actwatch_uganda_os_ 2011.pdf

www.ACTwatch.info Copyright © 2012 Population Services International (PSI). All rights reserved.

Evidence for Malaria Medicines Policy

Outlet Survey

Republic of Uganda

2011 Survey Report

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Acknowledgements

ACTwatch is funded by the Bill and Melinda Gates Foundation.

This study was implemented by Population Services International (PSI).

ACTwatch’s Advisory Committee:

Mr. SuprotikBasu Advisor to the United Nations (UN) Secretary General's Special Envoy for

Malaria Mr. Rik Bosman Supply Chain Expert, Former Senior Vice President, Unilever

Ms. Renia Coghlan Global Access Associate Director, Medicines for Malaria Venture (MMV)

Dr. Thom Eisele Associate Professor, Tulane University

Mr. Louis Da Gama Malaria Advocacy & Communications Director, Global Health Advocates

Dr. Paul Lalvani Executive Director, RaPIDPharmacovigilance Program

Dr. RamananLaxminarayan Senior Fellow, Resources for the Future

Dr. Matthew Lynch Malaria Program Director, VOICES, Johns Hopkins University Centre for Communication Programs

Dr. Bernard Nahlen Deputy Coordinator, President's Malaria Initiative (PMI)

Dr. Jayesh M. Pandit Head, Pharmacovigilance Department, Pharmacy and Poisons Board-Kenya

Dr. Melanie Renshaw Chief Technical Advisor, ALMA

Mr. Oliver Sabot Vice-President, Vaccines Clinton Foundation

Ms. Rima Shretta Senior Program Associate, Strengthening Pharmaceutical Systems Program, Management Sciences for Health

Dr. Rick Steketee Science Director, Malaria Control and Evaluation Partnership in Africa (MACEPA) Dr. Warren Stevens Health Economist

Dr. Gladys Tetteh Deputy Director Country Programs, Systems for Improved Access to Pharmaceuticals and Services, Management Sciences for Health Prof. Nick White, OBE Professor of Tropical Medicine, Mahidol and Oxford Universities

Prof. Prashant Yadav Professor of Supply Chain Management, MIT-Zaragoza International Logistics Program Dr. Shunmay Yeung Paediatrician & Senior Lecturer, London School of Hygiene and Tropical Medicine(LSHTM)

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The following individuals contributed as follows to the research study in Uganda: Peter Buyungo ACTwatch Country Program Coordinator, PACE/PSI-Uganda, was

responsible for all aspects of implementation and management of the survey, including oversight of training, data collection, and data entry.

Henry Kaula

ACTwatch Assistant, PACE/PSI-Uganda, assisted the Country Program Coordinator and Consultant with the coordination and facilitation of trainings, data collection, and data entry.

Elizabeth Nansubuga Consultant; led the coordination of training, data collection and data entry.

Susan Kambabazi Research Manager, PACE/PSI-Uganda, assisted in training fieldworkers and supervised data collection.

Andrew Kironde Finance Director, PACE/PSI-Uganda, was responsible for overall budget tracking for all project activities.

Dr Susan Mukasa Mpanga

Executive Director, PACE/PSI-Uganda, was responsible for the overall coordination of the study in-country.

Dr Dennis Rubahika Senior Officer, NMCP, Ministry of Health, was the focal point person responsible for overall coordination of partners within the MOH.

Dr George Mukone Senior Medical Officer, NMCP, MOH, assisted with advocacy of the project.

Julius Ngigi Research Associate, ACTwatch Central, assisted with the field preparations, and trained field workers and conducted the analysis.

Dr. Kathryn O’Connell

Principal Investigator, ACTwatch Central, provided overall technical guidance.

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

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The ACTwatchGroup is comprised of the following individuals: PSI ACTwatch Central Tanya Shewchuk, Project Director; Dr. Kathryn O’Connell, Principal

Investigator; Hellen Gatakaa, Senior Research Associate; Stephen Poyer, Illah Evance, Julius Ngigi, Research Associates; Meghan Bruce, Policy Advocacy and Communications; Linda K.Ongwenyi, ACTwatch Project Assistant.

PSI ACTwatch Country Program Coordinators

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

LSHTM Dr. Kara Hanson, Principal Investigator; Edith Patouillard, Dr. Catherine

Goodman, Benjamin Palafox, Sarah Tougher, Immo Kleinschmidt, co-investigators. LSHTM is responsible for the supply chain research component of ACTwatch.

The Independent Evaluator for the Affordable Medicines Facility-malaria Phase 1 Evaluation is comprised of the following individuals: LSHTM Dr. Kara Hanson, Principal Investigator, Dr. Catherine Goodman, Sarah

Tougher, Dr. Barbara Wiley, Dr. Andrea Mann, co-investigators.

ICF International Dr. Fred Arnold, Director, Dr. Yazoume Ye, Dr. Ruilin Ren, co-investigators.

Suggested citation:

ACTwatch Group, Program for Accessible Health, Communication & Education (PACE) and the Independent Evaluation (IE) Team. (2012) ACTwatch Outlet Survey Report 2011 (Round 4). Endline Outlet Survey Report for the Independent Evaluation of Phase 1 of the Affordable Medicines Facility - malaria (AMFm), Uganda. Kampala, Uganda: ACTwatch/PACE/IE.

ACTwatch Contacts

Uganda Mr. Peter Buyungo Director, Research Department Program for Accessible Health, Communication & Education Uganda Plot 2 Ibis Vale, Kololo P.O. Box 27659, Kampala Phone: +256 312-351100 / +256 414-230080 Email: [email protected]

ACTwatch Central Dr. Kathryn O’Connell

ACTwatch Principal Investigator

Malaria & Child Survival Department

Population Services International

Regional Technical Office

P.O. Box 14355-00800 Nairobi, Kenya

Phone: + 254 20 4440125/6/7/8

Email: [email protected]

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Table of Contents

List of Tables ..............................................................................................................................7

List of Figures ...........................................................................................................................11

Definitions ...............................................................................................................................12

Classification of ACTs ..............................................................................................................15

Classification of treatment for severe malaria ......................................................................20

Classification of RDTs ..............................................................................................................21

List of Abbreviations ...............................................................................................................22

Executive Summary .................................................................................................................24

Overview of ACTwatch ............................................................................................................. 24 Overview of the independent evaluation process ................................................................... 24 Endline outlet survey methods ................................................................................................ 25 Key findings from the outlet survey ......................................................................................... 26 Key findings on AMFm implementation: process and key contextual factors ........................ 34

1. Background ..................................................................................................................36

1.1 Overview of ACTwatch and the AMFm phase 1 ................................................................ 36 1.1.1 ACTwatch Research Project ............................................................................................. 36 1.1.2 AMFm phase 1 ................................................................................................................ 37

1.2Overview of the AMFm Phase 1 Independent Evaluation (IE) ........................................... 38 1.3 Country background – context .......................................................................................... 42

1.3.1 Overview of the country .................................................................................................. 42 1.3.2 Description of health care system ................................................................................... 43 1.3.3Epidemiology of malaria .................................................................................................. 45 1.3.4 Antimalarial Policies and Regulatory Environment ......................................................... 46 1.3.5 Malaria control strategy ................................................................................................. 47 1.3.6 Malaria financing ............................................................................................................ 48

2. Methods .......................................................................................................................50

2.1 Outlet survey ...................................................................................................................... 50 2.1.1 Outlet survey indicators .................................................................................................. 50 2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators ........................................ 52 2.1.3Sampling Approach .......................................................................................................... 54 2.1.4Data collection ................................................................................................................. 57 2.1.5Data processing................................................................................................................ 59 2.1.6 Data analysis ................................................................................................................... 59

3. Results- Outlet survey .................................................................................................62

3.1 Characteristics of the sample ............................................................................................. 62 3.2 Availability of antimalarial drugs ..................................................................................... 102

3.2.1 Antimalarials in stock .................................................................................................... 102 3.2.2 Antimalarials in stock by type ....................................................................................... 103 3.2.3 Stockouts of quality-assured ACTs ................................................................................ 110 3.2.4Population coverage of outlets with quality-assured ACTs ............................................ 111

3.3 Pricing of antimalarials (Affordability) ............................................................................. 112 3.3.1 Cost to patients of antimalarials ................................................................................... 112 3.3.2 Gross percentage markup between purchase price and retail selling price .................. 118 3.3.3Availability and cost to patients of diagnostic tests (RDT/microscopy) ......................... 124

3.4 Quality-assured ACTs market share ................................................................................. 129

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3.5 Provider knowledge of first-line antimalarial treatment and ACT regimen .................... 132 3.6 AMFm logo ....................................................................................................................... 136

4. AMFm implementation: process and key contextual factors .................................145

4.1 Introduction ..................................................................................................................... 145 4.2 Methods ........................................................................................................................... 145 4.3 Findings ............................................................................................................................ 145

4.3.1Description of the AMFm implementation process ........................................................ 145 4.3.2 Implementation of AMFm supporting interventions ..................................................... 151 4.3.3 Key events and context ................................................................................................. 154 4.3.4Conclusion ...................................................................................................................... 154

5. Summary of findings .................................................................................................157

5.1 Quality of data collected .................................................................................................. 157 5.2 Availability of quality-assured ACTs ................................................................................. 157 5.3 Pricing/affordability of quality-assured ACTs .................................................................. 157 5.4 Market share of quality-assured ACTs ............................................................................. 158

6. References .................................................................................................................159

7. Acknowledgements ...................................................................................................162

8. Appendices ................................................................................................................163

8. 1 Questionnaire ................................................................................................................. 163 8.2 ACTs classified as quality-assured .................................................................................... 178 8.3 Final sample ..................................................................................................................... 187 8.4 Survey team ..................................................................................................................... 204 8.5 Description of outlet types visited for this survey ........................................................... 206 8.6 Sampling weights ............................................................................................................. 208 8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs) ....................... 209 8.8 Nationally Registered ACTs .............................................................................................. 218 8.9 Child QAACTs ................................................................................................................... 221 8.10 RDT manufacturers submitting to WHO for product testing ......................................... 222

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List of Tables

IE Tables

Table 2.1. 1: Primary AMFm indicators ................................................................................................. 50

Table 2.1. 2: Primary ACTwatch indicators ........................................................................................... 51

Table 3.1.1: Outlets enumerated by location, drugs stocked and final interview status Uganda, 2011 ...................................................................................................................................................... 96

Table 3.1.2: Outlets enumerated* [Uganda], 2011 .............................................................................. 97

Table 3.1.3: Outlets with antimalarials in stock* [Uganda], 2011** ................................................... 98

Table 3.1.4: Number of products audited [Uganda], 2011 ................................................................... 99

Table 3.1.5: Outlets with at least one staff member who completed secondary school or primary school [Uganda] 2011 ................................................................................................................. 100

Table 3.1.6: Outlets with a staff member with a health-related qualification [Uganda], 2011 ......... 101

Table 3.2.1: Outlets with antimalarials in stock in [Uganda], 2011 .................................................... 102

Table 3.2.2: Outlets with non-artemisinin therapy in stock [Uganda], 2011 ..................................... 103

Table 3.2.3. a: Outlets with artemisinin monotherapy in stock (all dosage forms) [Uganda], 2011 .. 104

Table 3.2. 3.b: Outlets with oral artemisinin monotherapy in stock [Uganda], 2011 ........................ 105

Table 3.2.4: Outlets with non-quality-assured ACTs in stock [Uganda], 2011 ................................... 106

Table 3.2.5.a: Outlets with quality-assured ACTs in stock [Uganda], 2011 ........................................ 107

Table 3.2.5.b: Outlets with quality-assured ACTs with and without the AMFm logo in stock [Uganda], 2011 ............................................................................................................................................ 108

Table 3.2.5.c: Public health facility outlets with quality-assured ACTs among ALL public health facilities in [Uganda], 2011 ......................................................................................................... 109

Table 3.2.6: Outlets with stock-outs of quality-assured ACTs [Uganda], 2011 .................................. 110

Table 3.2.7: Percentage of the population living in censused “sub-counties” with outlets with quality-assured ACTs in stock at the time of survey [Uganda], 2011 ..................................................... 111

Table 3.3.1: Cost to patients of non-artemisinin therapy, in US dollars, [Uganda], 2011 .................. 112

Table 3.3.2: Cost to patients of artemisinin monotherapy, in US dollars, [Uganda], 2011 ................ 113

Table 3.3.3: Cost to patients of non-quality-assured ACTs, in US dollars, [Uganda], 2011 ................ 114

Table 3.3.4: Cost to patients of quality-assured ACTs, in US dollars, [Uganda], 2011 ....................... 114

Table 3.3. 5.d: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for TABLETS, in US dollars [Uganda], 2011 ............................ 117

Table 3.3.6: Gross percentage markup between purchase price and retail selling price of non-artemisinin therapy [Uganda], 2011 .......................................................................................... 118

Table 3.3.7: Gross percentage markup between purchase price and retail selling price of artemisinin monotherapy [Uganda], 2011 .................................................................................................... 119

Table 3.3. 8: Gross percentage markup between purchase price and retail selling price of non-quality-assured ACTs [Uganda], 2011 ........................................................................................ 120

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Table 3.3.9. a: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs [Uganda], 2011 ..................................................................................................... 121

Table 3.3.10: Median total gross markup between first-line buyer price and retail selling price of quality-assured ACTs bearing the AMFm logo, in US dollars, [Uganda], 2011 .......................... 123

Table 3.3.11: Availability of any diagnostic test for malaria, Uganda, 2011....................................... 124

Table 3.3.12: Availability of malaria microscopy, Uganda, 2011 ........................................................ 125

Table 3.3.13: Cost to patients of malaria microscopy in 2010 US dollars Uganda, 2011 ................... 126

Table 3.3.14: Availability of rapid diagnostic tests for malaria, Uganda, 2011 .................................. 127

Table 3.3.15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in 2010 US dollars Uganda, 2011 ............................................................................................................................................ 128

Table 3.4.1:Percentage breakdown of antimalarial sales volumes by antimalarial type, Uganda, 2011 .................................................................................................................................................... 129

Table 3.4.2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, [Uganda], 2011 ...................................................... 130

Table 3.4.3: Percentage breakdown of antimalarial sales volumes by outlet type, [Uganda], 2011 . 131

Table 3.5.1: Provider knowledge of first-line antimalarial treatment, [Uganda], 2011 ..................... 132

Table 3.5.2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult. [Uganda], 2011 ........................................................................................................................... 133

Table 3.5.3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child, [Uganda], 2011 ........................................................................................................................... 134

Table 3.5.4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Uganda], 2011 ............................................................................................................................................ 135

Table 3.6.1: Provider recognition of AMFm logo, [Uganda], 2011 ..................................................... 136

Table 3.6.2: Provider knowledge of the AMFm logo [Uganda], 2011 ................................................ 137

Table 3.6.3: Sources from which providers have seen or heard of the AMFm logo, [Uganda], 2011 138

Table 3.6.4: Percentage of antimalarials bearing the AMFm logo, [Uganda], 2011 ........................... 139

Table 3.6.5: Provider knowledge of the AMFm programme, [Uganda], 2011 ................................... 140

Table 3.6.6: Sources from which providers have seen or heard of AMFm [Uganda], 2011 ............... 141

Table 3.6.7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Uganda], 2011 ................................................................... 142

Table 3.6.8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Uganda], 2011 ......................................................................................... 143

Table 3.6.9: Providers who have received training on antimalarials with the AMFm logo, [Uganda], 2011 ............................................................................................................................................ 144

Table 4.3.1: Recommended retail prices for AMFm co-paid ACTs in 2010 US dollars ....................... 152

Table 4.3.2: Summary of key factors likely to have supported or hindered achievement of AMFm goals in Uganda) ......................................................................................................................... 155

Table 8.2. 1: List of Quality-Assured ACTs for availability, price and market share indicators .......... 179

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Table 8.3.1: List of clusters/sub-districts sampled and their population, Uganda, 2011 ................... 187

Table 8.4. 1: List of staff members involved in the survey, [Uganda], 2011....................................... 204

Table 8.5. 1: Description of outlet types visited for this survey, Uganda, 2011 ................................. 206

Table 8.7. 1: AETD Calculation details by antimalarial type ............................................................... 211

Table 8.8. 1: Nationally Registered ACTs ............................................................................................ 218

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ACTwatch Tables

Table A.1: Availability of antimalarials, by outlet type ......................................................................... 64

Table A.2: Availability of antimalarials, by public health facility outlet type ........................................ 66

Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type ............................................................................................................................................... 67

Table A. 4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type .......... 69

Table A. 5: Price of antimalarials, by outlet type .................................................................................. 70

Table A. 6: Affordability of antimalarials, by outlet type ...................................................................... 72

Table A. 7: Availability of diagnostic tests patients, by outlet type ...................................................... 73

Table A 8: Price of diagnostic tests patients, by outlet type................................................................. 75

Table A.9: Availability of diagnostic tests, by public health facility outlet type ................................... 76

Table A.10: Market share, by outlet type ............................................................................................. 77

Table A.11: Provider knowledge, by outlet type .................................................................................. 79

Table A.12: Provider perceptions, by outlet type ................................................................................. 80

Table A.13: Provider knowledge, by outlet type .................................................................................. 81

Table A.14: Availability of antimalarials, by Endemicity ....................................................................... 82

Table A.15: Availability of antimalarials among outlets stocking at least one antimalarial, by endemicity .................................................................................................................................... 84

Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by Low endemicity . 86

Table A.17: Price of antimalarials, by Low endemicity ......................................................................... 87

Table A.18: Affordability of antimalarials, by Low endemicity ............................................................. 88

Table A.19: Availability of diagnostic tests, by Low endemicity ........................................................... 89

Table A.20: Price of diagnostic tests, by Low endemicity ..................................................................... 90

Table A.21: Market share, by Low endemicity ..................................................................................... 91

Table A.22: Provider knowledge, by endemicity .................................................................................. 92

Table A.23: Provider perceptions, by endemicity ................................................................................. 93

Table B.1: Market share by antimalarial category within each outlet type ......................................... 94

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List of Figures Figure 1. Availability of antimalarials among all outlets, by outlet type .............................................. 27

Figure 2. Outlet types stocking antimalarials ....................................................................................... 28

Figure 3. Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type ...................................................................................................................................................... 29

Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests .. 30

Figure 5. Median price of antimalarial treatment per AETD in the private sector, by outlet type ...... 31

Figure 6. Market share of AETDs sold/distributed in the past week (7 days) within outlet types ....... 32

Figure 7. Relative Market share of AETDs sold/distributed in the past week (7 days) across outlet types ............................................................................................................................................. 33

Figure 8. Provider knowledge of recommended first-line treatment and dosing regimens ................ 34

Figure 1.2. 1. AMFm Phase 1 Results Framework ................................................................................. 39

Figure 1.2. 2: The Independent Evaluation Impact model ................................................................... 40

Figure 1.2. 3: The Independent Evaluation Design ............................................................................... 40

Figure 1.3. 1: Location of Uganda ......................................................................................................... 43

Figure 1.3. 2: National Health Facility Availability Standards, 2009 Situation ...................................... 43

Figure 1.3. 3: Distribution of functional health units by health facility level and ownership ............... 45

Figure 1.3. 4: Comparison of national malaria control indicators, 2006 and 2009 .............................. 47

Figure 3.1. 1: Survey flow diagram, [Uganda], 2011 ............................................................................. 62

Figure 4.3. 1:Timeline of key events related to AMFm implementation process and context Uganda .................................................................................................................................................... 156

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Definitions Term Definition

Adult Equivalent

Treatment Dose

(AETD)

An AETD is the number of milligrams (mg) of an antimalarial drug needed to treat a

60 kg adult.

Antimalarial Any medicine recognized by the WHO for the treatment of malaria. Medicines used

solely for the prevention of malaria were excluded from analysis of key indicators in

this report.

Artemisinin-based

Combination

Therapy (ACT)

An antimalarial that combines artemisinin or one of its derivatives with an

antimalarial or antimalarials of a different class. Refer to Combination Therapy

(below).

Artemisinin

monotherapy

An antimalarial medicine that has a single active compound, where this active

compound is artemisinin or one of its derivatives.

Artemisinin and its

derivatives

Artemisinin is a plant extract used in the treatment of malaria. The most common

derivatives of artemisinin used to treat malaria are artemether, artesunate, and

dihydroartemisinin.

Booster Sample A booster sample is an extra sample of units (in this case, outlets) of a type not

adequately represented in the main survey, but which are of special interest. In this

survey, public health facilities and pharmacies were targeted by a booster sample. All

public health facilities in the county in which a selected sub-county was located were

eligible for inclusion in the booster sample; all pharmacies in the district in which a

selected sub-county was located were eligible for inclusion in the booster sample. A

full description of the booster sample methods is provided in the methods section.

Cluster The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit that hosts a population of approximately 10,000 to 15,000 inhabitants. These units are defined by political boundaries, and in Uganda they were generally defined as sub-counties, except in Kampala where they were defined as parishes.

Censused sub-

county

A sub-county where field teams conducted a full census of all outlets with the potential to sell antimalarials.

Combination

therapy

The use of two or more classes of antimalarial drugs/molecules in the treatment of

malaria that have independent modes of action.

Dosing/treatment

regimen

The posology or timing and number of doses of an antimalarial used to treat malaria.

This schedule often varies by patient weight.

Enumerated

Outlets

Outlets that were visited by a member of one of the field teams, and, at a minimum,

basic descriptive information was collected (sections C1-C9 of the outlet survey

questionnaire).

First-line

treatment

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

Monotherapy An antimalarial medicine that has a single mode of action. This may be a medicine

with a single active compound or a synergistic combination of two compounds with

related mechanisms of action.

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Nationally

registered ACTs

ACTs registered with a country’s national drug regulatory authority and permitted for

sale or distribution in-country. Each country determines its own criteria for placing a

drug on its nationally registered listing.

Non-artemisinin

therapy

An antimalarial medicine that does not contain artemisinin or any of its derivatives.

Outlet Any point of sale or provision of a commodity to an individual. Outlets are not

restricted to stationary points of sale and may include mobile units or individuals.

Refer to Appendix 8.5 for a description of the outlet types visited for this survey.

Oral artemisinin

monotherapy

Artemisinin or one of its derivatives in a dosage form with an oral route of

administration. These include tablets, suspensions, and syrups and exclude

suppositories and injections.

Quality-assured

Artemisinin-Based

Combination

Therapies

(QAACTs)

QAACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and

Malaria’s Quality Assurance Policy.

For the purpose of the Independent Evaluation, a QAACT is any ACT which appeared

on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality

assurance policy prior to baseline or endline data collection (see

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General),

or which previously had C-status in an earlier Global Fund quality assurance policy

and was used in a program supplying subsidized ACTs.

At endline, QAACTs were defined as any ACT which appeared on the Global Fund’s

indicative list of antimalarials meeting its quality assurance policy as at September

2011, or which previously had C-status in an earlier Global Fund quality assurance

policy and was used in a program supplying subsidized ACTs.

Rapid Diagnostic

Test (RDT) for

malaria

Malaria rapid diagnostic tests, sometimes called "dipsticks" or malaria rapid

diagnostic devices, assist in the diagnosis of malaria by providing evidence of the

presence of malaria parasites in human blood. RDTs do not require laboratory

equipment, and can be performed and interpreted by non-clinical staff.

Screened An outlet that was administered the screening questions (S1 to S4) of the outlet

survey questionnaire (see Screening criteria).

Screening criteria The set of requirements that must be satisfied before the full questionnaire is

administered.

In this survey, an outlet met the screening criteria if (1) they had antimalarials in

stock at the time of the survey visit, or (2) they report having stocked them in the

past three months.

Second-line

treatment

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

Sub-district (SD) The primary sampling unit, or cluster, for the outlet survey. It is an administrative

http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General

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unit determined by the Ministry of Health (MOH) that host a population size of

approximately 10,000 to 15,000 inhabitants. These units frequently are defined by

geographical, health, or political boundaries, and are based around wards.

In Uganda, they were defined as sub-counties or parishes in Uganda.

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Classification of ACTs Term Definition

Quality-assured ACTs

[QAACTs]:

For the purpose of the Independent Evaluation, a QAACT is any ACT which

appeared on the Global Fund's Indicative List of antimalarials meeting the

Global Fund's quality assurance policy as at September 20111, or which

previously had C-status in an earlier Global Fund quality assurance policy

and was used in a programme supplying subsidised ACTs.

In Uganda, the following quality-assured ACTs were found in outlets:

ARTEFAN 20/120 15-24KG


ARTEFAN 20/120 35+ KG ADULTS


ARTEMETHER + LUMEFANTRINE 3-8 YEARS


ARTEMETHER + LUMEFANTRINE <3 YEARS

ARTEMETHER + LUMEFANTRINE >14 YEARS

CO-FALCINUM 25-34KG

CO-FALCINUM 35KG AND ADULTS

COARSUCAM ADULT +14 YEARS

COARSUCAM CHILD 6-13 YEARS

COARSUCAM TODDLER 1-5 YEARS

COARTEM 20/120

COARTEM 20/120 25-35 KG

COARTEM DISPERSIBLE 15-25KG


FALCIMON KIT ADULTS

LARIMAL ADULT 14+ YEARS

LARIMAL CHILD 1-6 YEARS

LUMARTEM 15 TO <25KG


LUMARTEM 35KG AND ABOVE

LUMARTEM 5KG TO <15KG

WINTHROP ADULT +14 YEARS

WINTHROP CHILD 6-13 YEARS

WINTHROP INFANT 2-11 MONTHS

WINTHROP TODDLER 1-5 YEARS

1http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General

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First-line, quality-

assured ACTs

[FAACTs]:

Government recommended first-line ACTs (any ALregardless of strength)

for uncomplicated malaria meeting the quality-assured definition. A

complete listing of these antimalarials is provided in the appendices. In

Uganda, the following first-line quality-assured ACTs were found in

outlets:









CO-FALCINUM 25-34KG

CO-FALCINUM 35KG AND ADULTS

COARTEM 20/120

COARTEM 20/120 25-35 KG







Non-first-line, quality-

assured ACTs

[NAACTs]:

ACTs that are not the government’s recommended first-line treatment for

uncomplicated malaria, but which do meet the quality-assured definition.

A complete listing of these antimalarials is provided in the appendices. In

Uganda, the following non-first-line quality-assured ACTs were found in

outlets:


COARSUCAM CHILD 6-13 YEARS

COARSUCAM TODDLER 1-5 YEARS

FALCIMON KIT ADULTS

LARIMAL ADULT 14+ YEARS

LARIMAL CHILD 1-6 YEARS





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Non-quality-assured

ACTs:

ACTs that do not meet with the definition of being quality-assured.

In Uganda, the following non-quality-assured ACTs were found in outlets:

AMATEM

AMONATE FDC ADULT

ARCO

ARTEFAN 40/240

ARTEQUIN 300/375

ARTEQUIN 600/1500

ARTEQUIN 600/750

ARTEQUIN PAEDIATRIC

ARTERAQUIN

ARTRIN

CACH-ART 20/120

CO-ARTESIANE PEDIATRIC

CO-ARTESUN 50/153

CO-MALARTEM

CO-METHER

DARTE-Q

DUACT ADULTS OVER 13YRS

DUO-COTECXIN

DUO-COTECXIN ADULTS CHILDREN >6YRS OLD

DUO-COTECXIN CHILDREN 5-20KG

FANTEM 20/120

FANTEM 20/120 15-24KG

FANTEM 20/120 25-34KG

FANTEM 20/120 35KG AND ABOVE

FANTEM 20/120 5-14KG

LARITEM 20/120

LONART

LONART FORTE

LONART PAEDIATRIC

LONART-DS

LUMAREN

LUMETHER

LUMERAX

LUMITER

P-ALAXIN

P-ALAXIN PAEDIATRIC

RIDMAL 40/320

ZYSUNATE PLUS

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Other ACT Classifications

Child QAACTs QAACTs in a combination of strength and pack size targeted at

children.

A complete listing of these antimalarials is provided in the appendices.

In Uganda, the following child QAACTs were found in outlets:

ARTEFAN 20/120 15-24KG (AJANTA PHARMA LTD)

ARTEFAN 20/120 5-14KG (AJANTA PHARMA LTD)

ARTEMETHER + LUMEFANTRINE 3-8 YEARS (CIPLA PHARMA LTD/IPCA LABORATORIES LTD)

ARTEMETHER + LUMEFANTRINE <3 YEARS (CIPLA PHARMA LTD/IPCA LABORATORIES LTD)

COARSUCAM TODDLER 1-5 YEARS (SANOFI AVENTIS)

COARTEM DISPERSIBLE 15-25KG (NOVARTIS PHARMA AG)

COARTEM DISPERSIBLE 5-15KG (NOVARTIS PHARMA AG)

LARIMAL CHILD 1-6 YEARS (IPCA LABORATORIES LTD)

LUMARTEM 15 TO <25KG (CIPLA PHARMA LTD)

LUMARTEM 5KG TO <15KG (CIPLA PHARMA LTD)

WINTHROP INFANT 2-11 MONTHS (SANOFI AVENTIS)

WINTHROP TODDLER 1-5 YEARS (SANOFI AVENTIS/MAPHAR)

Nationally registered

ACTs:

ACTs registered with a country’s national drug regulatory authority and

permitted for sale or distribution incountry. Each country determines its

own criteria for placing a drug on its nationally registered listing. A full list

of nationally registered antimalarials can be found in the appendices. In

Uganda, the following nationally registered drugs were found in outlets:

ARCO





ARTEFAN 40/240





ARTEQUIN 300/375

ARTEQUIN 600/750

ARTEQUIN PAEDIATRIC

ARTERAQUIN

ARTRIN

CACH-ART 20/120

CO-ARTESIANE PEDIATRIC

CO-METHER


COARTEM 20/120

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COARTEM 20/120 25-35 KG



DUO-COTECXIN

DUO-COTECXIN ADULTS CHILDREN >6YRS OLD

DUO-COTECXIN CHILDREN 5-20KG

FALCIMON KIT ADULTS

LARITEM 20/120

LONART

LONART FORTE

LONART PAEDIATRIC

LONART-DS

LUMAREN





LUMETHER

LUMITER

P-ALAXIN

P-ALAXIN PAEDIATRIC

RIDMAL 40/320





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Classification of treatment for severe malaria

Term Definition

Any treatment for

severe malaria

WHO recommends parenteral artesunate as first-line treatment in the

management of severe falciparum malaria in African children, with artemether

or quinine injections as acceptable alternatives if parenteral artesunate is not

available2.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.In Uganda, the following

treatments for severe malaria were in outlets:

ARFAM INJECTION 80

ARTEETHER

ARTEMEDINE

ARTEMETHER

ARTEMETHER RTITAS

ARTENAM

ARTENAM PEDIATRIC

ARTEPHARM

ARTESIANE 100

ARTESIANE 20 PAEDIATRIC

ARTESIANE 40

ARTESIANE 80

ARTESUN 60MG

BETAMOTIL

EMAL

G-SUNATE 200

G-SUNATE 50

KWINIL

LAQUINE

LARITHER

LOGOQUIN

MOSQIN

PLASMOTRIM-200

PLASMOTRIM-50

QUINAS

QUINAX DIHYDROCHLORIDE

QUININE

QUININE DICHLORHYDRATE 80 600MG/2ML and DIHYDROCHLORIDE

ROGOQUIN

ROMETHER 80MG/1ML

STERILE QUININE DHYDROCHLORIDE CONCENTRATION

2Guidelines for the treatment of malaria, 2nd edition – revision 1.WHO. Geneva: 2010.

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Classification of RDTs Term Definition

RDTs from a

manufacturer that has

submitted a product to

WHO Malaria RDT

Product Testing

Rounds 1-3

RDTs from a manufacturer that has submitted at least one product for

testing during rounds 1-3 of the WHO Malaria RDT Product Testing cycle

(2008-2011)3. A complete listing of these manufacturers is provided in the

appendices.

In Uganda, products from the following submitting manufacturers were

found in outlets:

FIRST RESPONSE MALARIA ANTIGEN P.f

MALARIA AG P.F SD RAPID TEST

MALARIA ANTIGEN P.F SD RAPID TEST FOR VITRO DIAGNOSTIC

MALERISCAN MALARIA PF ANTIGENTEST

ONE STEP MALARIA P.F TEST

SD BIOLINE MALARIA Ag Pf

SD BIOLINE MALARIA Ag Pf/Pan

WONDFO MALARIA P.F ONE STEP MALARIA P.F

RDTs from a

manufacturer that has

not submitted a

product to WHO

Malaria RDT Product

Testing Rounds 1-3

RDTs from a manufacturer that has not submitted a product for testing

during rounds 1-3 of the WHO Malaria RDT Product Testing (2008-2011).

In Uganda, products from the following non-submitting manufacturers

were found in outlets:

ASTEL PF CASSETE

MALARIA (PF) WHOLE BLOOD STRIP (CASSETTE)

NOVA TEST(CASSETTE)MALARIA PF

3Malaria rapid diagnostic test performance summary results of WHO malaria RDT product testing: rounds 1-3 (2008-2011). WHO. Geneva: 2011.

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List of Abbreviations -- No data were available

*** Undefined ratio as a non-zero value is being divided by a value of zero

ACT Artemisinin-based Combination Therapy

AETD Adult Equivalent Treatment Dose

AL Artemether-lumefantrine

AMT Artemisinin monotherapy

AMFm Affordable Medicines Facility – malaria

ASAQ Artesunate-amodiaquine

CAPSS Consortium for ACT Private Sector Pilot Subsidy

CCM Country Coordinating Mechanism

CETD

CHAI

Child Equivalent Treatment Dose

Clinton Health Access Initiative

CHW Community Health Worker

CI Confidence Interval

CIA Central Intelligence Agency

CIERPA

Centre International d'Études et de Recherches sur les Populations

Africaines

CMDs Community Medicine Distributors

CRDH Centre de Recherche pour le Développement Humain

CQ Chloroquine

DCs Data Contributors

DfID Department for International Development

DHS Demographic and Health Surveys

DNDi Drugs for Neglected Diseases initiative

FAACT First-line, Quality-assured Artemisinin Combination Therapy

FBO Faith-based organization

FCO Global Fund Focal Coordinating Office

FLB First-line Buyers

GDP Gross domestic product

GoU Government of Uganda

GPS Global Positioning System

HBMF Home-based Management of Fever

ICCM Integrated Community Case Management

IE Independent Evaluation/Evaluator

IEC Information, Education and Communication

IMF International Monetary Fund

IPTp Intermittent Preventive Treatment in pregnancy

IQR Interquartile Range

IRS Indoor Residual Spraying

ITN Insecticide Treated Net

JMS Joint Medical Store

KII Key Informant Interview

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LFA Local Fund Agent

LLIN Long-lasting Insecticidal Net

LRA Lord’s Resistance Army

LSHTM London School of Hygiene and Tropical Medicine

LTR Local Technical Representative

MACIS Malaria and Childhood Illness NGO Secretariat

M&E Monitoring and Evaluation

MICS Multiple Indicator Cluster Survey

MIS Malaria Indicator Survey

MMV Medicines for Malaria Venture

MOH Ministry of Health

n/a Not applicable: Indicates ratios cannot be calculated as the numerator is

zero

NAACT Non-first-Line, Quality-assured Artemisinin-based Combination Therapy

nAT Non-artemisinin Therapy

NDA National Drug Authority

NGO Nongovernmental organization

NMCP National Malaria Control Program

NMS National Medical Stores

nQAACT Non-Quality-assured Artemisinin-based Combination Therapy

OTC Over-the-counter

PACE Program for Accessible Health, Communication & Education

PMI President’s Malaria Initiative

POP Part one Pharmacies

PR Primary Recipient

PSI Population Services International

PPS Probability proportional to size

QAACT Quality-assured Artemisinin-based Combination Therapy

QC Quality Control

QCIL Quality Chemicals Industries Limited

RDT Rapid Diagnostic Test

RRP Recommended Retail Price

SP Sulfadoxine-pyrimethamine

SI Supporting Intervention

SOP Standard Operating Procedures

SSR Sub-sub Recipient

SURE Securing Ugandans’ Rights to Essential Medicines

TA Technical Assistance

UN United Nations

UNICEF United Nations Children’s Fund

USAID US Agency for International Development

USD United States Dollar

VHTs Village Health Teams

WHO World Health Organization

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Executive Summary

Overview of ACTwatch

The ACTwatch Outlet Survey involves quantitative research at the outlet level in ACTwatch countries

(Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo

[DRC]). Other elements of ACTwatch research include Household Surveys, led by Population Services

International (PSI), and Supply Chain Research, led by the London School of Hygiene & Tropical

Medicine (LSHTM). This report presents the results of a cross-sectional survey of outlets conducted

in Uganda between November 8th 2011 and December 12th 2011 and also serves as the endline for

the Affordable Medicines Facility – malaria (AMFm) Phase I Independent Evaluation.

The objective of the outlet survey is to monitor levels and trends in the availability, price and

volumes of antimalarials, and providers’ perceptions and knowledge of antimalarial medicines at

different outlets. Price and availability data on diagnostic testing services are also collected. This

report presents indicators on availability, price, volumes, affordability in outlets and provider

knowledge of antimalarials.

Overview of the independent evaluation process

The independent evaluation (IE) is part of a multi-faceted monitoring and evaluation framework

developed for Phase 1 of the Affordable Medicines Facility – malaria (AMFm). It is intended to assess

whether, and to what extent, AMFm Phase 1 achieves its objectives. The findings of the independent

evaluation will be summarized in a report to be considered by the Global Fund Board at the end of

Phase 1. The four main objectives of AMFm are: (i) to increase Artemisinin-based Combination

Therapy (ACT) affordability, (ii) to increase ACT availability, (iii) to increase ACT use, including among

vulnerable groups, and (iv) to “crowd out” other oral antimalarials by gaining market share.

Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene

and Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently

operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and

Zanzibar), and Uganda). In addition, the Global Fund contracted with Data Contributors (DCs) that

were responsible for in-country fieldwork, data analysis and country reports. These institutions are

Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de

Recherche pour le Développement Humain (CRDH).

The ACTwatch Project (www.actwatch.info), which is part of PSI, was responsible for the work in

Kenya, Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara

Health Institute) and Zanzibar, through funding from both the Bill and Melinda Gates Foundation

and the Global Fund. This work was carried out as part of their existing portfolio and funding stream

provided by the Bill and Melinda Gates Foundation for work in Nigeria, Madagascar, and Uganda.

DNDi subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital,

Kumasi, to undertake the work in Ghana. CRDH subcontracted with the Centre International

d'Etudes et de Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.

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25 | P a g e

The IE is based on a non-experimental design with a pre- and post-test intervention assessment in

which each participating country is treated independently as a case study. In addition to measuring

the changes in key indicators pre- and post-intervention, the evaluation includes an assessment of

the implementation process and a comprehensive documentation of the context, both to inform

assessments about causality and to aid in generalizability to other contexts. The current report is

based on the endline assessment in Uganda, conducted by PSI/ACTwatch. The results of the baseline

survey can be found in the Uganda 2010 outlet survey report (ACTwatch, 2010) and for all pilots in

the Multi-Country Baseline Report (Independent Evaluation Team, 2011). Analysis of changes

between baseline and endline outlet surveys will be presented in the Multi-Country Endline Report

(Independent Evaluation Team, 2012), together with the data that the IE team has compiled from

national household surveys. In addition, country case studies on context/process were conducted

by the IE, and these case studies are summarized in the present report.

Endline outlet survey methods

A cluster sampling approach was used because there were no reliable lists of all outlets stocking

antimalarials. Clusters were sub-counties/parishes, with an average of 10,000 to 15,000 inhabitants.

In Uganda, 44 clusters (urban [18 clusters] and rural [26 clusters]), were selected with probability

proportional to size (PPS)—a sampling technique in which the probability that a particular sub-

district (sub-county/parish in Uganda) is selected is proportional to its population size. The sample

size was powered to detect a change of 20% percentage points in availability of quality-assured ACTs

between baseline and endline in rural and urban areas.

The inclusion criteria for this study were outlets that stocked an antimalarial at the time of survey or

had stocked antimalarials in the previous three months. An outlet is defined as any point of sale or

provision of commodities for individuals. Outlets included in the survey were: 1) public health

facilities (government hospitals, health centres, health posts, and other government health

facilities); 2) private not-for-profit health facilities (mission and NGO health facilities); 3) private for-

profit health facilities; 4) registered pharmacies; 5) unregistered, informal drug stores; 6) groceries,

dukas and general merchandise stores; 6) kiosks; and 7) community medicine distributors (CMDs)

(analogous to community health workers (CHWs) in other countries). Refer to the Appendix 8.5 for

definitions and numbers of each type of outlet included in the analysis.

A structured endline questionnaire was developed, which included questions to measure indicators

for the Independent Evaluation. Fieldworkers recorded the outlets’ basic details and then asked a

screening question about the availability of antimalarials to decide whether to proceed with the full

interview or not. The questionnaire was administered to a senior person at the outlet to collect data

on outlet identification, outlet characteristics, provider knowledge, antimalarials and rapid

diagnostic tests (RDTs) stocked and stock outs of quality-assured ACTs. They recorded information

on “audit sheets” on all antimalarials and RDT products stocked in terms of their price and volume

sold in the past week. Data quality control tools used in the field were based on those implemented

by ACTwatch for the baseline survey. A paper questionnaire was used to collect data.

To ensure a high level of data quality, standardized guidelines were used to clean the data. For the

analysis, the ACTwatch team used a standardized tabulation plan for all ACTwatch tables presented

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26 | P a g e

in this report and analysis “do files” in STATA, which produced all the required ACTwatch indicators.

In addition, the IE team provided a tabulation plan for all IE tables presented in this report, and

analysis “dofiles” in STATA, which produced all the required indicators and automatically generated

the IE tables. All analysis was run using STATA version 11, recording results in a log file.

Key findings from the outlet survey

Data were collected between theNovember 8th 2011 and December 12th 2011. A total of 16,521

outlets were approached. Of these, 314 outlets were not screened for various reasons: 51 providers

refused to be interviewed; 47 outlets were closed down permanently; 120 outlets were not open at

the time of the survey visit; in 63 outlets, providers were not available for interview at the time of

the survey visit; 24 providers were unable to be interviewed for other reasons. Overall, 16,207

outlets agreed to participate in the ACTwatch outlet survey and were screened. Of these, 3,285

outlets met our screening criteria; however, interviews could not be conducted for 58 outlets. Of the

3,227 interviews conducted, 89 reported having stocked antimalarials at any point in the three

months prior to the interview and 3,138 outlets stocked antimalarials at the time of the interview.

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AVAILABILITY OF ANY ANTIMALARIAL: Stocking rates of any antimalarial varied by outlet type. In the public/not-for-profit sector, 99% of public health facilities and 94% of private not-for-profit facilities had at least one antimalarial in stock on the day of interview. Of CHWs, who according to government policy may treat using antimalarials, 11% stocked an antimalarial. There was variation in the private for-profit sector. Over 90% of private for-profit facilities, pharmacies and drug stores stocked antimalarials. This is in contrast to 0.4% of the 11,931 general retailers that were surveyed (Figure 1).

Figure 1. Availability of antimalarials among all outlets, by outlet type

0

20

40

60

80

100

N=692 N=1021 N=43 N=1756 N=848 N=415 N=1213 N=11931 N=14451 N=16207

Public healthfacility

Communityhealthworker

Private not-for-profit

healthfacility

TOTAL Public/ Not-for-

profit

Private for-profit health

facility

Pharmacy Drug store Generalretailer

TOTALPrivate for-

profit

TOTAL Alloutlets

Public / Not-for-profit Sector Private for-profit Sector All outlets

%

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OUTLET TYPES STOCKING ANTIMALARIALS: Figure 2 shows the relative distribution of all outlets that had at least one antimalarial in stock. Drug stores were the most common type of outlet stocking antimalarials, followed by private for-profit health facilities, community health workers, and public health facilities.

Figure 2. Outlet types stocking antimalarials

Public Health Facility

8%

Community Health Worker/Community Medicine Distributor

9%

Private not-for-profit 2%

Private for-profit health facility 23%

Pharmacy 1%

Drug Store 55%

General Retailer (local Market/Duka)

2%

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AVAILABILITY OF DIFFERENT CLASSES OF ANTIMALARIALS: Among facilities that stocked antimalarials on the day of the survey, overall quality-assured ACT (QAACT) availability in 2011 was 67%. In public health facilities that stocked antimalarials, QAACT availability was 92%. QAACT availability was also high among private not-for-profit outlets (80%) but lower among community health workers (CHWs) (55%). In the private for-profit sector, availability was 63%. However, there was considerable variation within the private for-profit sector. QAACT availability was higher in pharmacies (96%) than in private for-profit facilities (77%), general retailers (74%) or drug stores (60%). Availability of QAACTs with the AMFm logo was much higher than that of QAACTs without the logo overall (58% vs. 16%), in both public health facilties (83% vs. 42%) and in the private for-profit sector (61% vs. 8%). Availability of QAACTs with the logo was higher in outlets in urban versus in rural areas (70% vs. 55%). Availability of non-quality-assured ACTs was 28% (data not shown). Non-quality-assured ACTs were more commonly found in urban than in rural outlets in both 2010 and 2011. Availability of oral artemisinin monotherapy (AMT) was negligible in both surveys. Figure 3. Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type

0

20

40

60

80

100

N=678 N=84 N=41 N=803 807 N=399 N=1112 N=18 N=2336 N=3139




health facility


profit


facility


TOTALPrivate for-

profit

TOTAL Alloutlets

Public / Not-for-Profit Sector Private for-profit Sector All outlets

%

Quality Assured ACT (QAACT) QAACTS with AMFm logo Any non-artemisinin therapy

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AVAILABILITY OF DIAGNOSTIC BLOOD TESTING: Of outlets stocking antimalarials in the last three months, 96% of private not-for-profit facilities, 75% of public health facilities and 70% of CHWs reported offering any testing services. There was variation in the private sector: 55% of private for-profit facilities, 31% of pharmacies and 7% of drugs stores stocked tests, while no general retailers had tests available. Figure 4. Proportion of outlets with microscopic blood testing facilities and rapid diagnostic tests

0

20

40

60

80

100

N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=2397


Communityhealth worker

Private not-for-profit health

facility

TOTAL Public /Not-for-profit

Private -for-profit health

facility


TOTAL Privatefor-profit

Public / Not for Profit Sector Private for-profit Sector

%

Any diagnostic test Rapid diagnostic tests Microscopic blood tests

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PRICE OF ANTIMALARIALS: In the public and private not-for-profit sectors and for CHWs, the median price of QAACTs was US Dollar (USD) 0.00, reflecting the policy of free ACT provision.

In the private for-profit sector, the median QAACT price was USD 1.96 in urban and rural areas, and USD 1.96 overall. The median price for QAACTs was much higher than the recommended retail price (RRP), which was USD 0.47. The median price in private for-profit outlets for a QAACT carrying the AMFm logo was USD 1.96 per AETD. This is 3.3 times the median price of the most popular antimalarial thatis not a QAACT, SP, in tablet form (USD 0.59). There was no difference in the private for-profit sector between the median price of QAACTs with and without the AMFm logo overall, although in urban areas the price of QAACTs without the AMFm logo was USD 2.74.

Figure 5. Median price of antimalarial treatment per Adult Equivalent Treatment Dose (AETD) in the private sector, by outlet type

$-

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

Private for-profithealth facility

Pharmacy Drug store General retailer TOTAL Private for-profit

Pri

ce, $

US

Quality Assured ACT (QAACT) QAACTS with AMFm logo

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VOLUMES OF ANTIMALARIALS SOLD/DISTRIBUTED: Overall market share of QAACTs was 57% in 2011, with non-artemisinin therapies (nAT) accounting for 31% of the overall market share. In private not-for-profit outlets, the QAACT market share was 51%. In the private for-profit sector, the QAACT market share was 39%. In public health facilities, QAACT market share was 81%, with nATs accounting for 18% of market share in public health facilities. QAACTs with the AMFm logo accounted for 76% of all QAACTs sold or distributed across all outlets, and 88% of QAACT volumes in private for-profit outlets. Figure 6. Market share of AETDs sold/distributed in the past week (7 days) within outlet types

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Communityhealth worker


health facility

TOTAL Public /Not-for-profit


facility


TOTAL Privatefor-profit

TOTAL Alloutlets

Public/Not-for-profit Sector Private for-profit sector All outlets

Oral AMT Any nAT Non-quality-assured ACT Quality-assured ACT with the AMFm logo Quality-assured ACT

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The private for-profit sector was responsible for 53% of all antimalarials sold or distributed in 2011.

