ACTwatch Study Reference Document Republic of …... Page 1 Released 23 February 2016 Suggested citation ACTwatch Group and Population Services Kenya (PSK). (2015). ACTwatch Study

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

Evidence for Malaria Medicines Policy

ACTwatch Study Reference Document

Republic of Kenya

2014

www.ACTwatch.info Page 1

Released 23 February 2016 Suggested citation ACTwatch Group and Population Services Kenya (PSK). (2015). ACTwatch Study Reference Document: Republic of Kenya Outlet Survey 2014. Washington DC: PSI. Contact

Dr. Megan Littrell ACTwatch Principal Investigator PSI | 1120 19th St NW Suit 600 Washington DC 20036 [email protected]

Country contact Julius Ngigi Population Services International, ACTwatch Whitefield place, School Lane, Westlands P.O. Box 14355-00800, Nairobi

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

ACTwatch Team Andrew Andrada Erick Auko Dr. Hana Bilak Dr. Desmond Chavasse

Anne Wanyingi James Ombasa

Regional Coordinators John Maingi

Philemon Rono Lydia Wang’aya

Questionnaire Traffic control Gerald Musundi

Kevin Duff Gloria Kigo Tarryn Haslam Catharine Hurley Dr. Megan Littrell Julius Ngigi Ricki Orford Stephen Poyer Dr. Justin Rahariniaina

Rodgers Kegode Dickens Nyamogo Mary Omondi

Quality Control Team Anthony Njeru Eunice Mokua Cidee Khaseke Edwin Ochieng Oluko

Pamela Kuya Coding Clerks Brenda Yonga Martha Abucherry Elizabeth Lango Elvis Matthews Joseph Ogeto Teresa Mumbi

Dr. Andria Rusk Julianna Smith

Helen Kimanthi Shobby Ekasiba

Ann Nyawira Kiai Samwel Kimani

Raymond Sudoi Hamida Omar David Owino

Prudencial Bosibori Edwin Otieno

Kenya Malaria Control Unit Dr. Rebecca Kiptui

Joan Chebet Sophie June Alfred Luchivia

Gerald Njoroge

Enumerators

Dr. Andrew Nyandigisi

Kenya Pharmacy and Poisons Board Dr. Edward Abwao

Nancy Makio Salome Omondi Purity Kimuru

Supervisors Sicily Kamuri Tom Ruto Amina Day

Maureen Okumu Bevarlyne Kadenyi Linda Kwamboka Joshua Mwasia Bendetta Kathina Moses Angela Williams Munyan Ian Nickson Leiyan

PS Kenya Dr. Anne Musuva

Janet Obare Victor Nduku Rosemary Okoth

Monicah Ireri Laban Kibet Linda Norah

Data Collection Management Ipsos: Samuel Muthoka Oscar Mutinda Hulda Kibera

Stephen Ouma Marlon Githua J.M. Makori Julie Sumba Jackline Nduta

Harmony Momanyi Mary Lagat Betty Mumo Joram Mburu Paul Mboya

http://www.actwatch.info/

mailto:[email protected]


Enumerators Innocent Omondi Brian Masika Brian Muchai Ben Nduati Christine Rwanda Muthoni Martin Mugendi Anne Mugo Wendy Macharia Robert Muriithi Edith Mukhongo Vincent Depaul Sylvia Natasha Michael Omondi Monicah Naisianoi Faith Vutagua Philemon Rono Jude Semut Kevin Onchama Mercy Ramogo Naomi Nyarangi Elijah Rogers Nicholas Muriuki Caroline Nelima Florence Otieno Richard Njoroge Osborn Nyambare Edwin Nyarango Bernard Omondi W. Robert Kamau Agnes Karimi James Mutua Caroline Wangare Bridie Mwema Julius Kitela Stephen Oguna Diana Omolo Roselida Obiero James Nzioki Malachi Ayega Caroline Muli Samuel Rachuonyo Abraham Kisundi Daisy Nyambura Irene Mutisya Catherine Onchuati Collins Ouko Wambui Gitau Jacinta Kyusa Fredrick Aika Armstrong Andaje Caleb Bosire Sophia Ngaire James Kitheka Jane Wanza Teresa Moraa Francis Nyakundi William Chepkwony Jacinter Mbaika



Table of Contents

List of Tables ...................................................................................................................................................... 4

List of Figures ..................................................................................................................................................... 6

Definitions .......................................................................................................................................................... 9

Introduction ..................................................................................................................................................... 11

Summary of Methods and Data Collection ...................................................................................................... 12

Summary of Key Findings ................................................................................................................................. 14

Results Section A: Core Indicators ................................................................................................................... 38

Results Section B: Core Indicators across Urban/Rural Location .................................................................... 54

Results Section C: Core Indicators by Type of Public Health Facility ............................................................... 79

Results Section D: Core Indicators across Survey Round: 2010, 2011, 2014 .................................................. 83

Annex 1: ACTwatch Background .................................................................................................................... 100

Annex 2: Kenya Background .......................................................................................................................... 103

Annex 3: Outlet Survey Methods ................................................................................................................... 107

Annex 4: Sampled Locations .......................................................................................................................... 112

Annex 5: Detailed Sample Description .......................................................................................................... 117

Annex 6: Questionnaire ................................................................................................................................. 119

Annex 7: Antimalarial Reference ................................................................................................................... 137

Annex 8: RDT Reference ................................................................................................................................ 141

Annex 9. Sampling Weights ........................................................................................................................... 143

Annex 10: Indicator Definitions ..................................................................................................................... 145

Annex 11. Adult Equivalent Treatment Dose (AETD) .................................................................................... 153

Annex 12: Antimalarial Volumes.................................................................................................................... 155



List of Tables

Results Core Indicators

Table S1: Key results, by outlet type - 2014 .................................................................................................................... 14

Table A1: Availability of antimalarials, among all screened outlets, by outlet type ....................................................... 38

Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type ..................... 40

Table A3: Antimalarial market composition ................................................................................................................... 42

Table A4a: Price of tablet formulation antimalarials, by outlet type ............................................................................. 43

Table A4b: Price of pre-packaged antimalarials, by outlet type ..................................................................................... 44

Table A5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type .......................... 45

Table A6: Malaria blood testing market composition .................................................................................................... 46

Table A7: Price of malaria blood testing, by outlet type ................................................................................................ 47

Table A8: Antimalarial market share .............................................................................................................................. 48

Table A9: Antimalarial market share across outlet type ................................................................................................ 49

Table A10: Malaria blood testing market share ............................................................................................................. 50

Table A11: Malaria blood testing market share, across outlet type ............................................................................... 51

Table A12: Provider case management knowledge and practices, by outlet type ......................................................... 52

Table A13: Provider antimalarial treatment knowledge and practices, by outlet type ................................................. 53

Results Across Urban/Rural Location

Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural location ......... 54

Table B2: Availability of antimalarials, among all outlets stocking at least one antimalarial, by outlet type, across urban/rural location ............................................................................................................................................... 59

Table B3: Antimalarial market composition, across urban/rural location ...................................................................... 64

Table B4a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location ................................ 65

Table B4b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location ....................................... 67

Table B5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location ............................................................................................................................................... 68

Table B7: Price of malaria blood testing, by outlet type, across urban/rural location ................................................... 69

Table B8a: Antimalarial market share, urban ................................................................................................................. 71

Table B8b: Antimalarial market share, rural ................................................................................................................... 72

Table B9a: Antimalarial market share across outlets, urban .......................................................................................... 73

Table B9b: Antimalarial market share across outlets, rural............................................................................................ 74

Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location ........... 75

Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location .... 77

Results by Type of Public Health Facility

Table C1: Availability of antimalarials, among screened outlets, by type of public health facility ................................ 79

Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by type of public health facility ..................................................................................................................................................................... 80

Table C5: Availability of malaria blood testing among antimalarial-stocking outlets*, by type of public health facility……………………………………………………………………………………………………………………………………………………………….81

Table C12: Provider antimalarial treatment knowledge and practices, by type of public health facility .............. 82



Results Across Survey Round: 2010, 2011, 2014

Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round .................... 83

Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round ...................................................................................................................................................................... 87

Table D3: Antimalarial market composition, across survey round ................................................................................. 90

Table D4: Price of tablet formulation antimalarials in 2010 USD, by outlet type, across survey round ........................ 91

Table D5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round ...................................................................................................................................................................... 94

Table D7: Price of malaria blood testing in 2010 USD, by outlet type, across survey round ......................................... 95

Table D8: Antimalarial market share, across survey round ............................................................................................ 96

Table D9: Antimalarial market share, across outlet type, across survey round ............................................................. 97

Table D12: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round ............... 98

Annexes

Table X1. Sampled locations ......................................................................................................................................... 112

Table X2: Detailed sample description ......................................................................................................................... 117

Table X3: Number of antimalarials audited .................................................................................................................. 137

Table X4: Quality-Assured (QA ACT) and Non-Quality Assured ACTs ........................................................................... 137

Table X5: Nationally Registered ACTs ........................................................................................................................... 139

Table X6: Severe Malaria Treatment ............................................................................................................................ 140

Table X7: Number of RDTs audited ............................................................................................................................... 141

Table X8: RDT Brand Names and Manufacturers* ....................................................................................................... 142

Table X9: Adult Equivalent Treatment Dose Definitions .............................................................................................. 154

Table X10: Antimalarial volumes, by outlet type .......................................................................................................... 155



List of Figures

Figure 1. Survey flow diagram, Kenya, 2014 ................................................................................................................... 13

Figure 2. Market composition: outlet type distribution, 2010-2014 .............................................................................. 16

Figure 3. Market composition: outlet type distribution, 2014, urban/rural .................................................................. 16

Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2010-2014 .............. 17

Figure 5. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2014, urban/rural... 17

Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2010-2014 ............ 18

Figure 7. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2014, urban/rural 18

Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2010-2014 .............................................................................................................................................................. 19

Figure 9. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2014, urban/rural ................................................................................................................................................... 19

Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2010-2014 ............................................................................................................ 20

Figure 11. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ in stock on the day of the survey, 2014, urban/rural .......................................................................................................... 20

Figure 12. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2010-2014 .............................................................................................................................................................. 21

Figure 13. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2014, urban/rural ................................................................................................................................................... 21

Figure 14. Types of quality-assured ACT and non-quality-assured ACT found among public and private ..................... 22

sector outlets, 2014 ........................................................................................................................................................ 22

Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2010-2014 .............................................................................................................................................................. 23

Figure 16. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2014, urban/rural ................................................................................................................................................... 23

Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2010-2014 ............ 24

Figure 18. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2014, urban/rural . 24

Figure 19. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, by regions targeted or not targeted for IPTp, 2014 ................................................................................................................................ 25

Figure 20. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2010-2014 .................................................................................................................................................. 26

Figure 21. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2014, urban/rural ....................................................................................................................................... 26

Figure 22. Antimalarial market share, 2010-2014 .......................................................................................................... 27

Figure 23. Antimalarial market share within sector, 2010-2014 .................................................................................... 27

Figure 24. Antimalarial market share, 2014.................................................................................................................... 28

Figure 25. Antimalarial market share, 2014, urban/rural ............................................................................................... 28

Figure 26. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2010-2014 .................... 29

Figure 27. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2014, urban/rural ......... 29

Figure 28. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2010-2014 ....................... 30

Figure 29. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2014, urban/rural............ 30

Figure 30. Percentage of antimalarial-stocking outlets with malaria RDTs, 2010-2014 ................................................. 31

Figure 31. Percentage of antimalarial-stocking outlets with malaria RDTs, 2014, urban/rural ..................................... 31



Figure 32. Malaria blood testing market share, 2014 ..................................................................................................... 32

Figure 33. Malaria RDT market share by manufacturer, across sector, 2014 ................................................................ 32

