The private commercial sector distribution chain for antimalarial drugs in Nigeria - Findings from a rapid survey

In November of 2008, the Global Fund to Fight HIV/AIDS, TB and Malaria announced that it would administer the first phase of an ambitious scheme to increase the availability of effective treatment for malaria, the Affordable Medicines Facility-malaria (AMFm). Artemisinin-based combination therapies (ACTs) are highly effective, but remain prohibitively expensive for those who are most vulnerable to malaria infection.1 The AMFm aims to significantly reduce the price of ACTs by offering a co-payment for ACTs purchased by eligible buyers at the top of the supply chain. Recognizing that the public and private sectors are important sources of antimalarials in most endemic countries, both public and private sector buyers will be entitled to purchase subsidised ACTs. The involvement of the private sector is an innovative element of AMFm, as many countries already have experience distributing ACTs in the public sector. To ensure that subsidised ACTs reach patients at the lowest possible cost, it is necessary to gain a better understanding of the private sector supply chains for antimalarials in each country participating in the AMFm. The objective of the rapid supply chain survey was therefore to assist Nigeria, which is one of the 11 countries invited to apply to the first phase of the AMFm, in the development of an effective implementation plan by providing an understanding of the current supply chain for antimalarials, and the way in which subsidised ACTs are likely to travel through this chain to reach patients. This report presents the findings of a series of semi-structured interviews conducted with government officials and private suppliers of malaria treatment operating at the various levels of the chain. Supplemental sections include brief discussions on the Nigerian drug monitoring system, on the proposed tax exemption for subsidised ACTs under the AMFm, and also on the private sector capacity to repackage and re-label imported subsidised ACTs. In addition, data from the December 2008 report on the first round of the ACTwatch Outlet Survey in Nigeria were used to estimate key variables, such as antimalarial market shares

ACTwatch 2009 Supply Chain Survey Results, Zambia

In Zambia, as in many low-income countries, private commercial providers play an important role in the treatment of malaria. To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailer behaviour and identify the factors that influence their stocking and pricing decisions. Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access. However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and the Democratic Republic of Congo). Other elements of ACTwatch include Retail Outlet and Household Surveys led by Population Services International (PSI). This report presents the results of a cross-sectional survey of antimalarial drug wholesalers conducted in Zambia between February and May 2009

ACTwatch 2009 Supply Chain Survey Results, Nigeria

In Nigeria, as in many low-income countries, private commercial providers play an important role in the treatment of malaria. To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailer behaviour and identify the factors that influence their stocking and pricing decisions. Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access. However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Nigeria, Cambodia, Benin, the Democratic Republic of Congo, Madagascar, Uganda and Zambia). Other elements of ACTwatch include Retail Outlet and Household Surveys led by Population Services International (PSI). This report presents the results of a cross-sectional survey of antimalarial drug wholesalers conducted in Nigeria between July and September 2009

The private commercial sector distribution chain for antimalarial drugs in Madagascar: Findings from a rapid assessment

ACTwatch is a research programme funded by the Bill and Melinda Gates Foundation that aims to provide and promote evidence and recommendations for policy makers on methods to increase availability and decrease the consumer price of quality‐assured Artemisinin‐based Combination Therapies (ACTs) throughout the private sector. Research has been carried out in seven countries (Cambodia, Uganda, Zambia, Nigeria, Benin, Madagascar and D.R. Congo) and encompasses Household Surveys, Outlet Surveys, as well as Supply Chain Surveys and Assessments.   As is the case in many developing countries, the private sector in Madagascar plays a pivotal role in facilitating access to malaria treatment. The Household and Outlet surveys conducted in Madagascar suggest that the general population tends to seek treatment through the private sector, and that private sector outlets make up a substantial portion of outlets that carry antimalarials.   In order to design future interventions that will improve access to diagnostic and effective treatment options, it is important to understand the structure of the private sector distribution chain for antimalarials, as well as the incentives, restrictions and challenges that actors within the market face. Despite the important role of the private sector in the supply of antimalarials, there is limited rigorous evidence on the subject. This report contributes to addressing this gap for Madagascar

A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Zambia, 2009

Alongside the public and non‐profit sectors, private commercial providers are also sources of malaria treatment in Zambia. To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailers' behaviour and identify the factors that influence their stocking and pricing decisions. Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers, and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access. However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Zambia, Cambodia, Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria and Uganda). This report presents the results from qualitative interviews with antimalarial drug wholesalers, retailers and other key stakeholders conducted in Zambia between February and May 2009. A summary of the key findings is given below. To provide a complete description of the supply chain for antimalarial drugs, this report should be read in conjunction with the report on the results of the structured supply chain survey also conducted as part of this study, available at www.actwatch.info