Figure 7. Relative Market share of AETDs sold/distributed in the past week (7 days) across outlet types

0

20

40

60

80

100

Public/Not-for-profitSector

Total Private for-profit

Private for-profithealth facility

Pharmacy Drug store General retailer

Oral artemisinin monotherapy Non-oral artemisinin monotherapy Non-artemisinin therapy

SP in public sector Non-QAACTs QAACTs with logo

QAACTs

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PROVIDER KNOWLEDGE: Overall, 78% of providers were able to correctly state artemether-lumefantrine (AL) as

the recommended first-line treatment for uncomplicated malaria in Uganda. Knowledge was higher among

providers at public/not-for-profit outlets, compared to the private for-profit sector (94% vs. 75% respectively).

Knowledge was lowest among general retailers (25%). There were few differences in providers’ ability to state

the recommended first-line treatment for children or adults.

Figure 8. Provider knowledge of recommended first-line treatment and dosing regimens

Key findings on AMFm implementation: process and key contextual

0

20

40

60

80

100

N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=2397 N=3227




health facility


profit


facility


TOTALPrivate for-

profit

TOTAL Alloutlets

Public / Not-for-profit Sector Private for-profit Sector All outlets

%

Correctly state the recommended first-line treatment for uncomplicated malaria

Correctly state pediatric dosing regimen for a two year old child

Correctly state adult dosing regimen

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factors

AMFm implementation: Fourteen first-line buyers (FLB) were registered with the Global Fund as of

January 31, 2012 (nine private for-profit FLBs, three private not-for-profit FLBs and two FLBs for the

public sector). Four of the private for-profit FLBs had placed orders by the end of 2011. FLBs from

both the private for-profit and private not-for-profit sector placed their first orders in March 2011.

The first deliveries for the private sector arrived in April 2011. Delays receiving orders were reported

in both the private for-profit and private not-for-profit sectors. In the public sector, a number of

factors contributed to delays in the placement of the first order. The first shipment of co-paid ACTs

for the public sector arrived in July 2011, and no stockouts of the adult package size of AL at the

National Medical Stores (NMS) resulting from the delays were reported. However, stock levels of the

adolescent and pediatric package sizes of AL were low by December 2010, and by March 2011 the

NMS was out of stock of these pack sizes. A total of 28,226,700 co-paid QAACT treatments were

delivered between April 2011 and December 2011, amounting to 0.84 treatments per capita (all of

the population of Uganda is considered at risk of malaria), of which 73% were delivered to the public

sector, 25% to the private for-profit sector, and 2% to the private non-for-profit FLBs. The

application of the Global Fund’s demand levers in Uganda resulted in only 57% of treatments

requested by FLBs in the second half of 2011 being approved. Only seven months had elapsed

between the date the first drugs arrived in Uganda and the midpoint of the 2011 outlet survey

fieldwork. Approximately USD 28.6 million was available from the Global Fund for supporting

interventions. The first disbursement of these funds was delayed until November 2011, and none of

this money was spent by the end of 2011. The only supporting interventions that occurred prior to

the end of data collection were the National Launch, a small-scale AMFm pre-disbursement

marketing campaign, and the establishment of recommended retail prices. These activities likely had

limited influence on AMFm outcomes, due to their scale.

Context: ACTs were recently granted over-the-counter status. Trend data (not shown in this report)

show that there was no significant increase in the availability of microscopy between 2010 and 2011

surveys, but availability of RDTs increased significantly in public health facilities (4% to 53%) and in

private not-for-profit outlets (9% to 51%). There was also a substantial depreciation of the Ugandan

shilling against the US dollar between the two outlet surveys.

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1. Background

1.1 Overview of ACTwatch and the AMFm phase 1

1.1.1 ACTwatch Research Project

In 2008, Population Services International (PSI) in partnership with the London School of Hygiene

and Tropical Medicine (LSHTM) launched a five-year multi-country research project called ACTwatch.

The project is designed to provide a comprehensive picture of the antimalarial market to inform the

evolution of national and international antimalarial drug policy. The research is designed to detect

changes in the availability, price and use of antimalarials over time and between sectors, and to

monitor the effects of policy or intervention developments at country level.

ACTwatch addresses both the supply and demand side of the market. The supply side is evaluated by

collecting level and trend data on antimalarials and rapid diagnostic tests (RDTs) in public and private

sector outlets and wholesalers of antimalarial drugs. To evaluate demand, data are collected at the

household level on consumer treatment-seeking behaviour and knowledge. In combination, the

research components thread together the antimalarial market and consumer behaviour. Findings

can help determine where and to what extent interventions may positively impact access to and use

of quality-assured ACTs and RDTs as well as resistance containment efforts.

The project is being conducted in seven malaria-endemic countries: Benin, Cambodia, DRC,

Madagascar, Nigeria, Uganda and Zambia between 2008 and 2012 (Shewchuck et al., 2011).

Countries were selected with the aim of studying a diverse range of markets from which

comparisons and contrasts could be made. The research in Uganda is planned as follows: three

outlet surveys (2008, 2009, 2010 and 2011); supply chain research (2009); and two household

surveys (2009 and 2012).

This report presents the results of a cross-sectional survey of outlets conducted in Uganda between

November 8th 2011 and December 12th 2011. Indicators to address the research questions were

developed in consultation with partners and the ACTwatch Advisory Committee. Indicators were

selected to provide relevant information for policymakers in relation to price, availability, volumes,

mark-ups and treatment seeking behaviour, including type of treatment and source. For the AMFm

baseline and endline evaluation, the ACTwatch questionnaire was adapted to include specific AMFm

indicators. The Independent Evaluator provided technical oversight on the analysis presented in this

report, to ensure that results are aligned as far as possible with the AMFm indicators. The 2011

Uganda Outlet Survey is being employed as part of the endline for the Independent Evaluation of the

AMFm Phase 1, and also represents the endline survey (Round 4) results as part of the ACTwatch

Project.

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1.1.2 AMFm phase 1

The success of malaria control efforts depends on a high level of coverage and use of effective

antimalarials such as artemisinin-based combination therapies (ACTs). Although these antimalarials

have been procured in large amounts by countries, evidence suggests that ACT use still remains far

below target levels. Reasons suggested for the low uptake of ACTs include interruptions in public

sector supply; limited availability outside major urban centers; the high prices of the drugs,

particularly in the private sector; lack of provider adherence to new recommendations; and patient

self-treatment with other more common and cheaper antimalarials (Sabot, Mwita et al. 2009).

Lowering the cost of ACTs to the end user through a subsidy mechanism could be an effective way to

increase their uptake (Arrow 2004).

In response to this issue, the Affordable Medicines Facility – malaria (AMFm) hosted by The Global

Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) was set up. As described by Adeyi

and Atun (Adeyi and Atun 2010), AMFm is a financing mechanism designed to incorporate three

elements: (1) price reductions through negotiations with ACT manufacturers; (2) a buyer subsidy, via

a co-payment at the top of the global supply chain by AMFm on behalf of eligible buyers from the

public, private for-profit and private not-for-profit sectors; and (3) support for interventions to

promote appropriate use of ACTs. Examples of these “supporting interventions” include training

providers and outreach to communities to promote ACT utilization. AMFm is being tested in a first

phase that includes 9 pilots in 8 countries: Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria,

Tanzania (mainland and Zanzibar) and Uganda.

It is expected that in the last quarter of 2012, the Global Fund Board will make a decision regarding

the future of the AMFm on the basis of evidence gathered during Phase 1 regarding progress toward

achieving its four stated objectives: (i) increased ACT affordability, (ii) increased ACT availability, (iii)

increased ACT use, including among vulnerable groups, and (iv) “crowding out” oral artemisinin

monotherapies (AMT), chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) by gaining market

share. The AMFm Phase 1 Independent Evaluation has been commissioned to address the need for

evidence to base the Global Fund Board decision.

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1.2 Overview of the AMFm Phase 1 Independent Evaluation (IE)

Through a competitive bid, the Global Fund contracted ICF Macro and the London School of Hygiene

and Tropical Medicine (LSHTM) to conduct the IE. The IE was carried out in all of the currently

operational Phase 1 pilots (Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and

Zanzibar), and Uganda)4. In addition, the Global Fund contracted Data Contributors (DCs) to be

responsible for in-country fieldwork, data analysis and country reports. These institutions are

Population Services International (PSI), Drugs for Neglected Diseases initiative (DNDi), and Centre de

Recherche pour le Développement Humain (CRDH). PSI was responsible for the work in Kenya,

Madagascar, Nigeria, Uganda, Tanzania mainland (which was subcontracted to the Ifakara Health

Institute) and Zanzibar. PSI's ACTwatch Project (www.actwatch.info) has contributed evidence for

the baseline work in Nigeria and Madagascar, which was conducted prior to the IE surveys. DNDi

subcontracted with the Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi,

to undertake the work in Ghana. CRDH subcontracted with the Centre International d'Etudes et de

Recherches sur les Populations Africaines (CIERPA) to undertake the work in Niger.

The purpose of the IE is to assess how AMFm has evolved in each pilot, and estimate changes

between the baseline and endline surveys in the values of key measures (availability, price, market

share and use of quality-assured ACTs) to inform decisions regarding the future of AMFm beyond

Phase 1. The IE is based on the AMFm (Phase 1) Monitoring and Evaluation (M&E) Results

Framework, with a focus on Outputs and Outcomes (Figure 1.2.1).

4In March 2011 the AMFm Ad Hoc Committee decided to removeCambodia from the evaluation due to the lack of an eligible ACT for subsidy.

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Figure 1.2. 1. AMFm Phase 1 Results Framework

ACTs: Artemisinin-based combination therapies; IEC: Information Education and Communication; GF: Global Fund, AMTs:

Antimalarial Treatment; SP: Sulfadoxine-pyrimethamine, CQ: Chloroquine; TA: Technical Assistance, SIVs: Supporting

Interventions

Source: Global Fund, AMFm Phase 1 Monitoring and Evaluation Framework, 2009

The IE is therefore designed to answer four questions related to the availability, affordability, market

share and use of ACTs. These questions are formulated as follows:

1. Has the AMFm mechanism helped increase the availability of quality-assured ACTs to

patients across public, private for-profit and not-for-profit sectors, in rural/urban areas?

2. Has the AMFm mechanism helped to reduce the cost of quality-assured ACTs to patients at

public, private for-profit and not-for-profit outlets in rural/urban areas to a price comparable

to the price of most popular antimalarials?

3. Has the AMFm mechanism helped increase use of quality-assured ACTs, including among

vulnerable groups, such as poor people, rural residents and children?

4. Has the AMFm mechanism helped increase the market share of quality-assured ACTs

relative to all antimalarial treatments in the public, private for-profit and not-for-profit

sectors in rural/urban areas?

To answer these questions, building on the AMFm results framework, the IE impact model (Figure

1.2.2) foresees that subsidizing ACTs, accompanied by effective supporting interventions, will lead to

a decrease in the ACT price. It is therefore anticipated in the model that if ACT price decreases, more

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outlets will be willing to stock the product and thereby increase availability. The increase in

availability and the substantial decrease in price will potentially lead to an increase in use.

While an evaluation based on a quasi-experimental design would have provided stronger evidence

to attribute any change in primary outcomes to the intervention, it is challenging to execute such a

study design for an evaluation of a complex public health program such as the AMFm, which is

implemented on a national scale with multiple players. The IE therefore uses a pre- and post-

test/intervention design (Figure 1.2.3) in which each participating country is treated independently

as a case study. As the literature suggests for the evaluation of such a complex intervention (Habicht,

Victora et al. 1999; Craig, Dieppe et al. 2008; World Health Organization 2009; Adeyi and Atun 2010),

in addition to measuring the changes in key indicators pre- and post-intervention, the evaluation

includes an assessment of the implementation process to determine whether any lack of impact

reflects implementation failure or genuine ineffectiveness. It also includes comprehensive

documentation of context both to inform assessments about causality and to aid in generalizability

to other contexts.

Figure 1.2. 2: The Independent Evaluation Impact model

Figure 1.2. 3: The Independent Evaluation Design

Price reductions

through

negotiations

with

manufacturers,

a subsidy in the

form of a buyer

co-payment,

and supporting

interventions

ACT Price

Decreased

ACT

Availability

Increased

ACT

Access and

Use

Increased

Malaria

Burden

Decreased

Outputs Outcomes ImpactInputs, Process

Baseline

Assessment

Endpoint

Assessment

ACT

availability, price,

market share and use

ACT

availability, price,

market share and use

Intervention

(Financing platform in place and

functional)

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The evaluation, therefore, includes two major components: (1) a pre- and post-intervention study of

key outcomes through outlet surveys and use of secondary household survey data, and (2)

documentation of key features of the context at baseline and endpoint, and the implementation

process in each pilot. The descriptions of context and implementation process provide the

information needed to interpret the changes in outcomes over the implementation period, and to

judge whether any observed changes are likely due to AMFm.

The evaluation is based on primary data collected from outlet surveys conducted at baseline and

endline (for questions related to availability, affordability and market share of ACTs); secondary data

from national household surveys (for question related to use of ACT), such as Demographic and

Health Surveys (DHS), Malaria Indicators Surveys (MIS), Multiple Indicator Cluster Surveys (MICS)

and ACTwatch household surveys; in-depth interviews with key stakeholders involved in the drug

supply chain in the country; and review of documents such as reports from AMFm operations

research, malaria treatment guidelines, pharmacy regulations, country-level reports from MOH and

donor partners, including national malaria control strategy documents, results from national

surveys, and any other documents relevant to the context data described above.

For each country, relevant indicators will be computed for the baseline and endpoint from the outlet

surveys. For secondary data from existing national household surveys, appropriate indicators will be

extracted from existing reports. To assess change, the IE will calculate the percentage point change

or the percent change (whichever is relevant for each indicator) between the baseline and the

endpoint. Contextual information will then be processed to help in the interpretation of these

results.

Pilot-specific case studies will be produced, making use of the qualitative and quantitative

approaches described above, to document and describe how the AMFm has evolved in each country.

The evaluation will distinguish two parts: (i) the upstream part, with emphasis on the business model

of the AMFm as a financing platform; and (ii) the downstream part, with emphasis on service

delivery to increase access to and use of ACTs, including by poor people. In the case studies, findings

from nationally representative outlet surveys will be compared before and after the introduction of

the AMFm, taking into account relevant contextual information and results from operational

research that become available to help learn how and why the new model unfolds in a variety of

contexts, while drawing lessons that can help future operations.

While this section gives an overview of the IE to provide the reader with the relevant context, this

report presents the country process, context and results of the endline outlet survey for Uganda.

This is Step 3 of a four-step process. Step 1 included the baseline outlet survey and the ACTwatch

Uganda country-specific baseline report. Step 2 integrated these results into a “Multi-country

Baseline Report,” produced by the Independent Evaluation Team. Findings from this endline outlet

survey will be used to inform Step 4, the development of the full AMFm Phase 1 Independent

Evaluation report, which will include results from all operational phase 1 pilots, to be submitted to

the Global Fund.

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1.3 Country background – context

1.3.1 Overview of the country

Uganda is a country in Eastern Africa. It is bordered by Sudan to the north, Kenya to the east,

Tanzania and Rwanda to the south and Democratic Republic of Congo (DRC) to the West. In 2010 the

population was estimated at 33.4 million, 19% of whom are under 5 years of age (Population

Division, 2011). Approximately 87% of people live in rural areas (Population Division, 2010). There

are over 15 different ethnic groups in Uganda, including Baganda, Banyakole, Basoga, Bakiga and

Iteso. The official languages are English and, since 2005, Swahili; Luganda, Arabic and around 40

other indigenous languages are spoken across the country.

The climate of Uganda is tropical and tempered by altitude. The country is generally flat and the

average altitude is around 1,100 meters above sea level. Due to this rather high altitude,

temperatures range from 21 to 25° Celsius. The hottest period of the year is from December to

February when the temperature rises to around 29° Celsius. The Central, Eastern, and Western

regions of the country have two rainy seasons per year, with heavy rains from March to May and

light rains between September and December. Reliability of the rain declines towards the north,

which has only one long rainy season from July to September.

Prior to 1986 Uganda experienced two decades of internal strife and political turmoil, including

power struggles between the government and traditional leaders; the 1971 military coup that saw

Idi Amin gain power; and continued leadership battles following the ousting of Amin. Since 1986

Uganda has remained relatively stable, and structural reforms focusing on infrastructure have led to

an overall economic improvement in most parts of Uganda, with the exception of the north. Serving

as a base for the Lord’s Resistance Army (LRA), the north was engulfed in an insurgency between

1986 and 2006 as the LRA battled the government (USDOS, 2011). In late 2005 the Ugandan military

forced the LRA out of northern Uganda, and relative calm has returned to this region. Since its

pacification the north has become an area of special focus for the government and for international

donors.

Uganda’s Gross Domestic Product (GDP) growth has been on a general upward trend over the past

two decades, from 1.6% in 1991 to 6.3% in 2010. Over this period the proportion of the population

living below the national poverty line has dropped from around 44% in 1996 to 25% in 2009,

surpassing the Millennium Development Goal of halving the 56% poverty rate recorded in 1992/93

(World Bank, 2011). Uganda is largely dependent on agriculture and fisheries for generating

employment, although the service sector – including tourism – was the largest contributor to GDP in

2009 (USDOS, 2011). Uganda has recently discovered commercially viable oil deposits and this may

provide the next economic impetus for the country.

Administratively, Uganda is divided into districts which are further sub-divided into lower

administrative units namely counties, sub-counties and parishes. Over time, the numbers of districts

and lower level administrative units have increased in number with the aim of making

administration and delivery of social services easier and closer to the people. This has however

placed increased strain on delivery of health services, as numbers of management and

administrative units and functions increase (President’s Malaria Initiative, 2010).

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Figure 1.3. 1: Location of Uganda

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

1.3.2 Description of health care system

The provision of health services in Uganda is decentralized, with districts and health sub-districts

playing a key role in the delivery and management of health services at those levels. The public

sector is organized into the following health services:

National, Regional and General Hospitals (operating at the district level and above);

Health Centre IV (operating at the county / health sub-district level);

Health Centre III (operating at the sub-county level);

Health Centre II (operating at the parish level); and

Health Centre I (Village Health Teams).

The government of Uganda has set national standards based on population ratios for the provision

of government-owned health facilities. As of 2009 there were substantial gaps between the

standards and actual provision, particularly at lower levels of the health system (Table 1.3.2.1).

Figure 1.3. 2: National Health Facility Availability Standards, 2009 Situation

Facility : Population Ratio

Type of Facility Standard 2009 Situation

National Referral Hospital 1 : 10,000,000 1 : 30,000,000

Regional Referral Hospital 1 : 3,000,000 1 : 2,307,692

General Hospital 1 : 500,000 1 : 263,157

Health Centre IV 1 : 100,000 1 : 187,500

Health Centre III 1 : 20,000 1 : 84,507

Health Centre II 1 : 5,000 1 : 14,940

Village Health Teams 1 : 1000 or 1 : 25 households No data

Source: Uganda Ministry of Health, 2010b.

https://www.cia.gov/library/publications/the-world-factbook/index.html

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Health Centre I is any structure at the community level that provides health services, often through

volunteers. Interventions at this level are increasingly organized into Village Health Teams (VHTs). By

the end of the 2008/2009 financial year – a period that includes data collection for this survey – only

13 out of 42 planned VHTs had been established (UMOH, 2010a, p xix).

Districts, under the supervision of a district health officer, are responsible for designing and

delivering health plans, and for managing their budgets. Funding is received from higher levels of

government. Under this structure, the Ministry of Health (MOH) is responsible for strategic planning,

policy development, technical assistance, and providing monitoring and evaluation, among other

duties. The national referral hospitals, Mulago hospital and Butabika mental health hospital, both

located in Kampala, are semi-autonomous. The regional referral hospitals have been granted self-

accounting status but remain under MOH oversight.

Over the past decade the government has focused on expanding its health infrastructure in an effort

to bring services closer to the people. However, this has placed increased strain on the delivery of

health services and budgets generally, as the numbers of administrative structures have increased to

manage these newly sub-divided areas. In addition, poor remuneration and working conditions in

the public sector have led to high attrition rates among staff. This is particularly evident in remote

rural areas, despite the adoption of a ‘Hard to Reach’ strategy by the government in an attempt to

incentivize staff to move to these locations (Health Performance Report 2010, p. 148). For example,

as of 2009 only 33% of posts in Health Centre IIs (predominantly located in rural areas) were filled.

For Health Centre IIIs this figure was 45%, rising to 55% and 61% for Health Centre IVs and General

Hospitals respectively (UMOH, 2010b, p.36). The government acknowledges the role played by

private not-for-profit staff, who in 2009 contributed around 30% of the combined public/not-for-

profit workforce (UMOH, 2010a, p. 158).

The government eliminated user fees in 2001, and services in public health facilities are thus free.

User fees remain in place in private wings of public hospitals.

The National Medical Stores (NMS) is the central procurement and supply body for the public sector

facilities in Uganda. Each public health facility makes projections and requisitions for medicines and

supplies, which are aggregated at district level and forwarded to NMS. The NMS then delivers the

medicines and supplies to the district. Further distribution to specific health facilities is done by the

districts. However, in early 2010, the NMS and MOH changed the national policy to introduce the

"push" system where lower level health facilities (Health Centres II and III) were to receive a

standard kit of set quantities of essential drugs, including ACTs, and other health supplies

(President’s Malaria Initiative, 2010, p.25). Hospitals and HCs IV would continue to be able to order

based upon their determined needs. It has been noted by the Ministry of Health that the change

from a ‘pull’ to a modified ‘push’ system will present challenges as there are limited quantities of

available essential drugs and quantification has been historically inaccurate, which may lead to more

stock-outs nationwide or even overstocks at the health-facility level.

In addition to government-run facilities and services, health care in Uganda is provided by private

not-for-profit facilities and private for-profit facilities. A breakdown of health units, by level and

owner, is shown in Table 1.3.2.2.

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Figure 1.3. 3: Distribution of functional health units by health facility level and ownership

Source: Adapted from Uganda Ministry of Health, 2010b.

The most recent figures indicate that around 60% of facilities are government-run, 23% are for-

profit, and 17% are not-for-profit.

The private sector plays a significant role in the health system in Uganda and includes hospitals and

clinics, as well as retail pharmacies and both registered and unregistered drug stores. A private

sector outlet was the first source of advice or treatment in 56% of child fever cases, according to

figures from the 2009 Malaria Indicator Survey (MIS). A US Agency for International Development

(USAID)-funded study from 2005 estimated there were 12,775 staff employed in private health

facilities. 9,500 of these professionals were working exclusively in the private sector, including more

than 1,500 doctors and 3,500 nurses (Mandeli et al., 2005, PHRplus). The national distribution of

health workers is inequitable between public and private sectors as well as geographically. While the

Central region (which includes Kampala) hosts only 27% of the population, this region includes 71%

of medical doctors and 81% of pharmacists (AHWO, 2009, p.29).

The private for-profit sector drug supply is dominated by large importers that also serve as

wholesale pharmacies. These wholesalers are found in major towns in Uganda and are the source of

drugs and medicines for most private health facilities. An important provider in the not-for-profit

drug supply market is the Joint Medical Store (JMS). The JMS was established in 1979 to serve

mission health facilities, but now operates a wider, not-for-profit wholesale enterprise that supplies

nongovernmental organizations (NGOs) and faith-based organizations (FBOs) in the country.

Uganda has a small number of local medicine manufacturers that undertake regular production,

including Kampala Pharmaceutical Industries and Quality Chemical Industries Limited. However, the

majority (90%) of products are imported. Results of a mapping exercise undertaken in 2008

estimated that 93-95% of imported medicines in Uganda are generic products (UMOH, 2008 cited in

MeTA, The role of local manufacturers in improving access to essential medicine, 2010).

1.3.3 Epidemiology of malaria

In most parts of Uganda, temperature and rainfall allow intense perennial malaria transmission.

Malaria is highly endemic across 95% of the country, affecting approximately 90% of the population.

These areas include the entire Central region and the majority of the Northern and Southern

regions. The remaining 5% of the country (10% of the population) consists of unstable and epidemic-

prone transmission areas in the highlands of the south- and mid-west, along the eastern border with

Kenya, and the northeastern border with Sudan (President’s Malaria Initiative (PMI), 2010, p.9).

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Results from the 2009 MIS show that Plasmodium (p.) falciparum is responsible for 99% of malaria

cases in Uganda. Both P. vivax and P. ovale are rare (estimated <1% of malaria cases in the country).

The most common malaria vectors are Anopheles gambiae and Anopheles funestus. Exposure to

malaria transmission measured during the entomological surveys has been found to be as high as

1,500 infective bites per person per year, but is generally in the range 100-400 in highly endemic

areas and around 5-50 infective bites in areas of moderate transmission (UMOH, 2005, p. 12).

Malaria is the most frequently reported disease at both public and private health facilities in Uganda,

and as such presents a major public health problem to the population. A recent PMI operational

document concisely summarizes the extent of the malaria burden in Uganda (PMI, 2010):

“Clinically-diagnosed malaria is the leading cause of morbidity and mortality, accounting for 25-40%

of outpatient visits at health facilities, 15-20% of all hospital admissions, and 9-14% of all hospital

deaths. Nearly half of inpatient deaths among children under five years of age are attributed to

clinical malaria. A significant percentage of deaths occur at home and are not reported by the

facility-based Health Management Information System.”

The current government estimates of the annual number of deaths from malaria range from 70,000

to 100,000 (UMOH, 2005).

1.3.4 Antimalarial Policies and Regulatory Environment

In 2004 the National Malaria Control Program (NMCP) adopted AL 20mg/120mg as the first-line

treatment for uncomplicated malaria, with artesunate-amodiaquine (ASAQ) 50mg/153mg as an

alternative first-line in the private for-profit sector (Uganda Malaria Control Strategic Plan, p. 18,

2005). Implementation of this policy in public sector facilities began in 2006 and was expanded to

community-based services in 2008 through the Home-based Management of Fever (HBMF) program

run by community medicine distributors (CMDs). This expansion followed the declassification of all

ACTs to over-the-counter medicines, also in 2008. Quinine is recommended for patients with

uncomplicated malaria whose AL treatment has failed and parenteral quinine is recommended for

the treatment of severe malaria. Artesunate suppositories are recommended for pre-referral

treatment of severe malaria at the community level where parenteral therapy is not possible.

At the time of data collection, the policy on diagnosis was for cases to be confirmed through

microscopy except in children under the age of five years, who were treated based on clinical signs.

Microscopic testing was to be provided free of charge in the public health system and made

available at Health Centre III and higher levels. In practice, many Health Centre III facilities did not

have the necessary facilities and hence diagnosis of malaria remained largely clinical at this level.

The inclusion of rapid diagnostic tests (RDTs) as part of the treatment policy was being considered

with pilot activities taking place at the Health Centre III level.

Uganda stopped registering new oral AMTs in 2005 (WHO, 2010a).

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1.3.5 Malaria control strategy

The National Malaria Control Program goals are to eliminate malaria as the major cause of illness

and death in Uganda, ensure families received universal access to malaria prevention and treatment,

and reduce all-cause mortality rate for children under five. The government has removed import

tariffs on RDTs, bed nets, antimalarials, and indoor residual spraying (IRS) commodities (M-TAP,

2010).

Table 3 presents key malaria control indicators as estimated by the 2006 DHS and 2009 MIS.

Although there have been some improvements in coverage of malaria control interventions, the

prevalence of parasitemia (45%) and anemia (62%) remain unexpectedly high. Results from the 2009

MIS show that 47% of households owned one or more insecticide-treated nets (ITNs) and 44% of

pregnant women and 33% of children under five had slept under an ITN the night before the survey.

The proportion of women receiving two doses of intermittent preventive treatment in pregnancy

(IPTp) was 32%.

Figure 1.3. 4: Comparison of national malaria control indicators, 2006 and 2009

Indicator 2006 DHS 2009 MIS

Percentage of households that own at least one ITN 16% 47% Proportion of children under five years of age sleeping under an ITN the previous night

10% 33%

Proportion of pregnant women sleeping under an ITN the previous night

10% 44%

Percentage of households sprayed in the previous 12 months 6% 6% Proportion of pregnant women who receive at least two doses of IPTp during antenatal care

16% 32%

Prevalence of parasitemia (by blood slide) in children 0-59 months n/a 45%

Prevalence of anemia in children 6-59 months (Hg < 11 g/dL) n/a 62%

Prevalence of severe anemia in children 6-59 months (Hg < 8 g/dL) n/a 10%

Source: Comparison table in Uganda Bureau of Statistics & ICF Macro, 2010. Uganda Malaria Indicator Survey 2009.

Focusing on case management, the MIS estimated that 36% of children under five were treated with

an antimalarial drug on the same or the next day after onset of fever. Although the proportion

receiving an ACT was only 14%, this did represent an increase on the 1% recorded by the 2006 DHS,

which was conducted before the rollout of AL to public health facilities. According to national policy,

all diagnosis and treatment of uncomplicated malaria is free of charge in the public sector. However,

since rollout in 2006 there have been three major national stock-outs of AL (PMI, 2009, p.5,). These

were the result of bottlenecks in grants, prolonged procurement procedures, and ineffective

distribution channels and pharmaceutical management systems once the drugs were in country.

Uganda was one of the first countries in Africa to actively promote HBMF through volunteer CMDs.

However, its implementation has been chronically impaired by repeated shortages of AL. The 2009

MIS indicated that only 18% of households reported knowledge of a community worker or CMD

within their community, and only 9% reported that the CMD had malaria medicines available. In

2010, integrated community case management (ICCM), which provides care for children under five

for malaria, diarrhea, pneumonia and care for neonates through voluntary VHTs was introduced as

national policy in Uganda. A two-year pilot of ICCM in 20 districts in Uganda, which includes training

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on case management and provision of drug supplies (including ACTs) to the village health volunteers,

is ongoing.

Despite delays in ACT supply, considerable investments have been made in training and supervision

of health workers, technical support for HBMF and ACT procurement, and quality testing to improve

malaria case management, including in the private sector. In 2010, training on malaria case

management, including severe malaria and supportive supervision, was provided to health workers

in 32 districts (including almost 3,000 workers from the private sector). More than 1,000 health

workers have received laboratory training in improved diagnostics. In addition, a number of small-to-

medium sized private clinics under the Uganda Health Marketing project provide free or subsidized

health services to their employees and the surrounding communities.

Since 2008 the Consortium for ACT private sector pilot subsidy (CAPSS) project has provided

subsidized AL in four districts of Uganda (Kamuli, Kaliro, Pallisa and Budaka). Branded as “ACT with a

leaf” to distinguish it from all other ACTs and antimalarials, the maximum recommended retail price

for each age-pack is printed on the product. The final price per age-pack ranged from UGX 200 to

UGX 800 (USD 0.10 to USD 0.40). Given the reported success of the pilot (CAPPS, 2010), an

extension of the CAPSS program (CAPSS Plus) has been undertaken and includes an assessment of

feasibility and acceptability of licensed drug shops providing a malaria diagnosis before selling

subsidized ACTs to patients or providing treatment for other common causes of infection. In 2010,

519,128 doses of “ACT with the leaf” were packaged.

In 2009, a World Health Organization (WHO)-led multi-country study on drug quality showed that of

the drugs sampled in Uganda (predominantly ACTs and SP), 26% failed standard confirmatory quality

control tests (US Pharmacopeia, 2010). While only a fraction of the drugs on the market were

sampled and no national estimates are possible, the results indicate the importance of monitoring

the quality of antimalarial drugs in addition to ensuring supply. The National Drug Authority

monitors drug quality through registration of pre-marketed medicines, inspection of factories that

manufacture antimalarial drugs, licensing of drug outlets, and post-marketing surveillance.

In 2010 a significant number of outlets selling expired drugs were closed down by the National Drug

Authority (NDA), and since this action monitoring of outlets selling drugs illegally has been

intensified by the NDA. Widespread publicity of drug thefts by government officials led to the

development of a monitoring unit under the President’s office. Highly publicized closing down of

outlets in the private sector carrying ‘not for sale’ government drugs and supplies has also been

noted in the media (personal communication, Uganda AMFm 2010 key informant interviews).

1.3.6 Malaria financing

Health financing in Uganda places a large burden on the household. The Ministry of Health estimates

that 50% of personal healthcare costs are met by out-of-pocket expenditure and that 9% of all

household expenditure is on health care (UMOH, 2010, p.11).

Funding for malaria control rose sharply between 2004 and 2006, from $12 million to $62 million,

but dropped by more than half in 2007 as earlier Global Fund grants expired or stalled (WHO, 2010).

In recent years the largest donors have been the Global Fund ($48 million in 2006), PMI ($22 million

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in 2008), and the government of Uganda ($7 million in 2008, double the financing provided in 2005).

Other donors include the United Nations Children’s Fund (UNICEF) and the Bill and Melinda Gates

Foundation.

After poor performance implementing the Global Fund Round 2 grant, greater success has been

achieved in more recent rounds. Uganda’s Round 4 application sought to support the introduction of

ACTs nationwide, and the $66 million phase 1 was completed in February 2008. Over 19 million ACT

treatments were procured and distributed (67% of the target) and over 34,000 health workers

underwent training on the new drug policy. Six districts participated in a pilot of RDTs and over 1,000

CMDs were trained in the use of ACTs for HBMF, although this latter figure is well short of the

original target of 8,600 (Global Fund, 2008). Phase 2 funding is on-going, although disbursement

(and thus expenditure) was frozen for a period beginning in late 2008 resulting in “severely

impaired” access to ACTs since October 2008 (Global Fund, 2009a). At the time of data collection, no

ACTs had been procured through the Round 4 Phase 2 grant (PMI, 2009, p.5).

A $51 million Round 7 Phase 1 grant was signed in August 2008 to cover the purchase and

distribution of 17.7 million long-lasting insecticidal nets (LLINs) over five years, beginning in 2009,

through mass campaigns and routine distribution.5

Funding through PMI – the second-largest donor in Uganda – has supported IRS campaigns in 8

districts, the distribution of nearly 2 million LLINs, and training to health care providers in IPTp. In

addition, PMI funds have supported the training of 10,000 health workers in malaria case

management, and twice provided for emergency procurements of ACTs during times of public sector

stock outs (PMI, 2009, p.7).

5 Due to administrative delays this proposal was later revised to cover mass campaigns only. 7.2 million nets were distributed – with the assistance of PMI – during 2010 (PMI, 2009).

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2. Methods

2.1 Outlet survey

2.1.1 Outlet survey indicators

The following table shows the AMFm Phase 1 primary indicators to be measured through the outlet

survey, and presented in this report. Results are presented by urban and rural locations and

nationally. They will also be presented by outlet type (though there may not be sufficient power to

detect statistical differences between outlet types).

Table 2.1. 1: Primary AMFm indicators Availability indicators

1.1 Proportion of censused outlets that have any antimalarials in stock at the time of survey visit in rural and urban areas

1.2 Proportion of outlets that have non-artemisinin monotherapy or non-artemisinin combination therapy in stock among

outlets with any antimalarials in stock at the time of survey visit in rural and urban areas

1.3 Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in stock at the

time of survey visit in rural and urban areas

1.4 Proportion of outlets that have non-quality-assured ACTs in stock among outlets with any antimalarials in stock at the

time of survey visit in rural and urban areas

1.5 Proportion of outlets that have quality-assured ACTs in stock at the time of survey visit among outlets with any

antimalarials in stock at the time of survey visit in rural and urban areas

1.6 Proportion of outlets with antimalarials in stock at the time of survey visit that have been out of stock of quality-assured

ACTs for at least 1 day in the last 7 days in rural and urban areas

1.7 Proportion of the population living in a “sub-district” where there is at least one outlet that had a quality-assured ACT in

stock at the time of the survey visit in rural and urban areas

Pricing indicators

2.1 Median cost to patients of one adult equivalent treatment dose (AETD) of quality-assured ACTs in rural and urban areas

2.2 Median cost to patients of one AETD of non-quality-assured ACTs in rural and urban areas

2.3 Median cost to patients of one AETD of artemisinin monotherapy in rural and urban areas

2.4 Median cost to patients of one AETD of non-artemisinin monotherapy or non-artemisinin combination therapy in rural

and urban areas

2.5 Median percentage markup between retail purchase and selling price of quality-assured ACTs in rural and urban areas

2.6 Median total markup from first-line buyer purchase price to retail selling price for quality-assured ACTs

Market share indicators

3.0 Total volume of quality-assured ACTs sold or distributed in the last week, as a proportion of the total volume of all

antimalarials sold or distributed in the last week in rural and urban areas

The following table shows the primary ACTwatch indicators measured through the outlet survey,

and presented in this report. Results are presented nationally and by endemicity. They will also be

presented by outlet type (though there may not be sufficient power to detect statistical differences

between outlet types).

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Table 2.1. 2: Primary ACTwatch indicators

Availability indicators

Proportion of censused outlets that have any antimalarials in stock at the time of survey visit.

Proportion of outlets that have any ACTs in stock among outlets with any antimalarials in stock at the time of survey, including:

Quality-assured ACTs o First-line quality-assured ACTs o Non-first-line quality-assured ACTs

Non-quality-assured ACTs

Nationally registered ACTs

Proportion of outlets that have any non-artemisinin therapy in stock at the time of survey visit, including:

Chloroquine

Sulfadoxine-pyrimethamine

Quinine

Proportion of outlets that have artemisinin monotherapy in stock among outlets with any antimalarials in stock at the time of survey visit, including

Oral artemisinin monotherapy

Non-oral artemisinin monotherapy

Stock-outs

Proportion of outlets that report no disruption in stock of any antimalarial, among outlets with any antimalarial in stock or reported stock-outs in the last three months. Proportion of outlets that report no disruption in the first-line quality-assured ACT, among outlets with any antimalarials in stock or reported stock-outs in the last three months.

Pricing indicators

Median cost to patients of one adult equivalent treatment dose (AETD) of ACTs, including:

Quality-assured ACTs o First-line quality-assured ACTs o Non-first-line quality-assured ACTs


Nationally registered ACTs Median cost to patients of one AETD of any non-artemisinin therapy, including:

Chloroquine

Sulfadoxine-pyrimethamine

Quinine

Median cost to patients of one AETD of artemisinin monotherapy, including


Non-oral artemisinin monotherapy

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Affordability

Median cost to patients of one adult equivalent treatment dose (AETD) of first-line quality-assured ACTs relative to the most popular antimalarial treatment. Median cost to patients of one AETD of first-line quality-assured ACTs relative to the minimum legal daily wage. Median cost to patients of one AETD of first-line quality-assured ACTs relative to the international reference price.

Market share indicators

Total volume of ACTs sold or distributed in the last week, as a proportion of the total volume of all anti-malarials sold or distributed in the last week.

Provider knowledge

Proportion of providers that can correctly state the recommended first-line treatment for uncomplicated malaria, among outlets with any antimalarials in stock or reported stock outs in the last three months. Proportion of providers that can state the dosing regimen of the first-line treatment for an adult among outlets with any antimalarials in stock or reported stock outs in the last three months. Proportion of providers that can state the dosing regimen of the first-line treatment for a two year old, among outlets with any antimalarials in stock or reported stock outs in the last three months.

2.1.2 Background on ACTwatch and the AMFm Phase 1 Indicators

While there are many similarities between the AMFm Phase 1 and ACTwatch indicators there are

notable differences, particularly in terms of the types of antimalarial classifications, denominators

for some provider indicators, prices (notably the use of different exchange rates and presentation of

median prices for tablet vs. other formulations) and the presentation of indicators in the report. The

following subsection helps to explain these differences by providing background on: 1) antimalarial

classifications 2) ACTwatch primary indicators and 3) AMFm Phase 1 primary indicators.

Classification of antimalarials

Antimalarials are presented within three broad policy-relevant categories:

Non-artemisinin Therapy (nAT)

Artemisinin Monotherapy (AMT)

Artemisinin-based Combination Therapy (ACT).

ACTs are further sub-divided as:

Quality-assured ACTs (QAACTs), which include:

o First-line, Quality-assured ACTs (FAACTs),

o Non-first-line Quality-assured ACTs (NAACTs)

Non-quality-assured ACTs (nQAACTs)

For further details on this classification see section 2.1.6.3 Classification of antimalarials.

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ACTwatch versus AMFm classifications

Given the objectives of the AMFm Phase 1, indicators focus on the following antimalarial

classifications: 1) non-artemisinin therapy, 2) AMT, 3) QAACTs and 4) nQAACTs.

In addition to these classifications, ACTwatch also presents data on FAACTs, NAACTs, and nationally

registered antimalarials, which are relevant for national policy. AMT is also further classified as oral

and non-oral AMT as per WHO recommendations that intravenous artesunate should be used as

first-line treatment in the management of severe P. falciparum malaria in African children and adults

(WHO, 2010b). ACTwatch further classifies non-artemisinin therapy into chloroquine, sulfadoxine-

pyrimethamine and quinine.

ACTwatch versus AMFm denominators

Provider knowledge

The ACTwatch indicator on provider knowledge of the first-line antimalarial treatment includes

outlets that had an antimalarial at the time of survey or in the previous three months. For the AMFm

Evaluation Indicator, only outlets that had an antimalarial in stock at the time of survey are included

in the denominator. Therefore, there are slight differences in the results for these knowledge

indicators.

Rapid diagnostic tests and malaria microscopy

The ACTwatch indicator on availability of RDTs and malaria microscopy includes outlets that had an

antimalarial at the time of survey or in the previous three months. For the AMFm Evaluation

Indicator, only outlets that had an antimalarial in stock at the time of survey are included in the

denominator. Therefore there are slight differences in the results for these diagnosis indicators.

ACTwatch versus AMFm evaluation exchange rates

Price Price data were collected in local currencies and converted to their USD equivalent. The USD

conversion used in this report (for ACTwatch indicators) is equivalent to the average interbank rate

for the period of data collection. This approach is used to facilitate comparisons over time between

other rounds of ACTwatch data collection, and between other ACTwatch countries. This differs from

the AMFm approach, which uses the average 2010 exchange rate over the whole year in which data

collection took place. Given these differences, separate tables for price indicators were provided to

the Independent Evaluator for AMFm, using the 2010 exchange rate. The prices presented in this

report are therefore slightly different from those presented in the “Multi-country Baseline Report”

produced by the Independent Evaluation Team, which synthesizes results from all pilot AMFm

countries.

In addition, a notable difference between the price measures for the AMFm indicators and the

ACTwatch indicators is the presentation of price for tablets and other formulations. Price measures

for ACTwatch only include tablet formulations. The price of non-tablet formulations, such as

powders for reconstitution, suspensions, suppositories and syrups, are excluded. In contrast to this,

the AMFm indicators present information for both tablet and non-tablet formulations.

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2.1.3 Sampling Approach

The sampling approach was based on that used in ACTwatch outlet surveys conducted in previous

survey rounds (including outlets in the public, private for-profit, and not-for-profit sectors)

(Shewchuk, O’Connell et al. 2011).

The target sampling units were all types of outlets that have the potential to sell or provide

antimalarials in Uganda. The outlets were classified into two main categories and sampling

procedures employed to select outlets within each category:

Category 1: public health facilities (this included national, regional and district hospitals; health

centres IV, III and II) and pharmacies.

Category 2: other antimalarial drug sellers (this included CMDs, drug stores, private hospitals and

clinics, NGO or faith-based hospitals and clinics, supermarkets or chain stores, grocery stores, dukas,

general merchandise outlets, general merchandise kiosks, and hawkers).

Sampling procedures were employed to select outlets within each category, as described below.

Sample size determination

The outlet survey is designed to measure differences in indicators over time. The sample size that

was needed depended on the type of indicator to be measured (proportion, mean or median) and

the level of precision required. The following paragraphs summarise the methodology for

determining the overall sample size needed to detect statistically significant changes over time in

proportions (increases).

The sample size calculations were based on Indicator 1.5 – Availability of QAACTS (the proportion of

outlets that sell QAACTs as a share of the number of outlets that had stocks of any kind of

antimalarials at the time of the survey). This indicator has been chosen because of concerns that

QAACTs were too rare at baseline to provide a feasible sample size for the price/affordability

indicators.

The required sample size for the endline survey is calculated in 3 steps:

1. The required number of outlets with antimalarials in stock on the day of the survey

2. The number of outlets that must be enumerated to arrive at this number of antimalarial-

selling outlets (“gross sample size”)

3. The number of sub-districts that must be visited to arrive at this number of outlets

(“operational sample size”).

The same sample size for the endline survey is a function of the reference indicator value measured

and the sample size achieved in the baseline survey. The required sample size for a single domain

for the endline survey is calculated using the following formula:

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2

21

2

221111

)(

)1(/)1()/11)(1(

PP

PPPPZPPZDeffn

where:

n = desired sample size for the endline survey for a specific domain (urban or rural)

P1 = the indicator value measured at the baseline survey

P2 = the expected value of the indicator at the endpoint survey

P = (P1+P2)/2

λ=the ratio of the baseline survey sample size over the endline survey sample size which can

only be solved in a recursive calculation

Z1-α = the standard normal 1-α quintile corresponding to an α (type I) error with a one-sided

test; replace α by α/2 if a two-sided test is desired

Z1-β = the standard normal 1-β quintile corresponding to the power of the test

Deff = the design effect for cluster sampling

The required sample size has been calculated on the basis of the following assumed values of the key

parameters:

P1 = the value of the key outcome indicator measured at baseline survey: 19.8% (for the urban

domain and 24.2% for the rural domain, respectively).

P2 = the expected value of the indicator at the endline survey; a 20 percentage point difference

will be desired (assuming that a 20% point increase is the minimum necessary to justify the

importance in public health policy terms)

P = (P1+P2)/2

P2 – P1 = the change in availability from baseline to endline is 20 percentage points (the minimum

level of change felt to be needed to justify continuing the intervention on public health grounds)

Z1-α = 1.64 corresponding to an α (type I) error of 5% with a one-sided test

Z1-β = 0.84 corresponding to a power of test at 80% (or a type II error of 20%)

Deff = estimated design effect from the baseline survey data, which is 21 for the urban domain

and 18 for the rural domain.

This gives 1540 and 900 outlets in the denominator of the indicator, for the urban and rural

domains, respectively, which are the number of outlets having any kind of antimalarial stocks at the

time of the survey.

The estimated gross sample size (number of outlets enumerated) needed for the QAACT

availability indicator is determined by the following formula:

amPnN /

1

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, n1= the number of outlets with antimalarial stocks at

the time of the survey, which is 1540 and 900 for the urban and rural domains, respectively.

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The value of Pam (the proportion of outlets having antimalarials in stock at the time of the survey

among all outlets enumerated) was estimated based on the 2010 survey data. These data indicated

that 33% of the outlets in urban areas and 35% of the outlets in rural areas, on average, had

antimalarials in stock at the time of the survey. By applying these percentages to the above formula,

a total number of 4680 outlets in the urban domain and 2571 outlets in the rural domain must be

interviewed in order to detect a 20 percentage point increase in QAACT availability, for urban and

rural domains separately.

Number of sub-districts

To convert the gross sample size into the number of sub-districts, we apply the estimated average

number of outlets per sub-districts (noutlet). The number of outlets needed to reach the required

number of outlets with antimalarials in stock may be different for urban and rural areas depending

on the average number of outlets per sub-district (noutlet) and the percentage of outlets with

antimalarials (Pam) in urban and rural areas separately.

The 2010 survey results show that there are, on average, 262 outlets interviewed per urban sub-

district and 94 outlets interviewed per rural sub-district. By applying these estimated parameters,

the optimal number of sub-districts required to reach the estimated number of outlets would be 18

in the urban domain and 26 in the rural domain, giving a total of 44 sub-districts required in a

country.

Selection procedure of the sub-districts

The last census in Uganda was conducted in 2002 and was used as the sample frame for the 2011

outlet survey. The desired cluster size for the outlet survey was approximately 10,000 to 15,000

inhabitants, which corresponded most closely to a sub-county in Uganda. The list of sub-counties

from the 2002 census included population size, and sub-counties were classified as either urban or

rural (Uganda Population Census, 2002). In addition, a facility listing was used to confirm the location

of public health facilities (2011 Ministry of Health, Health Facility List) and pharmacies (2010

National Drug Authority listing of registered Pharmacies in Uganda).

The sample was selected using a stratified cluster design, with urban and rural areas constituting the

two strata. A total of 44 sub-counties (18 urban and 26 rural) were selected with probability

proportional to size from the 2002 census.

A second stage of sampling was conducted for sub-counties in Kampala.6 The population of Kampala

is far greater than the average population in other sub-counties, averaging over 300,000 people. In

order to aid fieldwork logistics, one parish was randomly selected within each selected sub-county

with probability proportional to size.