Figure 34. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2010-2014 .... 33

Figure 35. Private sector median price of QA ACT adult equivalent treatment dosages (AETD) with and .................... 33

without the ‘green leaf’ logo, 2010-2014 ....................................................................................................................... 33

Figure 36. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014 .................................................................................................. 34

Figure 37. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014, urban/rural ............................................................................. 34

Figure 38. Median private sector consumer prices for malaria RDT testing for adults and children 2014 .................... 35

Figure 39. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2010-2014 ................................................................................................................................................................................ 36

Figure 40. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2014, urban/rural ............................................................................................................................................................. 36

Figure 41. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2010-2014 ............................................................................................................................... 37

Figure 42. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2014, urban/rural .................................................................................................................... 37



Acronyms

ACT Artemisinin combination therapy AETD Adult equivalent treatment dose AL Artemether lumefantrine AMFm Affordable Medicines Facility – malaria

ASAQ Artesunate amodiaquine BMGF The Bill and Melinda Gates Foundation

CHW Community Health Worker

DFID Department for International Development

DHA PPQ Dihydroartemisinin piperaquine DOMC Division of Malaria Control

EMA European Medicines Agency

IM Intramuscular injection

IPT Intermittent Preventive Treatment IQR Interquartile Range IRS Indoor Residual Spraying ITN Insecticide Treated Net IV Intravenous injection Kg Kilogram KII Key Informant Interview KNBS Kenya National Bureau of Statistics KNMS Kenya National Medical Services KSH Kenya Shillings Mg Milligrams MOH Ministry of Health MOMS Ministry of Medical Services MOPHS Ministry of Public Health and Sanitation NGO Non-governmental Organization Pf Plasmodium falciparum PMI President’s Malaria Initiative

PPS Probability proportional to size

QA Quality-assured RDT Rapid diagnostic test SP Sulfadoxine‐pyrimethamine USAID United States Agency for International Development

USD United States Dollar

WHO World Health Organization



Definitions

Survey Methods Definitions

Outlet Any service delivery point or point of sale for commodities. Outlets are not restricted to

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

Outlets eligible for

inclusion in the

study

Outlets were administered a full questionnaire if they met at least one of three inclusion

criteria: (1) had one or more antimalarials in stock at the time of the survey visit; (2) reportedly

had one or more antimalarials in stock in the previous three months; or (3) provide malaria

blood testing (microscopy or rapid diagnostic tests) but do not provide antimalarial treatment.

Outlets not providing services to the general public (e.g. army and military clinics) were

excluded from the study.

Cluster The primary sampling unit, or cluster, for the outlet survey. It is an administrative unit

determined by the Kenya National Bureau of Statistics (KNBS) that hosts a population size of

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

In country, they were defined as locations.

Censused location A locality where field teams conducted a full census of all outlets with the potential to sell

antimalarials.

Booster Sample A booster sample was collected by extending the primary sampling unit to a higher

administrative unit for sampling certain outlet types. This extension achieves a larger sample

size for specific outlets, allowing for estimates among key outlet types. In this survey, a booster

sample was collected for public health facilities and pharmacies. The administrative unit for

the census of public health facilities and pharmacies was extended beyond location to the

Division level. See Annex 9 for a detailed description of the booster sampling methods.

Malaria Product Indicator Definitions

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

the prevention of malaria were excluded from analysis of key indicators in this report.

Dosing/treatment

regimen

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

schedule often varies by patient weight.

Adult Equivalent

Treatment Dose

(AETD)

An AETD is the number of milligrams (mg) of an antimalarial drug required to treat a 60 kg

adult (see Annex 11).

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

active compound or a synergistic combination of two compounds with related mechanisms of

action.

Artemisinin and its

derivatives

Artemisinin is a plant extract or synthetic plant extract used in the treatment of malaria. The

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

dihydroartemisinin.

Artemisinin-based

Combination

Therapy (ACT)

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

antimalarials of a different class.



Artemisinin

monotherapy

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

artemisinin or one of its derivatives.

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.

Non-artemisinin

therapy

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

First-line

treatment

The government recommended treatment for uncomplicated malaria. Kenya’s first‐line treatment is Artemether Lumefantrine.

Second-line

treatment

The government recommended second-line treatment for uncomplicated malaria. Kenya's

second-line treatment for uncomplicated malaria is Dihydroartemisinin-Piperaquine.

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.

Severe malaria

treatment

WHO recommends parenteral artesunate as first-line treatment in the management of severe

falciparum malaria, with artemether or quinine injections as acceptable alternatives if

parenteral artesunate is not available1. If complete treatment for severe malaria is not

possible, patients with severe malaria should be given pre-referral treatment and referred

immediately to an appropriate facility for further treatment. The following are options for pre-

referral treatment: rectal artesunate, injectable quinine, injectable artesunate and injectable

artemether.

Quality-assured

Artemisinin-Based

Combination

Therapies (QA

ACTs)

QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s

Quality Assurance Policy. A QA ACT is any ACT that appeared on the Global Fund's indicative

list of antimalarials meeting the Global Fund's quality assurance policy prior to data collection

(see http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/), or that

previously had C-status in an earlier Global Fund quality assurance policy and was used in a

program supplying subsidized ACTs. QA ACTs also include ACTs that have been granted

regulatory approval by the European Medicines Agency (EMA) – specifically Eurartesim® and

Pyramax®.

Quality-assured

ACT with the

“green leaf” logo,

or “co-paid ACTs”

The “green leaf” logo indicates that a quality-assured ACT was acquired through

a co-payment mechanism administered by the Global Fund (Affordable

Medicines Facility, malaria – or AMFm). These subsidized (co-paid) quality-

assured ACTs were available to first-line buyers in Country in the public and

private sector from 2010.

Quality-assured

RDT

QA RDTs are RDTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s

Quality Assurance Policy. A QA RDT is any RDT that appeared on the Global Fund's indicative

list of RDTs meeting the Global Fund's quality assurance policy prior to data collection (see

http://www.theglobalfund.org/en/procurement/quality/diagnostics/#Quality).

RDT with the

“checkmark” logo

The “checkmark” logo indicates that a quality-assured RDT was acquired

through a co-payment mechanism. These subsidized RDTs were available

to private sector pharmacies and health facilities from August 2013.

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


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

http://www.theglobalfund.org/en/procurement/quality/diagnostics/#Quality


Introduction This Kenya reference document is a detailed presentation of the 2014 national ACTwatch outlet survey (OS) conducted in Kenya. The 2014 OS follows previous survey rounds conducted as part of the Independent Evaluation of the Affordable Medicines Facility, malaria (AMFm) in 2010 and 2011. ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence. The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID, and DFID. See Annex 1 for more information about the ACTwatch project. Antimalarial market monitoring in Kenya from 2010 to present has been implemented in the context of strategies designed and implemented to improve coverage of appropriate case management. These include:

Scale up of quality-assured ACTs in the public and private sectors through mechanisms including the Global Fund co-payment mechanism piloted under the AMFm. The initial AMFm pilot period was 2010-2011 and co-paid ACTs were delivered to first-line buyers in Kenya from 2010-2014

National efforts to improve availability of malaria blood testing and confirmatory testing prior to antimalarial treatment in both the public and private sectors.

The 2014 OS was the third round of outlet surveys conducted in Kenya. This report presents trend lines with three data points: 1) the 2010 outlet survey; 2) the 2011 outlet survey; and 3) the most recent 2014 survey. These surveys are designed to monitor key antimalarial market indicators at national level and within urban/rural domains. ACTwatch outlet survey findings can inform ongoing monitoring, evaluation, and adjustment to policy, strategy, and funding decisions to strengthen malaria case management.

Report notes

This document is a complete reference for the 2015 outlet survey. Please see annexes for information about the study context, design, implementation and data analysis.

Table numbers are consistent across all sections (not including the annex tables), and are reflective of table descriptions available in Annex 10

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

Malaria testing and treatment prices are reported in US dollars. Price information is captured in local currency and converted to US dollars based on exchange rates available from www.oanda.com using the historical exchange rates tool. The average exchange rate over the entire data collection period is used for converting local currency captured during data collection to US dollars.


http://www.psi.org/

http://www.oanda.com/


Summary of Methods and Data Collection A nationally-representative antimalarial outlet survey was conducted in Kenya between November 7, 2014 and December 22, 2014. A full description of research design and methods is provided in Annex 3. Briefly, a representative sample of locations was selected from urban and rural domains (see sampled locations in Annex 4). Within selected clusters, a census of all outlets with the potential to sell or distribute antimalarials and/or provide malaria blood testing was completed. The geographic area for sampling outlets was extended to the division level to achieve a sufficient sample size for estimating key indicators for important outlet types. This booster sampling strategy was used to obtain a sufficient sample size for indicator estimates within public health facilities and pharmacies. Outlets were screened to determine eligibility. Outlets eligible for the survey met at least one of three criteria: 1) one or more antimalarials were in stock on the day of the survey; 2) one or more antimalarials were in stock in the three months preceding the survey; and/or 3) malaria blood testing (microscopy or RDT) was available. Outlets that do not serve the general public (e.g. military facilities) were excluded from the study. The results of the census are summarized in Figure 1. A detailed sample summary is provided in Annex 5.

A structured questionnaire was used to complete an audit of all antimalarials and RDTs as well as a provider interview (see Annex 6). See Annex 7 and Annex 8 for detailed summaries of antimalarials and RDTs audited. Double data entry was completed using Microsoft Access. All data cleaning and analysis was performed using Stata 13.1 (©StataCorp, College Station, TX). Data were weighted to account for variation in probability of outlet selection (see Annex 9), and standard error calculation reflected clustering of outlets at location and division levels. Standard indicators were constructed according to definitions applied across ACTwatch project countries (see Annex 10).



Figure 1. Survey flow diagram, Kenya, 2014

A Outlets enumerated*

14,127

B Outlets screened**

12,676

D Outlets interviewed***

2,449 1 = 2,133 2= 272 3= 44

Outlets not screened

1,451

Outlets that did not meet screening

criteria 10,199

Outlets not interviewed

28

1: Antimalarials in stock on day of visit 2: Antimalarials reportedly in stock during the previous 3 months but not on the day of the visit 3: Malaria blood testing available but no antimalarials in stock * Identified as outlets with potential to sell or distribute antimalarials and/or provide malaria blood testing during

the census or booster sampling ** Administered questions to assess current or recent (previous 3 months) availability of antimalarials and malaria

blood testing (microscopy or rapid diagnostic test) *** A partial or complete interview was conducted with an outlet representative

C Outlets that met screening criteria

2,477 1 = 2,159 2 = 272 3 = 46

Respondent not available 95 Outlet closed at time of visit 324 Outlet closed permanently 798 Other 182 Refused 52

Respondent not available 6 Outlet closed at time of visit 3 Other 3 Refused 16



Summary of Key Findings

Table S1: Key results, by outlet type - 2014

Public Health Facility

ALL Public / Not For-

Profit1

Private For-Profit

Facility

Registered Pharmacy

Unregistered Pharmacy

General Retailer ALL

Private2 ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Readiness for malaria case management Proportion of all screened outlets* with:

N=485 N=1,096 N=453 N=503 N=572 N=9,950 N=11,580 N=12,676

Availability of malaria blood testing 92.7 19.7 67.5 20.4 15.7 0.0 3.5 4.7

(88.9, 95.2) (15.4, 24.9) (63.4, 71.3) (17.6, 23.6) (12.7, 19.3) - (3.0, 4.1) (4.3, 5.2)

Availability of QA ACT 77.1 16.1 61.2 87.1 78.5 0.8 7.5 8.2

(72.6, 81.1) (12.2, 21.1) (57.2, 65.2) (84.8, 89.1) (76.0, 80.8) (0.4, 1.3) (6.7, 8.5) (7.4, 9.1)