A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Nigeria, 2009

In Cambodia, as in many low‐income countries, private commercial providers play an important role in the treatment of malaria.  To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailers' behaviour and identify the factors that influence their stocking and pricing decisions.  Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers, and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access.  However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Cambodia, Benin, the Democratic Republic of Congo, Madagascar, Nigeria, Uganda and Zambia).   This report presents the results from qualitative interviews with antimalarial drug wholesalers, retailers and other key stakeholders conducted in Cambodia between April and November 2009. A summary of the key findings is given below.  To provide a complete description of the supply chain for antimalarial drugs, this report should be read in conjunction with the report on the results of the structured supply chain survey also conducted as part of this study [1], available at www.actwatch.info. • As the bulk of antimalarial treatment is manufactured outside of the country, pharmaceutical importers, including PSI/Cambodia, constitute a critical component of Cambodia’s private sector distribution chain for antimalarials by ensuring a regular national supply of antimalarials and also by facilitating their distribution throughout the country. Non‐importing wholesalers also play a role in distributing antimalarials, particularly to more remote areas and to retail outlet types not targeted by importers, including more informal types such as drug shops, grocery stores, etc.   • The degree of competition varied by level in the distribution chain: at import level, competition was restrained by sole distributor and like agreements between foreign manufacturers and domestic importers, and also by a number of barriers to entry, including the costs of importing, the limited size of the overall market and lack of access to capital. Competition was less restrained at lower levels of the chain where the key barrier in theory to market entry was the difficulty of securing a license to operate, though many believed it was a barrier easily circumvented. • Commodities for malaria treatment, including ACTs and RDTs, were perceived to be generally available in the private sector distribution chain; however, availability of ACTs and RDTs at lower levels of the chain was poorer. At both wholesale and retail levels, stocking decisions were driven by perceived drug quality, which was in turn affected by factors such as media promotion and social marketing targeting wholesalers, retailers and consumers, as in the case of Malarine (the ACT brand socially marketed by PSI/Cambodia). However, supplier stock outs of Malarine combined with its perceived side effects led some providers to continue stocking alternatives treatments, including artemisinin monotherapies, even though they were aware that sales of such products were prohibited.   • Most wholesalers and retailers purchased new stock from either one or two suppliers. When choosing a supplier, factors considered were supplier selling prices, availability of delivery services, and perceived knowledge/expertise of the supplier in the treatment of malaria. Offering credit facilities was also cited as a strategy to attract custom, but access to supplier credit was perceived to be restricted to customers known to suppliers. 2 • Retailers and wholesalers had similar price setting behaviours. Providers reported setting their price on the basis of antimalarial purchase price and their price mark‐ups on the basis of transport costs. At the top of the chain, importers considered a broader range of costs when setting prices, including overhead and promotion costs among others. In addition, most providers admitted seeking profits, although many argued that their pricing decision was constrained by the price set by other shops. Second and third‐ degree price discrimination strategies were commonly reported by both retailers and wholesalers who varied prices on the basis of volume purchased and customer characteristics. • Retailers employed a wide range of tactics to gain competitive advantage over other businesses, attract consumers and generate demand. A retailer’s reputation for delivering high quality treatment, reflected in their length of operation in a market, positive consumer experiences, and through the provision of ‘cocktail’ therapies, was viewed as crucial to achieving this; however, providing added value services, such as of blood diagnostic testing, was not. Nevertheless, RDTs were available from many outlets and were perceived to be easy to use, although less precise than microscopy for confirming malaria infection

A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Benin, 2009

In Benin, as in many low‐income countries, private commercial providers play an important role in the treatment of malaria.  To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailers' behaviour and identify the factors that influence their stocking and pricing decisions.  Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers, and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access.  However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Benin, Cambodia, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia). This report presents the results from qualitative interviews with antimalarial drug wholesalers, retailers and other key stakeholders conducted in Benin in June 2009. To provide a complete description of the supply chain for antimalarial drugs, this report should be read in conjunction with the report on the results of the structured supply chain survey also conducted as part of this study, available at www.actwatch.info

A Qualitative Assessment of the Private Sector Antimalarial Distribution Chain in Benin, 2009

In Benin, as in many low‐income countries, private commercial providers play an important role in the treatment of malaria.  To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailers' behaviour and identify the factors that influence their stocking and pricing decisions.  Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers, and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access.  However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Benin, Cambodia, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia). This report presents the results from qualitative interviews with antimalarial drug wholesalers, retailers and other key stakeholders conducted in Benin in June 2009. To provide a complete description of the supply chain for antimalarial drugs, this report should be read in conjunction with the report on the results of the structured supply chain survey also conducted as part of this study, available at www.actwatch.info

ACTwatch 2009 Supply Chain Survey Results, Benin

In Benin, as in many low‐income countries, private commercial providers play an important role in the treatment of malaria.  To design effective interventions for improved access to accurate diagnosis and effective malaria treatment, there is a need to understand retailer behaviour and identify the factors that influence their stocking and pricing decisions.  Private commercial retailers are the last link in a chain of manufacturers, importers and wholesalers and their supply sources are likely to have an important influence on the price and quality of malaria treatment that consumers can access.  However, there is limited rigorous evidence on the structure and operation of the distribution chain for antimalarial drugs that serves the retail sector. The ACTwatch Supply Chain Study, one of the ACTwatch project components, aims to address this gap by conducting quantitative and qualitative studies on distribution chains for antimalarials in the ACTwatch countries (Benin, Cambodia, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia).  Other elements of ACTwatch include Retail Outlet and Household Surveys led by Population Services International (PSI).  This report presents the results of a cross‐ sectional survey of antimalarial drug wholesalers conducted in Benin in June 2009