In each selected sub-county (or parish, in the case of Kampala), a census of all Category 1 and

Category 2 outlets was conducted. All outlets that stocked antimalarials at the time of the survey or

in the past 3 months were eligible for interview.

6 In Kampala, sub-counties are called divisions. For the sake of consistency, we will refer to the Kampala divisions as sub-counties in the sampling section of this report.

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The sample was supplemented by a booster sample that included all public health facilities and

pharmacies (Category 1 outlets) operating in the administrative district of the sampled sub-counties.

Oversampling ensured adequate representation of relatively rare but important antimalarial outlet

types. All public health facilities (with the exception of community medicine distributors) and

pharmacies were included in the administrative district of the sampled sub-county.

Different approaches were used for the booster sample. All public health facilities located in the

corresponding county of the selected sub-county were included. All pharmacies located in the

corresponding district of the selected sub-county were included, given these outlets are less

common in Uganda than public health facilities. Exceptions to this booster sampling approach were

made for Kampala, given the use of parishes as the sampling unit. In Kampala, all public health

facilities in the sub-county of the selected parish were included. All pharmacies located in the

Kampala were included, given there were no pharmacy listings for the sub-county level.

All Category 1 booster outlets that stocked antimalarials at the time of the survey or in the past 3

months were eligible for interview.

2.1.4 Data collection

Preparatory phase

The study initially received ethical clearance from Uganda’s ethical approval committee (Makerere

University College of Health Sciences Research and Ethics Commmittee) at the Ministry of Health on

the 31st August 2011.

The questionnaire mirrored the ACTwatch questionnaire employed in Uganda in 2008 (Shewchuk et

al., 2011). However, the IE team made several adaptations to the questionnaire at endline in Uganda

to ensure that the IE indicators were included and other requests from key stakeholders were met

(e.g., the addition of questions on stockouts of quality-assured ACTs, training courses attended, and

knowledge of proper dosing of quality-assured ACTs).

Four modules were used in the outlet survey: 1) a screening module identified outlets that were

eligible for the audit and provider interview; 2) a provider module collected information on outlet

demographics (e.g., health qualifications of staff, number of staff that prescribe or dispense

medicines), provider knowledge of the first-line treatment, and provider perceptions; and 3) an

antimalarial audit module collected data for each antimalarial stocked, including information on

brand name, generic name and strengths, package type and size, recall of volumes sold over the

week before the survey, recall of last purchase price and selling price and 4) an RDT audit which

determine brand name, price and manufacturer of RDTs. The questionnaire was translated into

Luganda, Luo and Rutooro/Runyankole. Paper questionnaires were administered during data

collection.

Eighty-one (81) candidates participated in a seven-day outlet survey training between the 24th

October 2011 to November 1st 2011 at Makarere University, in Kampala. Standardised training

materials developed by ACTwatch were adapted to the national setting, and administered by PACE

research staff and ACTwatch central. Training sessions covered completing the questionnaire,

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informed consent, conducting the census, and identifying outlet types. Interviewers were trained to

identify antimalarial medicines, including the differences between ACTs and non-ACTs, trade names

and generics, packaged and loose tablets, and the various formulations. A field practice session was

undertaken to mimic actual data collection. Of the 81 candidates, 50 were selected as interviewers,

10 as supervisors and 10 as quality controllers.

Supervisors and quality controllers received additional training to clarify roles and responsibilities in the field. This training also included a review of logistical procedures to be followed during data collection.

Standard Operating Procedures (SOPs) developed by ACTwatch were used to help ensure high

quality data. The SOPs outline each element of data collection and management, e.g., questionnaire

translation, questionnaire pretesting, fieldworker training, and double data entry.

Fieldwork

Ten teams carried out data collection, each consisting of one team supervisor, one quality controller

and five interviewers. One coordinator was responsible for managing the supervisors and ensuring

that standardized methods were implemented. Fieldwork commenced on the 8thof November and

was completed on the 12th of December 2012.

During fieldwork, specific outlets were identified in sampled sub-counties using a number of

approaches. Official lists of outlets operating in selected sub-counties were obtained from the

Ministry of Health prior to fieldwork, and were then used to help verify outlets within each sub-

county. In addition, supervisors identified key informants (such as health officials and other local

government officials) and, through discussion with these key informants, obtained a list of potential

medicine outlets in their area and worked with them to draw up a rough sketch map of their

locations. To estimate the boundaries of each sub-county, supervisors liaised with sub-county chiefs

and with local guides. The teams were also provided with district and sub-county maps to further

identify boundaries. Road maps were also used where available. Finally, during data collection a

snowball technique was used whereby outlets included in the survey were asked to identify other

outlets stocking, or with the potential to stock, medicine in the sub-county.

For each outlet that was identified during the census, the outlet type and location were noted, along

with its longitude and latitude coordinates (obtained via hand-held Global Positioning System (GPS)

units). The fieldworker then identified the most senior staff member currently present at the outlet,

and screening questions were administered. For outlets that were eligible, the interviewer then read

the information sheet to the senior staff person and obtained witnessed oral consent to proceed

with the full interview. The questionnaire is included in the Appendix.

At the end of each day, all questionnaires were organised and reviewed by the supervisors or quality

controllers.

Teams were visited by supervisors and quality controllers in the field during the survey period. Spot

checks were conducted on at least 5% of all outlets by quality controllers. Supervisors observed 10%

of interviews, verifying adherence to study procedures. Regional coordinators from the research

agency, as well as PACE and ACTwatch central provided additional technical assistance and were in

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the field, extensively supervising the data collection process.

2.1.5 Data processing

Data recorded on paper questionnaires. Data were double-entered in Nairobi using a Microsoft

Access database developed by ACTwatch. The data were double-entered by an independent agency.

The final raw dataset was sent to ACTwatch Central, based in Nairobi, where cleaning was

conducted. Any clarifications or errors were documented and sent back to PACE for verification.

2.1.6 Data analysis

Data analysis process

Detailed data cleaning guidelines giving step-by-step instructions on how to clean each section of the

data using range and consistency checks were utilized during the analysis process. Commands

executed for data cleaning were documented using a “syntax file”, and the results of running these

commands using a “log file”.

A standardized tabulation plan was used for all tables presented in this report, which were produced

using standard analysis “do-files” in STATA. Analysis was run using STATA version 11, recording

results in a “log file”.

Accounting for the survey design in data analysis

We accounted for three aspects of the sampling design during the analysis:

Sampling weights: Sample weights were calculated for the outlet survey data to allow for 1)

difference in sampling probabilities due to variation in the size of strata, 2) the oversampling for

the booster sample, and 3) the sampling strategy, which involves a census of outlets in sub-

counties of varying size, selected using probability proportional to size (PPS) sampling. Weights

were based on sampling probabilities and were calculated by the IE after data cleaning was

complete. Appendix 8.6 provides a detailed description of the calculations performed and

weights used.

Clustering: As the sample was clustered at the level of the district for the booster sample and the

sub-county for other outlets, the calculation of the standard errors takes the clustering into

account because outlets in a given cluster are likely to be more similar to each other than to

outlets in other clusters. (The standard errors did not take into account clustering of products

within outlets because a complete list of all relevant products in each outlet was obtained and

no sampling was performed).

Stratification: As sub-counties were sampled separately in each stratum, it was necessary to

adjust for this in the calculation of standard errors.

To account for these design features in the tabulations, we used the STATA commands for analyzing

complex survey data (“svy” commands) to weight the data and calculate confidence intervals that

account for clustering and stratification. We declared the primary sampling unit (district), the weight

variable (wt), the strata and the finite population correction (fpc) equaling the sampling fraction for

each stratum (the number of sampled sub-counties in a stratum divided by the total number of sub-

counties in the stratum, or 0.5 if the sampling fraction was greater than 50 percent). This was

specified as:

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svysetdistrict [pweight=wt], strata (strata) fpc (fpc)

We calculated a proportion and its 95 percent confidence interval (CI) as:

svy: proportion VariableName

Classification of antimalarials

For the purpose of the analysis, antimalarials were split into three broad policy relevant categories:

non-artemisinin therapy (nAT), artemisinin monotherapy (AMT) and artemisinin-based combination

therapy (ACT).

- ACTs were further sub-divided into QAACTs and nQAACTs. QAACTs are ACTs that comply

with the Global Fund’s Quality Assurance Policy. For the purpose of the Independent

Evaluation, a QAACT is any ACT which appeared on the Global Fund's indicative list of

antimalarials meeting the Global Fund's quality assurance policy prior to baseline or endline

data collection

(see http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General), or

which previously had C-status in an earlier Global Fund quality assurance policy and was

used in a program supplying subsidized ACTs. At endline, QAACTs were defined as any ACT

which appeared on the Global Fund’s indicative list of antimalarials meeting its quality

assurance policy as at September 2011, or which previously had C-status in an earlier Global

Fund quality assurance policy and was used in a program supplying subsidized ACTs. A list of

all ACTs qualifying as QAACTs at the time of the endline survey is included in Appendix 8.2.

- ACTs were further sub-divided into First-line Quality-assured ACTs (FAACTs) and Non-first-

line Quality-assured ACTs (NAACTs), and nationally registered antimalarials, which are

relevant for national policy (WHO, 2010b). FAACTs are government recommended first-line

ACTs (i.e. AL in Uganda) for uncomplicated malaria meeting the quality-assured definition.

NAACTs are ACTs that are not the government’s recommended first-line treatment for

uncomplicated malaria (i.e., AL in Uganda), but which do meet the quality-assured

definition. FAACTs and NAACTs are only presented for the ACTwatch indicators.

- ACTs were also classified as nationally registered ACTs. Nationally registered ACTs are ACTs

registered with a country’s national drug regulatory authority and permitted for sale or

distribution in-country. Each country determines its own criteria for placing a drug on its

nationally registered listing. A list of nationally registered ACTs at the time of data collection

is given in appendix 8.8.Nationally registered ACTs are only presented for the ACTwatch

indicators.

- AMT were further classified into oral and non-oral AMT, to distinguish between non-oral

AMT, which are recommended for treatment of severe malaria, versus oral AMT, which are

targeted for removal from the market as a key policy goal.

- nATs were further classified into chloroquine, sulfadoxine-pyrimethamine, quinine,

amodiaquine or other nATs that may be found in the dataset (e.g., Halofantrine). These

categories are only presented for the ACTwatch indicators.


www.ACTwatch.info

61 | P a g e

Calculation of antimalarial volumes, prices and markups

Antimalarial volume and price data are reported in terms of adult equivalent treatment doses

(AETDs) using an AETD calculator developed by ACTwatch with some modifications (Shewchuk,

O'Connell et al. 2011). An AETD is defined as the number of milligrams (mg) of an antimalarial drug

needed to treat a 60 kg adult (refer to Appendix 8.7 for details). The number of mg/kg used to

calculate one AETD was defined as what was recommended for a particular drug in the treatment

guidelines for uncomplicated malaria in areas of low drug resistance issued by WHO (as of 5 April

2011). Where WHO treatment guidelines did not exist, such as for Halofantrine (Halfan), or

Dihydroartemisinin, AETDs were based on the product manufacturer’s treatment guidelines. In the

case of ACTs, which have two or more active antimalarial ingredients packaged together (either co-

formulated or co-blistered), the strength of the artemisinin-based component was used as the basis

for the AETD calculations. Information collected on the medicine strength and unit size, as listed on

the product packaging, was then used to calculate the number of AETDs contained in each unit.

Market share was calculated by dividing the number of AETDs of a particular antimalarial category

sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked

antimalarials, but some or all sales volumes were missing, we did not impute for missing values.

Price data are reported using median and inter-quartile range (IQR), which are appropriate for

describing distributions likely to be skewed. There are some differences in the exchange rate that

was used for ACTwatch and the IE.

For ACTwatch, price data were collected in local currencies and converted to their USD

equivalent using the average interbank rate for the period of data collection (USD =

2514.83UGX, source: www.oanda.com).

For the IE, price data were collected in local currencies and adjusted to 2010 prices in order

to facilitate comparisons to baseline estimates, which were adjusted to 2010 prices for all

pilots. Prices were adjusted using the ratio of the average national consumer price index for

2011 to the national average consumer price index for 2010 (IMF, International Financial

Statistics). These 2010 prices were then converted to their USD equivalent using the average

interbank rate for 2010 (USD = UGX2153.61, source www.oanda.com).

Retail gross percentage markups were calculated for each product as the difference between selling

price and purchase price, divided by purchase price. In cases where an outlet received an

antimalarial for free from its supplier and distributes the product for free, the retail markup was set

to 0%. In cases where an outlet received an antimalarial for free from its supplier, but does not

distribute the product for free, the retail markup was set to missing. The tables that present markup

data indicate the number of observations set to missing for this reason.

http://www.oanda.com/

www.ACTwatch.info

62 | P a g e

3. Results- Outlet survey

3.1 Characteristics of the sample

Throughout the document, reference will be made to the letters in this flow diagram (A to E) as a

reminder of which subset of outlets a given table is referring to.

Figure 3.1. 1: Survey flow diagram, [Uganda], 2011

*Enumerated means were visited and filled in at a minimum basic descriptive information (sections C1-C9 of

questionnaire) **Interviewed means that final interview status was ‘completed’ or ‘partially completed ‘but had stock in previous 3 months ***Outlets with no antimalarials in stock on day of visit but had stock in previous 3 months

Eligible respondent not available / Time not convenient for interview

Outlet not open at the time [ ] Outlet closed permanently [ ] Other [ ] Refused [ ]

Eligible respondent not available / Time not convenient for interview [ ]

Outlet not open at the time [ ]

Other [ ]

Refused [ ]

A

B

C

D

E

Outlets not screened

[314]

Outlets enumerated* [16,521]

Outlets screened [16,207]

Outlets which did not meet screening criteria

[12,922]

Outlets which met screening criteria

1=[3,195] or 2=[90]

Outlets not interviewed

[58]

Outlets interviewed** [3,227]

Outlets with no antimalarials in stock

on day of visit***

[89] Outlets with antimalarials in stock

on day of visit

[3,138]

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

Interview interrupted [3]

[63]

[129]

[47]

[24]

[51]

[30]

[9]

[0]

[16]

www.ACTwatch.info

63 | P a g e

www.ACTwatch.info

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


Community Health Worker

Private not-for-

profit health facility

TOTAL Public / Not-

for-profit

Private for-profit

health facility


Itinerant drug vendor

TOTAL Private

for-profit

TOTAL Outlets

%

(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 that had: N=692 N=1021 N=43 N=1756 N=848 N=415 N=1213 N=11931 N=44 N=14451 N=16207

Antimalarials in stock at the time of survey visit

98.7 10.6 94.1 20.8 94.8 99.6 92.2 0.4 0.0 13.9 14.8

(96.4,99.6) (3.0,31.2) (76.7,98.7) (10.1,38.0) (91.0,97.0) (98.0,99.9) (88.4,94.9) (0.1,0.9) -- (12.4,15.5) (12.8,17.1)

Any ACT 90.7 5.9 81.4 15.5 85.2 99.6 63.5 0.3 0.0 10.4 11.0

(85.7,94.0) (1.7,18.9) (58.8,93.1) (8.1,27.6) (78.9,89.9) (98.0,99.9) (54.6,71.6) (0.1,0.9) -- (8.7,12.4) (9.2,13.1)

Quality-assured ACT (QAACT) 90.5 5.9 75.6 15.3 72.8 95.4 55.0 0.3 0.0 9.0 9.8

(85.5,93.9) (1.6,18.9) (53.9,89.1) (8.0,27.4) (67.9,77.1) (90.5,97.8) (47.2,62.6) (0.1,0.9) -- (7.6,10.7) (8.3,11.6)

First-line (FAACT) 90.5 5.9 75.6 15.3 68.9 92.4 53.7 0.3 0.0 8.7 9.5

(85.5,93.9) (1.6,18.9) (53.9,89.1) (8.0,27.4) (63.2,74.1) (85.7,96.1) (45.9,61.3) (0.1,0.9) -- (7.3,10.3) (8.0,11.3)

Non first-line (NAACT) 0.1 0.0 10.9 0.3 18.3 53.1 5.5 0.0 0.0 1.4 1.3

(<0.1,0.8) -- (4.4,24.6) (0.1,1.0) (15.1,22.0) (42.6,63.3) (4.0,7.7) -- -- (1.0,2.0) (0.9,1.8)

Any child QAACT

70.2 5.8 43.9 12.7 11.0 45.8 4.0 <0.1 0.0 1.0 2.6

(62.9,76.6) (1.6,18.9) (29.8,59.1) (6.3,23.9) (8.7,13.9) (37.0,54.7) (2.8,5.7) (0.0,0.1) -- (0.7,1.3) (1.8,3.7)

QAACTs with the AMFm logo 82.2 1.2 37.0 9.5 68.2 89.9 50.6 0.3 0.0 8.4 8.4

(76.5,86.8) (0.3,5.1) (22.8,53.8) (5.6,15.7) (62.3,73.5) (83.3,94.2) (42.0,59.1) (0.1,0.9) -- (6.9,10.1) (7.0,10.0)

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- -- -- -- -- -- --

Non-quality-assured ACT 5.8 <0.1 19.3 1.0 45.2 92.2 20.3 <0.1 0.0 4.5 4.0

(4.0, 8.4) (0.0, 0.2) (8.0, 39.5) (0.5, 2.2) (34.6, 56.3) (87.2, 95.4) (14.4, 27.9) (0.0,<0.1) -- (3.1, 6.4) (2.6,6.0)

Nationally Registered ACT 90.7 5.9 81.4 15.5 84.8 99.6 62.4 0.2 0.0 10.2 10.9

(85.7,94.0) (1.7,18.9) (58.8,93.1) (8.1,27.6) (78.1,89.7) (98.0,99.9) (53.1,70.8) (0.1,0.7) -- (8.5,12.3) (9.0,13.0)

Any non-artemisinin therapy 94.6 <0.1 94.0 11.0 91.7 99.1 87.8 0.1 0.0 12.9 12.6

(92.0, 96.3) (0.0, 0.2) (76.5, 98.7) (6.4,18.3) (88.1, 94.3) (97.4, 99.7) (83.5, 91.1) (0.1, 0.3) -- (11.4,14.5) (11.0,14.4)

Sulfadoxine-pyrimethamine (SP) 87.8 <0.1 70.4 9.8 58.8 78.8 44.0 <0.1 0 7.1 7.4

(84.3, 90.6) (0.0, 0.2) (56.7, 81.2) (5.8,16.1) (52.7, 64.7) (71.1, 84.8) (35.4, 52.9) (0.0, 0.1) -- (5.8,8.7) (6.1,8.9)

Chloroquine (CQ) 1.6 0.0 3.6 0.2 13.0 50.0 17.1 0.1 0.0 2.4 2.1

(0.7, 3.5) -- (0.4, 23.8) (0.1,0.6) (10.2, 16.3) (39.3, 60.8) (13.2, 21.9) (0.0, 0.3) -- (1.9,3.1) (1.7,2.7)

Oral Quinine 41.3 0.0 70.4 5.5 78.4 97.3 79.8 0.1 0.0 11.6 10.6

(36.3, 46.5) -- (47.8, 86.1) (3.3,9.2) (73.3, 82.7) (94.2, 98.8) (74.5, 84.2) (0.0, 0.3) -- (10.2,13.2) (9.2,12.2)

Quinine Injection (IM/IV)**§ 47.4 0.0 77.8 6.3 73.1 80.9 29.3 0.0 0.0 6.1 6.1

(42.0, 52.9) -- (44.3, 93.9) (3.7, 10.5) (69.1, 76.7) (72.9, 86.9) (23.7, 35.7) -- -- (4.9, 7.5) (5.0, 7.4)

www.ACTwatch.info

Amodiaquine 0.0 0.0 0.0 0.0 5.6 1.0 5.2 0.0 0.0 0.8 0.7

-- -- -- -- (4.1, 7.7) (0.4, 2.5) (3.6, 7.5) -- -- (0.5, 1.0) (0.5,0.9)

Other† 0.0 0.0 0.8 <0.1 1.8 37.4 0.4 0.0 0.0 0.2 0.2

-- -- (0.1, 5.2) (0.0, 0.1) (1.1, 3.0) (28.4, 47.4) (0.2, 0.9) -- -- (0.1, 0.3) (0.1,0.3)

Any artemisinin monotherapy 4.2 7.5 33.1 7.9 29.0 75.8 4.3 0.0 0.0 1.8 2.6

(2.8, 6.3) (2.1, 23.9) (16.0, 56.1) (2.6,21.4) (24.3, 34.3) (67.2, 82.7) (2.8, 6.6) -- -- (1.2,2.6) (1.7,4.1)

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.1 0 0.0 0.0 0.0 <0.1 <0.1

-- -- -- -- (0.0, 0.8) -- -- -- -- (0.0, <0.1) (0.0,<0.1)

Non oral artemisinin monotherapy

4.2 7.5 33.1 7.9 29.0 75.8 4.3 0.0 0.0 1.8 2.6

(2.8, 6.3) (2.1, 23.9) (16.0, 56.1) (2.6,21.4) (24.3, 34.3) (67.2, 82.7) (2.8, 6.6) -- -- (1.2,2.6) (1.7,4.1)

Artesunate IV/IM*§

<0.1 0.0 0.0 <0.1 0.5 0.7 0.0 0.0 0.0 <0.1 <0.1

(0.0, 0.2) -- -- (0.0,<0.1) (0.1, 1.6) (0.1, 3.8) -- -- -- (<0.1,0.1) (<0.1,0.1)

Rectal Artesunate*§

0.3 7.5 0.0 6.7 0.1 1.7 0.0 0.0 0.0 <0.1 0.9

(0.0, 1.9) (2.1, 23.9) -- (1.9,21.2) (0.0, 0.6) (0.7, 4.1) -- -- -- (0.0,<0.1) (0.3,3.1)

Artemether IV/IM **§

4 0.0 33.1 1.2 28.6 75.4 4.3 0.0 0.0 1.8 1.7

(2.7, 5.8) -- (16.0, 56.1) (0.6,2.5) (23.9, 33.9) (66.8, 82.4) (2.7, 6.6) -- -- (1.2,2.6) (1.2,2.4)

Artemotil IV/IM **§

0.0 0.0 3.7 0.1 1.4 7.0 <0.1 0.0 0.0 0.1 0.1

-- -- (0.7, 18.4) (<0.1,0.7) (0.7, 2.9) (3.5, 13.4) (0.0, 0.2) -- -- (<0.1,0.2) (<0.1,0.2) Any treatment for severe malaria (artesunate IV/IM/rectal, quinine IV/IM,

artemether IV/IM, artemotilIV/IM)

47.9 7.5 77.8 13.0 75.6 87.2 30.1 0.0 0.0 6.4 7.2

(42.5, 53.3) (2.1, 23.9) (44.3, 93.9) (6.0,25.9) (71.7, 79.1) (79.3, 92.4) (24.6, 36.3) -- --

(5.1,7.8) (5.8,8.9)

Source: ACTwatch Outlet Survey, UGANDA, 2011.

†This category includes Atovaquone+Progruanil, Hydroxychloroquine, Mefloquine and Primaquine *WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children (Guidelines for the treatment of malaria, 2

nd edition – revisions 1].

**Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available (Guidelines for the treatment of malaria, 2nd

edition – revisions 1]. §

If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.

www.ACTwatch.info

Table A.2: Availability of antimalarials, by public health facility outlet type

National /Regional Hospital

District Hospital

Health centre IV

Health centre III

Health centre II

Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=51 N=30 N=56 N=261 N=294 N=692


92.3 97.5 94.9 99.1 99.6 98.7

(72.2,98.2] (84.2,99.6] (83.2,98.6] (93.9,99.9] (97.9,99.9] (96.4,99.6]

Any ACT 89.0 83.0 77.2 87.0 96.8 90.7

(59.9, 97.8) (68.3, 91.7) (58.6, 89.0) (79.7, 92.0) (93.1, 98.5) (85.7,94.0]

Quality-assured ACT (QAACT) 88.0 80.4 77.2 87.0 96.8 90.5

(61.7, 97.1) (63.6, 90.7) (58.6, 89.0) (79.7, 92.0) (93.1, 98.5) (85.5,93.9]

First-line (FAACT) 88.0 80.4 77.2 87.0 96.8 90.5

(61.7, 97.1) (63.6, 90.7) (58.6, 89.0) (79.7, 92.0) (93.1, 98.5) (85.5,93.9]

Non first-line (NAACT) 0.0 0.0 1.6 0.0 0.0 0.1

-- -- (0.2, 9.4) -- -- (<0.1,0.8]

Any child QAACT

36.2 59.2 58.8 62.5 82.0 70.2

(19.7, 56.7) (41.8, 74.5) (43.5, 72.5) (53.2, 71.0) (71.8, 89.1) (62.9,76.6]

QAACTs with the AMFm logo

41.0 68.7 66.0 80.3 90.7 82.2

(16.4, 71.1) (47.8, 84.0) (50.5, 78.6) (73.0, 86.1) (85.7, 94.0) (76.5,86.8]

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- --

Non-quality-assured ACT 72.7 54.6 0.5 1.0 1.1 5.8

(48.6, 88.3) (37.7, 70.5) (0.1, 3.1) (0.2, 4.1) (0.4, 3.0) (4.0, 8.4)

Nationally Registered ACT 89.0 83.0 77.2 87.0 96.8 90.7

(59.9, 97.8) (68.3, 91.7) (58.6, 89.0) (79.7, 92.0) (93.1, 98.5) (85.7,94.0]

Any non-artemisinin therapy 78.3 92.2 92.9 97.3 94.0 94.6

(65.2, 87.4) (78.2, 97.5) (82.4, 97.4) (93.6, 98.9) (89.5, 96.6) (92.0, 96.3)

Sulfadoxine-pyrimethamine (SP) 53.5 74.6 73.2 89.6 92.4 87.8

(42.8, 63.9) (50.9, 89.3) (56.8, 85.0) (85.3, 92.8) (87.6, 95.4) (84.3, 90.6)

Chloroquine 9.9 18.7 4.1 0.1 0.0 1.6

(2.3, 33.5) (5.8, 46.0) (1.1, 14.4) (0.0, 0.5) -- (0.7, 3.5)

Oral Quinine 55.7 85.7 60.3 73.2 6.1 41.3

(31.2, 77.7) (72.5, 93.2) (45.4, 73.5) (65.0, 80.1) (3.3, 10.8) (36.3, 46.5)

Quinine Injection (IM/IV) 73.4 54.6 0.5 1.0 1.2 47.4

(48.3, 89.1) (37.7, 70.5) (0.1, 3.1) (0.2, 4.2) (0.4, 3.2) (42.0, 52.9)

Amodiaquine 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- --

Other† 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- --

Any artemisinin monotherapy 35.3 22.3 23.4 0.0 0.6 4.2

(27.2, 44.4) (9.1, 45.3) (14.4, 35.8) -- (0.1, 4.0) (2.8, 6.3)

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- --


35.3 22.3 23.4 0.0 0.6 4.2

(27.2, 44.4) (9.1, 45.3) (14.4, 35.8) -- (0.1, 4.0) (2.8, 6.3)

ArtesunateIV/IM 0.9 0.0 0.0 0.0 0.0 <0.1

(0.2, 4.0) -- -- -- -- (0.0, 0.2)

Rectal Artesunate 0.0 0.0 0.0 0.0 0.6 0.3

-- -- -- -- (0.1, 4.0) (0.0, 1.9)

Artemether IV/IM 35.3 22.3 23.4 0.0 0.0 4.0

(27.2, 44.4) (9.1, 45.3) (14.4, 35.8) -- -- (2.7, 5.8)

Artemotil IV/IM 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- --

Any treatment for severe malaria (artesunate IV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

49.0 58.4 79.7 75.9 18.3 47.9

(36.3, 61.8) (40.1, 74.6) (64.8, 89.4) (67.8, 82.5) (11.8, 27.3) (42.5, 53.3)


†This category includes Atovaquone+Progruanil, Hydroxychloroquine, Mefloquine and Primaquine

www.ACTwatch.info

Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type



Private not-for-profit health facility

TOTAL Public / Not-

for-profit

Private for-profit

health facility Pharmacy Drug store

General retailer


TOTAL Private

for-profit

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Among outlets with an antimalarial in stock, proportion of outlets that had:

N=678 N=84 N=41 N=803 N=807 N=399 N=1112 N=18 N=0 N=2336 N=3139

Any ACT 91.8 55.4 86.6 74.7 89.8 100 69 75.6 0.0 75.6 75.4

(88.0, 94.5) (27.8, 80.0) (71.2, 94.4) (53.7,88.3) (85.2, 93.1) -- (61.2, 75.8) (38.9, 93.8) -- (67.7,82.1) (68.4,81.3)

Quality-assured ACT (QAACT)

91.7 55.2 80.4 73.9 76.6 95.8 59.7 73.7 0.0 62.5 67.1

(87.9, 94.4) (27.8, 79.8) (62.5, 91.0) (53.3,87.4) (72.8, 80.1) (90.7, 98.1) (52.6, 66.5) (36.6, 93.1) -- (59.2,71.3) (61.1,72.7)

First-line (FAACT) 91.7 55.2 80.4 73.9 72.6 92.8 58.3 73.7 0.0 63.3 65.4

(87.9, 94.4) (27.8, 79.8) (62.5, 91.0) (53.5,87.4) (67.7, 77.0) (85.8, 96.4) (51.1, 65.1) (36.6, 93.1) -- (56.9,69.2) (59.4,70.9)

Non first-line (NAACT) 0.1 0.0 11.6 1.4 19.3 53.3 6.0 0.0 0.0 10.4 8.6

(0.0, 0.9) -- (4.3, 27.7) (0.4,4.9) (16.1, 22.9) (42.8, 63.5) (4.4, 8.2) -- -- (8.0,13.4) (6.2,11.9)

Any child QAACT

71.1 55.0 46.7 71.1 11.6 45.9 4.4 3.3 0.0 7.1 17.8

(64.0, 77.3) (27.7, 79.6) (31.7, 62.3) (64.0, 77.3) (9.1, 14.7) (37.2, 54.9) (3.0, 6.2) (0.4, 23.8) -- (5.4,9.2) (13.4,23.1)

--


83.3 11.2 39.3 45.7 71.8 90.3 54.9 72.6 0.0 60.7 57.7

(78.2, 87.3) (5.0, 23.2) (24.1, 56.8) (29.2,63.1) (67.0, 76.2) (83.5, 94.5) (46.8, 62.7) (35.4, 92.8) -- (53.4,67.5) (50.4,64.7)

Other subsidised QAACT

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- -- -- -- -- -- --

Non-quality-assured ACT 6.0 0.2 20.8 5.1 52.6 98.1 25.4 1.9 0.0 33.8 28.1

(4.1, 8.8) (0.0, 2.0) (8.9, 41.2) (2.3, 10.6) (41.5, 63.5) (95.1, 99.3) (18.7, 33.4) (0.2, 14.3) -- (24.3,44.9) (19.2,39.2)

Nationally Registered ACT 91.8 55.4 86.6 74.7 89.3 100 67.7 63.9 0.0 74.3 74.4

(88.0, 94.5) (27.8, 80.0) (71.2, 94.4) (53.7,88.3) (84.4, 92.8) -- (59.4, 75.1) (42.8, 80.7) -- (65.9,81.3) (67.1,80.6)

Any non-artemisinin therapy 95.8 0.2 100 53.0 96.6 99.5 95.3 42.2 0.0 94.6 86.4

(93.7, 97.2) (0.0, 2.0) -- (27.3,77.2) (95.2, 97.5) (97.9, 99.9) (93.1, 96.9) (21.6, 66.0) -- (92.2,96.3) (74.3,93.3)

Sulfadoxine-pyrimethamine (SP)

88.9 0.2 74.8 47.2 62 79.1 47.8 9.7 0.0 51.1 50.7

(85.8, 91.4) (0.0, 2.0) (57.9, 86.6) (25.3,70.3) (56.2, 67.4) (71.3, 85.1) (39.2, 56.5) (1.7, 40.9) -- (43.4,59.6) (43.1,58.2)

Chloroquine 1.6 0.0 3.8 1.1 13.7 50.2 18.6 18.6 0.0 17.7 14.4

(0.7, 3.6) -- (0.5, 24.9) (0.4,3.2) (10.9, 17.0) (39.4, 61.0) (14.4, 23.7) (8.2, 37.0) -- (14.2,21.9) (11.8,17.5)

Oral Quinine 41.8 0.0 74.9 26.6 82.6 97.7 86.6 25.6 0.0 84.3 72.9

(36.8, 47.0) -- (53.6, 88.5) (15.0,42.8) (78.7, 85.9) (94.5, 99.1) (83.4, 89.3) (14.3, 41.5) -- (81.5,86.7) (64.5,79.9)

Quinine Injection (IM/IV) 48.0 0.0 82.8 30.2 77.0 81.2 31.9 0.0 0.0 44.7 41.9

(42.5, 53.6) -- (54.9, 95.0) (17.0,47.8) (73.9, 79.8) (73.2, 87.2) (25.6, 38.9) -- -- (38.9,50.8) (35.1,48.9)

Amodiaquine 0.0 0.0 0.0 0.0 5.9 1.0 5.7 0.0 0.0 5.6 4.5

-- -- -- -- (4.3, 8.1) (0.4, 2.6) (4.0, 8.1) -- -- (4.2, 7.4) (3.5,5.7)

www.ACTwatch.info

Table A.3: Availability of antimalarials among outlets stocking at least one antimalarial, by outlet type




TOTAL Public / Not-

for-profit

Private for-profit


General retailer


TOTAL Private

for-profit

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Other† 0.0 0.0 0.8 0.1 1.9 37.6 0.4 0.0 0.0 1.5 1.2

-- -- (0.1, 5.5) (0.0, 0.7) (1.1, 3.2) (28.5, 47.6) (0.2, 1.0) -- -- (1.1, 1.9) (0.8,1.7)

Any artemisinin monotherapy 4.3 71.0 35.2 37.9 30.6 76.1 4.7 0.0 0.0 13.1 18.0

(2.9, 6.3) (53.5, 83.9) (17.8, 57.6) (20.9,58.6) (25.8, 35.8) (67.4, 83.0) (3.0, 7.1) -- -- (9.5,17.8) (12.8,24.7)


0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 <0.1 <0.1

-- -- -- -- (0.0, 0.9) -- -- -- -- (<0.1,0.2) (<0.1,0.2)


4.3 71.0 35.2 37.9 30.6 76.1 4.7 0.0 0.0 13.1 18.0

(2.9, 6.3) (53.5, 83.9) (17.8, 57.6) (20.9,58.6) (25.8, 35.8) (67.4, 83.0) (3.0, 7.1) -- -- (9.5,17.8) (12.8,2.7)

ArtesunateIV/IM <0.1 0.0 0.0 0.01 0.5 0.7 0.0 0.0 0.0 0.2 0.1

(<0.1, 0.2) -- -- (<0.1,0.1) (0.1, 1.7) (0.1, 3.8) -- -- -- (<0.1,0.1) (<0.1,0.4)

Rectal Artesunate 0.3 71.0 0.0 32.2 0.1 1.7 0 0.0 0.0 0.05 6.4

(0.0, 1.9) (53.5, 83.9) -- (14.3,57.5) (0.0, 0.7) (0.7, 4.1) -- -- -- (<0.1,0.2) (2.0,18.6)

Artemether IV/IM 4.0 0.0 35.2 5.7 30.2 75.7 4.6 0.0 0.0 13.0 11.5

(2.7, 5.9) -- (17.8, 57.6) (2.7,11.8) (25.4, 35.4) (67.1, 82.7) (3.0, 7.1) -- -- (9.4,17.6) (8.1,16.1)

Artemotil IV/IM 0.0 0.0 4.0 0.5 1.5 7.0 <0.1 0.0 0.0 0.6 0.5

-- -- (0.7, 19.1) (0.1,3.2) (0.7, 3.1) (3.5, 13.4) (<0.1, 0.2) -- -- (0.3,1.0) (0.3,1.0)

Any treatment for severe malaria (artesunate IV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

48.5 71 82.8 62.5 79.6 87.5 32.7 0.0 0.0 46.2 49.4

(43.1, 54.0) (53.5, 83.9) (54.9, 95.0) (52.2,71.9) (76.5, 82.4) (79.6, 92.7) (26.6, 39.5) -- -- (40.0,52.5) (44.3,54.6)

Source: ACTwatchOutlet Survey, UGANDA, 2011.

www.ACTwatch.info

7 Information on expired stock was missing for 0.3% of cases [n=3,129]. 8 Information on acceptable storage condition was unavailable or missing for 2.1% of cases [n=3159].

Table A. 4: Disruption in stock, expiry and storage conditions of antimalarials, by outlet type



Private not-for-


TOTAL Public / Not-for-

profit

Private for-profit

health facility



TOTAL Private

for-profit

TOTAL Outlets

%

(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 that had: N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=0 N=2397 N=3227

No disruption in stock in the past 3 months 35.6 9.9 20.8 21.2 12.7 20.5 13.9 27.9 -- 14.1 15.5

(29.3,42.5) (5.0,18.6) (11.1,35.5) (14.0,30.9) (10.2,15.9) (14.7,27.9) (11.5,16.7) (18.9,39.2) (12.2,16.2) (13.8,17.5)

N=645 N=105 N=35 N=785 N=711 N=386 N=888 N=14 N=0 N=1,999 N=2,784 No disruption in stock of quality-assured ACT (QAACT) in the past 3 months, among outlets that have stocked QAACT in the past 3 months

44.3 10.5 50.6 27.5 46.3 63.0 38.9 31.8 -- 41.4 38.0

(36.3, 52.5) (5.0, 20.9) (31.9, 69.2) (16.6, 41.8) (41.0, 51.6) (53.2, 71.8) (34.4, 43.6) (24.6, 39.8) (37.5, 45.4) (32.7, 43.5)

N=645 N=105 N=35 N=785 N=682 N=380 N=875 N=14 N=0 N=1951 N=2736 No disruption in stock of first-line quality-assured ACT (FAACT) in the past 3 months, among outlets that have stocked FAACT in the past 3 months

44.3 10.5 50.6 27.5 46.2 63.0 38.9 31.8 -- 41.4 37.9

(36.3,52.5) (5.0,20.9) (31.9,69.2) (16.6,41.8) (40.9,51.6) (53.2,71.8) (34.4,43.6) (24.6,39.8) (37.4,45.4) (32.7,43.5)

N=678 N=84 N=39 N=801 N=806 N=400 N=1113 N=18 N=0 N=2337 N=3138

Expired stock of any antimalarial7

1.5 0.5 0.0 0.6 3.5 7.2 2.0 0.0 -- 0.4 0.4

(0.8, 2.8) (0.1, 2.3) -- (0.2, 1.9) (2.3, 5.2) (4.0, 12.5) (1.1, 3.6) -- (0.3, 0.6) (0.3, 0.6)

N=617 N=53 N=33 N=703 N=625 N=383 N=719 N=11 N=0 N=1,738 N=2,441

Expired stock of QAACT 1.2 17.4 0.0 6.6 0.4 1.2 0.1 0.0 -- 0.2 0.9

(0.4, 3.6) (4.9, 46.6) -- (2.4, 17.2) (0.2, 1.1) (0.4, 3.2) (0.0, 0.4) -- (0.1, 0.4) (0.4, 1.9)

N=617 N=53 N=33 N=703 N=586 N=373 N=700 N=11 N=0 N=1670 N=2373

Expired stock of FAACT 0.6 9.1 0 3.5 0.4 0.1 0.2 0.0 -- 0.3 1.0

(0.2, 1.9) (2.3, 29.7) -- (1.2,9.5) (0.2, 1.1) (0.0, 0.5) (0.0, 0.6) -- (0.1,0.5) (0.4,2.1)

N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=0 N=2397 N=3227

Acceptable storage conditions for medicines

8

98.6 100 99.4 99.3 95.8 99.8 96.9 89.7 -- 96.5 97.1

(97.2, 99.3) -- (96.4, 99.9) (98.7,99.7) (90.4, 98.2) (98.7, 100.0) (94.2, 98.4) (65.3, 97.6) (93.9,98.0) (94.9,98.3)

Source: ACTwatch Outlet Survey, UGANDA, 2011

www.ACTwatch.info

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




TOTAL Public / Not-

for-profit

Private for-profit


General retailer


TOTAL Private

for-profit

TOTAL Outlets

% % % % % % % % % % %

Proportion of first-line quality-assured ACT (FAACT) distributed free of cost (by volumes of AETDs)

99.7 94.6 50.3 95.9 2.9 0.0 0.0 0.0 -- 1.1 63.1

Median price of a tablet AETD:9

Median [IQR] (N of Antimalarials)











Quality-assured ACT (QAACT) $0.00 $0.00 $0.00 $0.00 $2.01 $1.34 $1.61 $1.01 -- $1.68 $1.17

[0.00-0.00] (1,964) [0.00-0.00] (81) [0.00-1.01] (85) [0.00-0.00] (2,130) [1.34-3.02] (1,028) [0.67-2.01] (1,251) [1.01-2.18] (999) [0.80-2.01] (13) [1.01-2.41] (3,291) [0.00-2.01] (5,421)

First-line (FAACT) $0.00 $0.00 $0.00 $0.00 $2.01 $1.01 $1.61 $1.01 -- $1.68 $1.01

[0.00-0.00] (1,963) [0.00-0.00] (81) [0.00-1.01] (80) [0.00-0.00] (2,124) [1.34-2.68] (748) [0.67-1.68] (875) [1.01-2.01] (828) [0.80-2.01] (13) [1.01-2.35] (2,464) [0.00-2.01] (4,588)


$0.00 $0.00 $0.84 $0.00 $2.01 $1.01 $1.61 $1.01 -- $1.68 $1.34

[0.00-0.00] (1,477) [0.00-0.00] (9) [0.00-1.34] (18) [0.00-0.00] (1,504) [1.34-3.02] (934) [0.67-1.68] (980) [1.01-2.01] (907) [0.80-2.01] (11) [1.01-2.41] (2,832) [0.40-2.01] (4,336)

Other subsidised QAACT $-- $-- $-- $-- $-- $-- $-- $-- -- $-- $--

--(0) --(0) --(0) --(0) --(0) --(0) --(0) --(0) --(0) --(0)

Child QAACT $0.0000 $0.00 $0.00 $0.00 $1.01 $0.50 $0.67 $0.00 -- $0.67 $0.00

[0.00-0.00](394) [0.00-0.00](48) [0.00-0.00](19) [0.00-0.00](556) [0.50-1.68](87) [0.34-0.67](171) [0.24-1.01](54) [n/a](1) [0.34-1.01](313) [0.00-0.20](869)

Non-quality-assured ACT $0.00 $1.68 $3.77 $1.34 $3.35 $4.02 $2.68 $0.67 -- $3.35 $3.35

[0.00-0.00] (89) [n/a] (1) [1.68-6.03] (18) [0.00-4.02] (108) [2.41-5.03] (730) [2.68-6.70] (1,842) [2.01-4.02] (525) [n/a] (1) [2.35-5.03] (3,098) [2.18-5.03] (3,206)

Sulfadoxine-pyrimethamine (SP)

$0.00 $ $0.20 $0.00 $0.50 $0.50 $0.50 $0.50 -- $0.50 $0.50

[0.00-0.00] (677) [-] (0) [0.00-0.50] (30) [0.00-0.00] (707) [0.50-0.67] (529) [0.44-0.50] (369) [0.40-0.67] (616) [0.50-0.67] (3) [0.50-0.67] (1,517) [0.30-0.67] (2,224)

Chloroquine $0.00 $ $0.32 $0.00 $0.67 $0.65 $0.65 $0.49 -- $0.65 $0.65

[0.00-0.00] (7) [-] (0) n/a] (1) [0.00-0.32] (8) [0.65-0.97] (90) [0.65-0.97] (162) [0.65-0.81] (155) [n/a] (1) [0.65-0.97] (408) [0.65-0.84] (416)


$-- $-- $-- $-- $16.75 $-- $-- $-- -- $16.75 $16.75

--(0) --(0) --(0) --(0) [n/a] (1) --(0) --(0) --(0) [n/a] (1) [n/a] (1)

Any treatment for severe malaria (artesunate IV/IM/rectal- quinine IV/IM, artemether IV/IM, artemotil IV/IM)

$0.00 $0.00 $9.65 $0.00 $14.17 $9.65 $8.72 $ -- $10.63 $9.65

[0.00-0.00] (441) [0.00-0.00] (57) [7.09-10.63] (53) [0.00-0.00] (551) [9.65-21.26] (877) [7.09-13.40] (827) [7.09-12.86] (373) [-] (0)

[7.09-16.08](2,077) [5.67-14.17](2,628)

Artesunate IV/IM $0.00 $ $ $0.00 $0.15 $0.71 $ $ $-- $0.15 $0.15

n/a] (1) [-] (0) [-] (0) [n/a] (1) [0.15-0.36] (3) [0.71-0.71] (4) [-] (0) [-] (0) --(0) [0.15-0.36] (7) [0.15-0.36] (8)

Quinine Injection IV/IM $0.00 $ $7.09 $0.00 $14.17 $7.09 $7.09 $ $-- $10.63 $10.63

[0.00-0.00] (399) [-] (0) [0.00-10.63] (35) [0.00-0.00] (434) [8.50-21.26] (592) [5.81-10.63] (372) [7.09-10.63] (315) [-] (0) --(0) [7.09-14.17](1,279) [7.09-14.17](1,713)


9 A total of 20,283 antimalarials were found in 3,138 outlets. Of these, 13,550 antimalarials are included in the pricing analysis; price indicators are based on tablet-formulation AETDs. Free antimalarials were found

in 25.1% of outlets with antimalarials, and 3,690 of the 19,774 antimalarials for which price information was recorded were available for free.

www.ACTwatch.info

www.ACTwatch.info

Table A. 6: Affordability of antimalarials, by outlet type




TOTAL Public / Not-

for-profit

Private for-profit


General retailer


TOTAL Private

for-profit

TOTAL Outlets

Median price of a tablet AETD relative to SP, the ‘most popular’ antimalarial treatment in Uganda:

Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio

Quality-assured ACT (QAACT) *** *** n/a *** 4.0 2.7 3.2 2.0 -- 3.4 2.3

QAACTs with the AMFm logo *** *** 4.2 *** 4.0 2.0 3.2 2.0 -- 3.4 2.7

First-line quality-assured ACT (FAACT)

*** *** n/a *** 4.0 2.0 3.2 2.0 -- 3.4 2.0

Median price of a tablet AETD relative to the minimum legal daily wage ($0.78)

10:

Ratio Ratio Ratio Ratio Ratio Ratio

Ratio Ratio Ratio Ratio

Quality-assured ACT (QAACT) n/a n/a n/a n/a 2.6 1.7 2.1 1.3 -- 2.2 1.5

QAACTs with the AMFm logo n/a n/a 1.1 n/a 2.6 1.3 2.1 1.3 -- 2.2 1.7

First-line quality-assured ACT (FAACT)

n/a n/a n/a n/a 2.6 1.3 2.1 1.3 -- 2.2 1.3

Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio Ratio

Median price of a first-line quality-assured tablet AETD relative to the international reference price ($1.42)

11

n/a n/a n/a n/a 1.4 0.7 1.1 0.7 -- 1.2 0.7

% % % % % % % % % % %

Proportion of outlets that: N=107 N=41 N=148 N=816 N=399 N=1158 N=24 N=0 N=2397 N=2545

Offer credit to consumers for antimalarials

12

-- 17.0 29.0 25.9 75.0 32.9 82.2 54.0 -- 78.6 77.3

(4.0,50.2) (13.8,51.0) (12.3,46.6) (71.0,78.7) (25.0,42.0) (78.6,85.2) (40.7,66.8) (75.4,81.6) (73.8,80.5)


10Minimum daily wage information taken from United States Department of State, 2010. Country Reports on Human Rights Practices. Available at: http://www.state.gov/g/drl/rls/hrrpt/2010/index.htm 11 International reference price taken from Management Sciences for Health, 2010. International drug price indicator guide. Available at: http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2010_en.pdf. $1.42 is the

median listed supplier price for 24 tablets of AL 20mg/120mg. 12 This question was not asked in Public Health Facilities. Information on outlets that offer credit to consumers for antimalarials was missing for 5.1% of cases [n=2415].

www.ACTwatch.info

Table A. 7: Availability of diagnostic tests patients, by outlet type




TOTAL Public / Not-

for-profit

Private for-profit

health facility



TOTAL Private

for-profit

TOTAL Outlets

%

(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 that had:13

N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=0 N=2397 N=3227

Any diagnostic test 74.9 70.2 95.6 74.6 54.5 30.5 7.1 0.0 -- 20.3 31.4

(69.2,79.9) (36.4,90.6) (76.8,99.2) (59.4,85.5) (49.1,59.8) (21.9,40.6) (5.0,9.9) -- -- (15.2,26.5) (24.5,39.2)

Microscopic blood tests 40.5 1.6 77.2 24.6 43.5 0.8 2.6 0.0 -- 13.7 16.0

(36.0,45.1) (0.3,8.4) (46.2,92.2 (13.9,39.9) (39.2,47.9) (0.2,4.0) (1.4,4.7) -- -- (10.0,18.6) (12.5,20.2)

Rapid diagnostic tests (RDTs) 53.0 70.2 51.3 61.5 20.8 30.1 4.6 0.0 -- 9.3 19.9

(44.7,61.2) (36.4,90.6 (29.2,72.9) (42.0,77.9) (16.0,26.6) (21.6,40.1) (3.1,6.7) -- -- (6.8,12.6) (12.9,29.5)

RDTs from a manufacturer that has submitted a product to WHO Malaria RDT Product Testing Rounds 1-3

50.0 70.2 29 57.9 15.1 11.1 3.6

0.0 -- 6.8

17.3

(41.9, 58.1) (36.4,90.6) (13.8,51.0) (37.3,76.0) (11.3,19.8) (6.8, 17.6) (2.3, 5.7) -- -- (5.0, 9.3) (10.1,27.8)

RDTs from a manufacturer that has not submitted a product to WHO Malaria RDT Product Testing Rounds 1-3

1.2 0.0 19.8 2.5 5.7 18.6 0.7

0.0 -- 2.3

2.4

(0.4, 3.2) -- (7.0, 44.8) (0.9, 7.1) (3.6, 8.8) (12.1, 27.4) (0.3, 1.5) -- -- (1.4, 3.9) (1.5,3.8)

Proportion of outlets that provided diagnostic tests for free, among outlets providing diagnostic tests

N=431 N=60 N=31 N=522 N=370 N=6 N=28 N=0 N=0 N=404 N=926

Any diagnostic test 98.2 100 14.7 90.3 0.6 0.0

--

8.1 -- --

1.7 51.5

(96.4, 99.1) -- (6.3, 30.7) (76.7, 96.4) (0.1, 4.8) (1.0, 42.1) (0.3, 8.1) (28.0, 74.4)

N=271 N=0 N=31 N=302 N=369 N=6 N=25 N=0 N=0 N=400 N=702

Microscopic blood tests 97.1 -- 14.7 71.7 0.6 0.0

--

0.0 -- --

0.5 22.4

(94.3, 98.5) (6.3, 30.7) (60.0, 81.0) (0.1, 4.8) -- (0.1, 4.1) (14.4,33.1)

13Information on proportion of outlets that had diagnostic tests was missing for 0.7% of cases [n=3204].

www.ACTwatch.info

N=177 N=60 N=1 N=238 N=4 N=0 N=3 N=0 N=0 N=7 N=245

Rapid diagnostic tests 100 100 100 100 0.0

-- 87.9

-- -- 60.5 99.2

-- -- -- -- -- (31.8,99.1) (14.1, 93.4) (96.6, 99.8)


www.ACTwatch.info

Table A8: Price of diagnostic tests patients, by outlet type




TOTAL Public / Not-

for-profit

Private for-profit


General retailer


TOTAL Private

for-profit

TOTAL Outlets

Median price of: Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Microscopic blood tests $0.00

[0.00, 0.00] (271)

$-- [n/a]

(0)

$0.34 [0.17,0.67]

(31)

$0.00 [0.00-0.17]

(302)

$0.67 [0.67-1.01]

(369)

$1.01 [0.67-1.01]

(6)

$0.34 [0.34,0.84]

(25)

$-- [n/a]

(0)

$-- [n/a]

(0)

$0.67 [0.67,1.01]

(400)

$0.67 [0.34,0.84]

(702)

Rapid diagnostic tests (RDTs) $0.00

[0.00, 0.00] (403)

$0.00 [0.00, 0.00]

(60)

$0.00 [0.00,0.67]

(17)

$0.00 [0.00-0.00]

(480

$1.01 [0.84-1.34]

(181)

$0.74 [0.67,0.84]

(108)

$0.67 [0.34, 1.01]

(60)

$-- [n/a]

(0)

$-- [n/a]

(0)

$1.01 [0.67, 1.01]

(349)

$0.00 [0.00, 0.67]

(829)


$0.00 [0.00, 0.00]

(391)

$0.00 [0.00, 0.00]

(60)

$0.00 [0.00,0.17]

(11)

$0.00 [0.00, 0.00]

(462)

$1.01 [0.84, 1.34]

(113)

$0.67 [0.60, 0.84]

(39)

$0.67 [0.34, 1.01]

(47)

$-- [n/a]

(0)

$-- [n/a]

(0)

$1.01 [0.67, 1.01]

(199)

$0.00 [0.00, 0.50]

(661)


$0.00 [0.00, 0.00]

(11)

$-- [n/a]

(0)

$1.34 [0.00,1.34]

(6)

$1.34 [0.00,1.34]

(17)

$1.01 [1.01, 1.34]

(59)

$0.84 [0.67,0.84]

(67)

$0.84 [0.67, 1.01]

(11)

$-- [n/a]

(0)

$-- [n/a]

(0)

$1.01 [0.74, 1.01]

(137)

$1.01 [0.67, 1.34]

(154)


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Table A.9: Availability of diagnostic tests, by public health facility outlet type

National /Regional Hospital

District Hospital

Health centre IV

Health centre III

Health centre II

Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=48 N=30 N=54 N=259 N=291 N=682

Any diagnostic test 56.8 81.6 88.8 86.7 63.4 74.9

(29.9, 80.2) (64.2, 91.6) (74.7, 95.5) (80.9, 91.0) (51.3, 73.9) (69.2,79.9)

Microscopic blood tests 57.4 81.6 84.4 70 3.7 40.5

(30.5, 80.5) (64.2, 91.6) (69.0, 92.9) (61.5, 77.3) (1.6, 8.2) (36.0,45.1)

Rapid diagnostic tests (RDTs) 0.0 21.4 19.3 55.6 62.5 53.0

-- (10.2, 39.4) (6.8, 43.8) (45.6, 65.2) (50.7, 72.9) (44.7,61.2)


0.0 11.7 14.4 51.8 61.3 50.0

-- (3.9, 30.3) (5.4, 33.3) (43.3, 60.2) (49.2, 72.2) (41.9, 58.1)


0.0 4 0.0 1.5 1.0 1.2

-- (0.6, 23.0) -- (0.4, 5.0) (0.3, 3.5) (0.4, 3.2)


14Information on proportion of outlets that had diagnostic tests was missing for 0.3% of cases [n=680].