Availability of QA ACT and malaria blood testing

72.7 14.4 46.9 19.5 13.8 0.0 2.6 3.5

(68.0, 77.0) (10.8, 19.0) (43.3, 50.6) (16.8, 22.6) (11.3, 16.8) - (2.3, 3.1) (3.2, 3.9)

Availability of QA ACT, blood testing not available

4.4 1.7 14.3 67.6 64.7 0.8 4.9 4.7

(2.3, 8.4) (1.2, 2.6) (12.2, 16.8) (63.7, 71.3) (61.5, 67.7) (0.4, 1.3) (4.3, 5.6) (4.1, 5.3)

Availability of QA ACT, malaria blood testing, and provider correct knowledge of first line treatment

71.9 14.2 44.6 19.4 12.7 0.0 2.5 3.4

(67.2, 76.2) (10.6, 18.8) (40.9, 48.3) (16.7, 22.5) (10.2, 15.7) - (2.1, 2.9) (3.0, 3.7)

Availability of any severe malaria treatment 74.2 13.1 43.7 26.8 15.6 0.0 2.7 3.5

(69.5, 78.4) (9.9, 17.3) (40.3, 47.1) (22.3, 31.9) (12.1, 19.9) (0.0, 0.1) (2.4, 3.1) (3.1, 3.8)

Readiness for malaria case management

Proportion of antimalarial-stocking outlets with:

N=457 N=517 N=342 N=487 N=535 N=252 N=1,616 N=2,133

Availability of malaria blood testing 93.8 87.4 76.0 20.9 16.4 0.0 28.5 35.6

(89.7, 96.4) (83.0, 90.8) (72.4, 79.2) (17.8, 24.4) (13.5, 19.9) - (24.8, 32.4) (32.5, 38.9)

Availability of QA ACT 83.4 86.8 83.6 90.5 84.2 26.2 70.5 72.5

(79.5, 86.6) (83.1, 89.7) (80.7, 86.1) (88.8, 92.0) (81.8, 86.3) (15.1, 41.6) (64.4, 76.0) (66.9, 77.5)

Availability of QA ACT and malaria blood testing

78.6 77.4 64.0 20.3 14.8 0.0 24.6 31.0

(74.2, 82.5) (72.8, 81.4) (60.8, 67.2) (17.3, 23.7) (12.1, 18.0) - (21.6, 27.9) (28.3, 33.8)

Availability of QA ACT, blood testing not available

4.8 9.4 19.5 70.2 69.4 26.2 45.9 41.5

(2.4, 9.0) (6.5, 13.4) (16.7, 22.7) (66.9, 73.3) (66.0, 72.5) (15.1, 41.6) (41.7, 50.2) (38.0, 45.1)

Availability of QA ACT, malaria blood testing, and provider correct knowledge of first line treatment

77.8 76.5 60.8 20.2 13.6 0.0 23.3 29.7

(73.3, 81.7) (71.9, 80.5) (57.2, 64.4) (17.2, 23.6) (10.9, 16.9) - (20.3, 26.5) (27.0, 32.6)

Availability of any severe malaria treatment 80.2 70.6 59.6 27.9 16.8 1.2 25.2 30.7

(75.6, 84.1) (63.2, 77.0) (55.3, 63.7) (23.5, 32.7) (13.0, 21.4) (0.4, 3.1) (22.1, 28.6) (27.5, 34.2)



Table S1: Key results, by outlet type - 2014



Profit1

Private For-Profit

Facility

Registered Pharmacy



Private2 ALL

Outlets

Readiness for IPTp Proportion of outlets with SP available:

N=485* N=140**

N=1,096* N=426**

N=453* N=83**

N=503* N=487**

N=572* N=535**

N=9,950* N=252**

N=11,580* N=1,616**

N=12,676* N=2,133**

Among all screened outlets* 13.9 3.1 18.1 50.8 53.6 1.8 5.3 5.1

(9.7, 19.6) (2.2, 4.2) (15.7, 20.8) (47.5, 54.1) (50.1, 56.9) (1.2, 2.6) (4.7, 6.0) (4.6, 5.8)

Among all screened outlets in endemic regions **

49.2 4.5 17.4 68.0 56.3 1.3 4.9 4.9

(40.0, 58.5) (3.1, 6.3) (13.0, 22.8) (64.1, 71.5) (48.1, 64.1) (0.6, 2.9) (4.1, 6.0) (4.0, 5.9)

Readiness for IPTp Proportion of outlets with SP available:

N=457* N=138**

N=517* N=156**

N=342* N=70**

N=487* N=81**

N=535* N=123**

N=252* N=64**

N=1,616* N=338**

N=2,133* N=494**

Among antimalarial-stocking outlets 15.0 16.5 24.7 52.8 57.5 62.0 49.6 45.6

(10.5, 21.1) (12.6, 21.3) (21.7, 28.0) (49.4, 56.2) (54.0, 60.8) (48.0, 74.3) (45.5, 53.6) (41.9, 49.3)

Among all screened outlets in endemic regions**

49.7 35.7 22.7 69.6 60.2 40.7 47.1 45.2

(40.4, 59.0) (27.3, 45.0) (17.3, 29.1) (64.9, 74.0) (52.3, 67.7) (27.4, 55.4) (41.1, 53.2) (40.8, 49.8)

Malaria market performance

% QA ACT market share within outlet type^ 78.9 76.5 58.9 42.5 52.7 36.0 47.9 51.4

Median price for one QA ACT adult equivalent treatment dose (AETD)

- - $1.41 $1.13 $1.13 $1.13 $1.33 -

[1.13-1.69] (239) [1.13-1.69] (449) [1.13-1.69] (455) [1.13-1.69] (41) [1.13-1.69] (1,184)

Median price for one pre-packaged pediatric QA AL #

- - $0.56 $0.56 $0.56 $0.56 $0.56 -

[0.56-1.13] (65) [0.45-0.90] (161) [0.56-0.79] (131) [0.56-1.13] (6) [0.56-1.13] (363)

Median price for an RDT ## - - $1.13 $1.13 $1.13 - $1.13 -

[1.13-1.69] (133) [1.13-1.13] (53) [1.13-1.13] (59) - [1.13-1.69] (245)

Median price for malaria microscopy ## - - $1.13 $1.13 $1.13 - $1.13 -

[0.56-1.13] (263) [1.13-1.13] (55) [1.13-1.13] (30) - [0.56-1.13] (348)

1 Inclusive of N= 58 screened and 43 antimalarial-stocking private not-for-profit outlets, and N= 553 screened and 17 antimalarial-stocking community health workers.

2 Inclusive of N= 102 screened and 0 antimalarial-stocking itinerant drug vendors.

* The denominator includes 119 outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).

** Areas designated for the use of SP for the purposes of IPTp are limited to malaria endemic areas where transmission is intense throughout the year, and P. falciparum prevalence is historically greater than 20%. These areas include altitudes ranging from sea level in the coastal area to up to 1,300 meters around the Lake Victoria basin.

Outlets with least one antimalarial in stock on the day of the survey.

^ Percent market volume (adult equivalent treatment dosages sold/distributed in the previous week) accounted for by quality-assured ACT (QA ACT) sale/distribution within the outlet type.

# Pre-packaged QA AL for a 10kg child. Prices shown here are only for the private sector as price in public sector was free.

## Price of having test conducted, inclusive of RDT cost and consultation / service fees for a child under five. Prices shown here are only for the private sector as price in public sector was free.

Source: ACTwatch Outlet Survey, Kenya, 2014.



11%3%

3%

12%

3%

31%

37%

2010N=1,471


Community Health Worker

Private Not For-Profit Facility

Private For-Profit Facility

Registered Pharmacy


General Retailer

Itinerant Drug Vendor

10%1% 3%

21%

12%33%

20%

2014N=1,50113% 3%

19%

3%30%

31%

2011N=1,348

Figure 2. Market composition: outlet type distribution, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

The private sector accounted for more than 75% of antimalarial-stocking outlets at each survey round. However, the proportion of outlets accounted for by private for-profit health facilities and registered pharmacies increased over time (15% in 2010 versus 33% in 2014) relative to the proportion accounted for by unregistered pharmacies and general retail outlets (68% in 2010 versus 53% in 2014).

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

In urban and rural areas, approximately half of antimalarial-stocking outlets are informal private sector outlets. However, in urban areas these are primarily unregistered pharmacies (41%) while in rural areas general retailers accounted for 40% of all antimalarial-stocking outlets. One-quarter of antimalarial-stocking outlets in rural areas were public sector outlets as compared with 10% in urban areas, where private for-profit health facilities (26%) and registered pharmacies (16%) were more common than in rural areas (private for-profit facilities, 14%; registered pharmacies, 4%).

6%

1% 3%

26%

16%

41%

9%

UrbanN=1,029




Private For-Profit Facility

Registered Pharmacy


General Retailer

Itinerant Drug Vendor

17%3%

5%

14%

4%18%

40%

RuralN=472



Figure 4. Percentage of outlets with at least one antimalarial in stock on the day of the survey, 2010-2014 Among all screened outlets, across survey round

Availability of antimalarials in public health facilities, registered pharmacies and unregistered pharmacies remained high (nearly 90% or higher) over time. However, 2014 shows a drop from 2011 levels in the availability of antimalarials in private not for-profit and private for-profit facilities. For each of the surveys, the availability of antimalarials among CHWs has been low (<5%).

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

Antimalarial availability was similar across urban and rural locations among private health facilities, registered pharmacies and unregistered pharmacies. Among public health facilities, 84% of all screened outlets in urban locations stocked antimalarials compared with 99% in rural locations.

0

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2010 2011 2014

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Public Health Facility Community Health Worker Private-Not-For-Profit Facility

Private-For-Profit Facility Registered Pharmacy Unregistered Pharmacy

General Retailer

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Public Health Facility Private For-ProfitFacility

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Urban Rural



Figure 6. Percentage of antimalarial-stocking outlets with ACT in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

ACT availability declined among antimalarial-stocking public health facilities between 2011 (97%) and 2014 (84%) and remained high among registered pharmacies over time (>90%). ACT availability among antimalarial-stock outlets increased over time among private for-profit facilities (2010, 58%; 2011, 84%; 2014, 93%), unregistered pharmacies (2010, 47%; 2011, 90%; 2014, 92%) and general retailers (2010, 0%; 2011, 24%; 2014, 27%).

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

ACT availability was similar among antimalarial-stocking outlets in urban versus rural areas across outlet type.

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2010 2011 2014

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Public Health Facility Private For-Profit Facility Registered Pharmacy

Unregistered Pharmacy General Retailer

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General Retailer

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Urban Rural



Figure 8. Percentage of antimalarial-stocking outlets with quality-assured ACT in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

QA ACT availability declined among antimalarial-stocking public health facilities between 2011 (97%) and 2014 (83%) and remained high among registered pharmacies between 2010 and 2014 (around 90%). QA ACT availability among antimalarial-stock outlets increased between 2010 and 2011 and increases were maintained in 2014 among private for-profit facilities (2010, 37%; 2011, 78%; 2014, 84%), unregistered pharmacies (2010, 33%; 2011, 86%; 2014, 84%) and general retailers (2010, 0%; 2011, 23%; 2014, 26%).

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

QA ACT availability was similar among antimalarial-stocking outlets in urban versus rural areas across outlet type.

0

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2010 2011 2014

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Public Health Facility Privat For-Profit Facility Registered Pharmacy


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General Retailer

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Urban Rural



Figure 10. Percentage of antimalarial-stocking outlets with quality-assured ACT marked with the ‘green leaf’ logo in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

The availability of co‐paid QA ACT marked with the ‘green leaf’ logo among antimalarial-stocking outlets decreased among public health facilities between 2011 (69%) and 2014 (30%). However, availability remained high (>70%) between 2011 and 2014 among private for-profit health facilities, registered pharmacies and unregistered pharmacies. One-fifth of antimalarial-stocking general retailers had QA ACT with the ‘green leaf’ logo in stock in 2011 (23%) and 2014 (21%).

