such, indicators are tabulated at the outlet level.

Table 14: Provider antimalarial treatment knowledge and practices

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

Numerator A. State first-line: providers who responded to p16 with a generic or brand name consistent with a national first-line treatment, or responded to p16with “ACT” or “ACTm,” and in p17 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 p16 or p17. B. First-line regimen, adult: providers who correctly stated the first-line generic ingredients and strengths in p17, and correctly stated: number of days, times per day, and tablets per dose to be taken. C. ACT most effective, adult and 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 and 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 p16 – please name the first-line medicine. B. First-line regimen, adult: All providers who responded to p16 (starting the series on first- line knowledge). C. ACT most effective, adult and child: All providers who responded to p10/11, including providers who responded with “don’t know,” who provided names of non-antimalarial

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medicines, and who responded with more than one antimalarial medicine not intended to be used as combination therapy. D. ACT most often recommended, adult and child: All providers who responded to p12/13, 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 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 60-kg 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 issued. The artemisinin derivative is used as the principal ingredient for ACT AETD calculations.

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

 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 64 amount of each active ingredient found in the package. The number of AETDs in a unit was calculated. 45F The number of AETDs in a monotherapy is calculated by dividing the total amount of active ingredient contained in the unit by the AETD (i.e. the total number of mg required to treat a 60-kg 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.

64 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. www.ACTwatch.info Page 154

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 WHO Use of Antimalarials, 2001 Artemether 960mg Note: this includes a recommended loading dose of 4mg/kg on the first day followed by a six-day course of 2mg/kg once daily. Artemether-Lumefantrine 480mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artemether] Artemisinin-Naphthoquine 2400mg WHO Use of Antimalarials, 2001 [Artemisinin] Thanh NX, Trung TN, Phong NC, et al. 2012. The efficacy and tolerability of Artemisinin-Piperaquine artemisinin-piperaquine (Artequick®) versus artesunate-amodiaquine 504mg [Artemisinin] (Coarsucam™) for the treatment of uncomplicated Plasmodium falciparum malaria in south-central Vietnam. Malaria Journal, 11:217. WHO Use of Antimalarials, 2001 Artesunate 960mg Note: this includes a recommended loading dose of 4mg/kg on the first day followed by a six-day course of 2mg/kg once daily. Artesunate-Amodiaquine 600mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artesunate] Artesunate-Mefloquine 600mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artesunate] Artesunate- Sulfadoxine- Pyrimethamine 600mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Artesunate] Atovaquone-Proguanil 3000mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 [Atovaquone] Chloroquine 1500mg WHO Guidelines for the treatment of malaria 3rd edition, 2015 WHO Guidelines for the treatment of malaria 3rd edition, 2015 Dihydroartemisinin- Note: the AETD under the new 2015 guidelines is now 480mg whereas Piperaquine 360mg 360mg was indicated in previous guidelines. Product availability for adult [Dihydroartemisinin] pre-packaged DHA PPQ in 2015 was still most commonly 360mg administered over a 3-day course of a total of 9 tablets (40/320). Dihydroartemisinin- Manufacturer Guidelines Piperaquine-Trimethoprim 256mg (Artecxin – Medicare Pharma; Artecom – Ctonghe) [Dihydroartemisinin] Dihydroartemisinin- Manufacturer Guidelines Sulfadoxine-Pyrimethamine 360mg (Dalasin – Adams Pharma) [Dihydroartemisinin] Manufacturer Guidelines Hydroxychloroquine 2000mg (Plaquenil – Sanofi Aventis) Mefloquine 1000mg WHO Model Formulary, 2008 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, 2016 Public Community Private Not TOTAL Private ANTI- General Itinerant TOTAL AETDs sold or distributed in the Health Health For-Profit Public / Not- For-Profit Pharmacy Drug Store MALARIAL Retailer Drug Vendor Private previous week by outlet type and Facility Worker Facility For-Profit Facility TOTAL antimalarial type:* # AETD # AETD # AETD # AETD # AETD # AETD # AETD # AETD # AETD # AETD # AETD (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) (95% CI) 20310.1 1846.9 3302.9 25460.0 5693.6 25782.9 474.4 40304.5 3512.8 75768.2 101228.2 1. Any ACT (13778.3, 26842.0) (732.5, 2961.4) (1072.2, 5533.6) (18197.3, 32722.7) (2236.8, 9150.5) (14285.0, 37280.8) (0.0, 966.3) (20215.3, 60393.7) (2228.9, 4796.6) (56012.3, 95524.1) (81054.1, 121402.3) First-line ACT (artemether 20231.1 1846.9 3248.1 25326.2 5594.8 20690.8 402.8 40041.5 3508.0 70237.9 95564.1 lumefantrine) (13695.6, 26766.7) (732.5, 2961.4) (1047.7, 5448.5) (18080.2, 32572.3) (2128.4, 9061.2) (11471.2, 29910.4) (0.0, 858.2) (20025.0, 60057.9) (2229.1, 4786.9) (51592.6, 88883.1) (75860.2, 115267.9)