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15There were a total of 55,814 AETDs(unweighted) sold or distributed in the past 7 days. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-quality-assured ACT; QAACT decompose fully into FAACT

and NAACT. Row and column totals exhibit minor rounding errors.


Table A.10: Market share, by outlet type

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed in the past week:

15




TOTAL Public / Not-

for-profit

Private for-profit


General retailer


TOTAL Private

for-profit

TOTAL Outlets

% % % % % % % % % % %

Any ACT 33.3 0.3 3.1 36.7 15.2 4.4 11.6 0.1 0.0 31.4 68.1

Quality-assured ACT (QAACT)

33.1 0.3 2.9 36.2 8.2 2.8 9.4 0.1 0.0 20.5 56.7

First-line (FAACT) 33.1 0.3 2.8 36.2 7.4 2.4 8.9 0.1 0.0 18.8 55.0

Non first-line (NAACT) 0.0 0.0 <0.1 <0.1 0.9 0.4 0.5 0.0 0.0 1.7 1.8


24.3 <0.1 1.0 25.4 7.0 2.5 8.4 0.1 0.0 18.0 43.3

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Non-quality-assured ACT 0.3 <0.1 0.2 0.5 7.0 1.7 2.2 0.0 0.0 10.9 11.4

Nationally Registered ACT 33.3 0.3 3.1 36.7 15.1 4.3

11.4 0.1 0.0 31.0 67.6

Any non-artemisinin therapy 7.4 0.0 2.6 9.9 9.0 2.0 10.4 0.1 0.0 21.5 31.4

SP 6.6 0.0 1.9 8.5 6.2 1.4 6.4 0.1 0.0 14.1 22.5

Chloroquine <0.1 0.0 <0.1 <0.1 0.3 0.2 1.0 <0.1 0.0 1.5 1.6

Oral Quinine 0.6 0.0 0.4 1.0 1.2 0.2 2.4 <0.1 0.0 3.9 4.9

Quinine Injection (IM/IV) 0.2 0.0 0.2 0.4 1.1 0.1 0.3 0.0 0.0 1.5 1.9

Amodiaquine 0.0 0.0 0.0 0.0 0.1 <0.1 0.3 0.0 0.0 0.4 0.4

Other† 0.0 0.0 0.0 0.0 <0.1 0.1 <0.1 0.0 0.0 0.1 0.1

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


<0.1 <0.1 <0.1 <0.1 0.4 0.1 <0.1 0.0 0.0 0.5 0.5

Artesunate IV/IM 0.0 0.0 0.0 0.0 0.2 <0.1 0.0 0.0 0.0 0.2 0.2 Rectal Artesunate 0.0 <0.1 0.0 <0.1 0.0 0.0 0.0 0.0 0.0 0.0 <0.1

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Artemether IV/IM <0.1 0.0 <0.1 <0.1 0.2 <0.1 <0.1 0.0 0.0 0.3 0.3

Artemotil IV/IM 0.0 0.0 0.0 0.0 <0.1 <0.1 0.0 0.0 0.0 <0.1 <0.1

Any treatment for severe malaria (artesunate iIV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

0.2 <0.1 0.3 0.4 1.5 0.1 0.3 0.0 0.0 2.0 2.4


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Table A.11: Provider knowledge, by outlet type




health facility

TOTAL Public / Not-

for-profit

Private for-profit

health facility



TOTAL Private

for-profit

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=0 N=2397 N=3227


16

95.4 92.5 93.0 93.7 80.4 92.0 73.8 24.6 -- 74.5 78.4

(92.6, 97.2) (86.8, 95.9) (76.7, 98.2) (90.5, 95.9) (76.1, 84.1) (87.9, 94.8) (69.5, 77.8) (6.4, 60.8) (69.6, 78.8) (73.6, 82.6)

Correctly state the dosing regimen of the first-line treatment for an adult

94.3 48.0 92.5 71.0 79.2 91.1 70.5 17.0 -- 71.6 71.5

(91.5, 96.2) (31.3, 65.1) (76.8, 97.9) (55.6, 82.7) (74.9, 82.9) (86.7, 94.1) (65.5, 75.0) (4.3, 48.2) (66.3, 76.4) (67.4, 75.3)

Correctly state the dosing regimen of the first-line treatment for a two-year old child

91.1 62.7 81.8 76.0 69.9 79.3 59.5 10.2 -- 61.3 64.3

(88.4, 93.2) (59.7, 65.6) (65.0, 91.6) (68.1, 82.4) (65.8, 73.7) (71.9, 85.1) (54.1, 64.8) (2.2, 36.3)

(55.9, 66.4) (60.2, 68.1)

N=107 N=41 N=148 N=816 N=399 N=1158 N=24 N=0 N=2397 N=2545

State at least one health danger sign in a child that requires referral to a public health facility

17:

95.4 59.7 89.2 70.8 87.4 75.4 71.6 -- 74.2 76.2

(92.7, 97.1) (35.0, 80.2) (79.7, 94.6) (63.2, 77.4) (82.2, 91.3) (71.5, 78.9) (53.1, 84.8) (70.5, 77.5) (72.0, 79.9)

Convulsions 87.5 50.9 81.1 47.7 62.1 47.4 22.3 -- 47.0 51.6

(84.8, 89.7) (27.5, 73.9) (70.2, 88.7) (40.8, 54.6) (54.3, 69.4) (42.3, 52.6) (12.2, 37.1) (43.0, 50.9) (45.2, 57.9)

Vomiting 57.0 22.2 50.9 31.2 46.6 38.5 49.2 -- 36.9 38.8

(37.4, 74.6) (8.9, 45.6) (36.0, 65.7) (24.5, 38.7) (35.7, 57.9) (33.6, 43.6) (38.9, 59.5) (32.2, 41.9) (34.2, 43.5)

Unable to drink/breastfeed 29.0 5.6 25 8.7 22.5 9.5 1.4 -- 9.2 11.3

(21.4, 38.2) (2.1, 14.2) (19.1, 32.0) (5.8, 12.8) (16.2, 30.4) (6.8, 13.1) (0.2, 10.8) (7.1, 11.9) (8.7, 14.7)

Excessive sleep/difficult to wake up

3.0 2.6 2.9 0.8 2.0 1.8 0.0 -- 1.5 1.7

(0.8, 10.4) (0.4, 16.5) (0.9, 8.6) (0.3, 2.0) (0.9, 4.8) (1.1, 3.0) -- (0.9, 2.3) (0.9, 2.9)

Unconscious/coma 22.0 15.0 20.8 24.3 16.2 18.1 0.0 -- 17.6 18.1

(13.8, 33.2) (7.7, 27.4) (13.6, 30.4) (17.4, 32.8) (13.3, 19.7) (6.7, 40.5) -- (14.8, 20.9) (15.3, 21.3)


16Information on proportion of providers that correctly state the recommended first-line treatment for uncomplicated malaria was missing for 0.1% of cases [n=3223]. 17This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for 0.3% of cases [n=2537]. Providers could state multiple responses and totals may sum

to more than 100%.

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Table A.12: Provider perceptions, by outlet type



Private not-for-


TOTAL Public / Not-

for-profit

Private for-profit

health facility



TOTAL Private

for-profit

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that: N=682 N=107 N=41 N=830 N=816 N=399 N=1158 N=24 N=0 N=2397 N=3227

Agree with the statement, “Customers often request an antimalarial by name.”

18

31.5 26.7 25.7 28.5 61.1 71.7 69.3 66.9 -- 67 59.1

(23.8, 40.3) (22.0, 32.1) (11.7, 47.4) (24.1, 33.4) (54.8, 67.1) (61.7, 79.9) (64.5, 73.6) (54.0, 77.7) (62.5, 71.2) (53.0, 64.9)

Agree with the statement, “I generally decide which antimalarial medicine customers receive.”

90.2 98.4 83.9 93.6 88.3 55.3 74.4 52 - 77.3 80.7

(85.7, 93.4) (92.9, 99.7) (65.3, 93.5) (87.2, 96.9) (84.4, 91.4) (41.5, 68.3) (68.2, 79.8) (28.5, 74.7) (71.1, 82.6) (74.3, 85.8)

Report that an ACT is the most effective antimalarial medicine for an adult

19

90.6 65.4 84.8 77.5 73.9 93.1 62.3 61.8 - 65.9 68.3

(86.9, 93.4) (40.5, 84.1) (70.8, 92.8) (63.5, 87.1) (68.6, 78.5) (86.3, 96.7) (55.7, 68.4) (50.8, 71.7)

(59.6, 71.8) (63.3, 72.9)

Report that an ACT is the most effective antimalarial medicine for a child

93.2 99.5 80.7 95.0 69.0 84.6 59.2 54.7 - 62.2 68.9

(91.1, 94.8) (95.5, 99.9) (60.1, 92.1) (90.0, 97.6) (64.4, 73.2) (75.7, 90.7) (52.9, 65.2) (37.2, 71.1)

(56.4, 67.6) (62.8, 74.3)


18Information on this pair of indicators was missing for 0.1% of cases [n=3224) 19Information on this pair of indicators was missing for 0.1% of cases [n=3224 ].

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Table A.13: Provider knowledge, by outlet type

National /Regional

Hospital District Hospital Health centre IV Health centre III Health centre II

TOTAL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=48 N=30 N=54 N=259 N=291 N=682


64.3 95.2 88.3 94.3 99.5 95.4

(60.2, 68.1) (80.5, 98.9) (71.5, 95.8) (82.9, 98.3) (96.3, 99.9) (92.6, 97.2)

Correctly state the dosing regimen of the first-line treatment for an adult

95.2 87.6 91.6 98.3 92.0 94.3

(80.5, 98.9) (71.1, 95.3) (78.8, 97.0) (95.3, 99.4) (87.6, 95.0) (91.5, 96.2)

Correctly state the dosing regimen of the first-line treatment for a two-year old child

77.3 75.0 88.4 96.3 89.8 91.1

(57.9, 89.4) (65.6, 82.5) (76.5, 94.7) (93.6, 97.9) (85.6, 92.9) (88.4, 93.2)


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Table A.14: Availability of antimalarials, by Endemicity

Low endemicity High endemicity

TOTAL Outlets

Public / Not-for-profit Private for-profit Total Public / Not-for-profit Private for-profit Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=265 N=7,688 N=7,953 N=1,491 N=6,763 N=8,254 N=16,207


40.2 13.6 14.4 19.2 14.1 15.1 14.8

(13.9,73.7) (10.6,17.3) (11.1, 18.4) (8.5,37.5) (12.6,15.7) (12.5,18.1) (12.8,17.1)

Any ACT 35.9 11.4 12.2 13.7 9.5 10.4 11.0

(112.1, 69.6) (8.5, 15.2) (9.1, 16.1) (6.7, 26.2) (8.1, 11.2) (8.6, 12.5) (9.2, 13.1)

Quality-assured ACT (QAACT) 35.6 9.7 10.5 13.6 8.4 9.4 9.8

(12.0, 69.1) (7.3, 12.7) (7.9, 13.7) (6.6, 25.9) (7.1, 9.9) (7.7, 11.4) (8.3,11.6)

First-line (FAACT) 35.6 9.1 9.9 13.6 8.3 9.3 9.5

(12.0, 69.1) (6.7, 12.3) (7.4, 13.2) (6.6, 25.9) (7.0,9.8) (7.6, 11.3) (8.0,11.3)

Non first-line (NAACT) 1.9 1.8 1.8 0.1 1.1 0.9 1.3

(0.5, 7.3) (1.1, 2.9) (1.1, 2.9) (<0.1, 0.9) (0.9, 1.5) (0.7, 1.3) (0.9,1.8)

Any child QAACT 25.3 1.2 1.9 11.6 0.8 3.0 2.6

(7.3, 59.4) (0.7, 1.9) (1.3, 2.9) (5.3, 23.5) (0.6, 1.2) (1.9, 4.6) (1.8,3.7)

QAACT with the AMFm logo 23.7 9.0 9.5 8.3 7.7 7.8 8.4

(10.3, 45.8) (6.6, 12.3) (7.0, 12.6) (4.7, 14.2) (6.4, 9.3) (6.6, 9.3) (7.0,10.0)

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- -- --

Non-quality-assured ACT 5.9 6.4 6.4 0.6 3.1 2.6 4.0

(1.6, 20.1) (4.1, 10.0) (4.0, 10.1) (0.3, 1.4) (2.4, 4.1) (1.9, 3.6) (2.6,6.0)

Nationally Registered ACT 35.9 11.0 11.8 13.7 9.5 10.3 10.9

(12.0, 69.6) (7.9, 15.2) (8.5, 16.2) (6.7, 26.2) (8.1, 11.1) (8.5, 12.4) (9.0,13.0)

Any non-artemisinin therapy 32.7 12.7 13.3 9.1 13 12.2 12.6

(13.5, 60.3) (9.7, 16.5) (10.2, 17.2) (5.2, 15.6) (11.7, 14.3) (10.7, 13.9) (11.0,14.4)

Sulfadoxine-pyrimethamine (SP) 28.3 8.2 8.9 8.2 6.2 6.6 7.4

(12.4, 52.4) (6.2, 10.9) (6.8, 11.5) (4.7, 13.9) (4.9, 7.6) (5.3, 8.1) (6.1,8.9)

Chloroquine <0.1 2.5 2.4 0.2 2.3 1.9 2.1

(0.0, 0.3) (1.9, 3.2) (1.9, 3.1) (0.1, 0.7) (1.6, 3.4) (1.3, 2.8) (1.7,2.7)

Oral Quinine 14.9 11.4 11.5 4.7 11.5 10.2 10.6

(8.3, 25.2) (8.6, 15.0) (8.7, 15.0) (2.7, 8.1) (10.4, 12.7) (8.9, 11.5) (9.2,12.2)

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Table A.14: Availability of antimalarials, by Endemicity


TOTAL Outlets


%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=265 N=7,688 N=7,953 N=1,491 N=6,763 N=8,254 N=16,207

Quinine Injection (IM/IV)**§

18.5 6.6 7.0 5.2 5.7 5.6 6.1

(9.1, 34.0) (4.6, 9.5) (4.9, 9.9) (3.0, 8.9) (4.7, 6.9) (4.7, 6.7) (5.0, 7.4)

Amodiaquine 0.0 0.7 0.7 0.0 0.8 0.6 0.7

-- (0.4, 1.2) (0.4, 1.2) -- (0.5, 1.2) (0.4, 1.0) (0.5,0.9)

Other† 0.0 0.2 0.2 <0.1 0.2 0.1 0.2

-- (0.2, 0.4) (0.2, 0.4) (0.0, 0.1) (0.1, 0.3) (0.1, 0.2) (0.1,0.3)

Any artemisinin monotherapy 7.2 2.3 2.4 7.9 1.5 2.7 2.6

(4.7, 10.8) (1.3, 3.9) (1.5, 4.0) (2.4, 23.1) (1.0, 2.1) (1.5, 5.0) (1.7,4.1)

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 <0.1 <0.1 <0.1

-- -- -- -- (0.0, 0.1) (0.0,<0.1) (0.0,<0.1)

Non oral artemisinin monotherapy 7.2 2.3 2.4 7.9 1.5 2.7 2.6

(4.7, 10.8) (1.3, 3.9) (1.5, 4.0) (2.4, 23.1) (1.0, 2.1) (1.5, 5.0) (1.7,4.1)

Artesunate IV/IM*§

<0.1 <0.1 <0.1 0.0 <0.1 <0.1 <0.1

(0.0, 0.3) (0.0, 0.1) (0.0, 0.1) -- (0.0, 0.1) (0.0, 0.1) (<0.1,0.1)


0.3 <0.1 <0.1 7.2 <0.1 1.4 0.9

(<0.1, 1.6) (<0.1, <0.1) (0.0, <0.1) (2.0, 23.0) (<0.1, <0.1) (0.5, 4.5) (0.3,3.1)

Artemether IV/IM**§

6.9 2.2 2.4 0.7 1.4 1.3 1.7

(4.6, 10.2) (1.3, 3.8) (1.4, 3.9) (0.3, 1.7) (1.0, 2.1) (0.9, 1.8) (1.2,2.4)

Artemotil IV/IM**§

1.2 0.1 0.1 0.0 0.1 0.1 0.1

(0.2, 6.9) (<0.1, 0.2) (<0.1, 0.2) -- (<0.1, 0.2) (<0.1, 0.2) (<0.1,0.2)

Any treatment for severe malaria 19 6.9 7.3 12.5 5.9 7.2 7.2

(9.2, 35.2) (4.7, 10.0) (5.1, 10.3) (5.3, 26.7) (4.8, 7.1) (5.5, 9.3) (5.8,8.9)


* WHO now recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria in African children [Guidelines for the treatment of malaria, 2nd edition – revisions 1]. ** Artemether or quinine injections are acceptable alternatives for the treatment of severe malaria if parenteral artesunate is not available [Guidelines for the treatment of malaria, 2nd edition – revisions 1]. § If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable artemether.

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Table A.15: Availability of antimalarials among outlets stocking at least one antimalarial, by endemicity

Low endemicity High endemicity TOTAL Outlets


%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=224 N=1,356 N=1580 N=579 N=980 N=1,559 N=3139

Any ACT 89.7 85 85.4 72 69.4 70.1 75.4

(84.1, 93.5) (76.3, 90.9) (77.6, 90.8) (49.3, 87.2) (61.7, 76.2) (64.1, 75.5) (68.4,81.3)


(83.6, 92.8) (64.7, 78.3) (67.4, 78.8) (49.1, 86.3) (54.2, 67.7) (56.7, 70.2) (61.1,72.7)

First-line (FAACT) 89.0 67.9 69.8 71.1 60.2 63.0 65.4

(83.6, 92.8) (58.0, 76.5) (61.2, 77.2) (49.1, 86.3) (53.5, 66.5) (56.2, 69.3) (59.4,70.9)

Non first-line (NAACT) 4.8 13.6 12.8 0.7 8.3 6.4 8.6

(2.2, 10.3) (10.1, 18.0) (9.4, 17.2) (0.1, 5.8) (6.2, 11.2) (4.4, 9.1) (6.2,11.9)

Any child QAACT 63.2 8.8 13.6 60.7 5.9 20.0 17.8

(44.2, 78.8) (6.1, 12.7) (10.7, 17.0) (44.1, 75.1) (4.2, 8.4) (14.1, 27.5) (13.4,23.1)

QAACT with the AMFm logo 59.3 67.2 66.5 43.2 56.4 53 57.7

(43.6, 73.4) (57.4, 75.7) (58.4, 73.8) (25.8, 62.5) (48.9, 63.6) (45.6, 60.3) (50.4,64.7)

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0

-- -- -- -- -- -- --

Non-quality-assured ACT 14.9 49.5 46.5 3.3 23.6 18.4 28.1

(6.7, 29.7) (36.8, 62.3) (33.3, 60.1) (1.3, 7.9) (18.0, 30.3) (13.8, 24.1) (19.2,39.2)


(84.1, 93.5) (68.9, 90.7) (70.7, 90.7) (49.3, 87.2) (61.5, 75.8) (63.9, 75.2) (67.1,80.6)

Any non-artemisinin therapy 81.8 94.7 93.6 47.8 94.5 82.5 86.4

(56.2, 94.0) (89.3, 97.5) (90.1, 95.9) (22.4, 74.4) (92.0, 96.2) (66.1, 92.0) (74.3,93.3)

Sulfadoxine-pyrimethamine (SP) 70.8 61.6 62.4 42.9 44.9 44.4 50.7

(41.2, 89.3) (56.2, 66.8) (58.2, 66.5) (20.8, 68.2) (34.8, 55.5) (35.9, 53.2) (43.1,58.2)

Chloroquine 0.1 18.8 17.1 1.3 17.0 13.0 14.4

(0.0, 0.6) (14.6, 23.7) (13.7, 21.3) (0.4, 3.9) (12.0, 23.6) (9.6, 17.4) (11.8,17.5)

Oral Quinine 37.2 84.9 80.7 24.7 83.9 68.8 72.9

(24.3, 52.2) (80.1, 88.7) (77.2, 83.9) (12.6, 42.9) (80.6, 86.7) (58.1, 77.8) (64.5,79.9)

Quinine Injection (IM/IV)**§ 46.2 49.5 49.2 27.3 41.7 38 41.9

(36.1, 56.6) (39.5, 59.6) (40.2, 58.3) (13.9, 46.6) (35.9, 47.8) (30.7, 46.0) (35.1,48.9)

Amodiaquine 0.0 5.2 4.7 0.0 5.8 4.3 4.5

-- (3.3, 8.0) (3.0, 7.4) -- (4.0, 8.4) (3.2, 5.8) (3.5,5.7)

Other 0.0 1.9 1.7 0.1 1.2 0.9 1.2

-- (1.4, 2.5) (1.2, 2.3) (0.0, 0.8) (0.7, 2.0) (0.5, 1.6) (0.8,1.7)

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Table A.15: Availability of antimalarials among outlets stocking at least one antimalarial, by endemicity



%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=224 N=1,356 N=1580 N=579 N=980 N=1,559 N=3139

Any artemisinin monotherapy 17.9 16.9 17.0 41.6 10.6 18.6 18.0

(9.2, 32.0) (11.0, 25.1) (11.4, 24.5) (23.2, 62.6) (7.5, 14.8) (11.6, 28.4) (12.8,24.7)

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.1 <0.1 <0.1

-- -- -- -- (0.0, 0.4) (<0.1, 0.3) (<0.1,0.2)

Non oral artemisinin monotherapy 17.9 16.9 17.0 41.6 10.6 18.6 18.0

(9.2, 32.0) (11.0, 25.1) (11.4, 24.5) (23.2, 62.6) (7.5, 14.8) (11.6, 28.4) (12.8,2.7)

Artesunate IV/IM*§

0.1 0.1 0.1 0.0 0.2 0.1 0.1

(0.0, 0.6) (0.0, 0.4) (0.0, 0.4) -- (0.0, 0.8) (0.0, 0.6) (<0.1,0.4)


0.6 <0.1 0.1 38 0.1 9.8 6.4

(0.2, 2.2) (<0.1, <0.1) (0.0, 0.2) (18.7, 61.9) (<0.1, 0.3) (3.4, 24.9) (2.0,18.6)

Artemether IV/IM **§

17.3 16.6 16.7 3.6 10.5 8.8 11.5

(8.4, 32.1) (10.8, 24.9) (11.1, 24.3) (1.4, 8.8) (7.5, 14.7) (6.0, 12.7) (8.1,16.1)

Artemotil IV/IM **§

2.9 0.6 0.8 0.0 0.5 0.4 0.5

(0.8, 9.8) (0.4, 1.0) (0.4, 1.4) -- (0.2, 1.4) (0.1, 1.1) (0.3,1.0)

Any treatment for severe malaria 47.4 51.5 51.2 65.3 42.8 48.5 49.4

(37.4, 57.7) (40.8, 62.2) (41.4, 60.9) (54.6, 74.6) (36.9, 48.8) (42.8, 54.3) (44.3,54.6)


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Table A.16: Disruption in stock, expiry and storage conditions of antimalarials, by Low endemicity


TOTAL Outlets Public / Not-for-profit Private for-profit Total Public / Not-for-profit Private for-profit Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3227

No disruption in stock in the past 3 months 30.2 14.9 16.4 19.5 13.6 15.1 15.5

(20.6, 42.0) (12.2, 17.9) (13.8, 19.3) (12.1, 29.8) (11.0, 16.7) (12.7, 17.9) (13.8,17.5)

N=217 N=1,181 N=1,398 N=568 N=818 N=1,386 N=2,784

No disruption in stock of quality-assured ACT (QAACT) in the past 3 months, among outlets stocking QAACT in the past 3 months

43.5 44.1 44.1 24.5 38.3 34.0 37.5

(28.5, 59.9) (38.6, 49.8) (38.3, 50.0) (13.8, 39.6) (33.4, 43.5) (27.9, 40.7) (32.4, 42.9)

N=217 N=1,147 N=1,364 N=568 N=804 N=1,372 N=2736

No disruption in stock of first-line quality-assured ACT (FAACT) in the past 3 months, among outlets stocking FAACT in the past 3 months

43.5 44.8 44.6 24.5 39.0 34.5 37.9

(28.5, 59.9) (38.9, 50.8) (38.7, 50.8) (13.8, 39.6) (34.1, 44.2) (28.2, 41.3) (32.7, 43.5)

N=223 N=1,356 N=1,579 N=578 N=981 N=1,559 N=3138

Expired stock of any antimalarial 4.1 0.4 0.5 0.3 0.4 0.4 0.4

(0.7, 20.2) (0.2, 0.6) (0.3, 0.9) (0.1, 0.9) (0.2, 0.7) (0.2, 0.7) (0.3, 0.6)

N=197 N=1,063 N=1,260 N=506 N=675 N=1,181 N=2,441

Expired stock of QAACT 18.4 0.3 1.3 3.6 0.1 0.6 0.9

(6.2, 43.5) (0.2, 0.6) (0.5, 3.4) (1.4, 8.9) (0.0, 0.5) (0.2, 1.5) (0.4, 1.9)

N=197 N=1,014 N=1,211 N=506 N=656 N=1,162 N=2373

Expired stock of FAACT 18.4 0.3 1.3 3.6 0.1 0.6 0.8

(6.2, 43.5) (0.1, 0.5) (0.5, 3.5) (1.4, 8.9) (0.0, 0.5) (0.2, 1.5) (0.4, 1.9)

N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3227

Acceptable storage conditions for medicines 99.0 97.5 97.6 99.4 95.9 96.8 97.1

(97.5, 99.6) (96.0, 98.4) (96.2, 98.5) (98.6, 99.7) (91.6, 98.1) (93.3, 98.5) (94.9, 98.3)


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Table A.17: Price of antimalarials, by Low endemicity



% % % % % % %

Proportion of first-line quality-assured ACT distributed free of cost (by volumes of AETDs)

97.7 3.6 69.4 94.9 0.0 59.7 63.1

Median price of a tablet AETD: Median [IQR] (N of Antimalarials)







Quality-assured ACT (QAACT) $0.00 $2.01 $1.68 $0.00 $1.51 $0.80 $1.17

[0.00-0.00] (557) [1.34-2.68] (2,122) [1.01-2.68] (2,679) [0.00-0.00] (1,573) [1.01-2.01] (1,169) [0.00-1.68] (2,742) [0.00-2.01] (5,421)

First-line (FAACT) $0.00 $2.01 $1.68 $0.00 $1.61 $0.67 $1.01

[0.00-0.00] (553) [1.34-2.68] (1,606) [0.80-2.41] (2,159) [0.00-0.00] (1,571) [1.01-2.01] (858) [0.00-1.61] (2,429) [0.00-2.01] (4,588)

QAACT with the AMFm logo $0.00 $2.01 $1.68 $0.00 $1.34 $1.01 $1.34

[0.00-0.00] (364) [1.34-2.68] (1,797) [1.01-2.68] (2,161) [0.00-0.00] (1,140) [1.01-2.01] (1,035) [0.00-1.68] (2,175) [0.40-2.01] (4,336)

Other subsidised QAACT $ $ $ $ $ $ $

[--] (0) [--] (0) [--] (0) [--] (0) [--] (0) [--] (0) [--] (0)

Non-quality-assured ACT $3.77 $3.35 $3.35 $0.00 $2.68 $2.68 $3.35

[0.00-6.03] (61) [2.41-5.03] (2,399) [2.41-5.03] (2,460) [0.00-2.01] (47) [1.84-4.02] (699) [1.68-4.02] (746) [2.18-5.03] (3,206)

Sulfadoxine-pyrimethamine (SP) $0.00 $0.67 $0.67 $0.00 $0.50 $0.50 $0.50

[0.00-0.00] (190) [0.50-0.67] (1,008) [0.50-0.67] (1,198) [0.00-0.00] (517) [0.34-0.50] (509) [0.10-0.50] (1,026) [0.30-0.67] (2,224)

Chloroquine $0.00 $0.65 $0.65 $0.00 $0.65 $0.65 $0.65

[0.00-0.00] (1) [0.65-0.97] (250) [0.65-0.97] (251) [0.00-0.32] (7) [0.65-0.81] (158) [0.49-0.81] (165) [0.65-0.84] (416)

Oral artemisinin monotherapy $ $ $ $ $16.75 $16.75 $16.75

[--] (0) [--] (0) [--] (0) [--] (0) [n/a] (1) [n/a] (1) [n/a] (1)

Median price of an AETD:

Any treatment for severe malaria $0.00 $14.17 $14.17 $0.00 $9.65 $7.09 $9.65

[0.00-10.63] (157) [10.63-21.26] (1,337) [9.21-20.10] (1,494) [0.00-0.00] (394) [7.09-14.17] (740) [0.00-10.63] (1,134) [5.67-14.17] (2,628)

Artesunate IV/IM $0.00 $0.45 $0.36 $ $0.15 $0.15 $0.15

[0.00-0.00] (1) [0.36-0.45] (4) [0.36-0.45] (5) [-] (0) [0.15-0.15] (3) [0.15-0.15] (3) [0.15-0.36] (8)

Quinine Injection IV/IM $0.00 $14.17 $14.17 $0.00 $7.09 $7.09 $10.63

[0.00-7.09] (126) [10.63-21.26] (813) [7.09-21.26] (939) [0.00-0.00] (308) [7.09-10.63] (466) [6.38-10.63] (774) [7.09-14.17] (1,713)

Source: ACTwatch Outlet Survey, UGANDA, 2011

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Table A.18: Affordability of antimalarials, by Low endemicity



Median price of a tablet AETD relative to SP, the most popular antimalarial treatment in Uganda:

Ratio Ratio Ratio Ratio Ratio Ratio Ratio

Quality-assured ACT (QAACT) *** 3.0 2.5 ***

3.0 1.6 2.3

QAACT with the AMFm logo *** 3.0 2.5 ***

2.7 2.0 2.7

First-line quality-assured ACT (FAACT) *** 3.0 2.5 ***

3.2 1.3 2.0

Median price of a tablet AETD relative to the minimum legal daily wage ($0.78):


Quality-assured ACT (QAACT) n/a 2.6

2.2 n/a 1.9 1.0 1.5

QAACT with the AMFm logo n/a 2.6 2.2

n/a 1.7 1.3 1.7

First-line quality-assured ACT (FAACT) n/a 2.6 2.2

n/a 2.1 0.9 1.3


Median price of a first-line quality-assured tablet AETD relative to the international reference price ($1.42)

n/a 1.4 1.2 n/a 1.1 0.5 0.7

% % % % % % %

Proportion of outlets that: N=33 N=1,369 N=1,402 N=115 N=1,028 N=1,143 N=2,545

Offer credit to consumers for antimalarials

20

12.6 75.6 73.6 39.4 80.5 79.7 77.3

(6.6, 22.7) (70.3, 80.2) (68.6, 78.0) (20.3, 62.3) (76.2, 84.3) (75.4, 83.4) (73.8, 80.8)


20 This question was not asked in Public Health Facilities

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Table A.19: Availability of diagnostic tests, by Low endemicity

Low endemicity High Endemicity TOTAL

Outlets Public / Not-for-profit Private for-profit Total Public / Not-for-profit Private for-profit Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets that had: N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3227

Any diagnostic test 58.1 27.6 30.6 77.8 15.8 31.8 31.4

(37.0, 76.6) (19.2, 37.9) (23.6, 38.6) (62.3, 88.2) (12.6, 19.5) (22.3, 43.0) (24.5,39.2)

Microscopic blood tests 34.3 19.0 20.5 22.8 10.5 13.6 16.0

(29.1, 40.0) (12.8, 27.3) (14.7, 27.9) (11.6, 39.9) (8.0, 13.6) (10.6, 17.4) (12.5,20.2)

Rapid diagnostic tests (RDTs) 41.2 13.3 16.0 65.5 6.9 22.0 19.9

(24.0, 60.7) (9.9, 17.6) (13.6, 18.8) (45.0, 81.5) (4.9, 9.6) (12.3, 36.2) (12.9,29.5)


N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3,227


31.5 9.2 11.4 63.0 5.4 20.3 17.3

(19.2, 47.2) (6.7, 12.4) (8.8, 14.5) (41.6, 80.3) (3.5, 8.1) (10.6, 35.3) (10.1, 27.8)


8.1 4.1 4.5 1.5 1.2 1.3 2.4

(1.9, 29.4) (2.5, 6.8) (2.9, 7.0) (0.4, 4.6) (0.7, 2.3) (0.8, 2.2) (1.5, 3.8)

Proportion of outlets that provided diagnostic tests for free, among outlets providing diagnostic tests

N=133 N=275 N=408 N=389 N=129 N=518 N=926

Any diagnostic test 72.9 0.0 15.7 92.6 3.6 66.7 51.5

(46.0, 89.5) -- (6.8, 32.3) (80.4, 97.4) (0.8, 15.2) (43.6, 83.8) (28.0, 74.4)

N=92 N=274 N=366 N=210 N=126 N=336 N=702

Microscopic blood tests 62.6 0.0 10.4 74.6 1.1

(0.1, 8.1)

32.1 22.4

(39.4, 81.2) -- (4.9, 20.7) (62.8, 83.6) (24.9, 40.4) (14.4, 33.1)

N=47 N=4 N=51 N=191 N=3 N=194 N=245

Rapid diagnostic tests 100 0.0 89.9 100 87.9 99.8 99.2

-- -- (70.3, 97.1) -- (31.6, 99.1) (98.2, 100.0) (96.6, 99.8)


21Excluding outlets with RDTs where the manufacturer could not be identified.

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Table A.20: Price of diagnostic tests, by Low endemicity



Median price of: Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Median US$

[IQR] (N)

Microscopic blood tests $0.00

[0.00, 0.34] (92)

$0.67

[0.67, 1.01] (274)

$0.67

[0.67, 1.01] (366)

$0.00

[0.00, 0.17] (210)

$0.67

[0.34,0.67] (126)

$0.34

[0.00, 0.67] (336)

$0.67

[0.34, 0.84] (702)

Rapid diagnostic tests (RDTs) $0.00

[0.00, 0.00] (99)

$1.01 [0.67, 1.01]

(255) $1.01

[0.34, 1.01] (354)

$0.00 [0.00, 0.00]

(381) $0.67

[0.50,1.01] (94)

$0.00 [0.00, 0.00]

(475) $0.00

[0.00, 0.67] (829)


$0.00 [0.00, 0.00]

(94) $1.01

[0.67,1.01] (140)

$0.84 [0.00, 1.01]

(234) $0.00

[0.00, 0.00] (368)

$0.67 [0.34, 1.01]

(59) $0.00

[0.00, 0.00] (427)

$0.00 [0.00, 0.50]

(661)


$1.34 [1.34, 1.34]

(5)

$1.01 [0.84,1.34]

(107)

$1.01 [0.84,1.34]

(112)

$0.00 [0.00, 0.00]

(12)

$0.84 [0.67, 1.01]

(30)

$0.84 [0.67, 1.01]

(42)

$1.01 [0.67,1.34]

(154)


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Table A.21: Market share, by Low endemicity

Low endemicity High endemicity TOTAL Outlets Public/Not-for-profit Private for-profit Total Public/Not-for-profit Private for-profit Total

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed in the past week:22

% % % % % % %

Any ACT 13.5 13.7 27.2 23.2 17.7 40.9 68.1


First-line (FAACT) 13.4 5.9 19.3 22.8 13.0 35.7 55.0

Non first-line (NAACT) <0.1 0.7 0.7 0.0 1.0 1.0 1.8

QAACT with the AMFm logo 8.4 5.5 13.9 16.9 12.5 29.4 43.3

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Non-quality Assured ACT 0.1 7.1 7.2 0.4 3.8 4.1 11.4


Any non-artemisinin therapy 1.5 9.2 10.7 8.4 12.3 20.7 31.4

SP 1.2 6.3 7.6 7.2 7.7 15.0 22.5

Chloroquine 0.0 0.6 0.6 <0.1 1.0 1.0 1.6

Oral Quinine 0.2 1.2 1.4 0.8 2.7 3.5 4.9

Quinine Injection (IM/IV) <0.1 0.8 0.9 0.4 0.7 1.0 1.9

Amodiaquine 0.0 0.2 0.2 0.0 0.2 0.2 0.4

Other † 0.0 0.1 0.1 0.0 <0.1 <0.1 0.1

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Non oral artemisinin monotherapy <0.1 0.1 0.1 <0.1 0.4 0.4 0.5

Artesunate IV/IM 0.0 0.0 0.0 0.0 0.2 0.2 0.2

Rectal Artesunate 0.0 0.0 0.0 <0.1 0.0 <0.1 <0.1

Artemether IV/IM <0.1 0.1 0.1 <0.1 0.2 0.2 0.3

Artemotil IV/IM 0.0 <0.1 <0.1 0.0 <0.1 <0.1 <0.1

Any treatment for severe malaria 0.1 0.9 1.0 0.4 1.0 1.4 2.4


22There were a total of 55,814 AETDs (unweighted) sold or distributed in the past 7 days. Any ACT subgroups are not mutually exclusive: Any ACT subdivides fully into QAACT and Non-quality-assured ACT; QAACT decompose fully into FAACT and NAACT. Row and column totals exhibit minor rounding errors.


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Table A.22: Provider knowledge, by endemicity


TOTAL Outlets Public / Not-for-profit Private for-profit Total Public / Not-for-profit Private for-profit Total

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that can: N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3227


96.9 72.9 75.3 93.1 75.5 80.0 78.4

(94.7, 98.2) (64.4, 80.0) (68.1, 81.3) (89.3, 95.6) (69.2, 80.8) (73.7, 85.2) (73.6, 82.6)

N=33 N=1,369 N=1,402 N=115 N=1,028 N=1,143 N=2545

State at least one health danger sign in a child that requires referral to a public health facility

23:

79.9 73.7 74.0 90.7 74.5 77.4 76.2

(70.0, 87.1) (66.9, 79.5) (67.6, 79.5) (81.9, 95.4) (70.1, 78.5) (72.3, 81.8) (72.0, 79.9)

Convulsions 69.3 48.0 49.1 83.0 46.3 52.9 51.6

(58.5, 78.2) (42.2, 53.8) (43.7, 54.6) (73.0, 89.8) (41.1, 51.6) (43.8, 61.8) (45.2, 57.9)

Vomiting 37.1 30.0 30.3 53.1 41.3 43.4 38.8

(23.5, 53.2) (25.0, 35.4) (26.3, 34.7) (35.7, 69.7) (35.9, 46.9) (38.8, 48.0) (34.2, 43.5)

Unable to drink / breastfeed 28.8 8.3 9.4 24.4 9.8 12.4 11.3

(19.0, 41.3) (5.4, 12.6) (7.1, 12.3) (17.9, 32.3) (7.3, 13.1) (8.9, 17.0) (8.7, 14.7)

Excessive sleep / difficult to wake up 0.0 1.6 1.5 3.3 1.4 1.7 1.7

-- (0.8, 3.2) (0.7, 3.0) (1.2, 9.2) (0.7, 2.7) (0.8, 3.6) (0.9, 2.9)

Unconscious / coma 28.3 23.5 23.7 19.6 14.0 15.0 18.1

(20.7, 37.5) (20.3, 27.0) (20.9, 26.9) (11.7, 31.0) (11.0, 17.6) (11.8, 19.0) (15.3, 21.3)


23This question was not asked in Public Health Facilities. Information on proportion of providers that correctly state at least one health danger sign was missing for 0.3% of cases [n=2,537]. Providers could state multiple responses and totals may sum

to more than 100%.

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Table A.23: Provider perceptions, by endemicity


TOTAL Outlets


%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers that: N=236 N=1,369 N=1,605 N=594 N=1,028 N=1,622 N=3,227

Agree with the statement, “Customers often request an antimalarial by name.”

43.0 70.0 67.3 25.7 65.1 54.9 59.1

(35.3, 51.1) (64.2, 75.2) (62.8, 71.5) (21.2, 30.7) (58.7, 71.0) (47.3, 62.3) (53.0, 64.9)

Agree with the statement, “I generally decide which antimalarial medicine customers receive.”