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

Availability of QA ACT with the ‘green leaf’ logo was similar among antimalarial-stocking outlets in urban versus rural areas across outlet type.

0

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Urban Rural



Figure 12. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

The majority of antimalarial-stocking registered pharmacies had non-QA ACT in stock across survey rounds (>85%). Availability has increased over time among unregistered pharmacies from 29% in 2010 to 50% in 2014. Public health facilities, and general retailers generally did not have non-QA ACT in stock across survey rounds (<5%).

Figure 13. Percentage of antimalarial-stocking outlets with non-quality-assured ACT in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

Non-quality-assured ACT availability is higher among antimalarial-stocking urban as compared with rural outlets across private sector outlet types including private for-profit facilities (54% versus 33%), registered pharmacies (89% versus 69%), unregistered pharmacies (54% versus 33%) and general retailers (6% versus 1%).

0

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2010 2011 2014

Pe

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nta

ge o

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General Retailer

Pe

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Urban Rural



19%

0%

8%

4%

32%

22%

Non-QA ACT Private

N=3,093

32%

7%36%

5%

14%7%

Non-QA ACT PublicN=62

95%

QA ACT PrivateN=2,245

100%

QA ACT PublicN=979

AL tablet

ASAQ tablet

ASMQ tablet

A PPQ tablet

AS SP tablet

DHA PPQ tablet

AN tablet

AL non-tablet

ASMQ non-tablet

DHA PPQ non-tablet

Figure 14. Types of quality-assured ACT and non-quality-assured ACT found among public and private sector outlets, 2014 Among all ACT medicines audited, across sector, 2014

The majority of QA ACT products were audited in the private sector and all products audited in the public sector were AL

tablets. A variety of non-QA ACT products were audited in the public and private sector and the majority of these were tablet

formulations (>75%) including non-QA AL tablets (32% of public and 19% of private sector non-QA ACT) and non-QA DHA PPQ

tablets (36% of public and 32% of private sector non-QA ACT). Common manufacturers of non-QA AL and DHA PPQ included

Bliss GVS Pharmaceuticals (AL and DHA PPQ) and Beijing Holley-Cotec Pharmaceuticals (DHA PPQ).



Figure 15. Percentage of antimalarial-stocking outlets with non-artemisinin therapy in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

The availability of non-artemisinin therapy among antimalarial-stocking outlets has generally decreased since 2010 among

public and private sector outlets. In 2014, availability was highest among general retailers (81%) and lowest among private

for-profit facilities (52%).

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

Data trends suggest higher availability of non-artemisinin therapy among antimalarial-stocking outlets in rural versus urban areas among public and private sector outlet types.

0

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Urban Rural



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Public Health Facility Private For-Profit Facility

Registered Pharmacy Unregistered Pharmacy

General Retailer

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

SP availability was similar among antimalarial-stocking public and private facilities and general retailers in urban versus rural areas. Data trends suggest higher availability among registered pharmacies and unregistered pharmacies located in rural versus urban areas.

Figure 17. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

SP is used for intermittent preventive treatment of malaria in pregnancy and should be dispensed during antenatal clinic visits. SP availability among antimalarial‐stocking health facilities has declined in recent years including among public health facilities (2010, 75%; 2011, 57%; 2014, 15%) and private for-profit facilities (2010, 43%, 2011, 42%; 2014 25%). More than half of antimalarial-stocking outlets had SP available in 2014 among registered pharmacies (53%), unregistered pharmacies (58%) and general retailers (62%).

0

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Figure 19. Percentage of antimalarial-stocking outlets with SP in stock on the day of the survey, by regions targeted or not targeted for IPTp, 2014 Among all outlets with at least one antimalarial in stock, 2014

SP is used for intermittent preventive treatment of malaria in pregnancy and should be dispensed during antenatal clinic visits. In keeping with the WHO guidelines published in 2012 to limit SP use for IPTp to malaria-endemic areas, Kenya has designated areas for the use of SP for the purposes of IPTp to those where transmission is intense throughout the year, and P. falciparum prevalence is historically greater than 20%. These areas include altitudes ranging from sea level in the coastal area to up to 1,300 meters around the Lake Victoria basin. SP availability among antimalarial‐stocking health facilities in target areas is higher on average than availability in non-target areas. Half of the public health facilities in target areas had SP on-hand, compared to 2% of public health facilities in non-target areas. Similarly, SP availability in registered pharmacies was also higher in target areas compared to non-target areas (70% compared to 50%). Availability among private-for-profit facilities (23% and 25%) and unregistered pharmacies (60% and 57%) was nearly the same across target and non-target areas.

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Pe

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Figure 20. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2010-2014 Among all outlets with at least one antimalarial in stock, across survey round

Treatments for severe malaria include artesunate IV/IM, quinine IV/IM, artemether IV/IM, artemotil IV/IM, and artesunate suppositories. Severe malaria treatment availability among antimalarial-stocking outlets has remained similar over time among public health facilities (80% in 2014) and private for-profit health facilities (59% in 2014), and has declined between 2010 and 2014 among registered pharmacies (66%, 28%) and unregistered pharmacies (26%, 17%).

Figure 21. Percentage of antimalarial-stocking outlets with any severe malaria treatment in stock on the day of the survey, 2014, urban/rural Among all outlets with at least one antimalarial in stock

Severe malaria treatment availability was higher among antimalarial-stocking unregistered pharmacies in rural (28%) versus urban areas (14%). Data trends suggest higher availability in rural versus urban registered pharmacies as well as urban versus rural private for-profit health facilities.

0

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General Retailer

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Urban Rural



Figure 22. Antimalarial market share, 2010-2014 Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class, across survey round

The antimalarial market share for the private sector has increased from 67% in 2010 and 63% in 2011 to 88% in 2014. QA ACT market share has increased from 26% in 2010 to 57% in 2011 and 51% in 2014. QA ACT marked with the ‘green leaf’ logo indicating co-payment accounted for half of all antimalarials distributed in 2011 dropping to 40% in 2014.

Figure 23. Antimalarial market share within sector, 2010-2014 Relative market volume (sale/distribution) of antimalarial AETDs, within sector, by antimalarial class, across survey round

Approximately half of antimalarials distributed by the public sector were QA ACT in 2010 (54%) and 2011 (49%), increasing to 77% in 2014. In the private sector, QA ACT market share increased from 12% in 2010 to 62% in 2011 and dropped to 48% in 2014 in the context of increasing market share for non-QA ACT (2010, 11%; 2011, 7%; 2014, 20%). QA ACT with the ‘green leaf’ logo have accounted for the majority of QA ACT treatment distributed by the private sector over time and approximately half of QA ACTs distributed in the public sector in 2014.

0102030405060708090

100

Public Private Public Private Public Private

2010 2011 2014

Pe

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ge o

f to

tal m

arke

t vo

lum

e

QAACT without 'green leaf' QAACT with 'green leaf' Non-QAACT

SP Other non-artemisinin therapy Oral artemisinin monotherapy

Non-oral artemisinin monotherapy

0

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Public Private Public Private Public Private

2010 2011 2014

Pe

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f se

cto

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Figure 24. Antimalarial market share, 2014 Relative market volume (sale/distribution) of antimalarial AETDs, by outlet type and antimalarial class

Private sector market share in 2014 (88%) is comprised of relative market share for unregistered pharmacies (31%), registered pharmacies (41%), private for‐profit health facilities (12%), and general retailers (5%).

Figure 25. Antimalarial market share, 2014, urban/rural Relative market volume (sale/distribution) of antimalarial AETDs, by sector and antimalarial class

The private sector distributed 92% of the antimalarials in urban locations as compared with 72% in rural locations. QA ACT accounted for half of antimalarials distributed in urban areas (50%) compared to 60% in rural areas. ‘Green leaf’ co‐paid QA ACT market share was higher in rural (40%) as compared with urban areas (11%). Non‐QA ACT accounted for 22% of antimalarials distributed in urban areas, compared with 5% in rural areas.

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Public Private Private for-ProfitHealth Facility

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Figure 26. Percentage of antimalarial-stocking outlets with malaria blood testing available, 2010-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

Blood testing availability has increased among antimalarial-stocking health facilities including public health facilities (2010, 46%; 2011, 55%; 2014, 94%) and private not-for-profit facilities (2010, 53%; 2011, 45%; 2014, 74%). Availability has remained low over time among registered pharmacies (21% in 2014) and unregistered pharmacies (16% in 2014).

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

Data trends suggest higher availability of malaria blood testing (RDT or microscopy) among antimalarial-stocking outlets in urban versus rural areas.

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Figure 29. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2014, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months

Malaria microscopy was more commonly available among urban versus rural public health facilities (71% versus 54%) and private for-profit health facilities (66% versus 45%).

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Urban Rural

Figure 28. Percentage of antimalarial-stocking outlets with malaria microscopy available, 2010-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

Malaria microscopy availability has increased over time among antimalarial-stocking health facilities including public health facilities (2010, 41%; 2011, 42%; 2014, 61%) and private for-profit facilities (2010, 49%; 2011, 40%; 2014, 61%). Malaria microscopy is generally not available among registered pharmacies (8% in 2014) and unregistered pharmacies (6% in 2014).

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Figure 31. Percentage of antimalarial-stocking outlets with malaria RDTs, 2014, urban/rural Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across urban and rural zones

RDT availability among antimalarial-stocking outlets was higher among public health facilities in rural (73%) versus urban areas (62%). Among private sector outlet types, data trends suggest higher availability in urban versus rural areas.

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Figure 30. Percentage of antimalarial-stocking outlets with malaria RDTs, 2010-2014 Among all outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

Availability of malaria RDTs among antimalarial‐stocking outlets was less than 10% across all outlet types in 2010. By 2014, availability had increased significantly among public health facilities (68%) but remained relatively low among private for-profit facilities (29%), registered pharmacies (15%) and unregistered pharmacies (12%).

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Figure 32. Malaria blood testing market share, 2014 Relative market volume (sale/distribution) of malaria blood testing using mRDTs and microscopy, by outlet type and type of test

More than half of all malaria blood tests were performed by public sector outlets (53%) and the majority of these tests were performed using microscopy. Malaria RDTs accounted for less than one-third of all tests performed (25%). Private for-profit facilities accounted for the majority of malaria blood testing performed by the private sector (42% of all tests performed).

Figure 33. Malaria RDT market share by manufacturer, across sector, 2014 Relative market volume (sale/distribution) of malaria RDTs by manufacturer, within the public and private sector outlet types

Among RDTs performed within public sector outlets, the majority (99%) were manufactured by Access Bio Inc. (99%). Within the private sector, Access Bio Inc. accounted for 64% of the market share followed by Standard Diagnostics (19%).

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RegisteredPharmacy

UnregisteredPharmacy

General Retailer

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Microscopy RDT

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RegisteredPharmacy




Figure 34. Private sector median price of antimalarial adult equivalent treatment dosages (AETD), 2010-2014 Among all SP and quality-assured ACT (tablet formulation only) available in the private sector, in 2010 US dollars to account for inflation, across survey round

The median private sector price for one adult equivalent treatment dose (AETD) of QA ACT decreased between 2010 and 2011, however, the price of QA ACT more than doubled between 2011 and 2014 and in 2014 remained more than 2.5 times more expensive than SP. The price of SP has remained similar over time and the price of non-QA ACT has increased over time and in 2014 non-QA ACT (tablet formulation) is three times as expensive as QA ACT.

Figure 35. Private sector median price of QA ACT adult equivalent treatment dosages (AETD) with and without the ‘green leaf’ logo, 2010-2014 Among all quality-assured ACT (tablet formulation only) available in the private sector, in 2010 US dollars to account for inflation, across survey round

The median private sector price for one AETD of QA ACT with the green leaf logo was similar to the price of QA ACT without the logo in 2011 and 2014.