79.0 0.0 0.0 79.0 61.1 291.1 0.0 262.3 4.8 619.3 698.3 Artesunate amodiaquine (0.0, 188.6) - - (0.0, 188.6) - (0.0, 600.8) - (93.0, 431.7) - (340.2, 898.3) (419.1, 977.5)

0.0 0.0 54.8 54.8 16.2 1565.7 32.0 0.0 0.0 1613.9 1668.8 Artesunate SP - - - - (0.0, 81.4) (800.1, 2331.4) - - - (841.1, 2386.8) (885.0, 2452.5)

0.0 0.0 0.0 0.0 21.5 2553.6 39.6 0.0 0.0 2614.7 2614.7 Dihydroartemisinin piperaquine - - - - (0.0, 88.0) (1421.2, 3686.0) (0.0, 112.5) - - (1350.1, 3879.4) (1350.1, 3879.4)

0.0 0.0 0.0 0.0 0.0 681.7 0.0 0.7 0.0 682.4 682.4 Other ACT β - - - - - (227.3, 1136.1) - - - (233.3, 1131.5) (233.3, 1131.5)

20310.1 1769.0 2577.1 24656.3 3631.3 3398.6 214.1 32868.9 2768.7 42881.6 67537.9 Quality-assured ACT (QA ACT) (13778.3, 26842.0) (669.2, 2868.9) (307.3, 4847.0) (17277.6, 32035.0) (1143.6, 6119.0) (1747.6, 5049.5) (0.0, 541.2) (17222.1, 48515.7) (1729.2, 3808.2) (27234.9, 58528.3) (48289.6, 86786.2)

187.4 118.5 1562.0 1867.9 2600.8 0.0 78.4 31008.1 2299.4 35986.7 37854.6 QA ACT with the “green leaf” logo - - (0.0, 4149.9) (0.0, 4048.2) (570.9, 4630.7) - (2.2, 154.5) (15458.1, 46558.1) (1397.1, 3201.7) (20238.0, 51735.3) (21950.4, 53758.7) QA ACT without the “green leaf” 20122.7 1650.6 1015.1 22788.4 1030.5 3398.6 135.7 1860.8 469.3 6894.9 29683.4 logo (13600.7, 26644.6) (544.6, 2756.5) (181.6, 1848.7) (15873.8, 29703.1) (0.0, 2225.3) (1747.6, 5049.5) (0.0, 1829.3) (547.5, 3174.1) - (4491.9, 9298.0) (23384.3, 35982.4)

20231.1 1769.0 2577.1 24577.3 3586.6 3222.6 214.1 32606.6 2764.0 42393.8 66971.2 QA artemether lumefantrine (13695.6, 26766.7) (669.2, 2868.9) (307.3, 4847.0) (17191.8, 31962.9) (1088.1, 6085.1) (1728.5, 4716.7) (0.0, 541.2) (17040.6, 48172.5) (1728.0, 3799.9) (26844.3, 57943.3) (47742.8, 86199.5)

0.0 77.9 725.8 803.7 2062.3 22384.3 260.3 7435.6 744.0 32886.6 33690.3 Non-quality assured ACT (non-QA ACT) - - - - (717.9, 3406.7) (12312.4, 32456.3) (0.0, 526.9) (2075.3, 12795.8) (266.9, 1221.1) (21301.6, 44471.5) (21837.5, 45543.1)

20159.3 1705.0 1786.2 23650.5 3426.2 14608.9 251.6 18568.1 1883.7 38738.5 62389.0 Nationally registered ACT (13614.0, 26704.6) (594.2, 2815.8) (754.8, 2817.6) (16704.3, 30596.7) (546.0, 6306.5) (8619.1, 20598.7) (43.2, 460.1) (8002.9, 29133.2) (1018.6, 2748.7) (27359.0, 50118.0) (50300.3, 74477.6)