92.1 79.4 80.7 94.0 76.0 80.7 80.7

(87.3, 95.2) (68.6, 87.2) (70.4, 88.0) (86.0, 97.5) (68.8, 82.0) (72.2, 87.0) (74.3, 85.8)

Report that an ACT is the most effective antimalarial medicine for an adult

82.2 70.2 71.4 76.5 63.3 66.7 68.3

(61.8, 92.9) (61.0, 78.1) (64.7, 77.3) (60.2, 87.6) (56.5, 69.6) (60.7, 72.2) (63.3, 72.9)

Report that an ACT is the most effective antimalarial medicine for a child

96.0 62.3 65.6 94.8 62.1 70.6 68.9

(92.1, 98.0) (51.9, 71.6) (55.9, 74.1) (88.4, 97.8) (55.2, 68.5) (62.5, 77.6) (62.8, 74.3)


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

Each antimalarial category as a proportion of the total volume of all antimalarials (AETDs) sold or distributed within a given outlet type in the past week:



Private not-for-profit HF

TOTAL Public / Not-

for-profit

Private for-profit

HF



TOTAL Private

for-profit

TOTAL Outlets

N=16,052 N=91 N=2,395 N=18,538 N=17,714 N=7,026 N=12,484 N=52 N=0 N=37,276 N=55,814

% % % % % % % % % % % Any ACT 81.9 99.6 54.6 78.7 61.9 68.5 52.7 49.8 -- 58.9 68.1

Quality-assured ACT (QAACT) 81.3 99.1 50.5 77.6 33.3 43.0 42.7 49.8 -- 38.5 56.7

First-line (FAACT) 81.3 99.1 50.1 77.6 29.9 37.3 40.4 49.8 -- 35.2 55.0

Non first-line (NAACT) 0.0 0.0 0.4 <0.1 3.4 5.7 2.3 0.0 -- 0.4 1.8

QAACTs with the AMFm logo 59.8 14.6 17.9 54.4 28.3 38.2 38.1 46.1 -- 33.7 43.3

Other subsidised QAACT 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- 0.0 0.0 Non-quality-assured ACT 0.6 0.4 4.1 1.0 28.6 25.5 10.0 0.0 -- 20.4 11.4

Nationally Registered ACT 81.9 99.6 54.4 78.6 61.4 67.1 51.7 38.4 -- 58.0 67.6

Any non-artemisinin therapy 18.1 0.0 44.8 21.3 36.6 30.7 47.1 50.2 -- 40.3 31.4

SP 16.2 0.0 33.1 18.1 25.3 21.0 29.0 38.5 -- 26.4 22.5

Chloroquine <0.1 0.0 0.5 0.1 1.2 3.8 4.5 11.8 -- 2.9 1.6

Oral Quinine 1.6 0.0 6.9 2.2 5.0 3.6 10.8 <0.1 -- 7.2 4.9

Quinine Injection (IM/IV) 0.4 0.0 4.3 0.9 4.5 0.9 1.4 0.0 -- 2.8 1.9

Amodiaquine 0.0 0.0 0.0 0.0 0.5 <0.1 1.4 0.0 -- 0.8 0.4

Other † 0.0 0.0 0.0 0.0 0.2 1.3 0.1 0.0 -- 0.2 0.1

Oral artemisinin monotherapy 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 -- 0.0 0.0

Non oral artemisinin monotherapy <0.1 0.4 0.6 0.1 1.5 0.8 0.2 0.0 -- 0.9 0.5

Artesunate IV/IM 0.0 0.0 0.0 0.0 0.7 0.2 0.0 0.0 -- 0.3 0.2 Rectal Artesunate 0.0 0.4 0.0 <0.1 0.0 0.0 0.0 0.0 -- 0.0 <0.1

Artemether IV/IM <0.1 0.0 0.6 0.1 0.8 0.6 0.2 0.0 -- 0.5 0.3

Artemotil IV/IM 0.0 0.0 0.0 0.0 <0.1 0.1 0.0 0.0 -- <0.1 <0.1

Any treatment for severe malaria (artesunate iIV/IM/rectal, quinine IV/IM, artemether IV/IM, artemotil IV/IM)

0.4 0.4 4.8 0.9 6.1 1.7 1.6 0.0

-- 3.7 2.4



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AMFm Endline Phase 1 Indicators

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Table 3.1.1: Outlets enumerated by location, drugs stocked and final interview status Uganda, 2011

Final interview status Urban n Rural n Total n

Number of outlets enumerated (Flow Diagram Reference A) 8031 8490 16521

Number of outlets stocking drugs at the time of the survey visit 2503 2602 5105

Number of outlets meeting the screening criteria* (Flow Diagram

Reference C) 1459 1826 3285

Number of outlets stocking antimalarials at the time of the survey

visit (Flow Diagram Reference E) 1416 1723 3139

Number of outlets without antimalarials in stock at the time of the

survey visit, but who had antimalarials in stock at some time in the 3

months previous to the survey 7 81 88

Final interview status Outlet Not Screened 117 197 314

Interview interrupted 0 0 0 Eligible respondent not available 21 42 63 Outlet not open at the time 40 89 129 Outlet closed permanently 19 28 47 Refused 25 26 51 Other 12 12 24

Outlet did not meet screening criteria 6455 6467 12922 Outlet met screening criteria, but not interviewed (total) 36 22 58

Interview interrupted 3 0 3 Eligible respondent not available 18 12 30 Outlet not open at the time 3 6 9 Refused 12 4 16 Other 0 0 0

Completed interview 1403 1794 3197 Partially completed interview 20 10 30

Interview interrupted 6 2 8 Eligible respondent not available 3 5 8 Outlet not open at the time 0 0 0 Refused 11 3 14 Other 0 0 0

Response rate (%) % % % Proportion of outlets enumerated that were screened 98.5 97.7 98.1 Proportion of outlets meeting screening criteria that were interviewed** 97.5 98.8 98.2

* The number of outlets meeting the screening criteria is defined as the sum of the number of outlets stocking antimalarials at the time of the survey and the number of outlets without antimalarials in stock at the time of the survey, but who had antimalarials in stock at some time in the 3 months previous to the survey ** Response rate was calculated as outlets where final interview status was “Completed interview” or “Partially completed interview” as a percentage of all outlets meeting the screening criteria (i.e. flow diagram reference D divided by C).

Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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Table 3.1.2: Outlets enumerated* [Uganda], 2011

Number of outlets enumerated, by location and type of outlet

Type of outlet

Urban Rural Total Censused

sub-counties

Booster sample Total

Censused sub-

counties Booster sample Total

Censused sub-


Public health facility 36 115 151 96 462 558 132 577 709

Private not-for-profit health facility 14 0 14 30 0 30 44 0 44 Private for-profit outlet

Private for-profit health facility 536 0 536 376 0 376 912 0 912 Pharmacy 66 304 370 12 53 65 78 357 435 Drug store 477 0 477 838 0 838 1315 0 1315 General retailer 6257 0 6257 5771 0 5771 12028 0 12028 Itinerant drug vendor 33 0 33 11 0 11 44 0 44 Total 7369 304 7673 7008 53 7061 14377 357 14734

Community health worker 193 0 193 841 0 841 1034 0 1034

Total 7612 419 8031 7975 515 8490 15587 934 16521

* Flow diagram reference A


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Table 3.1.3: Outlets with antimalarials in stock* [Uganda], 2011**

Number of outlets with antimalarials in stock at the time of the survey where an interview was conducted, by location and type of outlet

Type of outlet

Urban Rural Total Censused sub-


Censused sub-counties


Censused sub-counties


Public health facility 32 112 144 89 445 534 121 557 678 Private not-for-profit health facility 13 0 13 28 0 28 41 0 41

Private for-profit outlet

Private for-profit health facility 482 0 482 325 0 325 807 0 807 Pharmacy 59 276 335 12 52 64 71 328 399 Drug store 436 0 436 676 0 676 1112 0 1112 General retailer 4 0 4 14 0 14 18 0 18 Itinerant drug vendor 0 0 0 0 0 0 0 0 0 Total 981 276 1257 1027 52 1079 2008 328 2336

Community health worker 2 0 2 82 0 82 84 0 84 Total 1028 388 1416 1226 497 1723 2254 885 3139

* Flow diagram reference E. An interview was conducted if final interview status for an outlet was “Completed interview” or “Partially completed”. ** These numbers form the denominator for all subsequent tables, unless specified otherwise. Any variation in the stated denominator in subsequent tables is due to missing data on specific variables.


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Table 3.1.4: Number of products audited [Uganda], 2011

Number of products audited by outlet type, product type, and location Urban Rural Total

Number of

products audited

Number of

products audited

Number of

products audited


Public health facility 351 1615 1966

Private not-for-profit health facility 23 63 86

Private for-profit outlet 2160 1202 3362

Community health worker 3 78 81

Total 2537 2958 5495

Non-quality-assured ACTs Public health facility 75 17 92

Private not-for-profit health facility 15 16 31 Private for-profit outlet 3320 1239 4559


Total 3410 1273 4683

Artemisinin monotherapy Public health facility 27 15 42

Private not-for-profit health facility 7 11 18 Private for-profit outlet 640 207 847

Community health worker 1 56 57 Total 675 289 964

Non-Artemisinin therapy




Community health worker 0 1 1 Total 4670 4471 9141

All antimalarials





Total 11292 8991 20283


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Table 3.1.5: Outlets with at least one staff member who completed secondary school or primary school [Uganda] 2011

Outlets with at least one staff member who completed secondary school or primary school* (n) as a percentage of all outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet.

Type of outlet

Urban Rural Total Percentage

(95% CI) N Percentage


(95% CI) N

At least one staff member completed primary school

Public health facility 100.0 142 100.0 532 100.0 674

Private not-for-profit health facility 100.0 13 100.0 28 100.0 41


Private for-profit health facility 100.0 478 99.3(93.8,99.9) 325 99.6(96.7,100.0) 803

Pharmacy 100.0 333 100.0 64 100.0 397

Drug store 100.0 434 100.0 676 100.0 1110

General retailer 100.0 4 80.3(61.0,91.4) 14 81.4 (63.0,91.8) 18

Itinerant drug vendor -- 0 -- 0 -- 0

Total 100.0 1249 99.3(97.5,99.8) 1079 99.5 (98.2,99.8) 2328

Community health worker 100.0 2 93.2(87.0,96.5) 82 93.2 (87.2,96.5) 84

Total 100.0 1406 98.7(97.3,99.4) 1721 99.0 (97.8,99.5) 3127

At least one staff member completed secondary school

Public health facility 100.0 137 99.5 (97.2,

99.9) 514 99.5(97.7,99.9) 651



Private for-profit health facility 99.2(97.9,99.7) 475 96.0(90.7,98.4) 324 97.4(94.1,98.8) 799

Pharmacy 100.0 332 100.0 64 100.0 396

Drug store 97.7(96.1,98.7) 424 97.4(95.0,98.7) 664 97.5(95.5,98.6) 1088

General retailer 89.7(46.0,98.9) 4 38.8(20.9,60.4) 14 41.7(25.1,60.5) 18


Total 98.6(97.5,99.2) 1235 95.5(92.7,97.2) 1066 96.2(94.2,97.6) 2301

Community health worker 100.0 2 14.0 (8.8, 21.7) 79 14.4 (9.2, 21.8) 81

Total 98.7(97.7,99.2) 1387 87.0(73.7,94.1) 1687 89.4(78.6,95.1) 3074

* The two groups are not mutually exclusive. Providers noted as having completed primary school include those who have completed secondary school and those who have not completed secondary school but who have completed primary school.


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Table 3.1.6: Outlets with a staff member with a health-related qualification [Uganda], 2011

Outlets with at least one staff member with a health-related qualification* (n) as a percentage of all outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 99.8 (98.7, 100.0) 144 99.7 (97.8, 100.0) 534 99.7 (98.3, 100.0) 678



Private for-profit health facility 100.0 482 100.0 324 100.0 806

Pharmacy 100.0 334 98.6 (97.1, 99.3) 64 99.7 (98.7, 99.9) 398

Drug store 98.5 (96.3, 99.4) 436 98.6 (97.1, 99.3) 676 98.6 (97.4, 99.2) 1112

General retailer 0.0 4 16.3 (4.6, 43.7) 11 15.1 (4.2, 41.7) 15

Itinerant drug vendor 0 0 0

Total 98.8 (98.2, 99.2) 1256 97.2 (94.6, 98.5) 1075 97.6 (95.8, 98.6) 2331

Community health worker 46.3 (4.9, 93.5) 2 2.6 (0.6, 10.4) 77 2.7 (0.7, 9.7) 79

Total 98.8 (98.3, 99.2) 1415 87.5 (71.8, 95.1) 1714 89.8 (77.2, 95.8) 3129 * A health-related qualification was defined as pharmacy, nurse or medical doctor related training. Pharmacy related training includes pharmacy studied to a certificate or diploma level; Nurse related training includes studying nursing to a certificate level (nurse aid) and diploma level; Medical doctor training includes clinical officers who studied medicine to a diploma level and fully qualified physicians.


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3.2 Availability of antimalarial drugs

3.2.1 Antimalarials in stock

Table 3.2.1: Outlets with antimalarials in stock in [Uganda], 2011

Indicator 1.1: Outlets that had any antimalarials in stock at the time of the survey visit* (n) as a percentage of all outlets where screening questions were completed** (N), by location and type of outlet

Type of outlet




(95% CI) N


Private not-for-profit health facility 100.0 13 93.4 (73.9, 98.6) 30 94.1 (76.7, 98.7) 43


Private for-profit health facility 96.0 (94.2, 97.2) 509 94.3 (86.9, 97.7) 339 95.0 (91.4, 97.2) 848

Pharmacy 99.5 (97.5, 99.9) 351 100.0 64 99.6 (98.0, 99.9) 415

Drug store 98.2 (97.1, 98.9) 456 91.2 (86.6, 94.4) 757 92.2 (88.4, 94.9) 1213

General retailer 0.1 (<0.1, 0.2) 6211 0.4 (0.2, 1.2) 5720 0.4 (0.1, 0.9) 11931

Itinerant drug vendor 0.0 33 0.0 11 0.0 44

Total 13.5 (11.8, 15.5) 7560 14.0 (12.0, 16.2) 6891 13.9 (12.4, 15.5) 14451


Total 14.1 (12.4, 15.9) 7914 15.1 (12.5, 18.1) 8293 14.8 (12.8, 17.2) 16207

* Flow diagram reference E ** Flow diagram reference B. Screening questions asked whether outlets had any medicines in stock that day, or any antimalarials in stock that day, and if not whether they had had any medicines, or any antimalarials, in stock in the previous 3 months.


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3.2.2 Antimalarials in stock by type

Table 3.2.2: Outlets with non-artemisinin therapy in stock [Uganda], 2011

Indicator 1.2: Outlets that had non-artemisinin monotherapy or non-artemisinin combination therapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 94.8 (87.7, 97.9) 144 96.0 (93.6, 97.5) 534 95.8(93.7,97.2) 678




Pharmacy 99.4 (97.4, 99.9) 332 100.0 64 99.5 (97.9, 99.9) 396

Drug store 96.0 (94.3, 97.2) 436 95.2 (92.4, 97.0) 676 95.3 (93.1, 96.9) 1112

General retailer 10.3 (1.1, 54.0) 4 44.1 (20.8, 70.4) 14 42.2 (21.6, 66.0) 18


Total 95.3 (94.5, 95.9) 1254 94.4 (91.0, 96.5) 1078 94.6 (92.2, 96.3) 2332

Community health worker 0.0 2 0.2 (0.0, 2.2) 82 0.2 (<0.1, 2.0) 84

Total 95.1 (94.3, 95.9) 1412 84.1 (68.9, 92.7) 1721 86.4 (74.3, 93.3) 3133

* Flow diagram reference E


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Table 3.2.3.a: Outlets with artemisinin monotherapy in stock (all dosage forms) [Uganda], 2011

Indicator 1.3: Outlets that had artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N


Private not-for-profit health facility 53.9 (42.6, 64.8) 12 33.0 (14.4, 59.0) 27 35.2 (17.8,57.6) 39

Private for-profit outlets

Private for-profit health facility 37.0 (32.4, 42.0) 482 25.9 (19.6, 33.4) 322 30.6 (25.8,35.8) 804

Pharmacy 77.4 (67.0, 85.2) 331 70.3 (59.9, 78.9) 64 76.1 (67.4,83.0) 395

Drug store 6.7 (4.5, 9.8) 436 4.3 (2.5, 7.4) 675 4.7 (3.0, 7.1) 1111

General retailer 0.0 4 0.0 14 0.0 18


Total 26.0 (21.0, 31.8) 1253 9.1 (5.6, 14.4) 1075 13.1 (9.5, 17.8) 2328

Community health worker 53.7 (6.5, 95.1) 2 71.0 (52.9, 84.3) 82 71.0 (53.5,83.9) 84†

Total 25.6 (20.7, 31.3) 1411 16.1 (9.9, 25.0) 1718 18.0(12.8,24.7) 3129

* Flow diagram reference E †Community Health Workers were found stocking Artesunate suppositories (Plasmotrim

TM-50), which is recommended for pre-referral

treatment of severe malaria


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Table 3.2. 3.b: Outlets with oral artemisinin monotherapy in stock [Uganda], 2011

Outlets that had oral artemisinin monotherapy in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 0.0 144 0.0 534 0.0 678



Private for-profit health facility 0.3 (<0.1, 2.8) 480 0.0 321 0.1 (<0.1, 0.9) 801

Pharmacy 0.0 330 0.0 63 0.0 393

Drug store 0.0 436 0.0 675 0.0 1111



Total 0.1 (<0.1, 1.2) 1250 0.0 1073 0.03 (<0.1,0.2) 2323

Community health worker 0.0 2 0.0 82 0.0 84

Total 0.1 (<0.1, 1.1) 1408 0.0 1716 0.03 (<0.1,0.2) 3124



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Table 3.2.4: Outlets with non-quality-assured ACTs in stock [Uganda], 2011

Indicator 1.4: Outlets that had non-quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 28.7 (19.9,39.3) 144 2.3 (1.2, 4.1) 534 6.0 (4.1, 8.8) 678

Private not-for-profit health facility 72.3 (29.1,94.3) 12 14.8 (4.3,40.1) 27 20.8 (8.9, 41.2) 39


Private for-profit health facility 60.9 (48.4,72.1) 481 46.6 (31.2,62.7) 322 52.6 (41.5,63.5) 803

Pharmacy 99.0 (94.1,99.8) 333 93.8 (76.8,98.6) 64 98.1 (95.1,99.3) 397

Drug store 38.6 (26.7,52.1) 436 23.0 (15.5,32.9) 675 25.4(18.7,33.5) 1111 General retailer 33.7 (4.5, 84.6) 4 0.0 14 1.9 (0.2, 14.3) 18


Total 53.3(39.0,67.1) 1254 27.8 (17.2,41.7) 1075 33.8(24.3,44.8) 2329

Community health worker 0.0 2 0.2 (<0.1, 2.2) 82 0.2 (<0.1, 2.0) 84

Total 51.9 (37.2,66.4) 1412 22.0 (12.7,35.3) 1718 28.1 (19.1,39.2) 3130



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Table 3.2.5.a: Outlets with quality-assured ACTs in stock [Uganda], 2011

Indicator 1.5: Outlets that had quality-assured ACTs in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 90.2(82.8,94.6) 144 91.9(87.3,94.9) 534 91.7(87.9,94.4) 678

Private not-for-profit health facility 91.1 (50.6, 99.0) 12 79.1 (59.0, 90.9) 27 80.4 (62.5, 91.0) 39


Private for-profit health facility 79.1 (76.4, 81.6) 482 74.9 (68.9, 80.0) 324 76.6 (72.8, 80.1) 806 Pharmacy 96.8 (91.2, 98.9) 332 91.3 (66.7, 98.2) 64 95.8 (90.7, 98.1) 396

Drug store 69.8 (62.7, 76.0) 436 58.0 (49.4, 66.1) 676 59.7 (52.6, 66.5) 1112

General retailer 56.0 (12.5, 91.9) 4 74.7 (34.7, 94.3) 14 73.7 (36.6, 93.1) 18 Itinerant drug vendor -- 0 -- 0 -- 0

Total 76.0 (71.2, 80.2) 1254 62.2 (54.0, 69.8) 1078 65.4 (59.1, 71.2) 2332


Total 77.0 (72.8, 80.7) 1412 64.6 (57.1, 71.4) 1721 67.1 (61.1, 72.6) 3133



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Table 3.2.5.b: Outlets with quality-assured ACTs with and without the AMFm logo in stock [Uganda], 2011

Indicator 1.5: Outlets that had quality-assured ACTs with and without the AMFm in stock (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N

Stocked QAACTs with the AMFm logo



38.2 (14.3, 69.7) 12 39.4 (22.7, 59.1) 27 39.3 (24.1, 56.8) 39



Pharmacy 90.4 (82.3, 95.0) 332 89.9 (68.9, 97.3) 64 90.3 (83.4, 94.5) 396

Drug store 63.7 (55.1, 71.4) 436 53.3 (43.6, 62.8) 676 54.9 (46.8, 62.7) 1112



Total 70.1 (63.7, 75.8) 1254 57.8 (48.3, 66.7) 1076 60.7 (53.4, 67.5) 2330


Total 69.6 (63.8, 74.9) 1412 54.7 (45.7, 63.3) 1719 57.7 (50.4, 64.7) 3131

Stocked QAACTs without the AMFm logo

Public health facility 49.3 (30.0,

68.9) 144 41.0 (27.1, 56.6) 534 42.2 (30.0, 55.5) 678


70.2 (51.9, 83.7)

12 52.2 (33.3, 70.5) 27 54.1 (36.9, 70.4) 39



Pharmacy 37.8 (28.5,48.1) 331 48.1 (36.9, 59.5) 63 39.7 (31.3, 48.6) 394

Drug store 10.1 (6.9, 14.7) 436 6.2 (4.5, 8.5) 675 6.8 (5.2, 8.8) 1111



Total 11.8 (8.4, 16.4) 1251 7.3 (5.7, 9.4) 1075 8.4 (7.0, 10.1) 2326


Total 14.8 (10.4,

20.8) 1409 15.8 (10.7, 22.6) 1718 15.6 (11.4, 20.9) 3127



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Table 3.2.5.c: Public health facility outlets with quality-assured ACTs among ALL public health facilities in [Uganda], 2011 Public health facilities that had quality-assured ACT in stock (n) as a percentage of ALL PUBLIC HEALTH FACILITIES screened (N), location

Type of outlet




(95% CI) N



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3.2.3 Stockouts of quality-assured ACTs

Table 3.2.6: Outlets with stock-outs of quality-assured ACTs [Uganda], 2011

Indicator 1.6: Outlets that were out of stock of all quality-assured ACTs for at least 1 day in the last 7 days (n) as a percentage of outlets with any quality-assured ACTs in stock at the time of the survey visit or in the 4 weeks preceding the survey visit (N), by location and type of outlet*

Type of outlet

Urban Rural Total

Percentage (95% CI) N



Public health facility 2.2 (0.4, 10.3) 133 2.9 (0.8, 10.0) 497 2.8 (0.9, 8.3) 630 Private not-for-profit health facility 0.0 11 0.0 24 0.0 35


Private for-profit health facility 3.6 (1.6, 8.0) 421 9.5 (5.8, 15.3) 269 7.0 (4.2, 11.4) 690 Pharmacy 1.5 (0.6, 3.7) 309 1.6 (0.9, 3.1) 56 1.5 (0.7, 3.2) 365 Drug store 7.5 (4.7, 11.7) 329 7.4 (5.0, 10.9) 514 7.5 (5.4, 10.3) 843 General retailer 0.0 3 11.7 (1.4, 54.3) 12 11.1 (1.5, 49.7) 15 Itinerant drug vendor -- 0 -- 0 -- 0 Total 5.0 (3.3, 7.6) 1062 8.0 (6.0, 10.7) 851 7.3 (5.5, 9.6) 1913


Total 4.7 (3.2, 7.0) 1208 6.5 (4.5, 9.3) 1449 6.1 (4.5, 8.3) 2657

*This indicator measures stock-outs of quality-assured ACTs among outlets that have recently stocked these products. The denominator may include outlets which had no antimalarials in stock on the day of the survey but which had stocked them in the previous 3 months. A stock-out is defined as being out of stock of all quality-assured ACTs for at least 1 day in the last seven days. Outlets that have recently stocked QAACTs are defined as outlets with any QAACTs in stock at the time of the survey visit or in the 4 weeks preceding the survey visit.


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3.2.4 Population coverage of outlets with quality-assured ACTs

Table 3.2.7: Percentage of the population living in censused “sub-counties” with outlets with quality-assured ACTs in stock at the time of survey [Uganda], 2011 Indicator 1.7: Population living in a censused “sub-counties” where there was at least one of a given type of outlet with a quality-assured ACT in stock at the time of the survey visit (n) as a percentage of the total population living in all the censused “sub-counties” (N), by location.

Urban Rural Total




At least one public health facility stocking quality-assured ACTs 66.7 (19.8, 94.2) 487554 96.2 (75.0, 99.5) 902154 92.5 (74.5, 98.1) 1389708 At least one private not-for-profit health facility stocking quality-assured ACTs 27.8 (13.6, 48.5) 46.2 (26.8, 66.8) 43.9 (27.0, 62.4) At least one private for-profit outlet stocking quality-assured ACTs 100.0 100.0 100.0 At least one community health worker stocking quality-assured ACTs 11.1 (1.9, 44.7) 19.2 (6.8, 43.8) 18.2 (7.0, 39.7)

At least one outlet of any type stocking quality-assured ACTs 100.0 100.0 100.0

Source of the Population data: Uganda National Census Frame, 2002 Source: AMFm Phase 1 Independent Evaluation Outlet Survey (Endline)

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3.3 Pricing of antimalarials (Affordability)

3.3.1 Cost to patients of antimalarials

Table 3.3.1: Cost to patients of non-artemisinin therapy, in US dollars, [Uganda], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of non-artemisinin monotherapy or non-artemisinin combination therapy, by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of products

Median cost [IQR]

Number of

products Median cost

[IQR]

Number of

products

All dosage forms

Public health facility 0.00 [0.00, 0.00] 284 0.00 [0.00, 0.00] 1109 0.00 [0.00, 0.00] 1393 Private not-for-profit health facility 4.11 [0.35, 6.11] 34 2.46 [0.00, 6.11] 85 2.46 [0.00, 6.11] 119

Private for-profit outlet 4.93 [1.14, 8.14] 4169 4.93 [1.14, 7.13] 3169 4.93 [1.14, 7.13] 7338 Community health workers -- 0 -- 0 -- 0

Total 4.93 [0.78, 8.14] 4487 4.59 [0.78, 7.13] 4363 4.93 [0.78, 7.13] 8850

Tablets


Private for-profit outlet 1.17 [0.70, 4.07] 2252 1.64 [0.59, 4.11] 1624 1.17 [0.59, 4.11] 3876 Community health workers -- 0 -- 0 -- 0

Total 1.14 [0.59, 3.29] 2455 0.98 [0.59, 4.07] 2467 0.98 [0.59, 4.07] 4922

Oral liquids


Private for-profit outlet 7.13 [6.11, 8.14] 1175 6.11 [6.11, 7.13] 988 6.11 [6.11, 7.13] 2163 Community health workers -- 0 -- 0 -- 0 Total 7.13 [6.11, 8.14] 1189 6.11 [6.11, 7.13] 1006 6.11 [6.11, 7.13] 2195

Injectables


Private for-profit outlet 16.55 [8.28, 24.83] 742 12.41 [8.28, 16.55] 557 12.41 [8.28, 16.55] 1299 Community health workers -- 0 -- 0 -- 0 Total 12.41 [8.28, 24.83] 843 8.28 [8.28, 16.55] 890 9.93 [8.28, 16.55] 1733

Other

Public health facility -- 0 -- 0 -- 0 Private not-for-profit health facility -- 0 -- 0 -- 0

Private for-profit outlet -- 0 -- 0 -- 0 Community health workers -- 0 -- 0 -- 0

Total -- 0 -- 0 -- 0

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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Table 3.3.2: Cost to patients of artemisinin monotherapy, in US dollars, [Uganda], 2011

Indicator 2.3: Median cost to patients of one adult equivalent treatment dose (AETD)* of artemisinin monotherapy, by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products All dosage forms


Private for-profit outlet 15.02 [11.27, 22.82] 600 15.02 [11.74, 23.47] 199 15.02 [11.74, 23.47] 799

Community health workers 0.00 [n/a] 1 0.00 [0.00, 0.00] 56 0.00 [0.00, 0.00] 57

Total 14.08 [10.52, 21.91] 635 0.17 [0.00, 14.08] 281 11.27 [0.00, 18.78] 916 All oral dosage forms


Private for-profit outlet 19.56 [n/a] 1 -- 0 19.56 [n/a] 1

Community health workers -- 0 -- 0 -- 0

Total 19.56 [n/a] 1 -- 0 19.56 [n/a] 1

Tablets

Public health facility -- 0 -- 0 -- 0 Private not-for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet 19.56 [n/a] 1 -- 0 19.56 [n/a] 1 Community health workers -- 0 -- 0 -- 0

Total 19.56 [n/a] 1 -- 0 19.56 [n/a] 1

Oral liquids Public health facility -- 0 -- 0 -- 0 Private not-for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet -- 0 -- 0 -- 0 Community health workers -- 0 -- 0 -- 0 Total -- 0 -- 0 -- 0

Injectables

Public health facility 0.00 [0.00, 0.00] 27 0.00 [0.00, 0.00] 13 0.00 [0.00, 0.00] 40 Private not-for-profit health facility 14.08 [9.39, 35.21] 7 12.78 [11.27, 14.08] 11 12.78 [11.27, 14.08] 18 Private for-profit outlet 15.02 [11.27, 23.47] 581 15.02 [11.74, 23.47] 198 15.02 [11.74, 23.47] 779 Community health workers -- 0 -- 0 -- 0

Total 14.08 [11.27, 22.53] 615 14.08 [11.27, 23.47] 222 14.08 [11.27, 23.47] 837

Other†

Public health facility -- 0 0.00 [0.00, 0.00] 2 0.00 [0.00, 0.00] 2 Private not-for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet 0.00 [0.00, 6.26] 18 18.78 [n/a] 1 0.00 [0.00, 6.26] 19 Community health workers 0.00 [n/a] 1 0.00 [0.00, 0.00] 56 0.00 [0.00, 0.00] 57

Total 0.00 [0.00, 3.13] 19 0.00 [0.00, 0.00] 59 0.00 [0.00, 0.00] 78

* An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial † Other category includes Artesunate suppository branded G-sunate 200 and Plasmotrim-50


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Table 3.3.3: Cost to patients of non-quality-assured ACTs, in US dollars, [Uganda], 2011

Indicator 2.2: Median cost to patients of one adult equivalent treatment dose (AETD)* of non-quality-assured ACTs by location, type of outlet and dosage form.

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

All dosage forms



Community health workers 0 1.96 [n/a] 1 1.96 [n/a] 1

Total 5.09 [3.13, 10.43] 3322 3.91 [2.74, 7.82] 1265 4.69 [2.74, 8.80] 4587

Tablets



Community health workers 0 1.96 [n/a] 1 1.96 [n/a] 1

Total 3.91 [2.74, 5.87] 2309 3.13 [2.35, 4.69] 897 3.91 [2.54, 5.87] 3206 Oral liquids

Public health facility 0.00 [0.00, 0.00] 3 -- 0 0.00 [0.00, 0.00] 3 Private not-for-profit health facility 7.82 [0.00, 10.43] 5 7.82 [0.00, 9.39] 8 7.82 [0.00, 9.39] 13



Total 11.48 [8.35, 15.65] 951 10.43 [8.35, 15.65] 351 10.43 [8.35, 15.65] 1302

Injectables Public health facility -- 0 -- 0 -- 0 Private not-for-profit health facility -- 0 -- 0 -- 0 Private for-profit outlet -- 0 -- 0 -- 0

Community health workers -- 0 -- 0 -- 0 Total -- 0 -- 0 -- 0

Other (Artequin Peadiatric)


Private for-profit outlet 34.43 [15.65, 39.12] 62 35.21 [32.86, 39.12] 17 34.43 [31.30,39.12] 79


Total 34.43 [15.65, 39.12] 62 35.21 [32.86, 39.12] 17 34.43[31.30,39.12] 79



Table 3.3.4: Cost to patients of quality-assured ACTs, in US dollars, [Uganda], 2011

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Indicator 2.1: Median cost to patients of one adult equivalent treatment dose (AETD)* of quality-assured ACTs, by presence of the AMFm logo, location and type of outlet

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Adult equivalent treatment dose (AETD)*

All QAACTs



Community health worker 0.00 [0.00, 1.96] 3 0.00 [0.00, 0.00] 78 0.00 [0.00, 0.00] 81

Total 1.96 [0.98, 3.13] 2477 1.17 [0.00, 1.96] 2944 1.37 [0.00, 2.35] 5421




Community health worker 1.96 [n/a] 1 0.00 [0.00, 0.00] 8 0.00 [0.00, 0.00] 9 Total 1.96 [1.17, 3.13] 1986 1.56 [0.00, 2.35] 2350 1.56 [0.47, 2.35] 4336

QAACTs without the AMFm logo


Private for-profit outlet 2.74 [1.88, 3.91] 332 1.96 [1.17, 2.74] 126 1.96 [1.37, 3.13] 458 Community health worker 0.00 [0.00, 0.00] 2 0.00 [0.00, 0.00] 70 0.00 [0.00, 0.00] 72

Total 1.56 [0.00, 3.13] 490 0.00 [0.00, 1.17] 594 0.00 [0.00, 1.56] 1084

Pediatric formulation -Pack for a two-year old child (10kg)**

All QAACTs



Community health worker 0.00 [n/a] 1 0.00 [0.00, 0.00] 47 0.00 [0.00, 0.00] 48

Total 0.59 [0.00, 1.17] 309 0.00 [0.00, 0.00] 560 0.00 [0.00, 0.23] 869 QAACTs with the AMFm logo

Public health facility 0.00 [0.00, 0.00] 51 0.00 [0.00, 0.00] 343 0.00 [0.00, 0.00] 394 Private not-for-profit health facility 0.39 [n/a] 1 0.00 [0.00, 0.00] 2 0.00 [0.00, 0.00] 3


Community health worker 0 0.00 [0.00, 0.00] 4 0.00 [0.00, 0.00] 4 Total 0.78 [0.20, 1.17] 266 0.00 [0.00, 0.20] 425 0.00 [0.00, 0.59] 691




Community health worker 0.00 [n/a] 1 0.00 [0.00, 0.00] 43 0.00 [0.00, 0.00] 44

Total 0.00 [0.00, 0.00] 43 0.00 [0.00, 0.00] 135 0.00 [0.00, 0.00] 178 * An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial. **Pediatric formulations (PFs) are packages intended for children. In the calculation of median cost we include only packages whose age (weight) range includes a 2 year old (10kg) child.


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Table 3.3.5.a : Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales volumes (SP) for ALL DOSAGE TYPES, in US dollars [Uganda], 2011 Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national private for-profit sales volumes in [Uganda] that is not a quality-assured ACT, for ALL DOSAGE TYPES (SP), by location and type of outlet

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products




Table 3.3.5.b: Cost to patients of the most popular antimalarial in terms of national private for-profit outlet sales volumes (SP) for TABLETS, in US dollars [Uganda], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national private for-profit sales volumes in [Uganda] that is not a quality-assured ACT, for TABLETS (SP), by location and type of outlet

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products




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Table 3.3.5.c: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for ALL DOSAGE TYPES, in US dollars [Uganda], 2011 Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national sales volumes for all outlet types in [Uganda] that is not a quality-assured ACT, for ALL DOSAGE TYPES (SP), by location and type of outlet

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

All outlets 0.59 [0.59, 0.78] 987 0.59 [0.23, 0.78] 1237 0.59 [0.35, 0.78] 2224



Table 3.3. 5.d: Cost to patients of the most popular antimalarial in terms of national outlet sales volumes for all outlet types (SP) for TABLETS, in US dollars [Uganda], 2011

Indicator 2.4: Median cost to patients of one adult equivalent treatment dose (AETD)* of the most popular antimalarial in terms of national sales volumes for all outlet types in [Uganda] that is not a quality-assured ACT, for TABLETS (SP), by location and type of outlet

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

All outlets 0.59 [0.59, 0.78] 987 0.59 [0.23, 0.78] 1237 0.59 [0.35, 0.78] 2224



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3.3.2 Gross percentage markup between purchase price and retail selling price

Table 3.3.6: Gross percentage markup between purchase price and retail selling price of non-artemisinin therapy [Uganda], 2011

Median percentage markup between purchase price and retail selling price of non-artemisinin monotherapy or non-artemisinin combination therapy by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of

products Median markup

[IQR]

Number of


[IQR]

Number of

products

Public health facility 0.0 [0.0, 0.0] 259 0.0 [0.0, 0.0] 1104 0.0 [0.0, 0.0] 1363

Private not-for-profit health facility 40.0 [0.0, 166.0] 19 36.4 [0.0, 78.6] 56 36.4 [0.0, 86.7] 75

Private for-profit outlet Private for-profit health facility 100.0 [50.0, 194.1] 1053 76.5 [40.0, 150.0] 711 87.5 [42.9, 150.0] 1764

Pharmacy 48.1 [25.0, 81.8] 1174 66.7 [37.9, 100.0] 220 50.0 [25.0, 87.5] 1394

Drug store 53.8 [33.3, 100.0] 845 53.8 [33.3, 100.0] 1489 53.8 [33.3, 100.0] 2334

General retailer 33.3 1 20.0 [7.1, 100.0] 7 20.0 [7.1, 100.0] 8


Total 66.7 [36.4, 150.0] 3073 60.0 [33.3, 106.4] 2427 66.7 [33.3, 109.4] 5500

Community health worker -- 0 47.1 1 47.1 1

Total 66.7 [33.3, 127.3] 3351 50.0 [25.0, 100.0] 3588 52.2 [25.0, 100.0] 6939

Note: 17 markups were treated as missing, because the purchase price was zero and the selling price was non-zero.


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Table 3.3.7: Gross percentage markup between purchase price and retail selling price of artemisinin monotherapy [Uganda], 2011 Median percentage markup between purchase price and retail selling price of artemisinin monotherapy by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility 0.0 [0.0, 0.0] 19 0.0 [0.0, 0.0] 14 0.0 [0.0, 0.0] 33 Private not-for-profit health facility

14.3 [-100.0, 14.3] 3 33.3 [16.7, 200.0] 6 33.3 [16.7, 200.0] 9


Private for-profit health facility 76.5 [42.9, 150.0] 140 66.7 [38.5, 133.3] 66 66.7 [40.0, 133.3] 206 Pharmacy 31.6 [16.7, 60.0] 265 42.9 [25.0, 66.7] 40 33.3 [17.6, 60.0] 305 Drug store 40.0 [20.0, 87.5] 16 66.7 [50.0, 100.0] 22 66.7 [50.0, 100.0] 38 General retailer -- 0 -- 0 -- 0 Itinerant drug vendor -- 0 -- 0 -- 0 Total 60.0 [25.0, 108.3] 421 66.7 [42.9, 113.3] 128 66.7 [33.3, 108.3] 549

Community health worker 0.0 1 0.0 [0.0, 0.0] 56 0.0 [0.0, 0.0] 57 Total 60.0 [25.0, 104.2] 444 0.0 [0.0, 50.0] 204 16.7 [0.0, 66.7] 648

Note: 1 markup was treated as missing, because the purchase price was zero and the selling price was non-zero.


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Table 3.3. 8: Gross percentage markup between purchase price and retail selling price of non-quality-assured ACTs [Uganda], 2011 Median percentage markup between purchase price and retail selling price of non-quality-assured ACTs by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of products

Median markup [IQR]

Number of

products

Public health facility 0.0 [0.0, 0.0] 63 0.0 [0.0, 0.0] 15 0.0 [0.0, 0.0] 78 Private not-for-profit health facility 38.5 [-83.3, 66.7] 12 33.3 [33.3, 80.0] 14 33.3 [33.3, 80.0] 26 Private for-profit outlet:

Private for-profit health facility 60.0 [36.4, 100.0] 447 55.6 [33.3, 92.3] 248 60.0 [34.6, 100.0] 695

Pharmacy 33.3 [20.0, 53.8] 1540 42.9 [25.0, 66.7] 307 33.3 [22.0, 55.6] 1847 Drug store 55.6 [30.4, 100.0] 259 50.0 [25.0, 100.0] 285 50.0 [27.3, 100.0] 544 General retailer 122.2 1 -- 0 122.2 1 Itinerant drug vendor -- 0 -- 0 -- 0 Total 50.0 [30.0, 92.3] 2247 50.0 [30.0, 89.7] 840 50.0 [30.0, 90.5] 3087


Total 50.0 [27.3, 87.5] 2322 50.0 [29.9, 87.5] 870 50.0 [28.2, 87.5] 3192



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Table 3.3.9.a: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs [Uganda], 2011 Indicator 2.5: Median percentage markup between purchase price and retail selling price of quality-assured ACTs by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of products

Median markup [IQR]

Number of


[IQR]

Number of

products


Private for-profit outlet Private for-profit health facility 150.0 [100.0,300.0] 470 150.0 [100.0,233.3] 286 150.0 [100.0,233.3] 756 Pharmacy 100.0 [66.7, 185.7] 743 100.0 [75.0, 200.0] 131 100.0 [66.7, 185.7] 874 Drug store 127.3 [66.7, 200.0] 369 100.0 [50.0, 200.0] 444 100.0 [60.0, 200.0] 813 General retailer 6.4 [6.4, 100.0] 2 66.7 [50.0, 66.7] 4 66.7 [50.0, 66.7] 6

Itinerant drug vendor -- 0 -- 0 -- 0 Total 133.3 [71.4, 233.3] 1584 114.3 [66.7, 212.5] 865 127.3 [66.7, 220.0] 2449

Community health worker 0.0 [0.0, 42.9] 3 0.0 [0.0, 0.0] 78 0.0 [0.0, 0.0] 81 Total 100.0 [40.0, 200.0] 1944 33.3 [0.0, 140.0] 2589 56.3 [0.0, 150.0] 4533



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Table 3.3.9.b: Gross percentage markup between purchase price and retail selling price of quality-assured ACTs, by presence of the AMFm logo, [Uganda], 2011

Indicator 2.5: Median percentage markup between purchase price and retail selling price of quality-assured ACTs by presence of the AMFm logo by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of products

Median markup [IQR]

Number of products

Median markup [IQR]

Number of

products QAACTs with the AMFm logo

Public health facility 0.0 [0.0, 0.0] 208 0.0 [0.0, 0.0] 1261 0.0 [0.0, 0.0] 1469 Private not-for-profit health facility 100.0 [-100.0,150.0] 3 0.0 [0.0, 108.3] 10 0.0 [0.0, 108.3] 13 Private for-profit outlet

Private for-profit health facility 166.7[100.0,300.0] 426 150.0[100.0,233.3] 264 150.0[100.0,250.0] 690 Pharmacy 100.0 [66.7, 200.0] 593 110.5[87.5,200.0] 107 100.0 [66.7, 200.0] 700 Drug store 133.3 [66.7, 200.0] 328 100.0 [56.3, 200.0] 414 100.0 [60.0, 200.0] 742 General retailer 6.4 1 66.7 [66.7, 66.7] 3 66.7 [50.0, 66.7] 4 Itinerant drug vendor 0 0 0 Total 150.0 [81.8, 233.3] 1348 127.3 [66.7, 220.0] 788 133.3 [66.7, 233.3] 2136

Community health worker 42.9 1 0.0 [0.0, 0.0] 8 0.0 [0.0, 0.0] 9 Total 113.3 [60.0, 233.3] 1560 66.7 [0.0, 150.0] 2067 100.0 [0.0, 180.0] 3627


Public health facility 0.0 [0.0, 0.0] 130 0.0 [0.0, 0.0] 342 0.0 [0.0, 0.0] 472 Private not-for-profit health facility 0.0 [0.0, 0.0] 16 0.0 [0.0, 0.0] 33 0.0 [0.0, 0.0] 49 Private for-profit outlet

Private for-profit health facility 105.7 [0.0, 150.0] 44 133.3 [37.1, 200.0] 22 133.3 [37.1, 185.7] 66 Pharmacy 66.7 [15.4, 100.0] 150 66.7 [40.0, 140.0] 24 66.7 [22.7, 100.0] 174 Drug store 80.0 [50.0, 166.7] 41 66.7 [40.0, 105.7] 30 71.4 [42.9, 120.6] 71 General retailer 100.0 [100.0, 100.0] 1 0.0 [0.0, 0.0] 1 0.0 [0.0, 0.0] 2 Itinerant drug vendor 0 0 0 Total 100.0 [40.0, 150.0] 236 71.4 [37.1, 150.0] 77 100.0 [40.0, 150.0] 313

Community health worker 0.0 [0.0, 0.0] 2 0.0 [0.0, 0.0] 70 0.0 [0.0, 0.0] 72 Total 15.0 [0.0, 100.0] 384 0.0 [0.0, 0.0] 522 0.0 [0.0, 14.3] 906

Note: *12 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. (QAACTs with logo) **15 markups were treated as missing, because the purchase price was zero and the selling price was non-zero. (QAACTs without logo)


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Table 3.3.10: Median total gross markup between first-line buyer price and retail selling price of quality-assured ACTs bearing the AMFm logo, in US dollars, [Uganda], 2011 Indicator 2.6: Median total gross markup* between first-line buyer price** and retail selling price per adult equivalent treatment dose (AETD)*** of quality-assured ACTs bearing the AMFm logo, by location and type of outlet

Type of outlet

Urban Rural Total

Median markup [IQR]

Number of


[IQR]

Number of


[IQR]

Number of

products

Public health facility -0.11 [-0.12, -0.03] 211 -0.11 [-0.12, -0.03] 1265 -0.11 [-0.12, -0.03] 1476

Private not-for-profit health facility 2.81 [1.05, 4.57] 5 0.85 [-0.03, 1.44] 13 0.85 [-0.03, 1.44] 18



Pharmacy 1.05 [0.66, 1.70] 803 1.53 [1.05, 2.56] 175 1.11 [0.66, 1.89] 978 Drug store 1.83 [1.11, 2.61] 406 1.75 [1.05, 2.29] 500 1.75 [1.05, 2.29] 906 General retailer 1.83 [1.83, 1.83] 1 1.05 [0.81, 2.22] 10 1.05 [0.81, 2.22] 11 Itinerant drug vendor -- 0 -- 0 -- 0

Total 1.89 [1.12, 3.06] 1766 1.83 [1.11, 2.67] 1062 1.83 [1.11, 2.69] 2828

Community health worker 1.83 [1.83, 1.83] 1 -0.02 [-0.02, -0.02] 8 -0.02 [-0.02, -0.02] 9

Total 1.83 [1.05, 3.00] 1983 1.44 [-0.03, 2.22] 2348 1.44 [0.34, 2.29] 4331

*Median total gross markup is the median of the difference between the retail selling price and the mean first-line buyer price for each QAACT. **First Line Buyer (FLB) price data were provided by The Global Fund. *** An AETD is the number of milligrams (mg) of a given drug that is required to treat a 60 kg adult. AETDs were calculated for every audited antimalarial


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3.3.3 Availability and cost to patients of diagnostic tests (RDT/microscopy)

3.3.3.1 Any diagnostic test

Table 3.3.11: Availability of any diagnostic test for malaria, Uganda, 2011

Outlets where any diagnostic tests (microscopy or RDT) were available* (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit** (N), by location and type of outlet.

Type of outlet




(95% CI) N

Public health facility 76.2 (64.6,84.9) 144 74.7 (67.9,80.4) 532 74.9 (69.1,79.9) 676

Private not-for-profit health facility 92.2 (58.6,99.0) 12

96.0 (74.2,99.5) 26 95.6 (79.4,99.2) 38



Pharmacy 31.9 (21.5,44.4) 326 24.3 (16.5,34.1) 64 30.5 (22.0,40.6) 390

Drug store 10.1 (7.8, 13.0) 433 6.6 (4.2, 10.1) 675 7.1 (5.0, 10.0) 1108



Total 34.9 (27.2,43.5) 1242 16.9 (11.8,23.6) 1076 21.1 (16.0,27.3) 2318

Community health worker 0.0 2 71.1 (38.9,90.5) 82 70.8 (39.5,90.0) 84

Total 38.0 (31.7,44.8) 1400 30.2 (22.9,38.7) 1716 31.8 (25.8,38.5) 3116

* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the day of the survey visit ** Flow diagram reference E


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3.3.3.2 Malaria microscopy

Table 3.3.12: Availability of malaria microscopy, Uganda, 2011

Outlets where malaria microscopic tests were available* (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit** (N), by location and type of outlet

Type of outlet




(95% CI) N

Public health facility 52.3 (42.2,62.3) 144 38.3 (33.3,43.5) 531 40.3 (35.8,44.9) 675 Private not-for-profit health facility 92.2 (58.6,99.0) 12 75.3 (43.8,92.3) 26 77.1 (49.2,92.2) 38


Private for-profit health facility 47.1 (37.2,57.2) 478 42.2 (36.9,47.8) 323 44.3 (39.8,48.8) 801 Pharmacy 1.0 (0.2, 4.9) 327 0.0 64 0.8 (0.2, 4.0) 391 Drug store 3.4 (1.7, 6.8) 433 2.3 (1.1, 4.8) 676 2.5 (1.4, 4.4) 1109 General retailer 0.0 4 0.0 14 0.0 18 Itinerant drug vendor -- 0 -- 0 -- 0 Total 25.4 (19.5,32.5) 1242 10.9 (7.4, 15.7) 1077 14.3 (10.6,19.1) 2319


Total 27.8 (22.6,33.7) 1400 14.0 (10.6,18.2) 1716 16.8 (13.3,21.0) 3116

* Malaria microscopic testing is considered to be available if the respondent reported that the service is available in the outlet on the day of the survey visit ** Flow diagram reference E


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Table 3.3.13: Cost to patients of malaria microscopy in 2010 US dollars Uganda, 2011 Median cost to patients of one malaria diagnostic test with microscopy, by outlet type and patient age

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of outlets

reporting price of malaria

microscopy Median cost

[IQR]

Number of outlets


microscopy Median cost

[IQR]

Number of outlets


microscopy

Adults





Pharmacy 1.17 [0.78, 1.17] 6 0 1.17 [0.78, 1.17] 6

Drug store 0.78 [0.39, 1.17] 13 0.59 [0.39, 0.98] 11 0.59 [0.39, 0.98] 24

General retailer -- 0 -- 0 -- 0


Total 0.78 [0.78, 1.17] 254 0.78 [0.59, 0.98] 144 0.78 [0.78, 1.17] 398


Total 0.78 [0.78, 1.17] 340 0.59 [0.00, 0.78] 357 0.78 [0.39, 0.98] 697

Children





Pharmacy 1.08 [0.78, 1.17] 6 -- 0 1.08 [0.78, 1.17] 6

Drug store 0.78 [0.39, 1.17] 13 0.59 [0.39, 0.78] 11 0.59 [0.39, 0.78] 24

General retailer 0 0 0


Total 0.78 [0.78, 1.17] 254 0.78 [0.39, 0.98] 144 0.78 [0.59, 1.17] 398


Total 0.78 [0.59, 1.17] 340 0.39 [0.00, 0.78] 357 0.78 [0.20, 0.78] 697


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3.3.3.3 Diagnostic test with rapid diagnostic tests

Table 3.3.14: Availability of rapid diagnostic tests for malaria, Uganda, 2011

Outlets where rapid diagnostic tests were available (n) as a percentage of outlets with any antimalarials in stock at the time of the survey visit* (N), by location and type of outlet.