$4.61 $4.61

$5.25

$2.30

$0.52

$1.75

$0.46 $0.46$0.66

$0.00

$1.00

$2.00

$3.00

$4.00

$5.00

$6.00

$7.00

$8.00

$9.00

$10.00

2010 2011 2014

20

10

USD

Non QAACT Quality-Assured ACT SP

$3.45

$0.58

$1.58$1.15

$0.46

$1.75

$0.00

$1.00

$2.00

$3.00

$4.00

$5.00

$6.00

2010 2011 2014

20

10

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QAACT without "green leaf"logo QAACT with "green leaf"logo



Figure 36. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014 Among all SP, QA ACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2014 US Dollars

The private sector median price for AL pre-packaged for a two-year old child was $0.56 across all private sector outlet types. The median price of one QA ACT AETD was $1.50 in the private sector, ranging from a median of $1.13 among general retailers to $1.69 among private for-profit health facilities. Similarly the price of SP was least expensive among general retailers ($0.34) in comparison with registered pharmacies ($0.68).

Figure 37. Private sector median price of SP and quality-assured ACT adult equivalent treatment dosages (AETD) and pre-packaged pediatric quality-assured AL, 2014, urban/rural Among all SP, QA ACT, and pre-packaged pediatric (treatment for a 2 year old child) QA AL (tablet formulation only) available in the private sector, in 2014 US Dollars

The private sector median price for QA AL pre-packaged for a two-year old child was the same in urban and rural areas ($0.56). AETD median prices for SP and QA ACT were higher in urban versus rural areas.

$0.56

$1.69

$0.56$0.68

$1.35

$0.56$0.56

$1.35

$0.56

$0.34

$1.20

$0.56$0.56

$1.50

$0.56

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

SP AETD QA ACT AETD Pediatric QA AL

Me

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Private For-Profit Facility Registered Pharmacy Unregistered Pharmacy General Retailer All private

$0.56

$1.69

$0.56$0.39

$1.13

$0.56

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

SP AETD QA ACT AETD Pediatric QA AL

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Urban Rural



Figure 38. Median private sector consumer prices for malaria RDT testing for adults and children 2014 Among all RDTs available within private for-profit health facilities, pharmacies and unregistered pharmacies, inclusive of consultation and service fees, in 2014 US dollars

The median private sector price for malaria blood testing with an RDT, inclusive of service and consultation fees, was $1.13 across all private sector outlet types for both adults and children under five. The median price for blood testing with malaria microscopy was also $1.13 across outlet types (data not shown).

$1.13 $1.13$1.13 $1.13$1.13 $1.13$1.13

$1.13

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

RDT - Adult RDT - Child

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Private-For-Profit Health Facility Registered Pharmacy Unregistered Pharmacy All Private



Figure 39. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2010-2014 Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

Across survey rounds, more than 90% of providers among antimalarial‐stocking public health facilities and registered pharmacies correctly stated the first‐line treatment for uncomplicated malaria (AL). Knowledge of first line treatment increased over time among providers at private for-profit health facilities (93% in 2014), unregistered pharmacies (91% in 2014) and among general retailers (29%).

Figure 40. Percentage of providers who correctly state the first-line treatment for uncomplicated malaria, 2014, urban/rural Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months

First-line treatment knowledge was similar among providers in urban versus rural areas across outlet type.

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Figure 41. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2010-2014 Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months, across survey round

Overall, the percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child rose across the survey rounds. It also rose within outlet types with the exception of registered pharmacies where it fell from 69% in 2010 to 64% in 2011.

Figure 42. Percentage of providers who correctly state the first-line dosing regimen for uncomplicated malaria for a two-year old child, 2014, urban/rural Among providers in outlets with at least one antimalarial in stock on the day of the survey or within the past three months

Knowledge of the dosing regimen for a two-year old child using the first-line treatment for uncomplicated malaria was similar among providers in urban versus rural areas across outlet type.

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Results Section A: Core Indicators

Table A1: Availability of antimalarials, among all screened outlets, by outlet type



Private Not-For-Profit

Health Facility

ALL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking:

N=485 N=553 N=58 N=1,096 N=453 N=503 N=572 N=9,950 N=11,580 N=12,676

Any antimalarial at the time of survey visit

92.5 2.6 78.2 18.6 73.3 96.3 93.2 2.9 10.7 11.3

(89.5, 94.7) (1.3, 5.0) (68.7, 85.5) (14.2, 24.0) (68.5, 77.6) (94.2, 97.7) (91.7, 94.4) (2.1, 4.0) (9.8, 11.7) (10.4, 12.3)

Any ACT 77.2 2.1 75.6 16.2 67.9 96.2 85.8 0.8 8.3 8.8

(72.7, 81.2) (0.9, 4.5) (65.6, 83.5) (12.2, 21.1) (63.6, 71.8) (94.1, 97.5) (82.9, 88.3) (0.4, 1.4) (7.3, 9.3) (7.9, 9.8)

Artemether

Lumefantrine (AL)

77.2 2.1 75.6 16.2 66.4 94.2 83.9 0.8 8.1 8.7

(72.7, 81.2) (0.9, 4.5) (65.6, 83.5) (12.2, 21.1) (62.2, 70.3) (91.7, 96.0) (81.1, 86.3) (0.4, 1.4) (7.2, 9.1) (7.8, 9.7)

Artesunate Sulfadoxine Pyrimethamine (ASSP)

0.3 0.0 0.0 0.0 2.1 12.2 3.8 0.0 0.4 0.4

(0.1, 0.9) - - (0.0, 0.1) (1.3, 3.3) (8.8, 16.8) (2.3, 6.3) (0.0, 0.1) (0.3, 0.6) (0.3, 0.6)

Artesunate Amodiaquine (ASAQ)

0.0 0.0 0.0 0.0 4.5 16.5 6.1 0.0 0.6 0.6

- - - - (3.2, 6.3) (13.6, 19.9) (4.8, 7.8) - (0.5, 0.8) (0.5, 0.7)

DHA PPQ 1.9 0.0 18.2 1.5 22.9 73.2 34.2 0.1 3.3 3.1

(1.3, 3.0) - (11.5, 27.5) (1.0, 2.3) (19.7, 26.5) (67.1, 78.5) (28.7, 40.3) (0.0, 0.1) (2.8, 3.8) (2.6, 3.7)

Quality Assured ACT (QA ACT)

77.1 2.1 75.6 16.1 61.2 87.1 78.5 0.8 7.5 8.2

(72.6, 81.1) (0.9, 4.5) (65.6, 83.5) (12.2, 21.1) (57.2, 65.2) (84.8, 89.1) (76.0, 80.8) (0.4, 1.3) (6.7, 8.5) (7.4, 9.1)

QA AL 77.1 2.1 75.6 16.1 60.6 85.5 77.9 0.8 7.5 8.1

(72.6, 81.1) (0.9, 4.5) (65.6, 83.5) (12.2, 21.1) (56.7, 64.4) (83.1, 87.6) (75.4, 80.2) (0.4, 1.3) (6.7, 8.4) (7.3, 9.0)

QA ACT with the ‘green leaf’ logo

27.5 0.8 51.1 7.5 53.9 82.7 71.0 0.6 6.7 6.8

(22.1, 33.7) (0.4, 1.8) (36.5, 65.5) (5.1, 10.8) (50.0, 57.7) (80.5, 84.8) (67.5, 74.2) (0.4, 1.1) (6.0, 7.6) (6.0, 7.7)

QA ACT without the ‘green leaf’ logo

64.6 1.5 43.2 12.0 14.9 17.2 16.3 0.2 1.6 2.4

(58.8, 69.9) (0.5, 4.3) (27.2, 60.7) (8.8, 16.0) (12.3, 18.1) (14.4, 20.2) (14.1, 18.8) (0.1, 0.4) (1.4, 1.9) (2.1, 2.8)

QA ACT – child (<5 years)

65.3 1.1 43.8 11.8 26.8 44.0 34.5 0.3 3.4 4.0

(59.7, 70.4) (0.4, 3.3) (28.2, 60.7) (8.6, 15.9) (23.6, 30.3) (40.6, 47.5) (31.0, 38.3) (0.2, 0.6) (2.9, 3.9) (3.5, 4.5)

QA ACT – adult 39.5 1.8 63.2 10.6 50.0 77.6 66.7 0.5 6.3 6.6

(33.1, 46.2) (0.8, 4.3) (48.7, 75.6) (7.4, 14.9) (45.3, 54.7) (74.8, 80.1) (63.6, 69.7) (0.3, 0.9) (5.5, 7.1) (5.8, 7.4)

Non-quality-assured ACT (non-QA ACT)

2.5 0.0 33.5 2.6 36.2 84.4 46.7 0.1 4.5 4.3

(1.7, 3.5) - (18.6, 52.6) (1.3, 5.2) (33.0, 39.6) (79.9, 88.1) (40.3, 53.1) (0.0, 0.1) (3.8, 5.2) (3.7, 5.1)

Nationally Registered ACT

75.8 2.1 73.0 15.8 65.6 94.5 83.0 0.8 8.0 8.6

(70.9, 80.2) (0.9, 4.5) (63.0, 81.2) (11.9, 20.6) (61.7, 69.2) (92.4, 96.0) (80.3, 85.4) (0.4, 1.3) (7.1, 9.0) (7.7, 9.5)

Any non-artemisinin therapy

69.8 0.5 52.3 12.4 38.3 62.0 65.6 2.3 7.2 7.6

(64.2, 74.9) (0.2, 1.2) (37.9, 66.3) (9.3, 16.5) (33.8, 43.0) (57.9, 65.9) (62.2, 68.8) (1.6, 3.4) (6.5, 8.1) (6.9, 8.5)



Table A1: Availability of antimalarials, among all screened outlets, by outlet type



Private Not-For-Profit

Health Facility

ALL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=485 N=553 N=58 N=1,096 N=453 N=503 N=572 N=9,950 N=11,580 N=12,676

Sulfadoxine-Pyrimethamine

13.9 0.5 13.9 3.1 18.1 50.8 53.6 1.8 5.3 5.1

(9.7, 19.6) (0.2, 1.2) (8.0, 23.0) (2.2, 4.2) (15.7, 20.8) (47.5, 54.1) (50.1, 56.9) (1.2, 2.6) (4.7, 6.0) (4.6, 5.8)

Oral Quinine 41.5 0.0 33.5 7.3 12.0 20.2 24.6 0.1 1.9 2.3

(36.1, 47.2) - (19.1, 51.9) (5.1, 10.3) (9.6, 14.9) (16.5, 24.5) (20.2, 29.5) (0.0, 0.4) (1.6, 2.2) (2.0, 2.7)

Quinine IV/IM 54.2 0.0 41.9 9.4 22.7 11.2 10.9 0.0 1.5 2.1

(48.2, 60.1) - (26.1, 59.5) (6.8, 12.8) (19.5, 26.2) (8.6, 14.3) (7.6, 15.2) (0.0, 0.1) (1.3, 1.8) (1.8, 2.4)

Other non-artemisinin therapy

0.9 0.0 1.9 0.2 3.9 14.2 8.4 0.5 1.1 1.1

(0.4, 1.9) - (0.3, 10.2) (0.1, 0.7) (2.5, 5.9) (12.0, 16.7) (6.7, 10.6) (0.2, 1.4) (0.8, 1.7) (0.7, 1.6)

Oral artemisinin monotherapy

0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0

- - - - (0.0, 0.3) - - - - -


50.8 0.0 48.4 9.4 32.2 24.3 8.7 0.0 1.9 2.5

(45.6, 56.0) - (35.0, 62.0) (6.8, 12.9) (29.0, 35.5) (20.0, 29.2) (6.6, 11.3) (0.0, 0.1) (1.6, 2.2) (2.2, 2.8)

Injectable artemether 4.0 0.0 42.2 3.4 28.2 23.9 8.6 0.0 1.7 1.9

(2.6, 6.0) - (28.3, 57.5) (1.8, 6.2) (25.2, 31.4) (19.5, 28.8) (6.6, 11.1) (0.0, 0.1) (1.5, 2.0) (1.6, 2.2)

Injectable artesunate 49.6 0.0 11.2 6.7 6.6 4.3 1.2 0.0 0.4 0.8

(44.3, 54.9) - (6.7, 18.2) (5.0, 9.0) (5.1, 8.6) (2.6, 7.0) (0.6, 2.6) - (0.3, 0.5) (0.7, 1.0)

Injectable artemotil 0.0 0.0 0.0 0.0 1.5 5.2 0.9 0.0 0.2 0.1

- - - - (0.9, 2.3) (3.2, 8.5) (0.5, 1.6) - (0.1, 0.2) (0.1, 0.2)

Any treatment for severe malaria

74.2 0.0 61.2 13.1 43.7 26.8 15.6 0.0 2.7 3.5

(69.5, 78.4) - (48.2, 72.7) (9.9, 17.3) (40.3, 47.1) (22.3, 31.9) (12.1, 19.9) (0.0, 0.1) (2.4, 3.1) (3.1, 3.8)


At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria.




Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type


Private Not-For-Profit Health

Facility

ALL Public 1

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=457 N=43 N=517 N=342 N=487 N=535 N=252 N=1,616 N=2,133

Any ACT 83.5 96.7 86.8 92.6 99.9 92.1 27.0 77.1 78.3

(79.6, 86.8) (93.1, 98.5) (83.2, 89.8) (90.4, 94.3) (99.7, 99.9) (89.0, 94.3) (15.7, 42.5) (69.8, 83.1) (71.8, 83.7)

Artemether Lumefantrine

(AL)

83.5 96.7 86.8 90.5 97.8 90.0 27.0 75.6 76.9

(79.6, 86.8) (93.1, 98.5) (83.2, 89.8) (88.4, 92.3) (96.8, 98.5) (87.1, 92.3) (15.7, 42.5) (68.5, 81.4) (70.6, 82.2)


0.3 0.0 0.2 2.8 12.7 4.1 1.6 3.9 3.5

(0.1, 1.0) - (0.1, 0.6) (1.7, 4.7) (9.1, 17.4) (2.5, 6.8) (0.5, 4.8) (2.8, 5.6) (2.5, 4.9)


0.0 0.0 0.0 6.2 17.2 6.6 0.0 5.8 5.1

- - - (4.6, 8.3) (14.3, 20.4) (5.1, 8.4) - (4.8, 7.1) (4.2, 6.3)

DHA PPQ 2.1 23.2 8.0 31.3 76.0 36.7 2.0 30.4 27.7

(1.4, 3.2) (13.8, 36.4) (5.6, 11.2) (26.2, 36.9) (70.6, 80.7) (30.7, 43.3) (0.7, 5.2) (25.8, 35.4) (23.5, 32.3)


83.4 96.7 86.8 83.6 90.5 84.2 26.2 70.5 72.5

(79.5, 86.6) (93.1, 98.5) (83.1, 89.7) (80.7, 86.1) (88.8, 92.0) (81.8, 86.3) (15.1, 41.6) (64.4, 76.0) (66.9, 77.5)

QA AL 83.4 96.7 86.8 82.7 88.8 83.6 26.2 69.9 72.0

(79.5, 86.6) (93.1, 98.5) (83.1, 89.7) (79.7, 85.3) (87.0, 90.4) (81.2, 85.8) (15.1, 41.6) (63.8, 75.4) (66.4, 76.9)


29.8 65.3 40.2 73.5 85.9 76.1 21.4 63.0 60.3

(24.0, 36.3) (47.1, 80.0) (33.5, 47.3) (69.1, 77.4) (83.9, 87.7) (72.6, 79.4) (12.9, 33.4) (57.6, 68.2) (55.5, 64.9)


69.8 55.2 64.2 20.4 17.8 17.5 5.5 15.4 21.3

(64.0, 75.0) (37.1, 72.0) (56.7, 71.2) (17.2, 23.9) (15.1, 20.8) (15.1, 20.2) (2.2, 13.3) (13.3, 17.8) (18.5, 24.5)


70.6 56.0 63.4 36.6 45.7 37.0 11.2 31.4 35.3

(65.2, 75.4) (38.3, 72.3) (56.7, 69.5) (32.2, 41.2) (42.3, 49.2) (33.3, 40.9) (5.8, 20.5) (27.7, 35.4) (31.5, 39.3)

QA ACT – adult 42.7 80.8 56.9 68.2 80.6 71.6 18.9 58.7 58.5

(36.0, 49.6) (61.1, 91.8) (48.1, 65.2) (64.7, 71.6) (78.4, 82.5) (68.3, 74.7) (11.3, 29.7) (53.5, 63.8) (53.6, 63.2)


2.7 42.8 14.0 49.4 87.7 50.1 2.0 41.6 38.3

(1.9, 3.8) (24.3, 63.6) (7.9, 23.5) (44.8, 54.0) (84.2, 90.5) (43.2, 57.0) (0.7, 5.2) (36.0, 47.5) (33.1, 43.7)

Nationally Registered ACT 82.0 93.4 85.0 89.4 98.1 89.0 26.0 74.7 75.9

(77.4, 85.8) (87.8, 96.5) (80.8, 88.4) (87.2, 91.3) (96.9, 98.8) (86.2, 91.4) (15.1, 41.0) (67.8, 80.5) (69.8, 81.1)


75.5 66.8 66.8 52.3 64.3 70.3 80.9 67.6 67.5

(70.1, 80.2) (52.0, 79.0) (59.4, 73.4) (47.5, 57.0) (60.6, 67.9) (66.9, 73.6) (68.6, 89.1) (63.4, 71.6) (63.7, 71.1)


15.0 17.8 16.5 24.7 52.8 57.5 62.0 49.6 45.6

(10.5, 21.1) (10.2, 29.3) (12.6, 21.3) (21.7, 28.0) (49.4, 56.2) (54.0, 60.8) (48.0, 74.3) (45.5, 53.6) (41.9, 49.3)

Oral Quinine 44.9 42.8 39.2 16.3 21.0 26.4 4.0 17.8 20.4

(39.0, 50.9) (25.7, 61.8) (31.9, 47.0) (13.3, 19.8) (17.3, 25.2) (21.7, 31.7) (1.1, 13.1) (15.5, 20.4) (17.8, 23.3)

Quinine IV/IM 58.6 53.6 50.5 30.9 11.6 11.7 0.4 14.0 18.4

(52.6, 64.5) (35.8, 70.5) (42.8, 58.2) (26.9, 35.3) (9.0, 14.8) (8.2, 16.4) (0.1, 2.1) (11.7, 16.5) (15.8, 21.4)



Table A2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type


Private Not-For-Profit Health

Facility

ALL Public 1

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

ALL Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


N=457 N=43 N=517 N=342 N=487 N=535 N=252 N=1,616 N=2,133


0.9 .42 1.2 5.3 14.7 9.1 17.9 10.7 9.6

(0.4, 2.0) (0.4, 12.9) (0.4, 3.4) (3.5, 7.8) (12.5, 17.3) (7.2, 11.3) (7.3, 37.6) (7.2, 15.7) (6.4, 14.0)


0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0

- - - (0.1, 0.4) - - - (0.0, 0.1) (0.0, 0.1)


54.9 61.9 50.7 43.9 25.3 9.3 0.8 17.8 21.8

(49.0, 60.7) (46.9, 74.9) (43.9, 57.6) (39.8, 48.1) (21.1, 30.0) (7.1, 12.2) (0.3, 2.4) (15.3, 20.6) (19.3, 24.5)

Injectable artemether 4.3 54.0 18.2 38.4 24.8 9.2 0.8 16.2 16.5

(2.8, 6.5) (37.8, 69.3) (11.2, 28.1) (34.9, 42.1) (20.5, 29.6) (7.0, 11.9) (0.3, 2.4) (14.0, 18.8) (14.3, 18.9)

Injectable artesunate 53.6 14.4 36.2 9.0 4.4 1.3 0.0 3.3 7.3

(47.7, 59.5) (8.3, 23.6) (29.8, 43.2) (6.9, 11.8) (2.7, 7.2) (0.6, 2.8) - (2.4, 4.5) (6.1, 8.7)

Injectable artemotil 0.0 0.0 0.0 2.0 5.4 1.0 0.0 1.4 1.3

- - - (1.3, 3.3) (3.3, 8.8) (0.6, 1.7) - (0.9, 2.2) (0.8, 1.9)


80.2 78.2 70.6 59.6 27.9 16.8 1.2 25.2 30.7

(75.6, 84.1) (65.3, 87.2) (63.2, 77.0) (55.3, 63.7) (23.5, 32.7) (13.0, 21.4) (0.4, 3.1) (22.1, 28.6) (27.5, 34.2)

1 This includes 17 CHWs

* Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. There were 67 antimalarial stocking outlets with partially completed interviews. The denominator includes only completed interviews.

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria.




Table A3: Antimalarial market composition

Outlet type, among outlets with at least 1 antimalarial in stock on the day of the survey:*



Private Not- For-Profit

Facility

ALL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

% % % % % % % % %

N=1,501 outlets 9.5 1.3 3.3 14.0 21.4 11.8 33.0 19.8 86.0

(7.9, 11.4) (0.6, 2.5) (2.3, 4.7) (11.7, 16.8) (19.3, 23.6) (8.6, 16.0) (28.3, 38.0) (14.5, 26.4) (83.2, 88.3)

* Excluding booster sample outlets. Outlets with at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.




Table A4a: Price of tablet formulation antimalarials, by outlet type

Private

For-Profit Facility

Registered Pharmacy Unregistered Pharmacy General Retailer ALL

Private

Median price of a tablet AETD*: Median [IQR]

(N of Antimalarials)

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Any ACT $2.25 $3.38 $2.25 $1.69 $2.25

[1.35-4.51] (655) [1.58-5.63] (2,115) [1.20-4.51] (1,432) [1.13-3.38] (84) [1.35-4.51] (4,286)

Artemether Lumefantrine (AL) $1.69 $1.69 $1.69 $1.35 $1.69

[1.13-3.15] (476) [1.13-2.82] (1,116) [1.13-2.25] (961) [1.13-1.69] (73) [1.13-2.25] (2,626)

Artesunate sulfadoxine pyrimethamine (ASSP)

$5.63 $5.63 $5.07 $9.91 $5.63

[5.07-6.20] (12) [5.07-6.08] (76) [4.51-7.88] (19) [8.56-11.26] (2) [5.07-7.88] (109)

DHA PPQ $3.94 $4.28 $4.51 $5.07 $4.51

[3.38-5.07] (115) [3.38-5.63] (569) [3.94-5.63] (291) [3.38-5.63] (6) [3.38-5.63] (981)

Quality assured ACT (QA ACT) $1.69 $1.35 $1.35 $1.20 $1.50

[1.13-2.25] (433) [1.13-1.80] (889) [1.13-1.80] (818) [1.13-1.69] (69) [1.13-2.25] (2,209)

QA ACT with ‘green leaf’ logo $1.69 $1.35 $1.35 $1.13 $1.50

[1.13-2.25] (360) [1.13-1.80] (784) [1.13-1.80] (725) [1.13-1.69] (61) [1.13-2.25] (1,930)

QA ACT without the ‘green leaf’ logo $1.69 $1.20 $1.35 $1.69 $1.35

[1.13-2.25] (71) [1.13-1.80] (105) [1.13-1.69] (92) [1.13-1.69] (8) [1.13-1.69] (276)

QA AL $1.69 $1.35 $1.35 $1.20 $1.50

[1.13-2.25] (410) [1.13-1.80] (809) [1.13-1.80] (781) [1.13-1.69] (69) [1.13-2.25] (2,069)

Non-quality-assured ACT (non-QA ACT) $4.51 $4.82 $4.51 $5.63 $4.51

[3.38-5.63] (222) [3.38-9.08] (1,226) [3.49-7.88] (614) [3.38-11.26] (15) [3.38-7.21] (2,077)

Sulfadoxine-Pyrimethamine $0.56 $0.68 $0.56 $0.34 $0.56

[0.45-1.13] (97) [0.56-1.69] (480) [0.56-1.13] (481) [0.34-0.45] (195) [0.39-0.90] (1,253)

Quinine $4.73 $3.78 $4.26 $1.14 $4.26

[2.37-7.10] (13) [3.31-4.73] (51) [2.37-4.73] (30) (1) [2.37-4.73] (95)

* AETD - adult equivalent treatment dose - is or the number of milligrams required to treat a 60kg adult (see Annex 11). Information provided by the respondent about price for a specific amount of antimalarial drug (e.g. price per tablet or price per specific package size) was converted to the price per AETD.