20946.7 48.2 3638.1 24633.0 7254.8 9042.0 729.2 69606.7 17435.3 104067.9 128700.9 2. Any non-artemisinin therapy (11963.5, 29929.9) - (1027.7, 6248.4) (15590.5, 33675.4) (3516.9, 10992.6) (3461.0, 14623.1) (0.0, 1906.1) (49541.0, 89672.5) (4605.2, 30265.3) (81836.4, 126299.5) (102862.3, 154539.5)

13601.1 0.0 1318.7 14919.8 2036.2 8585.3 338.3 33897.3 12074.6 56931.7 71851.5 Sulfadoxine pyrimethamine (5839.1, 21363.2) - (0.0, 3257.4) (7015.6, 22824.1) (918.7, 3153.7) (3001.6, 14168.9) - (22090.5, 45704.1) (1596.3, 22552.9) (39902.9, 73960.5) (52174.9, 91528.2)

6982.9 37.1 1983.3 9003.3 4020.7 393.8 368.7 7522.9 2622.8 14928.9 23932.2 Oral quinine (4278.2, 9687.6) - (287.3, 3679.3) (6288.1, 11718.5) (1127.9, 6913.5) (237.8, 549.7) (0.0, 783.8) (5240.7, 9805.1) (552.6, 4693.0) (10157.8, 19699.9) (18401.1, 29463.3)

355.8 11.1 224.7 591.6 684.3 33.2 13.7 309.0 0.0 1040.2 1631.8 Quinine IV/IM (219.8, 491.9) - (89.1, 360.3) (381.4, 801.9) (239.2, 1129.4) - (0.0, 60.9) (31.2, 586.7) - (547.1, 1533.2) (1076.8, 2186.8) www.ACTwatch.info Page 156

0.0 0.0 14.1 14.1 49.7 29.8 0.0 188.8 142.8 411.2 425.3 Other non-artemisinin therapy ^ - - - - (9.0, 90.5) - - (71.2, 306.5) (13.1, 272.4) (182.8, 639.5) (199.4, 651.2)

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3. Oral artemisinin monotherapy ------

48.7 0.0 121.0 169.7 411.7 132.0 14.0 79.6 0.0 637.4 807.1 4. Non-oral artemisinin monotherapy - - (0.0, 253.2) (41.1, 298.3) (128.9, 694.6) (58.6, 205.4) - - - (324.6, 950.1) (460.7, 1153.5)

48.2 0.0 120.6 168.8 387.0 71.6 14.0 79.6 0.0 552.3 721.1 Artesunate IV/IM # - - (0.0, 253.2) (44.9, 292.7) (108.2, 665.9) (31.2, 112.0) - - - (257.8, 846.8) (398.1, 1044.1)

0.5 0.0 0.4 0.9 23.2 29.2 0.0 0.0 0.0 52.3 53.3 Artemether IV/IM - - - - (0.0, 299.0) (9.4, 49.0) - - - (0.0, 114.5) (0.0, 113.8)

404.5 11.1 345.7 761.4 1094.5 155.6 27.8 388.6 0.0 1666.5 2427.8 Any severe malaria treatment (263.7, 545.3) - (124.4, 567.1) (488.4, 1034.3) (550.2, 1638.8) (82.7, 228.6) - (77.2, 700.0) - (1084.5, 2248.5) (1793.5, 3062.2)

41305.5 1895.1 7062.0 50262.7 13360.1 34956.9 1217.6 109990.9 20948.0 180473.5 230736.2 OUTLET TYPE TOTAL (27450.1, 55161.0) (805.5, 2984.8) (3152.3, 10971.8) (35937.7, 64587.7) (7693.0, 19027.3) (21074.1, 48839.6) (0.0, 2711.4) (72957.5, 147024.2) (7371.9, 34524.1) (143865.7, 217081.3) (190567.2, 270905.1) * A total of 25,427.4 AETDs were reportedly sold or distributed in the previous 7 days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. β Other types of ACT include artemisinin naphthoquine, artemisinin piperaquine, artesunate mefloquine, dihydroartemisinin piperaquine trimethoprim, and dihydroartemisinin SP. ^ Other non-artemisinin therapies include amodiaquine, atovaquone proguanil, chloroquine, hydroxychloroquine sulphate, and mefloquine. # At the time of the 2016 Benin ACTwatch outlet survey, artesunate IV/IM was the first-line treatment for severe malaria. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 10,577 antimalarials (in the census sample) were audited. Of these, 1,449 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information. Source: ACTwatch Outlet Survey, Benin, 2016.

A9n