Type of outlet




(95% CI) N





Pharmacy 31.4 (21.2, 43.8) 326 24.3 (16.5, 34.1) 64 30.1 (21.7, 40.1) 390

Drug store 6.9 (5.2, 9.0) 433 4.4 (2.7, 7.0) 675 4.8 (3.3, 6.9) 1108

General retailer 0.0 4 0.0 14 0.0 18 Itinerant drug vendor -- 0 -- 0 -- 0 Total 15.5 (12.2, 19.6) 1244 7.9 (5.2, 11.9) 1077 9.7 (7.2, 13.0) 2321


Total 16.9 (14.4, 19.6) 1402 20.5 (12.9, 31.1) 1718 19.8 (13.6, 27.9) 3120



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Table 3.3.15: Cost to patients of rapid diagnostic tests (RDTs) for malaria in 2010 US dollars Uganda, 2011

Median cost to patients of one rapid diagnostic test for malaria, by location, outlet type and patient age

Type of outlet

Urban Rural Total

Median cost [IQR]

Number of RDT products

Median cost [IQR]


Median cost [IQR]


Adults




Pharmacy 0.86 [0.78, 0.98] 90 1.02 [0.78, 1.17] 18 0.86 [0.78, 0.98] 108

Drug store 1.17 [0.78, 1.17] 29 0.78 [0.39, 0.98] 30 0.78 [0.39, 1.17] 59



Total 1.17 [0.98, 1.17] 227 0.98 [0.78, 1.17] 121 1.17 [0.78, 1.17] 348

Community health worker 0 0.00 [0.00, 0.00] 48 0.00 [0.00, 0.00] 48

Total 1.17 [0.78, 1.17] 276 0.00 [0.00, 0.59] 540 0.00 [0.00, 0.98] 816

Children




Pharmacy 0.78 [0.78, 0.98] 89 1.02 [0.78, 1.17] 18 0.86 [0.78, 1.02] 107

Drug store 1.17 [0.78, 1.17] 28 0.78 [0.39, 0.98] 30 0.78 [0.39, 1.17] 58



Total 1.17 [0.78, 1.17] 222 0.98 [0.70, 1.17] 122 1.17 [0.78, 1.17] 344

Community health worker 0 0.00 [0.00, 0.00] 48 0.00 [0.00, 0.00] 48

Total 1.17 [0.78, 1.17] 271 0.00 [0.00, 0.59] 542 0.00 [0.00, 0.78] 813


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3.4 Quality-assured ACTs market share

Table 3.4.1: Percentage breakdown of antimalarial sales volumes by antimalarial type, Uganda, 2011

Indicator 4.1: Total number of AETDs of each antimalarial type sold or distributed in the week preceding the survey visit (n), as a percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Urban Rural Total

Percentage N Percentage N Percentage N

Public health facility Quality-assured ACTs 57.1 84.9 81.3 Non-quality-assured ACTs 3.4 0.2 0.6 Oral artemisinin monotherapy 0.0 0.0 0.0 Non-oral artemisinin monotherapy 0.0 0.0 0.0 Non-artemisinin therapy 39.5 14.9 18.1 Total 100 5907.4 100 10144.4 100 16051.8


Quality-assured ACTs 63.6 49.5 50.5 Non-quality-assured ACTs 11.0 3.6 4.1 Oral artemisinin monotherapy 0.0 0.0 0.0 Non-oral artemisinin monotherapy 1.6 0.5 0.6 Non-artemisinin therapy 23.8 46.4 44.8 Total 100 517.6 100 1877.6 100 2395.2



Community health worker


All outlets Quality-assured ACTs 41.7 61.5 56.7 Non-quality-assured ACTs 15.5 10.0 11.4 Oral artemisinin monotherapy 0.0 0.0 0.0 Non-oral artemisinin monotherapy 0.8 0.4 0.5 Non-artemisinin therapy 42.0 28.0 31.4

Total 100 29263.3 100 26550.7 100 55813.9


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Table 3.4.2: Market share of quality-assured ACTs (QAACTs), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, [Uganda], 2011

Indicator 4.1: Total number of AETDs of QAACTs sold or distributed in the week preceding the survey visit (n), as a percentage all antimalarial AETDs sold or distributed in the week preceding the survey visit by outlets with any antimalarials in stock at the time of the survey visit (N), for all QAACTs, QAACTs with the AMFm logo and QAACTs without the AMFm logo, by location and type of outlet

Urban Rural Total

Percentage N Percentage N Percentage N

Public health facility

All QAACTs 57.1 84.9 81.3 QAACTs with logo 49.4 61.3 59.8

QAACTs without logo 7.7 23.6 21.5

Total number of AEDTS sold 5907.4 10144.4 16051.8

Private not-for-profit health facility All QAACTs 63.6 49.5 50.5 QAACTs with logo 11.0 18.4 17.9 QAACTs without logo 52.5 31.2 32.6 Total number of AEDTS sold 517.6 1877.6 2395.2 Private for-profit outlet All QAACTs 36.8 39.3 38.5 QAACTs with logo 31.9 34.6 33.7 QAACTs without logo 4.9 4.7 4.8 Total number of AEDTS sold 22832.0 14443.9 37275.9 Community health worker All QAACTs 100.0 99.1 99.1 QAACTs with logo 77.5 13.6 14.6 QAACTs without logo 22.5 85.5 84.6 Total number of AEDTS sold 6.3 84.8 91.0 All outlets All QAACTs 41.7 61.5 56.7 QAACTs with logo 35.4 45.9 43.3 QAACTs without logo 6.3 15.7 13.4 Total number of AEDTS sold 29263.2 26550.7 55813.9


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Table 3.4.3: Percentage breakdown of antimalarial sales volumes by outlet type, [Uganda], 2011

Indicator 4.1: Total number of AETDs sold or distributed in the week preceding the survey visit by each outlet type (n), as a percentage of all antimalarial AETDs sold or distributed in the week preceding the survey visit by all outlets with any antimalarials in stock at the time of the survey visit (N), by location and antimalarial type

Urban Rural Total

Percentage N

Percentage N Percentage N


Public health facilities 30.0 64.4 58.3

Private not-for-profit health facilities 2.4 5.6 5.1

Private for-profit outlets 67.5 29.4 36.2

Community health workers 0.0 0.6 0.5

Total 100 11885.9 100 15263.3 100 27149.2






Total 100 4681.6 100 3214.9 100 7896.5

Oral artemisinin therapies





Total 100 0.0 100 0.0 100 0.0

Non-oral artemisinin therapies





Total 100 216.9 100 149.9 100 366.8

Non-artemisinin therapies





Total 100 12478.8 100 7922.6 100 20401.4

All antimalarials





Total 100 29263.3 100 26550.7 100 55813.9


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3.5 Provider knowledge of first-line antimalarial treatment and ACT

regimen

Table 3.5.1: Provider knowledge of first-line antimalarial treatment, [Uganda], 2011

Providers able to correctly identify the antimalarial for first-line treatment (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit* (N), by location and type of outlet

Type of outlet




(95% CI) N

Public health facility 93.6 (84.9,97.4) 144 95.8 (92.5,97.7) 534 95.5 (92.7,97.3) 678 Private not-for-profit health facility 100.0 13 92.2 (73.1,98.1) 28 93.0 (76.7,98.2) 41



Pharmacy 92.3 (87.1,95.5) 332 90.7 (84.2,94.7) 64 92.0 (87.9,94.8) 396 Drug store 76.9 (72.0,81.1) 435 73.0 (67.6,77.7) 676 73.5 (69.1,77.6) 1111 General retailer 51.5 (10.6,90.5) 4 27.1 (6.4, 67.1) 14 28.5 (7.7, 65.7) 18 Itinerant drug vendor -- 0 -- 0 -- 0 Total 80.3 (78.0,82.3) 1253 73.1 (67.3,78.3) 1079 74.8 (70.4,78.8) 2332


Total 81.3 (79.0,83.4) 1412 77.9 (72.1,82.9) 1723 78.6 (74.2,82.5) 3135



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Table 3.5.2: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for an adult. [Uganda], 2011

Providers able to describe correctly the dosing regimen for quality-assured ACTs for an adult (n) as a percentage of the number of outlets with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*

Type of outlet




(95% CI) N

Public health facility 99.6(97.1,100.0) 129 98.4 (95.8,99.4) 483 98.6 (96.5,99.4) 612 Private not-for-profit health facility 100.0 10 100.0 24 100.0 34


Private for-profit health facility 94.0 (90.2,96.4) 375 96.0 (91.4,98.2) 243 95.2 (92.7,96.8) 618 Pharmacy 98.2 (96.0,99.2) 307 100.0 61 98.5 (96.6,99.4) 368 Drug store 95.5 (93.2,97.1) 297 94.3 (91.0,96.5) 411 94.5 (91.9,96.3) 708 General retailer 100.0 3 66.0 (47.0,80.9) 9 68.3 (52.5,80.8) 12 Itinerant drug vendor -- 0 -- 0 -- 0 Total 95.0 (93.4,96.2) 982 93.9 (90.9,95.9) 724 94.2 (92.1,95.7) 1706


Total 95.3 (93.9,96.4) 1123 87.2 (74.4,94.1) 1282 89.1 (79.5,94.5) 2405 * “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number of times the medicine should be taken per day and the duration of the dose in number of days for a 60kg adult for a specific product which they selected from the QAACTs that they stocked.


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Table 3.5.3: Provider knowledge of dosing regimen for quality-assured ACTs (QAACTs) for a child, [Uganda], 2011

Providers able to describe correctly the dosing regimen for quality-assured ACT for a child (n) as a percentage of the number of outlets with QAACTs in stock at the time of the survey visit (N), by location and type of outlet*

Type of outlet


(95% CI) N

Percentage (95% CI)

N Percentage

(95% CI) N


Private not-for-profit health facility 77.1 (63.1,86.9) 10 94.8 (78.2,98.9) 24 92.8 (80.8,97.5) 34

Private for-profit outlet Private for-profit health facility 76.0 (71.7,79.8) 378 81.2 (71.4,88.2) 239 79.0 (72.9,83.9) 617 Pharmacy 69.8 (61.2,77.2) 309 92.2 (89.3,94.4) 60 73.7 (65.0,80.8) 369 Drug store 81.3 (74.4,86.7) 296 79.7 (74.2,84.3) 407 80.0 (75.5,83.8) 703 General retailer 37.6 (4.7, 87.9) 3 40.7 (26.1,57.3) 9 40.5 (26.5,56.3) 12 Itinerant drug vendor -- 0 -- 0 -- 0 Total 77.4 (73.1,81.2) 986 78.9 (73.2,83.6) 715 78.5 (74.3,82.1) 1701

Community health worker 46.3 (4.9, 93.5) 2 86.1 (74.3,93.0) 51 85.8 (74.8,92.5) 53

Total 78.4 (74.7,81.7) 1129 82.3 (78.4,85.6) 1270 81.4 (78.2,84.1) 2399

* “Correctly describe” implies that the respondent correctly stated the number of tablets that should be taken at a time, the number of times the medicine should be taken per day and the duration of the dose in number of days for child under 2 years (10kg) for a specific product which they selected from the QAACTs that they stocked.


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Table 3.5.4: Reasons for not stocking quality-assured ACTs (QAACTs) by private providers, [Uganda], 2011

Private for-profit providers stating a specific reason for why they were not stocking QAACTs (n) as a percentage of all private for-profit outlets* not stocking QAACTs at the time of the survey visit** (N), by location

Urban Rural Total

Reason Percentage



(95% CI) N

Too expensive 35.9 (26.4, 46.8) 225 45.8 (37.5, 54.3) 369 44.4 (37.4, 51.6) 594

Not profitable 4.2 (2.2, 7.9) 225 5.4 (3.1, 9.4) 369 5.2 (3.2, 8.5) 594

The outlet is not allowed to sell them 17.3 (14.4, 20.8) 224 20.9 (15.1, 28.1) 369 20.4 (15.4, 26.5) 593

They have too many side effects 1.6 (0.6, 3.8) 225 0.7 (0.1, 2.9) 369 0.8 (0.3, 2.3) 594

They do not work well 7.5 (3.7, 14.8) 225 2.2 (1.1, 4.2) 369 2.9 (1.7, 5.0) 594 They are not available/my suppliers do not have it in stock 6.9 (4.4, 10.7) 224 9.9 (7.2, 13.5) 369 9.5 (7.1, 12.5) 593

My customers do not ask for them 22.8 (15.9, 31.6) 225 20.3 (14.8, 27.4) 369 20.7 (15.8, 26.6) 594

I don’t know about these drugs 4.9 (3.1, 7.8) 225 6.2 (3.4, 11.1) 369 6.1 (3.6, 10.0) 594

I am temporarily out of stock 22.3 (16.4, 29.5) 225 21.9 (17.6, 26.9) 369 22.0 (18.2, 26.2) 594

I am not responsible for stocking 19.5 (15.5, 24.3) 225 11.1 (6.6, 18.2) 369 12.3 (8.2, 18.0) 594

New outlet 2.1 (1.1, 4.0) 225 3.4 (1.4, 8.0) 369 3.2 (1.5, 6.9) 594

Customers can get it for free in public facilities 5.7 (3.8, 8.6) 225 9.1 (5.7, 14.2) 369 8.6 (5.7, 12.8) 594

Other: Is ANC outlet/not recommended in pregnancy 0.4 (0.1, 3.5) 225 0.5 (0.1, 3.6) 369 0.5 (0.1, 2.7) 594

Other: Stock other AMs/other AMs are effective 0.0 225 0.0 369 0.0 594

* This indicator excludes responses from public-health facilities and CHW. ** Note that a provider could give more than one response to this question. Percentage may add to more than 100


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3.6 AMFm logo

Table 3.6.1: Provider recognition of AMFm logo, [Uganda], 2011

Providers able to recognize the AMFm logo* (n) as a percentage of the number of outlets with antimalarials in stock at the time of the survey visit** (N), by location and type of outlet

Type of outlet




(95% CI) N


Private not-for-profit health facility 81.7 (47.3,95.7) 13 44.9 (24.3,67.4) 28 49.0 (29.4,68.9) 41

Private for-profit outlet Private for-profit health facility 72.4 (64.9,78.8) 482 76.0 (70.1,81.1) 323 74.5 (70.8,77.9) 805 Pharmacy 92.1 (83.3,96.5) 332 91.1 (65.6,98.2) 63 91.9 (84.5,96.0) 395 Drug store 66.5 (52.4,78.2) 435 67.8 (57.5,76.6) 673 67.6 (58.9,75.2) 1108 General retailer 0.0 3 3.5 (0.4, 26.6) 14 3.4 (0.4, 24.3) 17 Itinerant drug vendor -- 0 -- 0 -- 0 Total 70.7 (60.9,78.9) 1252 67.9 (59.6,75.3) 1073 68.6 (61.9,74.6) 2325


Total 70.6 (61.1,78.5) 1411 64.6 (55.4,72.8) 1714 65.8 (58.3,72.6) 3125

* All respondents were shown a visual aid depicting the AMFm logo. And were asked whether they have seen the symbol before. A provider is “able to recognize the AMFm logo” if they answer that they have seen the symbol before. ** Flow diagram reference E.


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Table 3.6.2: Provider knowledge of the AMFm logo [Uganda], 2011

Providers stating a specific meaning of the AMFm logo (n) as a percentage of outlets that recognized the AMFm logo (N), by location*

Meaning of AMFm logo


(95% CI) N

Percentage (95% CI)

N Percentage

(95% CI) N

Effective/quality antimalarial 13.7 (11.1, 16.8) 1045 9.7 (6.5, 14.4) 1209 10.6 (7.8, 14.2) 2254

Affordable antimalarial 5.5 (4.0, 7.4) 1046 2.1 (1.1, 4.0) 1211 2.8 (1.7, 4.6) 2257

An antimalarial in high demand 1.5 (1.0, 2.2) 1045 0.6 (0.2, 1.2) 1209 0.8 (0.4, 1.3) 2254 Effective/quality medicine 3.0 (2.0, 4.5) 1046 1.9 (1.0, 3.9) 1211 2.2 (1.3, 3.7) 2257

Affordable medicine 2.2 (1.6, 3.2) 1045 0.6 (0.3, 1.3) 1210 0.9 (0.5, 1.7) 2255

A medicine in high demand 0.5 (0.2, 1.0) 1043 0.3 (0.1, 1.0) 1208 0.3 (0.1, 0.8) 2251 It means nothing 0.6 (0.4, 1.2) 1043 0.1 (0.0, 0.3) 1210 0.2 (0.1, 0.4) 2253 A drug/medicine 8.6 (6.4, 11.6) 1044 5.9 (4.5, 7.7) 1211 6.5 (5.2, 8.1) 2255

An antimalarial 33.7 (29.4, 38.3) 1044 33.1 (24.7,42.7) 1210 33.2 (26.6,40.5) 2254

Artemisinin Combination Therapy (ACT)

91.3 (89.4, 92.9) 1047 88.8 (83.6,92.5) 1214 89.4 (85.5,92.3) 2261

Herbal medicine 15.7 (12.6, 19.5) 1045 14.1 (11.0,18.0) 1210 14.5 (11.9,17.5) 2255

Recommended treatment 2.6 (2.0, 3.3) 1045 2.2 (1.1, 4.4) 1210 2.3 (1.4, 3.8) 2255 Subsidized medicine 3.7 (2.7, 5.2) 1045 1.3 (0.7, 2.4) 1210 1.8 (1.1, 2.9) 2255

I don’t know what it means 22.5 (20.3, 24.8) 1043 27.3 (23.7,31.1) 1211 26.2 (23.3,29.4) 2254

Other: Trademark/Logo/Symbol 2.4 (1.8, 3.1) 1047 3.1 (2.0, 5.0) 1215 3.0 (2.0, 4.3) 2262

Other: Drugs meant for private sector

1.1 (0.5, 2.4) 1047 0.2 (0.0, 0.6) 1214 0.4 (0.2, 0.8) 2261

Other: Other 4.3 (3.1, 5.9) 1047 5.7 (3.6, 9.0) 1214 5.4 (3.8, 7.8) 2261

* Note that providers could give more than one response to this question. Percentage may add to more than 100


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Table 3.6.3: Sources from which providers have seen or heard of the AMFm logo, [Uganda], 2011

Providers stating a specific source where they have seen or heard of the AMFm logo (n) as a percentage of providers that recognized the AMFm logo (N), by location*

Urban Rural Total

Source Percentage

(95% CI) N

Percentage (95% CI)

N Percentage

(95% CI) N

On malaria medicine packaging

52.4 (47.6,57.2) 1047 50.3 (44.6,56.1) 1214 50.8 (46.3,55.3) 2261

On medicine packaging 21.2 (16.3,27.1) 1046 13.0 (9.0, 18.5) 1213 14.8(10.9,19.7) 2259

On posters 15.5 (12.9,18.5) 1047 11.3 (7.4, 16.8) 1214 12.2 (9.0, 16.4) 2261

On billboards 1.1 (0.6, 1.7) 1046 0.9 (0.3, 2.5) 1214 0.9 (0.4, 2.0) 2260

On TV/radio 27.7 (24.4,31.2) 1047 31.0(22.2,41.5) 1214 30.3 (23.5,38.1) 2261

On a prescription 1.3 (0.7, 2.2) 1047 0.5 (0.1, 1.7) 1214 0.6 (0.3, 1.5) 2261

In newspapers/magazines 4.8 (3.9, 5.9) 1047 2.6 (1.6, 4.3) 1213 3.1 (2.1, 4.5) 2260

In pharmacies/ drug shops 23.1 (20.0,26.4) 1047 17.3 (13.3,22.2) 1212 18.6 (15.2,22.5) 2259

In private clinics 7.7 (6.1, 9.8) 1047 9.2 (6.1, 13.5) 1212 8.9 (6.5, 12.0) 2259

In public health facilities 13.9(11.7,16.5) 1046 23.0 (17.2,30.0) 1214 21.0 (16.5,26.4) 2260

In training 6.4 (4.9, 8.4) 1047 7.8 (5.9, 10.4) 1213 7.5 (6.0, 9.4) 2260

From a supplier 1.9 (1.2, 3.1) 1047 1.3 (0.6, 3.0) 1213 1.4 (0.8, 2.6) 2260

From a public event 1.1 (0.6, 2.2) 1045 2.7 (1.4, 5.3) 1214 2.4 (1.3, 4.2) 2259

From a local leader 0.1 (0.0, 0.6) 1047 0.3 (0.1, 1.6) 1214 0.3 (0.1, 1.1) 2261

From a friend/family member 1.6 (1.0, 2.5) 1046 1.1 (0.5, 2.4) 1213 1.2 (0.7, 2.2) 2259

On the internet 0.3 (0.2, 0.7) 1046 100.0 1212 0.1 (0.0, 0.3) 2258

On a T-shirt 3.9 (2.5, 6.1) 1046 3.7 (1.9, 7.3) 1213 3.8 (2.2, 6.3) 2259

Don’t know 3.7 (2.4, 5.7) 1047 1.8 (0.6, 4.9) 1213 2.2 (1.1, 4.2) 2260

Other: Vehicle 1.2 (0.5, 2.7) 1047 2.1 (1.0, 4.2) 1214 1.9 (1.0, 3.5) 2261

Other: Researcher/baseline 0.4 (0.1, 3.5) 1047 0.2 (0.0, 1.5) 1214 0.3 (0.1, 1.1) 2261

Other: Med school 0.5 (0.2, 1.1) 1047 0.2 (0.0, 1.7) 1214 0.3 (0.1, 1.0) 2261

Other: Med association 0.2 (0.1, 0.6) 1047 0.1 (0.0, 0.4) 1214 0.1 (0.0, 0.3) 2261

Other: Med books/guidelines 0.1 (0.0, 0.3) 1047 0.1 (0.0, 0.4) 1214 0.1 (0.0, 0.3) 2261

Other: Calendar/Stickers/Brochure

0.1 (0.0, 0.3) 1047 0.0 1214 0.0 2261

Other: Net 0.1 (0.0, 0.3) 1047 100.0 1214 0.0 2261

Other: NGOs 0.0 1047 0.3 (0.1, 1.3) 1214 0.3 (0.1, 0.9) 2261

Other: Other 0.5 (0.2, 1.4) 1047 0.7 (0.3, 1.8) 1214 0.7 (0.3, 1.5) 2261



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Table 3.6.4: Percentage of antimalarials bearing the AMFm logo, [Uganda], 2011

Antimalarials bearing the AMFm logo (n) as a percentage of all antimalarials audited (N), by location and antimalarial type

Type of antimalarial




(95% CI) N




Private for-profit outlet 89.4 (86.0, 92.1) 2159 89.9 (85.8, 93.0) 1202 89.8 (86.9, 92.1) 3361


Total 85.3 (78.6, 90.1) 2536 77.1 (67.5, 84.5) 2958 79.1 (71.8, 84.9) 5494

All other antimalarials



Private for-profit outlet 0.2 (0.1, 0.3) 8242 0.1 (0.0, 0.6) 4665 0.2 (0.1, 0.4) 12907

Community health worker 0.0 1 0.0 58 0.0 59

Total 0.2 (0.2, 0.3) 8688 0.1 (0.0, 0.5) 5983 0.2 (0.1, 0.4) 14671

Total 20.3 (18.6, 22.1) 11224 21.1 (18.9, 23.5) 8941 20.9 (19.3, 22.6) 20165


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Table 3.6.5: Provider knowledge of the AMFm programme, [Uganda], 2011

Providers who have heard of “a programme that reduces the prices of antimalarial medicines known as ACTs” (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet

Urban Rural Total








Pharmacy 45.9 (37.9, 54.0) 326 41.1 (29.8, 53.4) 64 45.0 (38.4, 51.7) 390

Drug store 25.6 (20.0, 32.1) 433 22.5 (18.4, 27.3) 674 23.0 (19.4, 27.0) 1107

General retailer 0.0 4 3.5 (0.4, 26.6) 14 3.3 (0.4, 23.8) 18


Total 31.5 (27.4, 35.9) 1242 24.1 (19.8, 28.9) 1073 25.8 (22.2, 29.8) 2315


Total 31.5 (27.3, 35.9) 1400 23.8 (20.4, 27.6) 1708 25.4 (22.4, 28.6) 3108


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Table 3.6.6: Sources from which providers have seen or heard of AMFm [Uganda], 2011

Providers stating a specific source where they have seen or heard of “a programme that reduces the prices of antimalarial medicines known as ACTs” (n) as a percentage of providers that have heard of “a programme that reduces the prices of antimalarial medicines known as ACTs” (N), by location*

Urban Rural Total

Source Percentage

(95% CI) N

Percentage (95% CI)

N Percentage

(95% CI) N

On malaria medicine packaging 10.6 (4.8,22.1) 500 3.7 (1.9,6.9) 453 5.4 (2.8, 10.3) 953

On medicine packaging 5.3 (3.0, 9.2) 501 2.0 (0.7,5.5) 453 2.8 (1.4, 5.7) 954

On posters 5.2 (3.7, 7.3) 501 0.9 (0.2,3.4) 453 2.0 (0.9, 4.1) 954

On billboards 2.6 (1.4, 4.9) 500 100.0 452 0.7 (0.3, 1.4) 952

On TV/radio 65.8(61.6,69.8) 501 76.7(71.4,81.3) 453 73.9(69.6,77.8) 954

On a prescription 3.0 (1.8, 5.0) 501 0.9 (0.2, 4.0) 453 1.5 (0.7, 3.2) 954

In newspapers/magazines 14.4(11.8,17.4) 501 5.3 (3.0, 9.2) 453 7.6 (5.1, 11.1) 954

In pharmacies/ drug shops 8.8 (6.4, 12.0) 501 8.3 (5.1, 13.3) 453 8.4 (5.8, 12.0) 954

In private clinics 3.4 (1.6, 7.0) 500 2.3 (1.1, 4.9) 452 2.6 (1.4, 4.6) 952

In public health facilities 8.4 (6.5, 10.9) 501 7.1 (3.9, 12.6) 453 7.4 (4.8, 11.3) 954

In training 15.7(11.0,21.8) 501 11.2 (7.8, 15.8) 452 12.3 (9.3,16.2) 953

From a supplier 8.3 (5.9, 11.5) 501 4.6 (2.3, 8.8) 453 5.5 (3.5, 8.6) 954

From a public event 2.8 (1.8, 4.4) 501 1.6 (0.7, 3.7) 452 2.0 (1.1, 3.3) 953

From a local leader 0.3 (0.0, 1.3) 501 1.8 (0.7, 4.3) 452 1.4 (0.6, 3.2) 953

From a friend/family member 10.4 (7.9, 13.5) 501 8.4 (6.0, 11.7) 453 8.9 (6.9, 11.4) 954

SMS messages 0.2 (0.0, 1.3) 501 0.6 (0.1, 2.3) 453 0.5 (0.1, 1.7) 954

On the internet 0.3 (0.1, 1.3) 501 100.0 452 0.1 (0.0, 0.3) 953

Don’t Know 0.0 500 0.2 (0.1, 0.7) 453 0.2 (0.0, 0.5) 953

Other: Health programs 1.4 (0.5, 3.9) 500 0.3 (0.1, 1.1) 453 0.6 (0.2, 1.2) 953

Other: Researchers 0.8 (0.4, 1.4) 500 100.0 453 0.2 (0.1, 0.6) 953

Other: Meeting 0.9 (0.4, 1.7) 500 1.0 (0.2, 5.7) 453 1.0 (0.3, 3.7) 953



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Table 3.6.7: Provider stating that there is a maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Uganda], 2011

Providers stated that there is a RRP for antimalarials with the AMFm logo (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet




(95% CI) N





Pharmacy 34.6 (24.4, 46.3) 328 26.0 (18.0, 35.9) 64 33.0 (24.7, 42.5) 392

Drug store 8.5 (6.2, 11.6) 433 8.9 (5.6, 13.9) 676 8.9 (6.0, 12.9) 1109



Total 12.6 (10.7, 14.8) 1246 10.2 (7.2, 14.2) 1078 10.8 (8.3, 13.8) 2324


Total 12.3 (10.3, 14.5) 1404 9.5 (6.9, 12.9) 1720 10.0 (7.9, 12.7) 3124


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Table 3.6.8: Provider stating the correct maximum/recommended retail price (RRP) for antimalarials with the AMFm logo [Uganda], 2011

Providers stated the correct RRP for antimalarials with the AMFm logo (n) as a percentage of providers who responded that there was a RRP for antimalarials with the AMFm logo (N), by location and type of outlet

Type of outlet

Urban Rural Total




Public health facility 0.0 18 2.1 (0.2, 15.2) 67 1.9 (0.2, 13.2) 85




Pharmacy 0.2 (<0.1, 1.8) 101 10.7 (6.3, 17.4) 18 1.7 (0.4, 8.0) 119

Drug store 1.5 (0.2, 9.5) 42 4.0 (1.5, 10.7) 61 3.7 (1.4, 9.2) 103

General retailer -- 0 -- 0 -- 0


Total 4.4 (2.3, 8.4) 211 5.4 (2.4, 11.4) 123 5.1 (2.8, 9.1) 334


Total 4.2 (2.1, 8.0) 231 4.7 (2.2, 9.8) 195 4.6 (2.6, 8.1) 426


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Table 3.6.9: Providers who have received training on antimalarials with the AMFm logo, [Uganda], 2011

Outlet where at least one staff member has received training on antimalarials with the AMFm logo (n) as a percentage of outlets with antimalarials in stock at the time of the survey visit (N), by location and type of outlet

Type of outlet

Urban Rural Total








Pharmacy 25.2 (16.3, 36.8) 327 24.9 (18.6, 32.5) 64 25.1 (17.7, 34.3) 391

Drug store 19.5 (15.4, 24.4) 433 14.8 (11.6, 18.6) 675 15.5 (12.8, 18.6) 1108



Total 17.9 (15.3, 20.8) 1244 16.1 (12.8, 20.2) 1076 16.6 (14.0, 19.5) 2320


Total 17.3 (14.9, 19.9) 1402 14.9 (12.2, 18.1) 1716 15.4 (13.2, 17.8) 3118


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4. AMFm implementation: process and key contextual factors

4.1 Introduction

In order to document the implementation process of AMFm (supply of co-paid ACTs and supporting

interventions) and contextual factors that may influence the effectiveness of AMFm, the

Independent Evaluation team collected data in each AMFm pilot, using key informant interviews

(KIIs), a structured questionnaire on supporting interventions, and document review. These data

were collected to facilitate an assessment of (1) whether any improvement observed in AMFm

indicators between baseline and endline is likely to be due to AMFm and (2) whether a lack of

improvement in indicators can be reasonably attributed to a failure of AMFm. The methods and

findings for this activity in Uganda are summarised below.

4.2 Methods

Three types of key informants were included in interviews: those centrally involved in AMFm

implementation, antimalarial importers, and other stakeholders who were knowledgeable about the

AMFm process or other key contextual factors. A total of 23 interviews were conducted in

November and December 2011. Oral consent was obtained for all interviews, and participants were

assured of confidentiality and given the option of whether they wanted their interviews to be

recorded. Notes were taken during all interviews. Interviewers used a semi-structured interview

guide that covered AMFm governance, registration of FLBs, ordering and distribution of co-paid

drugs, supporting interventions (e.g., communications, training, regulation and recommended retail

prices), diagnostics, and key contextual events (e.g., weather anomalies, economic and political

factors, changes in other malaria control activities and changes in the health system more broadly).

Using the agreed template, the information from each interview was then broken into the

appropriate reporting categories, and findings across interviews were synthesized. In addition, a

form for quantifying supporting interventions was sent to the relevant authorities for completion.

Finally, key documents were reviewed such as policy documents, briefing documents and reports

prepared by the Clinton Health Access Initiative (CHAI), Global Fund grant documents, preliminary

findings of research studies, data on FLB orders, and communications materials.

4.3 Findings

4.3.1 Description of the AMFm implementation process

4.3.1.1 Amending the AMFm host grant

Uganda’s application to participate in AMFm was approved by the Global Fund Board in November

2009. However, Uganda was the last of the participating countries to sign the grant amendment

necessary to commence AMFm. An amendment to the Round 4, Phase II malaria grant was finally

signed on the February 10, 2011, the Global Fund’s final deadline for AMFm grant amendments,

after protracted negotiations between the Government of Uganda (GoU) and the Global Fund.

The primary impasse during the negotiations leading up to the grant amendment was the GoU’s

concern over the potential impact that AMFm-subsidized antimalarials could have on the domestic

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pharmaceutical industry (Nanyunja et al. 2011). In particular, there were fears that inexpensive ACTs

imported through AMFm would harm the financial sustainability of the Kampala-based

manufacturer Quality Chemicals Industries Limited (QCIL), if the latter was not eligible to supply

ACTs under AMFm. QCIL was established in 2005 to create domestic capacity to produce high-quality

antiretroviral drugs and ACTs. It is a partnership between a Ugandan pharmaceutical importer and

distributor (Quality Chemicals Limited), an Indian pharmaceutical manufacturer (Cipla Limited) and

the Government of Uganda. QCIL is regarded by the GoU as a strategic investment.

At the time the Global Fund Board approved Uganda’s application to AMFm, QCIL was not eligible to

supply ACTs under AMFm. In order to receive a co-payment under AMFm, a manufacturer must

meet the requirements of the Global Fund’s Quality Assurance Policy, among other obligations.

QCIL’s manufacturing plant received Good Manufacturing Practices certification in 2008, and

eventually became WHO pre-qualified to manufacture AL under license from Cipla Limited in

December 2010.

Once QCIL became pre-qualified to produce AL, negotiations between the GoU and the Global Fund

advanced. This permitted Uganda to participate in AMFm. QCIL requested to sign an AMFm Master

Supply Agreement in May 2011, which was signed in late 2011, but no AMFm orders were made for

QCIL-manufactured products before the end of 2011.

4.3.1.2 Governence structure

The Principal Recipient for all Global Fund grants in Uganda, including the AMFm host grant, is the

Ministry of Finance, Planning and Economic Development. The Sub-Recipient for malaria grants is

the National Malaria Control Programme (NMCP).

Other key bodies involved in the governance of the AMFm host grant include:

The Global Fund Focal Coordinating Office (FCO)

The Country Coordinating Mechanism (CCM)

The Local Fund Agent (LFA)

The AMFm Task Force

The FCO is situated in the MoH Planning Department. It coordinates the implementation of Global

Fund grants in all three disease areas. It is responsible for coordinating grant applications, selecting

suppliers (known as sub-sub recipients (SSRs)) and submitting program updates and progress

reports. The FCO also acts as the Secretariat for the CCM.

PricewaterhouseCoopers is the LFA in Uganda. The LFA’s role is to provide oversight and advisory

services to the Global Fund secretariat. In the context of AMFm, the LFA is responsible for assessing

the capacity of the PR to undertake the AMFm supporting interventions; reviewing grant

amendment documentation, such as progress updates and disbursement requests; and conducting

spot-checks of FLBs to ensure that they are complying with the conditions of participation set out in

the FLB undertaking agreements (The Global Fund, 2011b).

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The AMFm Task Force was established to provide oversight and advice to the NMCP on AMFm

implementation. It is a multi-sectoral body comprised of representatives of government agencies

(MoH and National Drug Authority (NDA)), implementing partners, civil society organizations, public,

private for-profit and private not-for-profit antimalarial procurers, the LFA, United Nations (UN)

agencies and organizations providing advisory and technical assistance (e.g., PMI and CHAI). The

specific roles of the Task Force are to share information on AMFm activities and implementation

challenges, advise the NMCP on programmatic decisions and provide oversight on establishing a

Recommended Retail Price (RRP) for AMFm co-paid ACTs, and to support quantification and

forecasting (NMCP 2011b). The Task Force also has a Manufacturer and First-Line Buyer Working

Group and an Advocacy and Social Marketing Working Group.

Between February and October 2011, the Task Force met 13 times and the Manufacturer and First-

Line Buyer Working Group met 9 times (NMCP 2011a). Key informants indicated that they generally

found the meetings to be a useful forum for sharing information. Several respondents mentioned

that they appreciated the opportunity to interact with the private sector FLBs. Some respondents

indicated that, while they had initially found the Task Force and Working Group meetings to be

useful, the meetings had “lost momentum” as a result of delays in receiving orders and in

implementing supporting interventions. Indeed, the Chair of the Manufacturer and First-Line Buyer

Working Group noted in the minutes for a meeting in mid-2011 that attendance was dwindling.

4.3.1.2 AMFm co-paid ACT supply mechanism

Public sector

Prior to AMFm, ACTs were procured for the public sector using GoU funds and funding from the

Global Fund. During 2009 and 2010, the GoU purchased approximately 8 million treatment courses

from QCIL. By mid-2010 the stocks available in the National Medical Stores (NMS) were well below

the recommended minimum stock levels, as a result of bottlenecks in procurement through the

Global Fund grants (PMI 2010; SURE 2010). The situation improved in the latter half of the year.

Ajanta Pharma signed a contract in April 2010 to supply ACTs with funds from the Round 4, Phase II

malaria grant. The first tranche of ACTs, totaling 9.4 million treatment courses, was delivered by

Ajanta to the NMS and JMS over May-October 2010. In addition, QCIL delivered a consignment of

ACTs to the NMS in December 2010 and January 2011. Nevertheless, the December 2010 stock

status report shows that the NMS was out of stock of the infant age-band of AL, in spite of the

deliveries received from Ajanta in October 2010 (SURE 2010).

There was a gap in placing orders for ACTs in the public sector in early 2011. Following the pre-

qualification of QCIL in December 2010, it was expected that Uganda would soon join AMFm. Orders

for the public sector were put on hold to take advantage of the cost savings that would arise from

the AMFm co-payment. The contract from the Round 4, Phase II malaria grant with Ajanta Pharma

for a second tranche of ACTs was eventually cancelled.

Although the amendment to the AMFm host grant was signed on February 10, 2011, the first order

was not approved until June 14, 2011. Key informants offered two explanations for the delay. First,

key informants indicated that there were minor delays as a result of discussions between the NMS,

the NMCP and Securing Ugandans’ Rights to Essential Medicines (SURE) regarding the appropriate

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composition of the order. In January 2011, the NMS indicated to the Health Policy Advisory

Committee of the MoH that, rather than distribute all four age-bands of AL, it intended to distribute

the 24-tablet packages only. They proposed that health workers could cut or divide the 24-tablet

packages to the appropriate size, given a patient’s weight. This would save space in the NMS

warehouses, and simplify logistics. In contrast, the national quantification prepared by SURE

calculated treatment needs in terms of the four age-bands, and the NMCP asserted that it was

necessary to have all age-bands available in health facilities to ensure appropriate case

management. An agreement was reached that the NMS would continue to distribute all age-bands

of AL.

Second, key informants indicated that there was a further delay in the approval of the first order

resulting from confusion over who would supply ACTs to the public sector. The Ministry of Health

initially intended to order nearly 20 million doses of AL from Cipla Limited using QCIL as the FLB. It

was envisioned that this order would cover the public sector’s needs for a period of two years. In the

meantime, the UK’s Department for International Development (DfID) initiated an emergency

procurement of ACTs through AMFm with Crown Agents Uganda as the FLB in response to looming

stockouts at the NMS that were expected in May-June 2011. This created concern over the financial

implications for QCIL and possible excess stocks in the public sector. An agreement was reached that

DfID would make a one-off emergency procurement of pediatric formulations of AL to prevent a gap

in stock, and QCIL would supply the remaining stock either as a FLB receiving orders from Cipla or a

manufacturer.

Key informants reported no further difficulties related to the approval or placing orders of AMFm co-

paid ACTs for the public sector.

In total, 20.7 million treatment courses of AMFm co-paid ACTs were approved and delivered for

Uganda’s public sector in 2011. The first order of co-paid ACTs for the public sector was delivered in

July 2011. Eighty percent of the total treatment courses delivered in 2011 had arrived in Uganda by

September 1, 2011. The October 1, 2011 Stock Status Report indicated that, based on average

monthly consumption, the stock levels of the three pediatric package sizes would last more than 8

months, and stocks of the adult-sized package would last more than three months (SURE 2011). The

high volume of ACTs that arrived at the NMS in July and August 2011 for the public sector took up

significant space in the NMS warehouses. Receipt of other drug orders had to be rescheduled to

accommodate the AMFm ACTs.

Once received by the NMS, co-paid ACTs were warehoused and distributed according to standard

procedures. Hospitals and Health Center Level IVs place orders according to their needs, while

Health Center Level IIs and Health Center Level IIIs receive a standard kit of medicines and other

health commodities, including ACTs, approximately every two months. No challenges specific to the

public sector distribution of AMFm co-paid ACTs were cited by key informants. However, several

respondents mentioned the inherent difficulties of determining the appropriate kit contents and

quantities in push distribution systems.

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Private not-for-profit sector

The Joint Medical Stores (JMS) is the primary procurement body for the private not-for-profit sector,

particularly faith-based health facilities. Prior to AMFm, the JMS received stocks from two main

sources: donors (such as PMI and the Global Fund) and stocks purchased with JMS funds directly

from manufacturers. Stocks received from funders are provided free of charge to private not-for-

profit health facilities, whereas stocks purchased with JMS funds are sold at an 18% markup. While

donated stocks are reserved for private not-for-profit providers, all registered outlets may purchase

the medicines bought with JMS resources. All stocks are stored centrally in warehouses in Kampala.

Clients must arrange pick-up or delivery, as the JMS does not distribute products.

Similar to the public sector, stocks of AL were very low at the JMS in the first half of 2010. By the end

of June 2010, the JMS was completely out of stock of three of the four age-bands of AL, and only had

17 packages of the18-tablet package size in stock (SURE 2011). The JMS received part of the Global

Fund Round 4, Phase II order that was delivered by Ajanta in the third quarter of 2011, which

improved the level of stock. In April and May 2011, 2.1 million treatments of AL procured by PMI

were delivered to the JMS, and 1.5 million treatments of AL procured by DfID were delivered in

August and September 2011.

As of January 2012, there were three registered FLBs from Uganda’s not-for-profit sector. By the end

of 2011, two of the private not-for-profit FLBs had placed a total of four orders for AMFm co-paid

ACTs. The first orders for the private not-for-profit outlets arrived in Uganda in July 2011. A total of

1.1 million treatments were ordered and 0.6 million treatments were delivered by the end of 2011.

The JMS sold AMFm co-paid ACTs with a markup of 18%. The JMS selling price for a 24-tablet

package of co-paid AL was reportedly USD 0.24.24 The JMS manages their stock based on the

principal of First In, First Out. They lowered the price of their existing stocks of AL to the same prices

as the AMFm co-paid ACTs to ensure that they could exhaust their stocks of antimalarials that were

previously purchased at a higher price. Antimalarials donated to the JMS at no cost were still

provided to private not-for-profit facilities free of charge.

The process of placing and receiving orders for the private not-for-profit sector was described as

straightforward. Both FLBs had a pre-existing relationship with Cipla, which facilitated orders. The

second order placed by the JMS was delayed by 134 days from the date that the order was approved

by the Global Fund to the date of delivery to the first port of entry. However, the JMS was notified

by the manufacturer in advance that the order would likely be delayed. In spite of the delay

receiving the second order, the JMS was reported to have good stock levels in the last quarter of

2011 due to stocks remaining from orders received in mid-2011 from PMI and DfID (SURE 2012).

24The exchange rate used was the average interbank exchange rate for 2011 Ugandan Shilling 2,337 to the USD.

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Private for-profit sector

By January 2012, nine private for-profit FLBs had registered to participate in AMFm, with four FLBs

placing orders from four manufacturers by the end of 2011. In total, 15 orders for a total of 7.9

million treatment courses were approved in 2011, and 6.9 million treatment courses were delivered

by the end of the year.

No major issues related to registering as FLBs or placing orders were reported. The FLBs that had

placed orders had pre-existing relationships with the manufacturer from which they ordered co-paid

ACTs. As of December 2011, there was a 1:1 relationship between FLBs and manufacturers. In some

cases, the FLB was the Local Technical Representative (LTR) for the manufacturer’s AMFm ACTs. This

likely facilitated orders, because according to national regulations the LTR is required to approve all

orders. Nevertheless, in the cases where the FLB was not the LTR for the AMFm co-paid product that

they ordered, interviewed FLBs explained that the LTR always approved the order quickly. Some FLBs

expressed dissatisfaction that, as a result of the 1:1 relationship, they were unable to purchase

stocks of co-paid ACTs from the manufacturer of their choice. They suggested that this reduced

competition among FLBs, and might also reduce availability.

Ordered co-paid ACTs cleared Ugandan customs smoothly. The National Drug Authority (NDA) was

briefed on AMFm in advance. There was some initial confusion on whether the 2% clearance fee

would be charged on the full value or the subsidized value of drugs imported through AMFm. This

appears to have been resolved prior to any AMFm co-paid ACTs arriving in Uganda. AMFm co-paid

ACTs cleared customs in 1-2 days.

Challenges related to receiving orders were noted. Some FLBs reported that their orders were

delayed or cut. Many FLBs thought that Uganda was at a disadvantage compared with other

countries, as a result of joining AMFm late. They felt that the participating manufacturers were

already overloaded with orders by the time Ugandan FLBs were permitted to place orders. As a

result of delays in receiving orders, some FLBs indicated that they experienced stockouts of all or

some age-bands in between orders.

With regards to distribution, AMFm co-paid ACTs were distributed through the FLBs’ normal

distribution chain. Some FLBs noted that initially the uptake of co-paid ACTs was very slow, due to

existing stocks of ACTs in the supply chain. This backlog took 1-3 months to clear, after which

demand for the co-paid ACTs increased. The FLBs were unanimous that sales volumes had the

potential to increase dramatically. In particular, all respondents thought that a national-scale

communications campaign would likely lower prices and increase demand for AMFm co-paid

products. Other FLBs thought that there was scope to increase orders through direct distribution

(sometime referred to as van-selling). The First-Line Buyers Working Group sought permission from

the NDA to permit direct-distribution of AMFm co-paid ACTs. At the time of the interviews, the NDA

had not yet decided whether they would permit this.

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4.3.2 Implementation of AMFm supporting interventions

The amendment to the AMFm host grant included a budget of USD 28.6 million for supporting

interventions (SIVs). Major planned activities included USD 16.8 million for the procurement and

scale-up of RDTs in the public sector in 22 districts; USD 4.3 million for provider training, supervision

and monitoring; and USD 3.1 million for public awareness and communications activities. However,

implementation of the AMFm supporting interventions had not yet started by the end of data

collection for the endline Outlet Survey. Although interim supporting interventions were initiated,

key informants were unanimous that these stopgap activities were inadequate.

The AMFm SIVs were stalled as a result of delays disbursing the first tranche of funds for supporting

intervention activities. The Round 4, Phase II grant, which hosts AMFm, has had performance

problems in the past. In 2009, the performance of the grant was rated as a C, the lowest possible

rating. The performance rating has since improved. Nevertheless, special conditions were specified

in the grant amendment letter, as a result of these performance issues. The PR was required to fulfill

reporting requirements before funds were disbursed. The Progress Update and Disbursement

Request was submitted to the Global Fund on June 27, 2011, and the first disbursement for USD 5.6

million was disbursed to the Ministry of Finance, Planning and Economic Development in November

2011. Prior to the arrival of the disbursement, considerable effort was made to initiate the process

to select the SSRs that would deliver services, like information, education and communication (IEC)

and training activities, but no funds had been spent by the end of 2011.

4.3.2.1 National Launch

A national launch was held on April 29, 2011 in Buliisa District, as part of World Malaria Day

celebrations. The vice president officiated at the ceremonies. The event was well-attended and

garnered some coverage in national and regional newspapers and television programs.