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was the first-line treatment for uncomplicated malaria. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows:

73 any ACT tablets, 47 artemether lumefantrine tablets, 2 artesunate sulfadoxine pyrimethamine tablets, 46 QA ACT tablets, 41 QA ACT AL tablets, 27 non-QA ACT tablets, 7 sulfadoxine pyrimethamine tablets, 1 quinine tablet.




Table A4b: Price of pre-packaged antimalarials, by outlet type

Private

For-Profit Facility


Private

Median price of one pre-packaged therapy:

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Adult QA AL $1.58 $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (240) [1.13-1.69] (452) [1.13-1.69] (460) [1.13-1.69] (42) [1.13-1.69] (1,194)

Pediatric QA AL * $0.56 $0.56 $0.56 $0.56 $0.56

[0.56-1.13] (65) [0.45-0.90] (161) [0.56-0.79] (131) [0.56-1.13] (6) [0.56-1.13] (363)

* Pediatric QA AL is the pre-packaged regimen appropriate for a 2 year old child. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows:

27 adult QA AL, 5 child QA AL.




Table A5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type


ALL Public1

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets*** stocking

N=471 N=573 N=375 N=490 N=556 N=405 N=1,826 N=2,399

Any malaria blood testing

94.0 73.0 74.3 21.0 16.1 0.0 25.2 31.6

(90.1, 96.4) (53.0, 86.7) (70.1, 78.0) (18.0, 24.3) (13.1, 19.7) - (21.3, 29.5) (28.0, 35.4)

N=470 N=571 N=375 N=490 N=555 N=403 N=1,823 N=2,394

Microscopic blood tests

60.9 47.3 61.1 8.2 5.7 0.0 17.4 21.5

(56.8, 64.9) (33.5, 61.6) (56.7, 65.4) (6.5, 10.4) (4.1, 7.7) - (14.8, 20.5) (18.7, 24.4)

N=470 N=571 N=375 N=490 N=555 N=403 N=1,823 N=2,394

Rapid diagnostic tests (RDTs)

68.2 51.7 29.2 15.0 12.3 0.0 12.6 17.8

(62.7, 73.3) (39.7, 63.5) (25.7, 33.0) (11.8, 18.9) (10.2, 14.8) - (10.5, 15.0) (15.7, 20.1)

N=469 N=570 N=374 N=490 N=555 N=403 N=1,822 N=2,392

Checkmark RDTs 0.1 0.3 0.5 1.3 0.0 0.0 0.2 0.2

(0.0, 0.2) (0.1, 1.3) (0.2, 1.1) (0.6, 3.1) - - (0.1, 0.4) (0.1, 0.4)

1 This includes 52 CHWs and 50 Private not-For-Profit outlets

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. *** Results in this table are derived using responses captured among outlets with blood testing information. There were 6 antimalarial-stocking outlets that had missing information about both

availability of microscopy and availability of RDTs. There were 18 antimalarial-stocking outlets that had partial information about blood testing availability.




Table A6: Malaria blood testing market composition

Outlet type, among outlets with malaria blood testing available on the day of the survey:*




Facility

ALL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

% % % % % % % % %

N=631 outlets 22.4 4.5 8.0 34.9 47.2 4.6 13.3 - 65.1

(18.7, 26.6) (2.1, 9.1) (5.5, 11.4) (29.7, 40.4) (43.0, 51.4) (3.4, 6.2) (10.4, 16.9) - (59.6, 70.3)

* Excluding booster sample outlets. Outlets with malaria blood testing available on the day of the survey, verified by presence of at least one RDT recorded in the RDT audit sheet and/or reported availability of malaria microscopy.




Table A7: Price of malaria blood testing, by outlet type

Private For-Profit

Facility Registered Pharmacy Unregistered Pharmacy

ALL Private

Total median price to consumers:*

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]



Adult $1.13 $1.13 $1.13 $1.13

[0.56-1.13] (263) [1.13-1.13] (55) [1.13-1.13] (30) [0.56-1.13] (348)

Child under age five

$1.13 $1.13 $1.13 $1.13

[0.56-1.13] (263) [1.13-1.13] (55) [1.13-1.13] (30) [0.56-1.13] (348)


Adult $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (134) [1.13-1.13] (55) [1.13-1.69] (59) [1.13-1.69] (248)

Child under five $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (133) [1.13-1.13] (53) [1.13-1.13] (59) [1.13-1.69] (245)

Median price excluding fees:**


Adult $0.17 $0.90 $0.68 $0.68

(1) [0.56-1.69] (13) [0.56-1.13] (21) [0.56-1.13] (35)

Child under five $0.17 $0.68 $0.68 $0.68

(1) [0.56-1.69] (12) [0.56-1.13] (21) [0.56-1.13] (34)



Table A8: Antimalarial market share

AETDs sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold / distributed:*


TOTAL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer TOTAL Private

ANTI-MALARIAL TOTAL***

% % % % % % % %

1. Any ACT 7.5 10.0 9.6 27.4 20.8 2.3 60.0 70.0

Artemether Lumefantrine (AL) 7.4 9.6 8.3 21.0 17.8 2.1 49.2 58.8

DHA PPQ 0.0 0.4 0.8 4.8 2.2 0.2 7.9 8.3

Quality Assured ACT (QA ACT) 7.4 9.4 6.9 17.4 16.3 1.8 42.3 51.7

QA ACT with the ‘green leaf’ logo 3.8 4.8 5.5 14.1 14.1 1.4 35.1 39.9

QA ACT without the ‘green leaf’ logo 3.6 4.6 1.4 3.2 2.2 0.4 7.2 11.8

Non-quality-assured ACT 0.1 0.6 2.7 10.0 4.5 0.5 17.7 18.3

Nationally Registered ACT 7.2 9.6 8.7 21.7 18.1 2.0 50.5 60.0

2. Any non-artemisinin therapy 1.8 2.1 1.8 12.6 9.5 2.6 26.5 28.6

Sulfadoxine-Pyrimethamine 1.4 1.5 1.6 11.8 9.0 2.5 24.9 26.4

Oral Quinine 0.2 0.4 0.0 0.2 0.1 0.0 0.4 0.8

Quinine IV/IM 0.2 0.2 0.1 0.2 0.1 0.0 0.4 0.6

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

4. Non-oral artemisinin monotherapy 0.1 0.2 0.3 0.6 0.2 0.0 1.2 1.4

Injectable artesunate 0.1 0.1 0.1 0.0 0.1 0.0 0.2 0.3

Injectable artemether 0.0 0.1 0.3 0.6 0.1 0.0 1.0 1.1

Injectable artemotil 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

5. Any treatment for severe malaria 0.3 0.4 0.5 0.8 0.3 0.0 1.6 2.0

OUTLET TYPE TOTAL**** 9.4 12.3 11.7 40.6 30.5 4.9 87.7 100.0

* A total of 35,645.28 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

*** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 6,651 antimalarials were audited. Of these, 325 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.




Table A9: Antimalarial market share across outlet type

AETDs sold or distributed in the previous week by antimalarial type as

a percentage of all AETDs sold / distributed within each outlet type:*


TOTAL Public

Private For-Profit

Facility

Registered Pharmacy


General Retailer

TOTAL Private

% % % % % % %

1. Any ACT 79.5 81.2 81.7 67.4 68.1 46.7 68.4

Artemether Lumefantrine (AL) 79.0 78.2 71.3 51.7 58.2 42.6 56.1

Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.6 0.6 0.3 0.2 0.5

DHA PPQ 0.5 2.9 6.9 11.7 7.3 3.1 9.0

Quality Assured ACT (QA ACT) 78.9 76.6 58.9 42.8 53.3 36.0 48.2

QA ACT with the ‘green leaf’ logo 41.0 39.2 47.3 34.8 46.1 28.5 40.0

QA ACT without the ‘green leaf’ logo 37.9 37.3 11.6 8.0 7.2 7.5 8.2

Non-quality-assured ACT 0.6 4.7 22.7 24.6 14.9 10.7 20.2

Nationally Registered ACT 76.8 77.7 74.3 53.4 59.4 40.7 57.6

2. Any non-artemisinin therapy 19.4 17.0 15.3 31.1 31.1 53.3 30.2

Sulfadoxine-Pyrimethamine 15.4 12.1 13.4 29.2 29.4 51.8 28.4

Oral Quinine 1.9 3.1 0.4 0.5 0.4 0.0 0.4

Quinine IV/IM 1.8 1.6 0.9 0.5 0.3 0.0 0.5

3. Oral artemisinin monotherapy 0.0 0.0 0.1 0.0 0.0 0.0 0.0

4. Non-oral artemisinin monotherapy 1.1 1.7 2.9 1.5 0.7 0.0 1.3

Injectable artesunate 1.0 0.8 0.5 0.0 0.2 0.0 0.2

Injectable artemether 0.1 0.9 2.1 1.4 0.5 0.0 1.1

Injectable artemotil 0.0 0.0 0.2 0.0 0.0 0.0 0.0

5. Any treatment for severe malaria 2.9 3.3 3.9 2.0 1.0 0.0 1.8

OUTLET TYPE TOTAL**** 100 100 100 100 100 100 100

* AETDs reportedly sold or distributed in the previous seven days: 2,883.8 public health facilities; 86.5 community health workers; 839.0 private not for-profit facilities; 4,077.4 private for-profit facilities; 15,788.6 registered pharmacies; 10,777.1 unregistered pharmacies; 1,192.9 general retailers. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

At the time of the 2014 Kenya ACTwatch outlet survey, artesunate amodiaquine was Kenya's first line treatment for uncomplicated malaria. Categories 1 through 4 sum to 100% within each column. A total of 6,651 antimalarials were audited. Of these, 325 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 27 public health facilities; 1 community health worker; 1 private not for-profit facility; 80 private for-profit facilities; 61 registered pharmacies; 123 unregistered pharmacies, 32 general retailers.




Table A10: Malaria blood testing market share

Number of malaria blood tests provided in the previous week by outlet type and blood test type as a percentage of all blood tests provided:*


TOTAL Public

Private For-Profit

Facility

Registered Pharmacy



BLOOD TEST TOTAL***

% % % % % % % %

1. Malaria microscopy 31.4 37.3 36.0 0.8 1.3 0.0 38.1 75.4

2. RDT 14.8 15.9 6.4 0.4 1.9 0.0 8.7 24.6


* A total of 16,815 malaria microscopy tests and 4,536 RDTs were reportedly administered in the previous seven days. *** Row sum – market share for the specified type of blood testing medicine. **** Column sum – market share for the specified outlet type. Categories 1 and 2 sum to 100% in the far-right column – malaria blood testing total column. A total of 788 malaria blood tests were audited. Of these, 22 malaria microscopy tests and 8 RDTs were not included in market share calculations due to incomplete or inconsistent information.