Key informants had mixed views on the impact of the national launch. Some respondents expressed

concern that the national launch was held too early, as only small quantities of co-paid ACTs had

arrived in Uganda. Others remarked that Buliisa District was too remote for the launch, and that the

launch would have received better coverage if it were held in Kampala or another large town. Many

suggested that the media coverage of the launch was overshadowed by violent demonstrations that

took place in Kampala on that same day.

4.3.2.2 Communication activities

All respondents were unanimous in their concern that the absence of scaled AMFm communication

activities was hindering the project’s implementation. At the time of the case study interviews, all

respondents felt that public awareness about AMFm was very low. Most key informants speculated

that the prices of AMFm co-paid ACTs were likely to be higher than target levels in most private for-

profit outlets. In the absence of marketing, low prices were likely to be perceived as a signal of low

quality. Key informants thought that shopkeepers would keep the price of AMFm co-paid ACTs at

similar levels as other ACTs to avoid perceptions that they are selling low-quality products.

A small-scale marketing campaign, referred to as AMFm pre-disbursement marketing was instigated

as a stopgap measure while waiting for Global Fund monies designated for IEC/Behavior Change

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Communication purposes. Support was raised from multiple partners. Medicines for Malaria

Venture (MMV) donated USD 80,000 to fund radio spots, CHAI contributed USD 15,000 for the

design and translation of marketing materials, while PACE produced the ratio spots, the Malaria

Consortium contributed to the graphic design and World Vision played a role in dissemination.

Another USD 6,800 was contributed by CHAI, Surgipharm, QCIL and Philips Pharma to print point-of-

sale materials, although no materials were printed by the end of 2011. Over a three-month period,

9,000 radio spots advertised that the AMFm co-paid antimalarials were rolled out.

Uganda’s experience with the Consortium for ACT Private Sector Subsidy (CAPSS) project, which

distributed subsidized ACTs bearing a green-leaf logo in drug shops, facilitated the pre-disbursement

marketing activities. Materials produced for CAPSS were updated with ease.

In addition, some implementing partners used existing platforms to publicize AMFm. For example,

Malaria and Childhood Illness NGO Secretariat (MACIS) used their bi-annual newsletter to

disseminate information about AMFm.

The participating FLBs were also actively promoting co-paid ACTs. . Some interviewed FLBs either

printed their own point-of-sale materials, or used posters or other promotional items provided by

the manufacturer.

Nevertheless, most respondents felt that the scale of the pre-disbursement marketing activities was

too small to have a significant impact on awareness of AMFm.

Recommended retail prices

RRPs were set by the AMFm Task Force, in consultation with the Manufacturers and First-Line

Buyers Working Group. RRPs were established for each age-band of AL and artesunate-amodiaquine

(Table 4.7.1). The price was set to factor in costs and “reasonable” markups for importers,

wholesalers and retailers. The RRPs in nearby countries, namely Kenya and Tanzania, were taken

into consideration when setting the RRP for Uganda.

Table 4.3.1: Recommended retail prices for AMFm co-paid ACTs in 2010 US dollars

Artemether + Lumefantrine Artesunate + Amodiaquine Pack size RRP (Ush) RRP (USD) Pack size RRP (Ush) RRP (USD)

6x1 300 0.12 25/67.5mg 3x1

200 0.08

6x2 600 0.23 50/135mg 3x1

400 0.16

6x3 900 0.35 100/270mg 3x1

600 0.23

6x4 1200 0.47 100/270mg 3x2

800 0.31

While the RRPs were generally perceived to be appropriate, most respondents thought awareness of

the recommendations was poor. Prices were printed on some point-of-sale and other promotional

materials, but not on medicine packaging. Adherence to the recommended prices was thought to be

low among retailers and wholesalers. Many FLBs expressed frustration over the lack of adherence to

recommended prices, as they believe that high prices were limiting uptake of co-paid ACTs.

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Other supporting interventions

No other AMFm SIVs took place prior to the end of 2011 Outlet Survey data collection.

4.3.2.3 Implementation of other interventions with potential implications for AMFm outcomes

The kit-based drug supply system

The introduction of the kit-based supply system in mid-2011 is widely believed to have improved the

availability of essential medicines in Level II and Level III Health Centers. Under the kit-based system,

each Level II and Level III Health Center receives a standard kit of drugs and commodities. Facilities

are supposed to receive the kits bimonthly, the composition of which is determined by the facility

type. Previously Hospitals and Health Centers at all levels ordered essential medicines from a budget

line at the NMS. An assessment of the kit-based system conducted six months after national

implementation found that the number of days out of stock of five tracer medicines decreased by

30% in Health Center IIs and 74% in Health Center IIIs (MOH, 2011a).

Recent refinements to the kit-based system might have further improved availability in public health

facilities. The standard kit is revised every six months. Health facilities are now also able to adjust the

quantities of drugs they receive by writing to the District Health Officer, copying the NMS. This

allows the kit to be customized to the needs of the health facility, and could help prevent stockouts

of ACTs in health facilities with large catchment populations or high burden of malaria. In April 2011,

the NMS introduced last-mile delivery to Level II Health Centers and Level III Health Centers. Many

stakeholders believe that this will improve delivery schedules and prevent bottlenecks in the

distribution system.

Integrated Community Case Management (ICCM)

Since 2010, ICCM has used voluntary Village Health Teams (VHTs) to provide care for children under

five years for malaria, diarrhea, pneumonia and neonatal care. VHTs receive training and are

supplied with ACTs and other health commodities. VHTs have been trained and are currently

receiving supplies in 24 of 112 districts. VHTs receive standard supply kits through a push system

supported by the district health officer.

Implementation of RDTs in the public and private not-for-profit sector

Workers in public health facilities in 21 districts were trained on the effective use of RDTs in malaria

case management in December 2010 and January 2011. It was planned that stocks of RDTs for these

21 districts would be procured as part of the AMFm SIVs. As this procurement had not taken place

by the end of 2011, the RDT training was unlikely to have decreased ACT use in the participating

districts.

PMI has supported the procurement of RDTs for private not-for-profit health facilities. These are

distributed through the JMS.

Consortium for ACT Private Sector Subsidy (CAPSS)

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In 2008-2010, the CAPSS project, led by the MoH Uganda and MMV, piloted the distribution of

subsidized ACTs through the private for-profit sector in four districts (Budaka, Pallisa, Kaliro and

Kamuli). The pilot distributed 1.1 million doses of subsidized ACTs, which continued to be supplied

until 2011 as a bridge until the AMFm co-paid drugs arrived in Uganda. The ACT distributed through

CAPSS was Coartem (AL) repackaged with a green leaf logo that was the prototype for the AMFm

logo. The CAPSS project used RRPs, which ranged from 200-800 UGX. The RRPs were communicated

in the mass-marketing campaign that accompanied the project, and they were printed on the

packages. It is likely that stock of the CAPSS-subsidized ACTs remained in the market at the time of

the 2010 and possibly the 2011 outlet surveys in Uganda. Uganda’s participation in CAPSS was

thought to have contributed to the country’s preparedness for AMFm.

In late 2011, MMV launched CAPSS Plus, which introduced RDTs and respiratory timers into private

drug shops in the four intervention districts. Both CAPSS and CAPSS Plus included a strong training

component.

Other important interventions

Other important malaria control interventions that rolled out during this period were the mass

distribution of 7.3 million LLINs targeted to pregnant women and children under five years in March-

June 2010 and the long-standing PMI-supported IRS program in 10 districts.

In addition, ACTs were granted over-the-counter (OTC) status by the Committee of National

Formularies. This permits registered drug shops and VHTs to sell and distribute ACTs. At the time of

the key informant interviews, a statutory instrument granting ACTs OTC status was still required. In

the interim, the NDA provided a formal letter to the MOH granting permission for the ACTs to be

distributed as OTC products. The budget for the AMFm SIVs included provisions to support the

implementation of this regulatory change, but no funds had been spent by the end of 2011.

4.3.3 Key events and context

The main contextual factor raised by key informants was the rapid depreciation of the Ugandan

shilling against the US dollar. On January 1, 2009, 1 US dollar was worth 1,944 Ugandan Shillings, but

by October 2011, this had depreciated to 2,830 UGX per USD. The exchange rate recovered slightly

by the end of the year. Respondents thought that the currency fluctuations were contributing to

inflation, which affected the purchasing power of Ugandan households. Stakeholders thought that

this could reduce the demand for all antimalarials in the private sector.

4.3.4 Conclusion

Table 4.7.2 summarizes key factors likely to have facilitated or hindered achievement of AMFm goals

and Figure 4.7.1 presents a timeline of all key events related to AMFm implementation and context.

In spite of Uganda’s late start in participating in AMFm, significant quantities of co-paid ACTs had

arrived in Uganda by the end of 2011. A total of 28,226,700 treatment courses were delivered over 8

months in 2011. The vast majority of co-paid ACTs delivered were destined for the public sector

(73.4%), while 24.5% were for the private for-profit sector and 2.1% were for the private not-for-

profit sector. Implementation of AMFm was hindered by the delayed start of the supporting

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interventions. Public awareness of AMFm was thought to be low, as was adherence to the RRP.

Implementation of the supporting interventions, particularly national-scale communications

activities, would have likely increased demand for AMFm co-paid ACTs.

Table 4.3.2: Summary of key factors likely to have supported or hindered achievement of AMFm goals in Uganda)

Factors which are likely to have supported achievement of AMFm goals

Factors which are likely to have hindered achievement of AMFm goals

Smooth process for registration of FLBs and ordering co-paid ACTs in the private sector

Promotional activities by FLBs

Inclusion of RRP on marketing materials

Use of green leaf logo

Improvement of logistics in the public sector pharmaceutical distribution chain

Preparedness for a private sector ACT subsidy as a result of the CAPSS pilot

FLB commitment to honoring recommended prices

Late start

No SIVs implemented by end of 2011

Lack of RRP on drug packaging

Limited number of FLB-manufacturer relationships established

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Figure 4.3.1:Timeline of key events related to AMFm implementation process and context Uganda

2010 2011

Activity Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

AMFm grants and orders AMFm grant amendment signed

Private for-profit sector orders of co-paid ACTs approved by Global Fund Private for-profit sector co-paid ACTs delivered to Uganda Public sector orders of co-paid ACTs approved by Global Fund Public sector co-paid ACTs delivered to Uganda Private not-for-profit sector orders approved by Global Fund Private not-for-profit co-paid ACTs delivered to Uganda Other ACT procurements for the public sector

9.4 million treatments of AL delivered from Ajanta Pharma

3.3 million treatments of AL delivered from QCIL

Other ACT procurement for the private not-for-profit sector PMI funded delivery to JMS

DFID funded delivery to JMS AMFm supporting interventions PUDR for supporting interventions submitted

Disbursement received by Ministry of Finance

National Launch

Pre-disbursement marketing activities: radio spots

Pre-disbursement marketing activities: point-of-sale materials

Non-AMFm interventions Introduction of the kit-based supply system Introduction of last-mile delivery Training of public sector health workers on RDTs in 21 districts

Delivery of RDTs purchased by PMI for PNFP facilities

Mass distribution of LLINs CAPSS

25

CAPSS Plus Research Activities 2010 IE outlet survey data collection

2011 IE outlet survey data collection

HAI price tracking surveys

25Although CAPSS officially ended in June 2010, MMV continued to supply subsidised ACTs to the intervention districts until the arrival of AMFm drugs.

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5. Summary of findings

5.1 Quality of data collected

During data collection quality control (QC) persons travelled with the field teams and visited a

sample of the outlets visited by the data collectors. The QCs went to 5%of outlets that met the

screening criteria and 5% that did not. They asked basic background questions to the outlet

attendants, and audited a selection of drugs present. Data were reviewed with supervisors on a daily

basis. Completed questionnaires were also reviewed by the supervisors. Any issues were fed back to

field teams, which minimised problems that arose in the field. In addition, regular communication

with ACTwatch Central ensured that problems could be resolved quickly when issues arose in the

field. Building on lessons learned from the first outlet survey (conducted in 2008), additional field

monitoring tools were used to help keep track of the number of outlets sampled and number of

antimalarials audited.

No major issues appeared during data cleaning or analysis.

5.2 Availability of quality-assured ACTs

Among facilities that stocked antimalarials at any time in the three months preceding the survey,

overall QAACT availability in 2011 was 67%. In public health facilities that stocked antimalarials,

QAACT availability was 92%. QAACT availability was also high among private not-for-profit outlets

(80%) but lower among CHWs (55%). In the private for-profit sector, availability was 63%. However,

there was considerable variation within the private for-profit sector. QAACT availability was higher in

pharmacies (96%) than in private for-profit facilities (77%), general retailers (74%) or drug stores

(60%).

Availability of QAACTs with the AMFm logo was much higher than that of QAACTs without the logo

overall (58% vs. 16%), in public health facilities (83% vs. 42%) and in the private for-profit sector

(61% vs. 8%). Availability of QAACTs with the logo was higher in urban than in rural areas (70% vs.

55%).

Availability of non-quality-assured ACTs was 28%. Non-quality-assured ACTs were more commonly

found in urban than in rural outlets in 2010 and 2011. Availability of oral AMT was negligible at in

both surveys.

5.3 Pricing/affordability of quality-assured ACTs

In the public and private not-for-profit sectors and for CHWs, the median price was USD 0.00,

reflecting the policy of free ACT provision.

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In the private for-profit sector, the median QAACT price was USD 1.96 in urban and rural areas. The

median price for QAACTs was much higher than the RRP, which was USD 0.47. In the private for-

profit sector, the overall median price was USD 1.96.

The median price in private for-profit outlets for a QAACT carrying the AMFm logo was USD 1.96 per

AETD. This is 3.3 times the median price of the dominant antimalarial that is not a QAACT (SP) in

tablet form (USD 0.59).

There was no difference in the private for-profit sector between the median price of QAACTs with

and without the AMFm logo overall, although in urban areas the price of QAACTs without the AMFm

logo was USD 2.74.

The gross percentage markup on QAACTs, measured among private for-profit outlets, was 127%. The

gross percentage markup in private for-profit outlets was higher for QAACTs with the logo than on

those without the logo (133% vs. 100%). In rural areas, the difference in markup between QAACTs

with and without the logo is even greater (127% v. 71%). Since the median price of QAACTs with the

AMFm logo is the same as the median price of QAACTs without the logo, the higher markups on

QAACTs with the logo could indicate that retailers in rural areas are taking advantage of the subsidy

to obtain higher markups on the co-paid products. As a comparator, the median gross percentage

markup on nAT in the private for-profit sector was 67%. The median total markup from the FLB price

to the retail price in private for-profit outlets was USD 1.83.

5.4 Market share of quality-assured ACTs

Overall market share of QAACTs was 57% in 2011, with nATs accounting for 31% of the overall

market share. In private not-for-profit outlets, the QAACT market share was 51%. In the private for-

profit sector, the QAACT market share was 39%. In public health facilities, QAACT market share

was81%, with nATs accounting for 18% of market share in public health facilities.

The private for-profit sector was responsible for 53% of all antimalarials sold or distributed in 2011.

Drug stores and retailers accounted for 22% of the total volumes sold or distributed over the

previous week.

QAACTs with the AMFm logo accounted for 76% of all QAACTs sold or distributed across all outlets,

and 88% of QAACT volumes in private for-profit outlets.

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World Bank, 2010. World databank. [online] Available at: <http://databank.worldbank.org>

[accessed 24 October 2011].

WHO (World Health Organization), 2009. deSavigny, D and T Adam, eds. Systems thinking for health

systems strengthening, Geneva.

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

WHO (World Health Organization), 2010b. Guidelines for the treatment of malaria, second edition.

Geneva: WHO Press.

http://databank.worldbank.org/

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162 | P a g e

7. Acknowledgements This report presents the results of the 2011 Uganda Outlet Survey. It is a comprehensive, nationally

representative outlet survey designed as part of the Global Fund to Fight AIDS, Tuberculosis and

Malaria’s independent evaluation of Phase 1 of the Affordable Medicines Facility-malaria.

This report would not have been possible without the efforts of a large number of people who

assisted with the data analysis, data processing, and preparation of the report, as well as those who

worked tirelessly to collect the 2010 survey data and analyze the results. We particularly appreciate

the efforts of the Uganda Division of Malaria Control for providing overall support for the survey.

Additional thanks are expressed to PACE/Uganda for providing project management support and

Makarere University Department of Social Work and Administration for implementing the fieldwork

and organising data entry. We would like to thank key informants for taking the time to provide us

with information regarding supporting interventions and the country context. We express our

appreciation to the Independent Evaluator, ICF International and LSHTM for their assistance during

the research process. We would like to thank the Global Fund and the Bill and Melinda Gates

Foundation for their support.

We would also like to express our thanks to the field teams and individuals involved in the survey.

Their names are presented in the Appendix.

Finally, we would like to thank the thousands of providers who took time to complete the interview.

Without them, we would have nothing to say.

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8. Appendices

8. 1 Questionnaire

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8.2 ACTs classified as quality-assured

Key indicators for the Independent Evaluation of AMFm measure the price, availability and market

share of quality-assured ACTs (QAACT). A QAACT is defined as any ACT that meets the Global Fund

to Fight AIDS, Tuberculosis and Malaria’s (The Global Fund) quality-assurance policy. According to

this policy, a quality-assured product must be either WHO pre-qualified and/or authorized for

marketing by a stringent Drug Regulatory Authority. Products that have not yet been WHO pre-

qualified or approved by a Stringent Drug Regulatory Authority must be evaluated and

recommended for use by an independent panel of technical experts hosted by World Health

Organization’s Department for Essential Medicines and Pharmaceutical Policies (The Global Fund

2010).

The list of antimalarials that complies with the quality-assurance policy varies over time.

Consequently, an operational definition that would establish a fixed list of QAACTs was adopted for

the purpose of the Independent evaluation endline outlet survey as follows: a QAACT is any ACT

which appeared on the Global Fund's Indicative List of antimalarials meeting the Global Fund's

quality assurance policy as at September 201126, or which previously had C-status in an earlier

Global Fund quality assurance policy and was used in a programme supplying subsidised ACTs.

In September 2011, the Global Fund provided the Independent Evaluator with the indicative list of

antimalarials that met the quality-assurance policy. Since brand names are not pre-qualified by the

WHO or registered when recommended by the Expert Review Panel, the Independent Evaluator

contacted each manufacturer on the list to get details on all of the brand names used for each

product appearing on the list and produced at the approved manufacturing site. In addition, quality-

assured products are also often re-packaged and re-branded for the use in domestic social

marketing or subsidy programmes. Details on the brand names used in in-country marketing

programmes were compiled by contacting national authorities, or the organization involved in the

marketing campaign (e.g., PSI and MENTOR).

For the availability, price, markup and market-share indicators, products were classified as quality-

assured ACTs if the brand name, generic name, strength, manufacturer and country of manufacturer

matched one of the entries in Table 8.2.1.

For the stockout indicator, a prompt card showing photographs of the ACTs classified as quality-

assured was used so the interviewer and respondent could identify QAACTs in stock during the

survey visit or in stock in the previous 4 weeks. Photographs of QAACTs used for social

marketing/subsidy programme were not included in the prompt card, unless the country in which

data collection took place had a social marketing or subsidy programme targeted to a QAACT.

26Refer to http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/#General for the most up to date list.


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Table 8.2.1: List of Quality-assured ACTs for availability, price and market share indicators

Brand Name Generic Name Strength Manufacturer Country of

manufacture

Package Size (tablets

per pack)

FDC Notes

ACT WITH A LEAF 4

MONTHS TO <3

YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg NOVARTIS PHARMA

AG

China or USA 6 or 30 Yes Repackaged by PSI

for distribution in

Uganda

ACT WITH A LEAF 3

YEARS TO <7 YEARS

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACT WITH A LEAF 7

YEARS TO <12 YEARS

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACT WITH A LEAF 12

YEARS AND ABOVE

ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Uganda

ACTIPAL ARTESUNATE +

AMODIAQUINE

25mg + 67.5mg SANOFI AVENTIS or

MAPHAR

Morocco 3 Yes C-status product.

Repackaged by PSI

for distribution in

Madagascar


AMODIAQUINE

50mg + 135mg SANOFI AVENTIS or

MAPHAR

Morocco 3 Yes C-status product.

Repackaged by PSI

for distribution in

Madagascar


AMODIAQUINE

50mg + 153mg STRIDES ARCO LABS India 6 No C-status product.

Repackaged by PSI

for distribution in

Madagascar

ARTEMEF 4 MONTHS

UP TO 3 YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD India 6 Yes QAACT – over

branded for Nigeria

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ARTEMEF 3 YEARS UP

TO 7 YEARS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

ARTEMEF 7 YEARS UP

TO 12 YEARS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

ARTEMEF 12 YEARS

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

ARTEQUIN 600/1500 ARTESUNATE +

MEFLOQUINE

200mg + 250mg MEPHA Switzerland 9 No Not included on the

prompt card used for

the stockout

indicator

ARSUAMOON 1-6

YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 6 or 150 No

ARSUAMOON 7-13

YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 12 or 300 No

ARSUAMOON

ADULTS

ARTESUNATE +

AMODIAQUINE

50mg + 150mg GUILIN

PHARMACEUTICAL

CO. LTD

China 24 or 600 No

ARTEFAN 20/120 5-

14KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg AJANTA PHARMA LTD India 6 or 180 Yes

ARTEFAN 20/120 15-

24KG

ARTEMETHER +

LUMEFANTRINE


ARTEFAN 20/120 25-

34KG

ARTEMETHER +

LUMEFANTRINE


ARTEFAN 20/120 35+

KG ADULTS

ARTEMETHER +

LUMEFANTRINE


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ARTEMETHER +

LUMEFANTRINE

<3 YEARS

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg IPCA LABORATORIES

LTD

India 6, 60 or 180 Yes

ARTEMETHER +

LUMEFANTRINE

3-8 YEARS

ARTEMETHER +

LUMEFANTRINE


LTD

India 12,120, or 360 Yes

ARTEMETHER +

LUMEFANTRINE

9-14 YEARS

ARTEMETHER +

LUMEFANTRINE


LTD

India 18, 180, or 540 Yes

ARTEMETHER +

LUMEFANTRINE

>14 YEARs

ARTEMETHER +

LUMEFANTRINE


LTD

India 24, 240, or 720 Yes

ARTESUNATE +

AMODIAQUINE CHILD

1-6 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 or 60 No

ARTESUNATE +

AMODIAQUINE

JUNIOR 7-13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 or 120 No

ARTESUNATE +

AMODIAQUINE

ADULT

ARTESUNATE +

AMODIAQUINE


LTD

India 24 or 240 No

ARTESUNATE +

AMODIAQUINE CHILD

1-6 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153.1 mg IPCA LABORATORIES

LTD

India 6 or 60 No

ARTESUNATE +

AMODIAQUINE

JUNIOR 7-13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 or 120 No

ARTESUNATE +

AMODIAQUINE

ADULT

ARTESUNATE +

AMODIAQUINE


LTD

India 24 or 240 No

COARSUCAM INFANT

2-11 MONTHS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

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COARSUCAM

TODDLER 1-5 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

COARSUCAM CHILD

6-13 YEARS

ARTESUNATE +

AMODIAQUINE

100mg + 270mg SANOFI AVENTI or

MAPHAR

Morocco 3 or 75 Yes

COARSUCAM ADULT

+14 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 6 or 150 Yes

COARTEM 20/120 5-

15 KG

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 30 or 180 Yes

COARTEM 20/120 15-

25 KG

ARTEMETHER +

LUMEFANTRINE


AG


COARTEM 20/120 25-

35 KG

ARTEMETHER +

LUMEFANTRINE


AG


COARTEM 20/120 ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 24, 216, 720 Yes

COARTEM

DISPERSIBLE 5-15KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 6 or 180 Yes

COARTEM

DISPERSIBLE 15-25KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 12 or 360 Yes

COARTEM

DISPERSIBLE 25-35KG

ARTEMETHER +

LUMEFANTRINE


AG

USA 18 or 540 Yes

COARTEM

DISPERSIBLE

ARTEMETHER +

LUMEFANTRINE


AG

USA 6 or 216 Yes

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COARTEM E FIXE 5-

15KG

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6 Yes Distributed by

MENTOR in Angola

COARTEM E FIXE 15-

25KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

COARTEM E FIXE

DISPERSIBLE 5-15KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

COARTEM E FIXE

DISPERSIBLE 15-25KG

ARTEMETHER +

LUMEFANTRINE


AG


MENTOR in Angola

CO-FALCINUM 5-14

KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

CO-FALCINUM 15-

24KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

CO-FALCINUM 25-

34KG

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

CO-FALCINUM 35KG

AND ADULTS

ARTEMETHER +

LUMEFANTRINE


branded for Kenya

COMBISUNATE

20/120 5-14KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg AJANTA PHARMA LTD India 6 Yes QAACT – over

branded for Nigeria

COMBISUNATE

20/120 15-24KG

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

COMBISUNATE

20/120 25-34KG

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

COMBISUNATE

20/120 35+ KG

ADULTS

ARTEMETHER +

LUMEFANTRINE


branded for Nigeria

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DAWA MSETO YA

MALARIA ALU

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12, 18, 24 Yes Repackaged by PSI

for distribution in TZ

FALCIMON KIT

YOUNG CHILDREN UP

TO 6 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153mg CIPLA PHARMA LTD India 6 No

FALCIMON KIT

CHILDREN 7-13

YEARS

ARTESUNATE +

AMODIAQUINE


FALCIMON KIT

ADULTS

ARTESUNATE +

AMODIAQUINE


LA COARTEM ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12 Yes Repackaged by PSI

for distribution in

Malawi

LARIMAL CHILD 1-6

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 No

LARIMAL JUNIOR 7-

13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 No

LARIMAL ADULT 14+

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 24 No

LARIMAL CHILD 1-6

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 6 No

LARIMAL JUNIOR 7-

13 YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 12 No

LARIMAL ADULT 14+

YEARS

ARTESUNATE +

AMODIAQUINE


LTD

India 24 No

LUMERAX ARTEMETHER +

LUMEFANTRINE


LTD

India 24 Yes

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LUMARTEM 5KG TO

<15KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD India 6 or 180 Yes

LUMARTEM 15 TO

<25KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 25 TO

<35KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 35KG

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 5KG TO

<15KG

ARTEMETHER +

LUMEFANTRINE

20mg + 120mg CIPLA PHARMA LTD Uganda 6 or 180 Yes

LUMARTEM 15 TO

<25KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 25 TO

<35KG

ARTEMETHER +

LUMEFANTRINE


LUMARTEM 35KG

AND ABOVE

ARTEMETHER +

LUMEFANTRINE


MALARIAKIT ARTESUNATE +

AMODIAQUINE


LTD

India 6 No Repackaged by PSI

for distribution in

Sudan

MALARPACK

COARTEM

ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6, 12 Yes Repackaged by PSI

for distribution in

Myanmar

PRIMO ARTEMETHER +

LUMEFANTRINE


AG


for distribution in

Rwanda

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SERENA DOSE

ENFANTS 1-5 YEARS

ARTESUNATE +

AMODIAQUINE

50mg + 153mg CIPLA PHARMA LTD India 6 Yes Repackaged by

PSI/Manufacturer for

distribution in DRC

TIBAMAL ARTEMETHER +

LUMEFANTRINE


AG

China or USA 6 or 12 Yes Repackaged by

manufacturer for

distribution in Kenya

WINTHROP INFANT

2-11 MONTHS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP TODDLER

1-5 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP CHILD 6-

13 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 3 or 75 Yes

WINTHROP ADULT

+14 YEARS

ARTESUNATE +

AMODIAQUINE


MAPHAR

Morocco 6 or 150 Yes

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8.3 Final sample

Table 8.3.1: List of clusters/sub-districts sampled and their population, Uganda, 2011

Region District Sub-county Population Urban/Rural Type

Northern Apac

Cegere 24,597 Rural Selected

Akokoro 26,766 Rural Booster - PHF and Part one Pharmacies (POP)

Apac 35,146 Rural Booster - PHF and POP

Ibuje 24,536 Rural Booster - PHF and POP

Apac T.C. 10,137 Urban Booster - PHF and POP

Alito 50,549 Rural Booster - POP only

Aboke 33,602 Rural Booster - POP only

Akalo 19,984 Rural Booster - POP only

Ayer 31,478 Rural Booster - POP only

Bala 30,309 Rural Booster - POP only

Abongomola 26,320 Rural Booster - POP only

Aduku 26,545 Rural Booster - POP only

Chawente 20,855 Rural Booster - POP only

Inomo 21,866 Rural Booster - POP only

Nambieso 32,888 Rural Booster - POP only

Aber 51,673 Rural Booster - POP only

Acaba 30,979 Rural Booster - POP only

Iceme 32,082 Rural Booster - POP only

Loro 40,530 Rural Booster - POP only

Minakulu 40,579 Rural Booster - POP only

Ngai 35,043 Rural Booster - POP only

Otwal 37,529 Rural Booster - POP only

West Nile

Arua

Koboko T.C. 29,727 Urban Selected

Kuluba 18,030 Rural Booster - PHF and POP

Lobule 35,403 Rural Booster - PHF and POP

Ludara 18,374 Rural Booster - PHF and POP

Midia 27,614 Rural Booster - PHF and POP

Oluvu 23662 Rural Selected

Nyadri 22,164 Rural Booster - PHF and POP

Oleba 23,286 Rural Booster - PHF and POP

Oluffe 17,096 Rural Booster - PHF and POP

Tara 14,062 Rural Booster - PHF and POP

Yivu 19,600 Rural Booster - PHF and POP

Kijomoro 25,835 Rural Booster - PHF and POP

Arua Hill 14,979 Rural Booster - POP only

Oli River 28,950 Rural Booster - POP only

Adumi 41,118 Rural Booster - POP only

Aroi 18,898 Rural Booster - POP only

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Dadamu 26,453 Rural Booster - POP only

Manibe 23,079 Rural Booster - POP only

Oluko 28,279 Rural Booster - POP only

Pajulu 34,728 Rural Booster - POP only

Offaka 17,953 Rural Booster - POP only

Ogoko 13,744 Rural Booster - POP only

Okollo 12,014 Rural Booster - POP only

Rhino Camp 15,643 Rural Booster - POP only

Rigbo 28,732 Rural Booster - POP only

Uleppi 6,240 Rural Booster - POP only

Aii - Vu 29,603 Rural Booster - POP only

Beleafe 13,820 Rural Booster - POP only

Katrini 26,474 Rural Booster - POP only

Odupi 38,406 Rural Booster - POP only

Omugo 31,191 Rural Booster - POP only

Uriama 16,910 Rural Booster - POP only

Ajia 18,906 Rural Booster - POP only

Arivu 17,166 Rural Booster - POP only

Logiri 23,917 Rural Booster - POP only

Vurra 31,872 Rural Booster - POP only

S.western

Bundibugyo

Nduguto 28,273 Rural Selected

Bubandi 17,287 Rural Booster - PHF and POP

Bubukwanga 18,333 Rural Booster - PHF and POP

Bundibugyo T.C 13,782 Urban Booster - PHF and POP

Busaru 31,770 Rural Booster - PHF and POP

Harugali 22,849 Rural Booster - PHF and POP

Kasitu 26,615 Rural Booster - PHF and POP

Kanara 11,204 Rural Booster - POP only

Karugutu 15,188 Rural Booster - POP only

Rwebisengo 24,677 Rural Booster - POP only

S.Western

Bushenyi

Shuuku 20,688 Rural Selected

Bugongi 20,124 Rural Booster - PHF and POP

Kabwohe-Itendero T.C 15,355 Rural Booster - PHF and POP

Kagango 32,119 Rural Booster - PHF and POP

Kigarama 34,276 Rural Booster - PHF and POP

Kitagata 30,960 Rural Booster - PHF and POP

Kyangyenyi 26,712 Rural Booster - PHF and POP

Nyabubare 35,111 Rural Booster - POP only

Bumbaire 30,458 Rural Booster - POP only

Bushenyi T.C. 22,422 Urban Booster - POP only

Kakanju 23,245 Rural Booster - POP only

Kyabugimbi 30,610 Rural Booster - POP only

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Kyamuhunga 38,918 Rural Booster - POP only

Kyeizoba 24,907 Rural Booster - POP only

Bihanga 19,585 Rural Booster - POP only

Burere 24,041 Rural Booster - POP only

Karungu 24,249 Rural Booster - POP only

Rwengwe 15,006 Rural Booster - POP only

Katerera 37,833 Rural Booster - POP only

Katunguru 2,937 Rural Booster - POP only

Kichwamba 23,756 Rural Booster - POP only

Ryeru 37,278 Rural Booster - POP only

Bitereko 23,200 Rural Booster - POP only

Kabira 31,985 Rural Booster - POP only

Kanyabwanga 13,972 Rural Booster - POP only

Kashenshero 16,494 Rural Booster - POP only

Kiyanga 14,114 Rural Booster - POP only

Mitooma 38,976 Rural Booster - POP only

Mutara 22,061 Rural Booster - POP only

Northern

Gulu

Layibi 25,426 Urban Selected

Bar-Dege 36,657 Urban Booster - PHF and POP

S.Western

Gulu

Laroo 21,214 Urban Booster - PHF and POP

Pece 36,133 Urban Booster - PHF and POP

Lamogi 37,625 Rural Booster - POP only

Amuru 135,723 Rural Booster - POP only

Atiak 27,013 Rural Booster - POP only

Pabbo 42,116 Rural Booster - POP only

Awach 11,160 Rural Booster - POP only

Bungatira 22,913 Rural Booster - POP only

Paicho 24,876 Rural Booster - POP only

Palaro 6,609 Rural Booster - POP only

Patiko 8,349 Rural Booster - POP only

Alero 41,010 Rural Booster - POP only

Anaka 12,597 Rural Booster - POP only

Koch Goma 8,550 Rural Booster - POP only

Purongo 6,641 Rural Booster - POP only

Bobi 16,720 Rural Booster - POP only

Koro 18,151 Rural Booster - POP only

Lakwana 13,388 Rural Booster - POP only

Lalogi 18,316 Rural Booster - POP only

Northern

Gulu

Odek 24,255 Rural Booster - POP only

Ongako 14,360 Rural Booster - POP only

Eastern

Iganga

Buyanga 34,132 Rural Selected

Ibulanku 38,197 Rural Booster - PHF and POP

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Makuutu 20,824 Rural Booster - PHF and POP

Namalemba 26,454 Rural Booster - PHF and POP

Namungalwe 28,061 Rural Booster - POP only

Bulamagi 40,489 Rural Booster - POP only

Iganga T.C. 39,472 Urban Booster - POP only

Nabitende 23,560 Rural Booster - POP only

Nakalama 25,760 Rural Booster - POP only

Nakigo 24,266 Rural Booster - POP only

Nambale 31,365 Rural Booster - POP only

Nawandala 22,893 Rural Booster - POP only

Bulange 28,878 Rural Booster - POP only

Ivukula 26,703 Rural Booster - POP only

Kibaale 23,824 Rural Booster - POP only

Magada 33,588 Rural Booster - POP only

Namutumba 35,167 Rural Booster - POP only

Nsinze 19,531 Rural Booster - POP only

Bukanga 33,545 Rural Booster - POP only

Bukooma 28,995 Rural Booster - POP only

Bulongo 28,546 Rural Booster - POP only

Ikumbya 22,937 Rural Booster - POP only

Irongo 24,479 Rural Booster - POP only

Nawampiti 18,389 Rural Booster - POP only

Waibuga 28,635 Rural Booster - POP only

Eastern

Jinja

Central Divison 26,698 Urban Selected

Mpumudde /Kimaka 19,901 Urban Booster - PHF and POP

Masese/Walukuba 24,614 Urban Booster - PHF and POP

Budondo 45,035 Rural Selected

Butagaya 48,032 Rural Booster - PHF and POP

Buyengo 27,573 Rural Booster - PHF and POP

Buwenge 46,951 Rural Booster - PHF and POP

Buwenge T.C 14,461 Rural Booster - PHF and POP

Busedde 31,172 Rural Booster - POP only

Kakira 27,651 Rural Booster - POP only

Mafubira 75,484 Rural Booster - POP only

S.Western

Kabarole

Western 13,770 Urban Selected

Eastern 13,681 Urban Booster - PHF and POP

Southern 13,542 Urban Booster - PHF and POP

Karambi 19,771 Rural Selected

Kibiito 38,816 Rural Booster - PHF and POP

Kisomoro 30,647 Rural Booster - PHF and POP

Rwiimi 24,999 Rural Booster - PHF and POP

Bukuku 21,536 Rural Booster - POP only

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Busoro 22,755 Rural Booster - POP only

Hakibaale 36,849 Rural Booster - POP only

Buheesi 32,600 Rural Booster - POP only

Kicwamba 26,578 Rural Booster - POP only

Mugusu 19,812 Rural Booster - POP only

Ruteete 41,558 Rural Booster - POP only

Central

Kampala

Kanyanya 18,757 Urban Selected

Mulago II 13,680 Urban Selected

Bwaise I 17,971 Urban Booster - PHF and POP

Bwaise II 16,808 Urban Booster - PHF and POP

Bwaise III 10530 Urban Booster - PHF and POP

Kawempe I 36,374 Urban Booster - PHF and POP

Kawempe II 13,240 Urban Booster - PHF and POP

Kazo Ward 14,751 Urban Booster - PHF and POP

Kikaya 14,543 Urban Booster - PHF and POP

Komamboga 5,674 Urban Booster - PHF and POP

Kyebando 33,007 Urban Booster - PHF and POP

Makerere I 6,755 Urban Booster - PHF and POP

Makerere II 11,777 Urban Booster - PHF and POP

Makerere III 13,575 Urban Booster - PHF and POP

Mpererwe 2,940 Urban Booster - PHF and POP

Mulago I 7,921 Urban Booster - PHF and POP

Mulago III 13,416 Urban Booster - PHF and POP

University (Makerere) 4,652 Urban Booster - PHF and POP

Wandegeya 5,894 Urban Booster - PHF and POP

Kibuye I 23,309 Urban Selected

Wabigalo 18001 Urban Selected

Bukasa 19,721 Urban Booster - PHF and POP

Buziga 9,638 Urban Booster - PHF and POP

Ggaba 20,230 Urban Booster - PHF and POP

Kabalagala 12,646 Urban Booster - PHF and POP

Kansanga – Muyenga 18,873 Urban Booster - PHF and POP

Katwe I 9,137 Urban Booster - PHF and POP

Katwe II 12,999 Urban Booster - PHF and POP

Kibuli 22,614 Urban Booster - PHF and POP

Kibuye II 9,703 Urban Booster - PHF and POP

Kisugu 17,715 Urban Booster - PHF and POP

Lukuli 16,775 Urban Booster - PHF and POP

Luwafu 11,210 Urban Booster - PHF and POP

Makindye I 13,374 Urban Booster - PHF and POP

Makindye II 14,220 Urban Booster - PHF and POP

Nsambya Central 30,274 Urban Booster - PHF and POP

Nsambya Housing Estate 737 Urban Booster - PHF and POP

Nsambya Police Barracks 7,524 Urban Booster - PHF and POP

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Nsambya Railway 3,872 Urban Booster - PHF and POP

Salaama 10,599 Urban Booster - PHF and POP

Mutungo 43,659 Urban Selected

Kiwatule 9,954 Urban Booster - PHF and POP

Banda 12,267 Urban Booster - PHF and POP

Bogolobi 8,820 Urban Booster - PHF and POP

Bukoto I 18,038 Urban Booster - PHF and POP

Bukoto II 20,820 Urban Booster - PHF and POP

Butabika 11,784 Urban Booster - PHF and POP

I.T.E.K 30 Urban Booster - PHF and POP

Kiswa 4,488 Urban Booster - PHF and POP

Kyambogo 1,959 Urban Booster - PHF and POP

Kyanja 8,293 Urban Booster - PHF and POP

Luzira 15,428 Urban Booster - PHF and POP

Luzira Prisons 9,514 Urban Booster - PHF and POP

Mbuya I 18,864 Urban Booster - PHF and POP

Mbuya II 9,415 Urban Booster - PHF and POP

Nabisunsa 759 Urban Booster - PHF and POP

Naguru I 3,861 Urban Booster - PHF and POP

Naguru II 26,137 Urban Booster - PHF and POP

Nakawa 5,908 Urban Booster - PHF and POP

Nakawa Institutions 87 Urban Booster - PHF and POP

Ntinda 9,094 Urban Booster - PHF and POP

U.P.K 270 Urban Booster - PHF and POP

Upper Estates 1,175 Urban Booster - PHF and POP

Kasubi 43,611 Urban Selected

Ndeeba 16,734 Urban Selected

Busega 22,478 Urban Booster - PHF and POP

Kabowa 28,378 Urban Booster - PHF and POP

Lubia 34,859 Urban Booster - PHF and POP

Lungujja 19,403 Urban Booster - PHF and POP

Mutundwe 26,956 Urban Booster - PHF and POP

Najjanankumbi I 12,241 Urban Booster - PHF and POP

Najjanankumbi II 10,746 Urban Booster - PHF and POP

Nakulabye 19,780 Urban Booster - PHF and POP

Namirembe 15,247 Urban Booster - PHF and POP

Nateete 23,839 Urban Booster - PHF and POP

Rubaga 20,816 Urban Booster - PHF and POP

Bukesa 7,889 Urban Booster - POP only

Civic Centre 1,308 Urban Booster - POP only

Industrial Area 454 Urban Booster - POP only

Kamwokya I 2,933 Urban Booster - POP only

Kamwokya II 15,249 Urban Booster - POP only

Kisenyi I 3,462 Urban Booster - POP only

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Kisenyi II 10,867 Urban Booster - POP only

Kisenyi III 4,981 Urban Booster - POP only

Kololo I 1,728 Urban Booster - POP only

Kololo II 1,418 Urban Booster - POP only

Kololo III 2,516 Urban Booster - POP only

Kololo IV 2,985 Urban Booster - POP only

Mengo 12,679 Urban Booster - POP only

Nakasero I 1,117 Urban Booster - POP only

Nakasero II 3,452 Urban Booster - POP only

Nakasero III 1,303 Urban Booster - POP only

Nakasero IV 1,130 Urban Booster - POP only

Nakivubo Shauliyako 1,219 Urban Booster - POP only

Old Kampala 3,907 Urban Booster - POP only

Eastern

Kamuli

Nawaikoke 39,897 Rural Selected

Bumanya 33,752 Rural Booster - PHF and POP

Gadumire 22,344 Rural Booster - PHF and POP

Namugongo 34,985 Rural Booster - PHF and POP

Namwiwa 23,689 Rural Booster - PHF and POP

Balawoli 33,580 Rural Booster - POP only

Bulopa 16,163 Rural Booster - POP only

Butansi 22,529 Rural Booster - POP only

Kamuli T.C. 11,344 Urban Booster - POP only

Kitayunjwa 43,166 Rural Booster - POP only

Nabwigulu 35,356 Rural Booster - POP only

Namasagali 23,686 Rural Booster - POP only

Namwendwa 43,042 Rural Booster - POP only

Bugaya 54,405 Rural Booster - POP only

Buyende 34,792 Rural Booster - POP only

Kagulu 44,327 Rural Booster - POP only

Kidera 39,682 Rural Booster - POP only

Nkondo 18,060 Rural Booster - POP only

Bugulumbya 31,299 Rural Booster - POP only

Kisozi 38,773 Rural Booster - POP only

Mbulamuti 22,982 Rural Booster - POP only

Nawanyago 21,038 Rural Booster - POP only

Wankole 18,441 Rural Booster - POP only

S.Western

Kasese

Bwera 37,741 Rural Selected

Ihandiro 11,588 Rural Booster - PHF and POP

Karambi 34,975 Rural Booster - PHF and POP

Kisinga 37,625 Rural Booster - PHF and POP

Kitholhu 14,131 Rural Booster - PHF and POP

Kyarumba 28,727 Rural Booster - PHF and POP

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Kyondo 16,335 Rural Booster - PHF and POP

Mahango 15,410 Rural Booster - PHF and POP

Munkunyu 26,845 Rural Booster - PHF and POP

Nyakiyumbu 22,815 Rural Booster - PHF and POP

Maliba 37,204 Rural Booster - POP only

Bugoye 31,618 Rural Booster - POP only

Karusandara 8,938 Rural Booster - POP only

Kasese T.C 53,907 Urban Booster - POP only

Katwe Kabatoro T.C. 5,821 Urban Booster - POP only

Kilembe 21,515 Rural Booster - POP only

Kitswamba 30,449 Rural Booster - POP only

Kyabarungira 38,020 Rural Booster - POP only

L.Katwe 13,293 Rural Booster - POP only

Muhokya 16,378 Rural Booster - POP only

Rukoki 19,698 Rural Booster - POP only

Central

Kayunga

Wabwoko-kitimbwa 38,593 Rural Selected

Bbaale 10,130 Rural Booster - PHF and POP

Galiraaya 14,362 Rural Booster - PHF and POP

Kayonza 44,772 Rural Booster - PHF and POP

Kayunga T.C 19,797 Urban Selected

Busana 48,160 Rural Booster - PHF and POP

Kangulumira 43,703 Rural Booster - PHF and POP

Kayunga 35,950 Rural Booster - PHF and POP

Nazigo 39,146 Rural Booster - PHF and POP

Central

Kiboga

Wattuba 14,868 Rural Selected

Bukomero 21,652 Rural Booster - PHF and POP

Butemba 23,928 Rural Booster - PHF and POP

Dwaniro 10,819 Rural Booster - PHF and POP

Gayana 10,313 Rural Booster - PHF and POP

Kapeke 11,106 Rural Booster - PHF and POP

Kibiga 20,010 Rural Booster - PHF and POP

Kiboga T.C 11,956 Urban Booster - PHF and POP

Kyankwanzi 9,534 Rural Booster - PHF and POP

Lwamata 20,644 Rural Booster - PHF and POP

Mulagi 10,949 Rural Booster - PHF and POP

Muwanga 12,710 Rural Booster - PHF and POP

Nsambya 26,283 Rural Booster - PHF and POP

Ntwetwe 24,700 Rural Booster - PHF and POP

Eastern

Kumi

Ongino 28,758 Rural Selected

Atutur 21,633 Rural Booster - PHF and POP

Kanyum 28,266 Rural Booster - PHF and POP

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Kumi 23,155 Rural Booster - PHF and POP

Kumi T.C. 8,807 Urban Booster - PHF and POP

Mukongoro 31,822 Rural Booster - PHF and POP

Nyero 22,924 Rural Booster - PHF and POP

Kachumbala 36,767 Rural Booster - POP only

Bukedea 25,130 Rural Booster - POP only

Kidongole 16,921 Rural Booster - POP only

Kolir 16,849 Rural Booster - POP only

Malera 26,736 Rural Booster - POP only

Kapir 22,321 Rural Booster - POP only

Kobwin 23,889 Rural Booster - POP only

Mukura 24,828 Rural Booster - POP only

Ngora 30,829 Rural Booster - POP only

Northern

Lira

Ogur 40,934 Rural Selected

Adekokwok 49,460 Rural Booster - PHF and POP

Amach 40,696 Rural Booster - PHF and POP

Aromo 26,745 Rural Booster - PHF and POP

Barr 32,261 Rural Booster - PHF and POP

Lira 19,626 Rural Booster - PHF and POP

Ojwina 29,547 Urban Selected

Adyel 28,346 Urban Booster - PHF and POP

Central 18,205 Urban Booster - PHF and POP

Railway 4,781 Urban Booster - PHF and POP

Apala 30,605 Rural Booster - POP only

Abako 38,364 Rural Booster - POP only

Aloi 45,045 Rural Booster - POP only

Amugo 20,066 Rural Booster - POP only

Omoro 28,967 Rural Booster - POP only

Agwata 27,915 Rural Booster - POP only

Batta 23,482 Rural Booster - POP only

Dokolo 34,489 Rural Booster - POP only

Kangai 33,880 Rural Booster - POP only

Kwera 19,619 Rural Booster - POP only

Aputi 22,627 Rural Booster - POP only

Awelo 30,129 Rural Booster - POP only

Muntu 25,005 Rural Booster - POP only

Namasale 18,428 Rural Booster - POP only

Adwari 19,450 Rural Booster - POP only

Okwang 12,353 Rural Booster - POP only

Olilim 13,388 Rural Booster - POP only

Orum 16,827 Rural Booster - POP only

Central

Masaka Butenga 45,148 Rural Selected

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Bigasa 37,253 Rural Booster - PHF and POP

Kibinge 31,315 Rural Booster - PHF and POP

Kitanda 25,840 Rural Booster - PHF and POP

Nyendo/Senyange 29,562 Urban Selected

Katwe/Butego 17,252 Urban Booster - PHF and POP

Kimanya/Kyabakuza 20,954 Urban Booster - PHF and POP

Bukakata 12,873 Rural Booster - POP only

Buwunga 38,358 Rural Booster - POP only

Kabonera 28,855 Rural Booster - POP only

Kisekka 44,063 Rural Booster - POP only

Kkingo 34,361 Rural Booster - POP only

Kyanamukaaka 45,203 Rural Booster - POP only

Kyazanga 41,410 Rural Booster - POP only

Lwengo 54,682 Rural Booster - POP only

Malongo 33,843 Rural Booster - POP only

Mukungwe 35,113 Rural Booster - POP only

Ndagwe 33,509 Rural Booster - POP only

Kalungu 46,809 Rural Booster - POP only

Kyamuliibwa 30,932 Rural Booster - POP only

Lukaya T.C. 14,147 Urban Booster - POP only

Lwabenge 28,089 Rural Booster - POP only

Bukulula 40,707 Rural Booster - POP only

Western

Masindi

Miirya 24,769 Rural Selected

Karujubu 16,714 Rural Booster - PHF and POP

Kimengo 10,379 Rural Booster - PHF and POP

Masindi T.C 28,300 Urban Booster - PHF and POP

Nyangahya 11,216 Rural Booster - PHF and POP

Pakanyi 40,306 Rural Booster - PHF and POP

Kigumba 40,054 Rural Booster - POP only

Kiryandongo 90,014 Rural Booster - POP only

Masindi-Port 7,231 Rural Booster - POP only

Mutunda 47,408 Rural Booster - POP only

Bwijanga 38,677 Rural Booster - POP only

Budongo 38,059 Rural Booster - POP only

Biiso 30,000 Rural Booster - POP only

Buliisa 33,363 Rural Booster - POP only

Eastern

Mbale

Kaato 12,770 Rural Selected

Bubutu 38,928 Rural Booster - PHF and POP

Bugobero 22,751 Rural Booster - PHF and POP

Bumbo 23,983 Rural Booster - PHF and POP

Bumwoni 30,245 Rural Booster - PHF and POP

Bupoto 25,533 Rural Booster - PHF and POP

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Butiru 39,167 Rural Booster - PHF and POP

Buwabwala 28,426 Rural Booster - PHF and POP

Buwagogo 17,670 Rural Booster - PHF and POP

Sibanga 23,093 Rural Booster - PHF and POP

Busiu 25,746 Rural Booster - POP only

Bufumbo 30,664 Rural Booster - POP only

Bukonde 16,796 Rural Booster - POP only

Bukyiende 23,246 Rural Booster - POP only

Bungokho 29,827 Rural Booster - POP only

Bungokho-Mutoto 36,478 Rural Booster - POP only

Busano 8,323 Rural Booster - POP only

Busoba 26,212 Rural Booster - POP only

Nakaloke 30,653 Rural Booster - POP only

Namanyonyi 19,662 Rural Booster - POP only

Wanale 13,834 Rural Booster - POP only

Bubiita 22,711 Rural Booster - POP only

Bududa 11,867 Rural Booster - POP only

Bukibokolo 15,309 Rural Booster - POP only

Bukigai 23,297 Rural Booster - POP only

Bulucheke 18,393 Rural Booster - POP only

Bumayoka 8,092 Rural Booster - POP only

Bushika 23,434 Rural Booster - POP only

Industrial 31,764 Urban Booster - POP only

Northern Division 28,716 Urban Booster - POP only

Wanale Division 10,650 Urban Booster - POP only

S. western

Mbarara

Kikagate 43,720 Rural Selected

Birere 35,028 Rural Booster - PHF and POP

Kabingo 30,351 Rural Booster - PHF and POP

Kabuyanda 42,024 Rural Booster - PHF and POP

Masha 19,925 Rural Booster - PHF and POP

Nyakitunda 31,679 Rural Booster - PHF and POP

Kakoba 34,271 Urban Selected

Kamukuzi 23,470 Urban Booster - PHF and POP

Nyamitanga 11,622 Urban Booster - PHF and POP

Nyamarebe 20,685 Rural Booster - POP only

Bisheshe 33,609 Rural Booster - POP only

Ibanda T.C. 22,728 Urban Booster - POP only

Ishongororo 37,247 Rural Booster - POP only

Kicuzi 10.277 Rural Booster - POP only

Kikyenkye 30,956 Rural Booster - POP only

Nyabuhikye 23,351 Rural Booster - POP only

Rukiri 19,782 Rural Booster - POP only

Buremba 27,324 Rural Booster - POP only

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Burunga 9,813 Rural Booster - POP only

Kanoni 32,144 Rural Booster - POP only

Kazo 30,477 Rural Booster - POP only

Rwemikoma 11,831 Rural Booster - POP only

Rugando 28,822 Rural Booster - POP only

Bugamba 28,822 Rural Booster - POP only

Mwizi 26,136 Rural Booster - POP only

Ndaija 24,806 Rural Booster - POP only

Nyakayojo 29,396 Rural Booster - POP only

Endinzi 18,495 Rural Booster - POP only

Kashumba 27,685 Rural Booster - POP only

Ngarama 31,655 Rural Booster - POP only

Rugaaga 35,463 Rural Booster - POP only

Bubaare 18,414 Rural Booster - POP only

Bukiro 12,922 Rural Booster - POP only

Kagongi 19,529 Rural Booster - POP only

Kakiika 15,096 Rural Booster - POP only

Kashare 19,981 Rural Booster - POP only

Rubaya 31,674 Rural Booster - POP only

Rubindi 20,835 Rural Booster - POP only

Rwanyamahembe 21,701 Rural Booster - POP only

Kanyaryeru 3,885 Rural Booster - POP only

Kashongi 37,622 Rural Booster - POP only

Kenshunga 17,826 Rural Booster - POP only

Kikatsi 10,736 Rural Booster - POP only

Kinoni 12,210 Rural Booster - POP only

Nyakashashara 9,405 Rural Booster - POP only

Sanga 8,946 Rural Booster - POP only

West Nile

Moyo

Moyo 30,907 Rural Selected

Moyo T.C 12,074 Urban Booster - PHF and POP

Dufile 20,217 Rural Booster - PHF and POP

Lefori 17,875 Rural Booster - PHF and POP

Metu 26,365 Rural Booster - PHF and POP

Aliba 24,202 Rural Booster - POP only

Gimara 23,802 Rural Booster - POP only

Itula 39,336 Rural Booster - POP only

Central

Mubende

Kassanda 38,080 Rural Selected

Bukuya 62,404 Rural Booster - PHF and POP

Kiganda 38,080 Rural Booster - PHF and POP

Myanzi 41,740 Rural Booster - PHF and POP

Butayunja 10,451 Rural Booster - POP only

Kakindu 16,943 Rural Booster - POP only

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Maanyi 30,321 Rural Booster - POP only

Malangala 19,130 Rural Booster - POP only

Bagezza 42,884 Rural Booster - POP only

Butoloogo 15,644 Rural Booster - POP only

Kasambya 73,147 Rural Booster - POP only

Kitenga 37,078 Rural Booster - POP only

Kiyuni 20,985 Rural Booster - POP only

Madudu 16,636 Rural Booster - POP only

Mubende T.C. 15,996 Urban Booster - POP only

Bulera 51,087 Rural Booster - POP only

Busimbi 42,636 Rural Booster - POP only

Kikandwa 21,414 Rural Booster - POP only

Mityana T.C. 34,116 Urban Booster - POP only

Ssekanyonyi 40,010 Rural Booster - POP only

Central

Mukono

Njeru T.C. 51,236 Urban Selected

Buikwe 27,976 Rural Booster - PHF and POP

Kawolo 31,366 Rural Booster - PHF and POP

Lugazi T.C. 27,979 Urban Booster - PHF and POP

Najja 30,885 Rural Booster - PHF and POP

Najjembe 27,233 Rural Booster - PHF and POP

Ngogwe 30,132 Rural Booster - PHF and POP

Nkonkonjeru T.C. 11,095 Urban Booster - PHF and POP

Nyenga 38,613 Rural Booster - PHF and POP

Ssi - Bukunja 19,948 Rural Booster - PHF and POP

Wakisi 33,397 Rural Booster - PHF and POP

Nabaale 28,369 Rural Selected

Kasawo 30,914 Rural Booster - PHF and POP

Kimenyedde 31,081 Rural Booster - PHF and POP

Nagojje 28,482 Rural Booster - PHF and POP

Ntunda 13,412 Rural Booster - PHF and POP

Seeta- Namuganga 32,937 Rural Booster - PHF and POP

Nama 33,004 Rural Booster - POP only

Goma 45,062 Rural Booster - POP only

Kkome Islands 9,703 Rural Booster - POP only

Kyampisi 28,594 Rural Booster - POP only

Mukono T.C. 46,506 Urban Booster - POP only

Nakisunga 39,545 Rural Booster - POP only

Ntenjeru 55,443 Rural Booster - POP only

Bugaya 7,589 Rural Booster - POP only

Busamuzi 12,620 Rural Booster - POP only

Bweema 6,833 Rural Booster - POP only

Nairambi 15,441 Rural Booster - POP only

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West Nile

Nebbi

Nebbi T.C 22,741 Urban Selected

Nyaravur 21,687 Rural Selected

Akworo 15,330 Rural Booster - PHF and POP

Erussi 44,026 Rural Booster - PHF and POP

Kucwiny 21,172 Rural Booster - PHF and POP

Nebbi 17,102 Rural Booster - PHF and POP

Parombo 24,776 Rural Booster - PHF and POP

Pakwach 14,956 Rural Booster - POP only

Pakwach T.C 17,625 Urban Booster - POP only

Panyango 30,355 Rural Booster - POP only

Panyimur 20,729 Rural Booster - POP only

Wadelai 15,811 Rural Booster - POP only

Atyak 21,475 Rural Booster - POP only

Jangokoro 23,013 Rural Booster - POP only

Kango 26,161 Rural Booster - POP only

Nyapea 22,249 Rural Booster - POP only

Paidha 24,927 Rural Booster - POP only

Paidha T.C 24,079 Urban Booster - POP only

Zeu 27,144 Rural Booster - POP only

Eastern

Pallisa

Kamonkoli 24,016 Rural Selected

Naboa 17,337 Rural Booster - PHF and POP

Budaka 22,912 Rural Booster - PHF and POP

Iki-Iki 24,143 Rural Booster - PHF and POP

Kaderuna 20,822 Rural Booster - PHF and POP

Kameruka 9,776 Rural Booster - PHF and POP

Lyama 17,483 Rural Booster - PHF and POP

Butebo 18,642 Rural Booster - POP only

Kabwangasi 18,761 Rural Booster - POP only

Kakoro 17,703 Rural Booster - POP only

Kibale 21,298 Rural Booster - POP only

Petete 16,926 Rural Booster - POP only

Bulangira 16,610 Rural Booster - POP only

Buseta 24,266 Rural Booster - POP only

Kadama 21,827 Rural Booster - POP only

Kagumu 17,340 Rural Booster - POP only

Kibuku 13,159 Rural Booster - POP only

Kirika 14,354 Rural Booster - POP only

Tirinyi 20,663 Rural Booster - POP only

Agule 20,977 Rural Booster - POP only

Apopong 17,930 Rural Booster - POP only

Gogonyo 17,208 Rural Booster - POP only

Kameke 20,470 Rural Booster - POP only

Kamuge 14,469 Rural Booster - POP only

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Kasodo 20,913 Rural Booster - POP only

Pallisa 10,496 Rural Booster - POP only

Pallisa T.C. 23,641 Urban Booster - POP only

Puti-Puti 16,436 Rural Booster - POP only

Central

Rakai

Kirumba 23,716 Rural Selected

Kalisizo 27,847 Rural Booster - PHF and POP

Kabira 26,097 Rural Booster - PHF and POP

Kasaali 22,793 Rural Booster - PHF and POP

Kyotera T.C. 7,590 Urban Booster - PHF and POP

Lwankoni 13,988 Rural Booster - PHF and POP

Nabigasa 18,549 Rural Booster - PHF and POP

Kaliiro 15,040 Rural Booster - POP only

Kasagama 5,164 Rural Booster - POP only

Kinuuka 7,260 Rural Booster - POP only

Lyantonde 14,366 Rural Booster - POP only

Lyantonde T.C. 7,508 Urban Booster - POP only

Mpumudde 16,701 Rural Booster - POP only

Kakuuto 26,426 Rural Booster - POP only

Kasasa 3,515 Rural Booster - POP only

Kibanda 15,506 Rural Booster - POP only

Kifamba 12,305 Rural Booster - POP only

Kyebe 16,020 Rural Booster - POP only

Byakabanda 13,792 Rural Booster - POP only

Ddwaniro 27,197 Rural Booster - POP only

Kacheera 17,754 Rural Booster - POP only

Kagamba (Buyamba) 27,523 Rural Booster - POP only

Kyalulangira 27,778 Rural Booster - POP only

Lwamaggwa 33,162 Rural Booster - POP only

Lwanda 24,965 Rural Booster - POP only

Rakai T.C. 5,974 Urban Booster - POP only

Eastern

Soroti

Asuret 24,727 Rural Selected

Arapai 25,314 Rural Booster - PHF and POP

Gweri 31,899 Rural Booster - PHF and POP

Kamuda 22,902 Rural Booster - PHF and POP

Katine 20,650 Rural Booster - PHF and POP

Soroti 11,697 Rural Booster - PHF and POP

Tubur 14,410 Rural Booster - PHF and POP

Eastern Division 15,766 Urban Booster - POP only

Nothern Division 16,097 Urban Booster - POP only

Western division 9,848 Urban Booster - POP only

Bugondo 22,551 Rural Booster - POP only

Kadungulu 17,125 Rural Booster - POP only

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Pingire 32,405 Rural Booster - POP only

Atiira 13,597 Rural Booster - POP only

Kateta 34,933 Rural Booster - POP only

Kyere 31,129 Rural Booster - POP only

Olio 24,739 Rural Booster - POP only

Eastern

Tororo

Western Division 19,902 Urban Selected

Eastern Division 14,908 Urban Booster - PHF and POP

Nagongera 28,907 Rural Booster - POP only

Iyolwa 25,146 Rural Booster - POP only

Kirewa 20,690 Rural Booster - POP only

Kisoko 15,062 Rural Booster - POP only

Mulanda 27,606 Rural Booster - POP only

Nabuyoga 20,097 Rural Booster - POP only

Paya 30,912 Rural Booster - POP only

Petta 11,592 Rural Booster - POP only

Rubongi 28,304 Rural Booster - POP only

Budumba 27,949 Rural Booster - POP only

Busaba 16,514 Rural Booster - POP only

Busolwe 20,051 Rural Booster - POP only

Butaleja 25,428 Rural Booster - POP only

Kachonga 29,266 Rural Booster - POP only

Nawanjofu 11,793 Rural Booster - POP only

Nazimasa 26,488 Rural Booster - POP only

Kwapa 15,670 Rural Booster - POP only

Mella 25,685 Rural Booster - POP only

Merikit 17,644 Rural Booster - POP only

Molo 13,067 Rural Booster - POP only

Mukuju 28,209 Rural Booster - POP only

Osukuru 35,998 Rural Booster - POP only

Central

Wakiso

Kakiri 29,829 Rural Selected

Ssisa 45624 Rural Booster - PHF and POP

Kasanje 31,526 Rural Booster - PHF and POP

Katabi 57,587 Rural Booster - PHF and POP

Masulita 20,166 Rural Booster - PHF and POP

Namayumba 26082 Rural Booster - PHF and POP

Nsangi 73,155 Rural Booster - PHF and POP

Wakiso 66,735 Rural Booster - PHF and POP

Wakiso T.C. 14,603 Urban Booster - PHF and POP

Ssabagabo-Makindye 136,322 Rural Selected

Nabweru 104,400 Rural Booster - PHF and POP

Busukuma 27,207 Rural Booster - PHF and POP

Gombe 39,849 Rural Booster - PHF and POP

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Kira 124,067 Rural Booster - PHF and POP

Nangabo 55,751 Rural Booster - PHF and POP

Division A 32,031 Urban Booster - POP only

Division B 23,055 Urban Booster - POP only


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8.4 Survey team

Table 8.4.1: List of staff members involved in the survey, [Uganda], 2011

Name Responsibility/role

Kawalya Bashir Quality Controller- Eastern team 1

Etiang Moses Quality Controller- Eastern team 2

Nakimuli Doreen Quality Controller - Central team 1

Kato Joel Quality Controller - Central team 2

Kawooya Lameck Quality Controller – Makindye Ssabagabo team 1

Kiwanuka Archileo Quality Controller – Makindye Ssabagabo team 2

Adikini Anne Quality Controller – West Nile team

Nyeko Godfrey Quality Controller – Northern team

Akatukunda Nancy Comfort Quality Controller – Western team

Asasira Jean Quality Controller – South Western team

Isabirye Allan Supervisor – Eastern team 1

Jwenjwe Francis Supervisor – Eastern team 2

Gayi Albert Supervisor – Central team 1

Kobusingye Jennifer Supervisor – Eastern team 2

Manzi Stoliva Supervisor – Makindye Ssabagabo team 1

Tusasire William Supervisor – Makindye Ssabagabo team 2

Awor Eresi Supervisor – West Nile team

Winga Malcom Supervisor – Northern team

Mugume Charles Supervisor – Western team

Busingye Dan Supervisor – South Western team

Mitala Denis Interviewer – Eastern team 1

Mudhasi Micheal Interviewer – Eastern team 1

Nabwire Caroline Interviewer - Eastern team 1

Nashuha Julia Vera Interviewer - Eastern team 1

Nabakazi Tracy Interviewer - Eastern team 1

Akello Mary Teddy Interviewer - Eastern team 2

Kasolo Gerald Interviewer - Eastern team 2

Ochieng Ferdinand Interviewer - Eastern team 2

Awor Grace Interviewer - Eastern team 2

Kanyere Matayo Interviewer - Eastern team 2

Katende George Interviewer - Central team 1

Ssenkungu Olivia Interviewer - Central team 1

Mwendeze Jackie Interviewer - Central team 1

Asingwire Mark Interviewer - Central team 1

Jjumba Joseph Interviewer - Central team 1

Kanyike Ronnie Interviewer - Central team 2

Kansiime Fred Interviewer - Central team 2

Komugisha Diana Interviewer - Central team 2

Nabatte Shamim Interviewer - Central team 2

Namutebi Mariam Interviewer - Central team 2

Kigonya Anthony Interviewer – Makindye Ssabagabo team 1

Nyamwire Bonita Interviewer – Makindye Ssabagabo team 1

Magezi Mariam Interviewer – Makindye Ssabagabo team 1

Sebugwawo Johnson Interviewer – Makindye Ssabagabo team 1

Nalumaga Stella Mayanja Interviewer – Makindye Ssabagabo team 1

Nalwanga Angella Interviewer – Makindye Ssabagabo team 2

Nabwanika Alice Interviewer – Makindye Ssabagabo team 2

Kabogooza Fred Interviewer – Makindye Ssabagabo team 2

Najjemba Lydia Interviewer – Makindye Ssabagabo team 2

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Ssenkungu Irene Interviewer – Makindye Ssabagabo team 2

Matata Jonathan Interviewer – West Nile team

Adiru Tamali Interviewer – West Nile team

Kaggwa Joseph Interviewer – West Nile team

Ocokoa Robert Interviewer – West Nile team

Bakashaba Andrew Interviewer – West Nile team

Odokomoch Sylivia Interviewer – Northern team

Okello Denis Interviewer – Northern team

Wagaba Godfrey Interviewer – Northern team

Akullo Sarah Interviewer – Northern team

Amonyi Desire Interviewer – Northern team

Nabaasa Alice Interviewer – Western team

Ninsiima Flavia Interviewer – Western team

Arinanye Agatha Interviewer – Western team

Tukahirwa Doreen Interviewer – Western team

Magara Lawrence Interviewer – Western team

Nyakaana Hellen Interviewer – South Western team

Nazziwa Rose Interviewer – South Western team

Nduhukire Alex Interviewer – South Western team

Muwanguzi Robert Interviewer – South Western team

Atuhaire Susan Interviewer – South Western team

Dr. Narathius Asingwire Team Leader

Joseph Kiwanuka Field Manager

Swizen Kyomuhendo Agency Field Regional Coordinator

Dr. Eric Awich Ocen Agency Field Regional Coordinator

Dr. Jenestic Twikirize Agency Field Regional Coordinator

Innocent Atwijukire Agency Field Regional Coordinator

Rogers Twesigye Agency Field Regional Coordinator

Isiko Enock Data Assistant-ACTWatch Endline outlet survey

Giulia Boselli ACTWatch Research Central Attachment

Richard Sebaggala Research Manager-PACE

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8.5 Description of outlet types visited for this survey

Table 8.5.1: Description of outlet types visited for this survey, Uganda, 2011

Public Health Facilities Description

National / Regional referral hospital

These government-run facilities provide free prescription medicines, medical consultations and diagnoses. They are staffed by qualified health practitioners. Parish-level facilities provide preventive and curative health services to outpatients. In addition to these services, sub-country facilities provide some inpatient care such as maternity, and in theory have laboratory services available. County-level health centres provide the same services as HC III, but are also equipped for emergency surgery procedures, including blood transfusion. District hospitals offer services available in HC IV, in addition to assistance to community-based care programmes and in-service training for staff. Regional referral hospitals have provision for specialist inpatient and outpatient services such ENT, dentistry, radiology and intensive care wards. In addition to these facilities, the 2 national referral hospitals are involved in teaching medical students and conducting research (UMOH, 2005).

District hospital

Health centre IV: County

Health centre III: Sub-county

Health centre II: Parish

Community medicine distributors Description

Community medicine distributor Provide free non-prescription medicines, including ACTs under the Home-Based Management of Fever (HBMF) program.

Private not-for-profit facilities Description

NGO and FBOhospital

These facilities provide prescription medicine at a nominal price following medical consultation or diagnosis. They are usually staffed with qualified health practitioners, though some smaller clinics run by NGOs have less well-qualified staff.

Private for-profit facilities Description

Private clinic / domiciliary / midwife

These for-profit facilities are staffed by qualified health practitioners and generally include a consultation/examination room. They are licensed by the MOH, the Uganda Medical and Dental Practitioners Association, and/or the Nurses and Midwives Council. These outlets sell prescription-only, licensed, and OTC medicines at a commercial rate, and in accordance with the laws on licensed pharmacies and/or licensed drug sellers. An unknown proportion of these outlets are not registered by the MOH.

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Pharmacies Description

Pharmacy

Licensed and highly regulated by the National Drug Authority (NDA), pharmacies sell prescription medicines at a commercial rate. Their staff must include at least one qualified pharmacist. Many of the other staff members are also qualified health practitioners. They sell all classes of medicines, including class A (narcotics), which are restricted to prescription-only sale by a registered pharmacist or licensed pharmacy.

Drug Stores Description

Drug store

These outlets are smaller than pharmacies, and typically stock a smaller range of medicines. In theory they are licensed by the NDA, although an unknown proportion of these outlets are not registered. Drug stores sell class C (non-prescription but licensed) medicines and OTC medicines at a commercial rate. NDA-licensed drug stores are staffed by qualified health dispensers or practitioners (e.g. enrolled nurses, clinical officers).

General Retailers Description

Grocery stores / Dukas / General merchandise stores

Businesses/points of sale thatsell fast moving consumer goods (e.g. food, household products), in addition to some medicines (most often antipyretics). Drugs sold at these locations are not regulated.

Kiosks

Other This category includes a small number of traditional healers (3) and mobile shops/hawkers (5) that were enumerated.

Formal Pharmacy

Drug Store

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8.6 Sampling weights

Sampling weights are needed to analyze the survey data if PPS cluster sampling is applied.

Otherwise, bias may be introduced in the calculated statistics if the sub-districts/sub-counties are

very different in size. If a complete sampling frame is available for applying PPS sampling, with the

measure of size being the population, sampling weights are easy to calculate. Assuming that the

distribution of the outlets is proportional to the population within each sampling stratum and that a

booster sample is applied, then for all the outlets enumerated in the selected sub-district not

including the public health facilities and the part one pharmacies (there is a separate weighting

procedure for these weights shown later), sampling weight is the inverse of the selection probability

of the selected sub-district, calculated as:

M n

M =W

hih

hi

hi

where

hiW = the sampling weight for the ith selected sub-district/sub-county of stratum h,

M hi = the total number of population (or total number of households) in the stratum h

hn = the number of sub-districts/sub-countys selected in stratum h, and

M hi = the number of population (or number of households) in the ith selected sub-district/sub-county

of stratum h

If no explicit stratification is used in the sample selection, then h=1.

The sampling weight for all the public health facilities and registeredpharmacies, which are included

in the sample from the entire district including the ones in the selected sub-district, is calculated

similarly but with the above parameters replaced by district-level characteristics:

**

*

*

hjh

hj

hj Mn

M =W

where

*

hjW = the sampling weight for the jth selected district (a district is selected if one or more of its sub-

districts are selected in the sample) of stratum h, *

hj M = the total number of population (or total number of households) in stratum h *

hn = the number of districts selected in stratum h, and

*

hjM = the number of population (or number of households) in the jth selected district of stratum h

With the above-calculated district-level weights (posterior weights because there is no direct

selection of districts in the sampling procedure), a booster sample outlet should be counted only

once in the data analysis even if two or more sub-districts/sub-counties are selected from the same

district.

The above-calculated sampling weights are cluster-wide weights. This means that all the outlets interviewed in the same sub-district/sub-county share the same sampling weight, for both public health facilitiesand registered pharmacies and all other facilities.

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8.7 Assumptions for calculating Adult-Equivalent Treatment Doses (AETDs)

Introduction

Antimalarial medicines are manufactured using a variety of active pharmaceutical ingredients,

dosage forms, strengths and package sizes. To analyze prices and volumes across products with

different characteristics, they are standardized using the AETD. Indicators based on price and

volume data, namely market share and antimalarial prices, are presented in terms of AETDs.

Assumptions for calculating AETDs

One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat a 60

kilogram (kg) adult. For each antimalarial medicine category, the number of mg in one AETD is set to

what was recommended in the treatment guidelines for uncomplicated malaria in areas of low drug

resistance issued by the WHO. Where WHO treatment guidelines did not exist, AETDs were based on

peer reviewed research, or the product manufacturer’s recommended treatment course for a 60kg

adult. A list of AETDs by antimalarial category prepared by PSI for the ACTwatch project (Shewchuk,

O'Connell et al. 2011)was reviewed and updated by the IE in April 2010. Refer to Table 8.7.1 for the

list used for the endline report.

Additional assumptions

1) For combination therapies, which have two or more active antimalarial ingredient packaged

together (either co-formulated or co-blistered) the AETD is based on the total amount of one

of the active ingredients. For ACTs, the artemisinin derivative was used as the basis of the

AETD.

2) Co-blistered combinations are assumed to be in a 1:1 ratio of tablets, with the following

exceptions:

Amodiaquine + Sulfadoxine + Pyrimethamine manufactured under the brand name

Dualkin;

Artesunate + Amodiaquine manufactured under the brand names Amonate Junior

and Amonate Adult;

Artesunate + Mefloquine manufactured under the brand names Artequin 600/1500,

Artequn 300/750, A + M1, A + M2, A + M3, A + M4, A + M5, Malarine for Adults,

Malarine for Teenagers, and Malarine for Children;

Artesunate + Sulfadoxine + Pyrimethamine manufactured under the brand names

SulamonPlus 500, Malosunat, Amalar, Artescope, Farenax, Artidox, Artedar,

Asunatedenk 100, Asunatedenk 200, Co-arinate, Arte-Plus.

3) Sulfamethoxypyrazine-pyrimethamine is assumed to have the same full adult treatment

dose as Sulfadoxine-pyrimethamine.

4) Artequick lacking strength information is assumed to contain Artemisinin 62.4mg and

Piperaquine phosphate 375mg.

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Methods for calculating price and market share indicators Information collected on the medicine’s strength and unit size, as listed on the product packaging,

was used to calculate the total amount of each active ingredient found in the package. Next, the

number of AETDs in a unit was calculated.27 For monotherapies, the number of AETDs in the unit

was calculated by dividing the total amount of the active ingredient contained in the unit, by the

AETD (i.e. by the total number of mg required to treat a 60kg adult). For combination therapies, the

number of AETDS in the unit was calculated by dividing the total amount of the active ingredient

that was used as the basis for the AETD by the AETD.

Calculating price indicators

Pricing indicators (Indicators 2.1-2.4) are presented in terms of the cost to patients for one AETD. For

each antimalarial audited, the cost to patients for one unit was computed based on the retail selling

price reported by the respondent for that product. This was then divided by the number of AETDs in

the unit to get the cost to patients for one AETD. (An exception is the pediatric price indicator for

quality-assured ACT (Indicator 2.1) where AETDs were not used. Rather, the price for a 2 year-old

child was calculated including only pediatric formulations whose age (weight) range includes a 2

year-old (10kg) child.)

Calculating market share

For each antimalarial audited, the number of AETDs sold over the past 7 days was calculated by

multiplying the number of units sold as reported by the respondent by the number of AETDs in the

unit.

Market share was then calculated by summing this for all antimalarials audited belonging to a

particular category, which was then divided by the sum of AETDs of all antimalarials sold.

Market share was calculated by dividing the number of AETDs of a particular antimalarial category

sold by the total number of AETDs of all antimalarials sold. In cases where outlets stocked

antimalarials, but some or all sales volumes were missing, we did not impute for missing values.

27The unit depends on the antimalarial medicine’s dosage form. For antimalarials in tablet, suppository or granule dosage form, the unit is the package. For antimalarials in injectable dosage form, the unit is the ampoule. For antimalarials in syrup or suspension dosage form, the unit is the bottle.

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Table 8.7.1: AETD Calculation details by antimalarial type

Antimalarial Category

Dose used for calculating

1 AETD

(mg required to treat a

60kg adult)

Generic product used for AETD mg

dose value Notes Source

Amodiaquine 1800mg WHO Model Formulary, 2008

Amodiaquine-Sulfadoxine-

Pyrimethamine 1800mg Amodiaquine

Info available only for Amodiaquine

(not the combination) WHO Model Formulary, 2008

Atovaquone-Proguanil 3000mg Atovaquone WHO Guidelines for the treatment of

malaria 2nd edition, 2010

Chloroquine 1500mg Info available for P.vivax malaria WHO Guidelines for the treatment of


Chloroquine-Sulfadoxine-

Pyrimethamine 1500mg Chloroquine

Info available for P.vivax malaria

Info only available for Chloroquine (not

the combination)

WHO Guidelines for the treatment of


Chlorproguanil-Dapsone 360mg Chlorproguanil Manufacturer Guidelines

(LapDap – GSK)

Halofantrine 1500mg or 1398mg

1500mg is for halofantrine

hydrochloride, as the strength is

normally reported in this manner. The

total dose for halofantrine base is 1398

mg.

Manufacturer Guidelines

(Halfan – GSK)

Hydroxychloroquine

1500mg

One tablet of 200mg

hydroxychloroquine sulfate is

equivalent to 155mg base.


(Plaquenil – Sanofi Aventis)

Mefloquine 900mg

WHO Model Formulary, 2008

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Mefloquine-Sulfadoxine-

Pyrimethamine 900mg Mefloquine

Info only available for Mefloquine (not

the combination) WHO Model Formulary, 2008

Primaquine 45mg This dose is for the gametocytocidal

treatment of P. falciparum.

WHO Guidelines for the treatment of


Quinacrine 2100mg

Recommendations for malaria

treatment are very dated. This value is

the treatment regimen for giardiasis,

which has also been used in the

treatment for malaria.

The Gardner & Hill article specifies

dosing is usually 100 mg three times a

day over 5 to 7 days for adults.

Gardner, T. B. and Hill, D. R. 2001.

Treatment of Giardiasis. Clinical

Microbiology Reviews. 14(1): 114-128

http://cmr.asm.org/cgi/content/full/14

/1/114#T2

Quinimax 10500mg Manufacturer Guidelines

(Quinimax – Sanofi Aventis)

Quinine 12600mg or

10408mg

12600mg is for quinine sulfate, a salt,

as quinine strengths are normally

reported for salts.

The total dose for quinine base based

on 24mg/kg is 10408mg for a 60kg

adult.

Both dosages are based on treatment

lasting 7 days.


Quinine-Sulfadoxine-Pyrimethamine 12600mg or

10408mg Quinine

12600mg is for quinine sulfate, a salt,

as quinine strengths are normally

reported for salts.

The total dose for quinine base based

on 24mg/kg is 10408mg for a 60kg

adult.

Both dosages are based on treatment

lasting 7 days.

Info available only for Quinine (not the

combination)


Sulfadoxine-Pyrimethamine 1500mg Sulfadoxine WHO Model Formulary, 2008

http://cmr.asm.org/cgi/content/full/14/1/114#T2

http://cmr.asm.org/cgi/content/full/14/1/114#T2

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Arteether 1050mg 1050mg is for 7 days of treatment WHO Use of Antimalarials, 2001

Artemether 960mg WHO Use of Antimalarials, 2001

Artesunate 960mg WHO Use of Antimalarials, 2001

Dihydroartemisinin 480mg


(Cotecxin – Holleypharm; MALUether –

Euromedi)

Artemether-Lumefantrine 480mg Artemether WHO Guidelines for the treatment of


Artemisinin-Naphthoquine 2400mg Artemisinin

Manufacturer Guidelines for this

product are 1000mg Artemisinin in a

single dose. According to WHO

Guidelines for the treatment of malaria

2nd edition, a three day course for ACTs

is recommended.

This treatment dose used is based upon

the WHO Artemisinin-MQ

recommendation 20 mg/kg in a divided

loading dose on the first day, followed

by 10mg/kg once a day for two more

days, plus mefloquine (15-25 mg of

base per kg) as a single or split dose on

the second and/or third day.

WHO Use of Antimalarials, 2001

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Artemisinin-Piperaquine 576mg Artemisinin

Krudsood, S. et al. 2007. Dose ranging

studies of new artemisinin-piperaquine

fixed combinations compared to

standard regimens of artemisinin

combination therapies for acute

uncomplicated falciparum malaria.The

Southeast Asian Journal of Tropical

Medicine and Public Health. 38(6):

971-8.

http://www.ncbi.nlm.nih.gov/pubme

d/18613536

Artemisinin-Piperaquine-Primaquine 576mg Artemisinin

Tangpukdee, N. et al. 2008. Efficacy of

Artequick versus artesunate-

mefloquine in the treatment of acute

uncomplicated falciparum malaria in

Thailand. The Southeast Asian Journal

of Tropical Medicine and Public Health.

39(1): 1-8

http://imsear.hellis.org/handle/123456

789/33676

Artesunate-Amodiaquine 600mg Artesunate WHO Guidelines for the treatment of


Artesunate-Halofantrine 600mg Artesunate

Relatively uncommon combination;

dosing information is difficult to find

and the value here is based on the

Artesunate-Amodiaquine, Artesunate-

SP, and Artesunate-Mefloquine values.

-

http://www.ncbi.nlm.nih.gov/pubmed/18613536

http://www.ncbi.nlm.nih.gov/pubmed/18613536

http://imsear.hellis.org/handle/123456789/33676

http://imsear.hellis.org/handle/123456789/33676

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Artesunate-Lumefantrine 600mg Artesunate






-

Artesunate-Mefloquine 600mg Artesunate WHO Guidelines for the treatment of


Artesunate-Piperaquine 600mg Artesunate






-

Artesunate-Pyronaridine 600mg Artesunate






-

Artesunate-Sulfadoxine-Pyrimethamine 600mg Artesunate WHO Guidelines for the treatment of


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Dihydroartemisinin-Amodiaquine 360mg Dihydroartemisinin




most common Dihydroartemisinin-

combinations

(Dihydroartemisinin+Piperaquine,

Dihydroartemisinin+SP and

Dihydroarteminn+Mefloquine) with

sources listed in the entries for those

products.

-

Dihydroartemisinin-Halofantrine 360mg Dihydroartemisinin





combinations





products.

-

Dihydroartemisinin-Lumefantrine 360mg Dihydroartemisinin





combinations





products.

-

Dihydroartemsinin-Mefloquine 360mg Dihydroartemisinin Manufacturer Guidelines

(Meflodisin – Adams Pharma)

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Dihydroartemisinin-Piperaquine 360mg Dihydroartemisinin WHO Guidelines for the treatment of


Dihydroartemisinin-Piperaquine-

Trimethoprim 256mg Dihydroartemisinin


(Artecxin – Medicare Pharma; Artecom

– Ctonghe)

Dihydroartemisinin-Pyronaridine 360mg Dihydroartemisinin





combinations





products.

-

Dihydroartemisinin-Sulfadoxine-

Pyrimethamine 360mg Dihydroartemisinin


(Dalasin – Adams Pharma)

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8.8 Nationally Registered ACTs

Table 8.8.1: Nationally Registered ACTs

DOSAGE FORM PACK SIZES LICENCE HOLDER COUNTRY OF MANUFACTURE LTR

TABLETS 1*4 BLISTER KUNMING PHARMACEUTICAL CORPORATION

CHINA SINO AFRICA MEDICINES LTD

TABLET

3 * 8 IN STRIP ,1*1*18 BLISTER, [ MOH 6'S,12,'S,18'S,24'S,30 *6 , 30*12 ,30*18,30*24, BLISTER]

CIPLA LTD INDIA QUALITY CHEMICALS LTD

TABLET 1*6 BLISTER CACHETPHARMACE UTICALS PVT LTD INDIA VRUSHIK INVESTMENTS (U) LTD

TABLETS 1*10*2*6 BLISTER IPCA LABORATORIES LTD INDIA ABACUS PHARMA (A) LTD

TABLETS 1*10*1*6 BLISTER IPCA LABORATORIES LTD INDIA ABACUS PHARMA (A) LTD

TABLETS

1 * 24, 1*3* 8, 1 * 36 * 6 BLISTERS, 1*30 (6'S,12'S, 18'S, 24'S), ACTM LOGO PACKS 1*30*6, 1*30*12, 1*30*18, 1*30*24 BLISTER

NOVARTIS PHARMA AG USA / SWITZERLAND SURGIPHARM (U) LTD

ORAL SUSPENSION 1*120ML BOTTLE DAFRA PHARMA NV/SA NETHERLANDS + BELGIUM LABOREX (U) LTD

POWDER FOR ORAL SUSPENSION 1*30ML, 1*60ML HDPE AGOG PHARMA LTD INDIA GITTOES PHARMACEUTICALS LTD

TABLET (FILM COATED) 1*3*8 BLISTERS CACHET PHARMACEUTICALS PVT LTD INDIA VRUSHIK INVESTMENTS UGNADA

TABLET (UNCOATED) 1X2X6 IN BLISTER AJANTA PHARMA LTD INDIA ABACUS PHARMA

TABLET (UNCOATED) 1X3X8 BLISTERS, 1*6, 2*6, 3*4, 4*6

AGOG PHARMA LTD INDIA GITTOES PHARMACEUTICALS LTD

TABLET (UNCOATED) 1*36*6, 1*30*6 BLISTERS

NOVARTIS PHARMA AG USA

SURGIPHARM (U) LTD

TABLET (UNCOATED) 1*3*8 BLISTERS MEDREICH PLC INDIA SURGIPHARM (U) LTD

TABLETS 1*1*24, 1*3*8 MACLEODS PHARMACEUTICALS LTD INDIA NORVIK ENTERPRISES LTD

TABLETS

1*1*24, 1*1*6, 1*1*12, 1*1*18, 1*30*6, 1*30*12, 1*30*18 & 1*30*24 BLISTER PACKS

CIPLA LTD INDIA QUALITY CHEMICALS LTD

TABLET

1*10*1*6, 1*10*2*6, 1*10*3*6, 1*10*4*6, 1*30*1*6, 1*30*2*6, 1*30*3*6, 1*30*4*6

IPCA LABORATORIES LTD

INDIA

ABACUS PHARMA (A) LTD

TABLET 1*6 BLISTER AJANTA PHARMA LIMITED INDIA ABACUS PHARMA

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TABLET 1*30*24 BLISTER QUALITY CHEMICALS INDUSTRIES LTD UGANDA QUALITY CHEMICALS INDUSTRIES LTD

ORAL SUSPENSION 1*60 ML BLISS GVS PHARMA INDIA DELMAW ENTERPRISES

POWDER FOR ORAL SUSPENSION 1*1*30 ML GLASS BOTTLE & 1*1*60ML PET BOTTLE

AGOG PHARMA LTD INDIA GITTOES P'CALS

SUPPOSITORY 1 * 6 STRIP BLISS GVS PHARMA LTD. INDIA DELMAW ENTERPRISES

TABLET 1*6 BLISTERS BLISS GVS PHARMA INDIA DELMAW ENTERPRISES

TABLET 1*4*6 BLISTER ASTRA LIFE CARE INDIA ASTRA PHARMA

TABLET 1*3*8 BLISTER RENE INDUSTRIES LTD UGANDA RENE INDUSTRIES LTD

TABLET

1*3*8 , 1*30*24,1*30*18,1*30* 12, 1*30*6 & UG PACKS 1*30*24,1*30*18,1*30* 12, 1*30*6 IN BLISTER, ACTM LOGO PACKS 1*30*6, 1*30*12, 1*30*18, 1*30*24 BLISTER

AJANTA PHARMA LTD INDIA ABACUS PHARMA

TABLET 1X10X(3X8) GVS LABS INDIA DELMAW ENTERPRISES LTD

TABLET 1X10X(2X6) GVS LABS INDIA DELMAW ENTERPRISES LTD

TABLET 1*(6+6) IN BLISTER CIPLA LTD INDIA QUALITY CHEMICALS LTD

TABLET 1*1*3*20 BLISTERS GUILIN PHARMACEUTICALS LTD CHINA STAR PHARMACEUTICALS LTD

TABLETS 1*20*3 , 1*20*6 BLISTER

GUILIN PHARMACEUTICAL CO. LTD CHINA

STAR PHARMACEUTICALS LTD

TABLETS 1*1*3*20 BLISTERS GUILIN PHARMACEUTICAL CO LTD CHINA STAR PHARMACEUTICALS LTD

TABLETS 1*1*3 (CHILD) 1*1*6 (ADULT) BLISTERS AJANTA PHARMA LIMITED INDIA ABACUS PHARMA

TABLET (UNCOATED + FILM COATED)

1*(12+12), 1*(6+6), 1*(3+3) IN BLISTER (ALU/PVC)

IDA INDIA JOINT MEDICAL STORES

TABLET 1*(3+3), 1*(6+6), 1*(12+12) BLISTER

GUILIN PHARMACEUTICAL CO CHINA

STAR PHARMACEUTICALS LTD

TABLETS 1*(12+12) IN BLISTERS CIPLA LTD INDIA QUALITY CHEMICALS LTD

TABLETS 1*(3+3) IN BLISTERS CIPLA LTD INDIA QUALITY CHEMICALS LTD

Tablets 1*(3+3) Tablets in Blisters

MEPHA LTD SWITZERLAND GOODMAN INTERNATIONAL LTD

TABLETS 1*(3+3) IN BLISTERS MEPHA LTD SWITZERLAND GOODMAN INTERNATIONAL LTD

TABLET 1*25*3 BLISTER SANOFI AVENTIS MOROCCO LABOREX (U) LTD


TABLET 1*25*3, 1*25*6 BLISTER

SANOFI AVENTIS MOROCCO LABOREX (U) LTD


TABLET 1*25*3, 1*25*6 SANOFI AVENTIS MOROCCO LABOREX (U) LTD

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BLISTER

TABLET 1*25*3 BLISTER SANOFI AVENTIS MOROCCO SURGIPHARM (U) LTD

ORAL PELLETS 1X1X3 IN STICK PACK SACHETS MEPHA LTD SWITZERLAND GOODMAN INTERNATIONAL

TABLET 1*1*9 BLISTER SHANGHAI PHARMA INDUSTRIAL CO LTD

INDIA ABACUS PHARMA AFRICA LTD

TABLET (FILM COATED) 1*1*6 BLISTER BEIJING HOLLEY- COTEC PHARMACEUTICAL CO.LTD

CHINA SUPER PHARMACEUTICALS (U) LTD

TABLET (FILM COATED) 1*1*8 BLISTER AJANTA PHARMA LTD INDIA ABACUS PHARMA

ORAL SUSPENSION 1*80ML BLISS GVS PHARMA LTD INDIA DELMAW ENTERPRISES

TABLET 1 *10 *9 BLISTER GVS LABS INDIA DELMAW ENTERPRISES

TABLET 1*1*9, 1 * 4 , 1*30*9 BLISTER

BEIJING HOLLEY COTEC PHARMACEUTICALS CO. LTD

CHINA SUPER PHARMACEUTICALS LTD

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8.9 Child QAACTs

The following products are considered as Child QAACTs for the purpose of ACTwatch:

Artemether Lumefantrine ACT with a leaf 4 months to <3 years (Novartis)

ACT with a leaf 3 years to <7 years (Novartis)

Artemef 4 months up to 3 years (Cipla)

Artemef 3 years up to 7 years (Cipla)

Artefan 20/120 5-14kg (Ajanta)

Artefan 20/120 15-24kg (Ajanta)

Artemether + Lumefantrine <3 years (Ipca Laboratories)

Artemether + Lumefantrine 3-8 years (Ipca Laboratories)

Coartem 20/120 5-15kg (Novartis)

Coartem 20/120 15-25kg (Novartis)

Coartem Dispersible 5-15kg (Novartis)

Coartem Dispersible 15-25kg (Novartis)

Coartem E Fixe 5-15kg (Novartis)

Coartem E Fixe 15-25kg (Novartis)

Coartem E Fixe Dispersible 5-15kg (Novartis)

Coartem E Fixe Dispersible 15-25kg (Novartis)

Co-Falcinum 5-14kg (Cipla)

Co-Falcinum 15-24kg (Cipla)

Combisunate 20/120 5-14kg (Ajanta)

Combisunate 20/120 15-24kg (Ajanta)

Dawa Mseto Ya Malaria Alu (6 and 12 tablet packs, Novartis)

La Coartem (6 and 12 tablet packs, Novartis)

Lumartem 5kg to <15kg (Cipla)

Lumartem 15kg to <25kg (Cipla)

Malarpack Coartem (6 and 12 tablet packs, Novartis)

Primo (6 and 12 tablet packs, Novartis)

Tibamal (6 and 12 tablet packs, Novartis)

Artesunate Amodiaquine

ACTipal 25mg/67.5mg (Sanofi Aventis)

ACTipal 50mg/135mg (Sanofi Aventis)

ACTipal 50mg/153mg (Strides Arco Labs)

Arsuamoon 1-6 years (Guilin Pharmaceutical)

Artesunate + Amodiaquine Child 1-6 years (Ipca Laboratories)

Coarsucam Infant 2-11 months (Sanofi Aventis)

Coarsucam Toddler 1-5 years (Sanofi Aventis)

Falcimon Kit Young Children up to 6 years (Cipla)

Larimal Child 1-6 years (Ipca Laboratories)

Malariakit (Ipca Laboratories)

Serenadose Enfants 50mg/153mg 1-5 years (Cipla)

Winthrop Infant 2-11 months (Sanofi Aventis)

Winthrop Toddler 1-5 years (Sanofi Aventis)

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8.10 RDT manufacturers submitting to WHO for product testing

The following manufacturers have submitted at least one RDT for testing during rounds 1-3 of the

WHO Malaria RDT Product Testing cycle (2008-2011).

Access bio, Inc.

ACON Laboratories, Inc.

Amgenix International, Inc.

AZOG, Inc.

Bhat Bio-Tech India (P) Ltd.

Biosynex

Blue Cross Bio-Medical (Beijing) Co., Ltd.

CTK Biotech, Inc.

Diagnostics Automation/Cortez Diagnostics, Inc.

DiaMed AG

Guangzhou Wonfo Biotech Co., Ltd

HBI Co., Ltd.

Human GmbH

ICT Diagnostics

IND Diagnostic Inc.

Innovatek Medical Inc.

InTec Products, Inc.

Inverness Medical Innovations, Inc.

J. Mitra & Co. Pvt. Ltd.

Orchid Biomedical Systems

Premier Medical Corporation Ltd.

Span Diagnostics Ltd

SSA Diagnostics & Biotech Systems

Standard Diagnostics, Inc.(now Alere Healthcare (Pty) Ltd)

Unimed International Inc.

Vision Biotech (Pty) Ltd.(now Alere Healthcare (Pty) Ltd)

Zephyr Biomedicals

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Evidence for Malaria Medicines Policy

actwatch_uganda_os_ 2011.pdf

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