Table A11: Malaria blood testing market share, across outlet type

Number of malaria blood tests provided in the previous week by blood test type as a percentage of all blood tests provided within each outlet type:*


TOTAL Public /

Private For-Profit

Facility

Registered Pharmacy



BLOOD TEST TOTAL***

% % % % % % % %

Total blood testing market

1. Malaria microscopy 68.0 70.1 84.9 65.4 41.5 0.0 81.5 75.4

2. RDT 32.0 29.9 15.1 34.6 58.5 0.0 18.5 24.6

Malaria RDT market

ACCESS BIO INC. 99.1 99.1 54.1 78.7 95.8 0.0 64.2 86.8

STANDARD DIAGNOSTICS INC. 0.5 0.5 25.8 2.4 1.1 0.0 19.3 7.2

CTK BIOTECH INC. 0.0 0.0 0.5 8.1 0.4 0.0 0.8 0.3

Other 0.3 0.4 14.4 10.8 2.8 0.0 11.7 4.4

Unknown 0.0 0.0 5.3 0.0 0.0 0.0 3.9 1.4

Checkmark RDT 0.0 0.0 0.7 6.0 0.0 0.0 0.8 0.3

* 21,351 malaria blood tests reportedly administered in the previous seven days: 9,250 public health facilities; 55 community health workers; 1,310 private not for-profit facilities; 9,712 private for-profit facilities; 340 registered pharmacies; 684 unregistered pharmacies.

*** Categories 1 through 2 sum to 100% in within each column.

The manufacturer information was missing for 8 RDTs audited. A total of 788 malaria blood tests were audited. Of these, 22 malaria microscopy tests and 8 RDTs were not included in market share calculations due to incomplete or inconsistent information.




Table A12: Provider case management knowledge and practices, by outlet type


ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

Proportion of providers who: %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Would refer a 2 year old child with symptoms of severe malaria to a health facility

- N=59 - N=490 N=550 N=403 N=1,443 N=1,502

Yes, would refer to health facility

NA 92.0

NA 90.6 84.9 88.4 87.0 87.3

(79.5, 97.1) (87.8, 92.9) (82.0, 87.4) (83.8, 91.8) (84.5, 89.1) (85.0, 89.4)

Would recommend that a client with a negative malaria blood test take an antimalarial

N=457 N=561 N=360 N=429 N=457 N=143 N=1,389 N=1,950

Yes – sometimes 21.3 21.8 30.6 30.0 30.0 11.2 27.1 26.1

(17.9, 25.2) (15.7, 29.3) (27.3, 34.2) (27.0, 33.3) (26.7, 33.5) (7.8, 15.8) (25.0, 29.2) (23.8, 28.6)

Yes – always 4.7 3.4 6.1 2.7 2.2 7.3 4.3 4.2

(3.2, 7.0) (2.4, 4.6) (4.1, 8.9) (1.9, 3.8) (1.2, 3.7) (3.0, 16.7) (3.2, 5.9) (3.1, 5.5)

Circumstances cited for recommending antimalarial treatment to a client who tested negative for malaria:*

N=103 N=130 N=130 N=126 N=146 N=24 N=426 N=556

Patient has signs and symptoms of malaria.

98.6 94.9 88.6 90.6 86.2 70.7 86.1 87.4

(96.3, 99.4) (90.0, 97.5) (84.7, 91.6) (86.6, 93.5) (82.8, 89.0) (49.0, 85.8) (82.9, 88.7) (84.4, 89.9)

Provider doesn't trust the test results.

19.4 16.3 7.6 11.6 15.8 24.4 13.1 13.6

(12.9, 28.1) (9.9, 25.8) (5.3, 10.7) (8.1, 16.4) (11.8, 21.0) (6.4, 60.6) (9.8, 17.3) (10.5, 17.4)

When the patient asks for antimalarial treatment.

8.4 3.9 4.0 10.1 7.0 2.0 5.7 5.4

(5.0, 13.8) (2.1, 6.9) (2.3, 6.8) (7.3, 13.7) (5.1, 9.5) (0.6, 6.2) (4.2, 7.5) (4.1, 7.0)

Other (all other reasons) 81.1 74.4 87.6 83.8 77.9 89.3 83.3 82.0

(65.4, 90.7) (57.6, 86.2) (81.2, 92.0) (74.2, 90.4) (65.9, 86.6) (75.6, 95.8) (76.1, 88.7) (74.4, 87.7)

Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria.




Table A13: Provider antimalarial treatment knowledge and practices, by outlet type


ALL Public 1

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: N=471 N=573 N=375 N=492 N=557 N=408 N=1,832 N=2,405 Correctly state the national

first-line treatment for uncomplicated malaria

98.7 96.1 92.8 96.2 91.0 29.3 71.5 74.8

(97.5, 99.3) (93.9, 97.5) (90.9, 94.3) (93.9, 97.6) (88.9, 92.7) (22.9, 36.6) (64.4, 77.7) (68.4, 80.3)

Correctly state the first-line dosing regimen for:

An adult 95.9 88.4 87.8 89.9 86.2 17.3 64.2 67.4

(92.9, 97.7) (84.1, 91.6) (85.7, 89.7) (87.9, 91.6) (83.8, 88.3) (12.9, 22.6) (57.0, 70.8) (61.0, 73.3)

A two-year old child 87.8 79.1 73.0 81.1 73.9 10.1 53.2 56.7

(84.4, 90.6) (72.4, 84.4) (69.4, 76.3) (78.6, 83.3) (70.6, 76.9) (7.0, 14.3) (47.0, 59.3) (51.0, 62.2)

Report an ACT as the most effective antimalarial medicine for:

Adults 96.7 93.9 89.2 95.0 87.6 29.1 69.3 72.6

(94.6, 98.0) (90.6, 96.2) (86.7, 91.3) (93.3, 96.2) (85.7, 89.3) (19.7, 40.7) (61.2, 76.4) (65.3, 78.9)

Children 94.7 91.6 87.3 96.3 85.6 21.9 65.8 69.3

(92.6, 96.3) (88.6, 93.8) (84.5, 89.6) (94.8, 97.4) (83.0, 87.8) (14.4, 31.8) (57.7, 73.2) (62.1, 75.7)

Report an ACT as the antimalarial he/she most commonly recommends for:

Adults 98.5 95.8 93.1 94.2 85.7 26.3 68.6 72.3

(96.3, 99.4) (93.2, 97.4) (91.2, 94.6) (92.2, 95.7) (83.3, 87.9) (17.0, 38.3) (60.2, 75.9) (64.6, 78.8)

Children 98.0 95.8 87.7 95.0 82.8 20.6 64.4 68.7

(95.7, 99.1) (92.6, 97.6) (85.3, 89.7) (92.8, 96.6) (79.6, 85.5) (13.5, 30.2) (56.5, 71.6) (61.4, 75.1)

1 This includes 52 community health workers and 50 private not-for profit outlets

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was Kenya's first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. 20 providers had missing information on the national first-line treatment, 19 on the first-line dosing regimen for adults and children, 18 on the most effective antimalarial medicine for adults and children and 19 on the most often recommended antimalarial for adults and children.




Results Section B: Core Indicators across Urban/Rural Location

Table B1: Availability of antimalarials, among all screened outlets, by outlet type, across urban/rural location



ALL Public / Not- For-Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


Urban N=182 Rural N=303






Urban N=6,342 Rural N=3,608




Urban 84.4 77.7 15.8 72.8 96.2 93.3 1.4 11.5 11.7

(78.4, 89.0) (69.4, 84.3) (11.5, 21.3) (66.9, 78.1) (93.9, 97.6) (91.8, 94.5) (1.0, 1.9) (10.5, 12.5) (10.7, 12.8)

Rural 98.5 78.7 21.2 74.9 97.8 93.0 5.3 9.3 10.5

(96.9, 99.2) (59.5, 90.3) (13.6, 31.6) (65.3, 82.6) (87.9, 99.6) (87.3, 96.2) (3.6, 7.8) (7.6, 11.4) (8.9, 12.5)

Any ACT

Urban 72.3 72.7 13.2 68.1 96.1 86.8 0.4 10.1 10.3

(64.5, 78.9) (63.8, 80.1) (9.4, 18.2) (63.2, 72.7) (93.8, 97.5) (83.9, 89.3) (0.3, 0.7) (9.1, 11.2) (9.3, 11.3)

Rural 80.9 78.7 18.9 67.1 97.8 81.7 1.3 5.1 6.5

(75.2, 85.6) (59.5, 90.3) (12.0, 28.5) (57.5, 75.3) (87.9, 99.6) (71.9, 88.6) (0.6, 3.0) (4.0, 6.5) (5.2, 8.1)

Artemether Lumefantrine (AL)

Urban 72.3 72.7 13.2 66.6 94.2 84.9 0.4 9.9 10.1

(64.5, 78.9) (63.8, 80.1) (9.4, 18.2) (61.9, 71.0) (91.4, 96.1) (82.1, 87.3) (0.3, 0.7) (8.9, 10.9) (9.1, 11.1)

Rural 80.9 78.7 18.9 65.4 94.9 79.8 1.3 5.0 6.4

(75.2, 85.6) (59.5, 90.3) (12.0, 28.5) (55.5, 74.2) (83.2, 98.6) (70.2, 86.8) (0.6, 3.0) (3.9, 6.4) (5.1, 8.0)


Urban 0.3 0.0 0.0 1.9 12.8 4.4 0.1 0.6 0.6

(0.1, 0.8) - (0.0, 0.1) (1.0, 3.3) (9.1, 17.9) (2.5, 7.7) (0.0, 0.2) (0.4, 0.9) (0.4, 0.8)

Rural 0.3 0.0 0.0 2.7 3.8 1.4 0.0 0.1 0.1

(0.1, 1.9) - (0.0, 0.3) (1.0, 7.0) (1.1, 12.4) (0.4, 4.7) - (0.1, 0.2) (0.1, 0.2)


Urban 0.0 0.0 0.0 5.3 17.2 6.2 0.0 0.9 0.8

- - - (3.9, 7.4) (14.1, 20.9) (5.1, 7.5) - (0.7, 1.0) (0.7, 1.0)

Rural 0.0 0.0 0.0 1.7 6.5 5.8 0.0 0.2 0.2

- - - (0.5, 6.1) (2.6, 15.1) (1.9, 16.1) - (0.1, 0.5) (0.1, 0.5)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











DHAPPQ

Urban 3.9 23.2 2.1 24.4 74.1 36.4 0.1 4.4 4.3

(2.5, 6.0) (15.0, 34.0) (1.3, 3.4) (20.6, 28.6) (67.5, 79.7) (30.0, 43.4) (0.0, 0.2) (3.8, 5.2) (3.7, 5.0)

Rural 0.5 12.9 0.9 17.9 61.0 25.4 0.0 1.2 1.2

(0.1, 2.8) (5.0, 29.5) (0.4, 2.1) (12.0, 25.8) (43.8, 75.8) (14.6, 40.5) (0.0, 0.2) (0.8, 1.8) (0.8, 1.7)


Urban 72.0 72.7 13.2 60.0 86.7 78.7 0.4 9.0 9.3

(64.3, 78.6) (63.8, 80.1) (9.4, 18.2) (55.4, 64.5) (84.3, 88.8) (76.5, 80.7) (0.2, 0.7) (8.2, 10.0) (8.4, 10.3)

Rural 80.9 78.7 18.9 65.4 93.3 77.8 1.3 4.9 6.3

(75.2, 85.6) (59.5, 90.3) (12.0, 28.5) (55.5, 74.2) (81.8, 97.7) (67.7, 85.4) (0.6, 3.0) (3.8, 6.3) (5.1, 7.9)

QA AL

Urban 72.0 72.7 13.2 59.4 85.0 78.2 0.4 9.0 9.2

(64.3, 78.6) (63.8, 80.1) (9.4, 18.2) (54.9, 63.7) (82.4, 87.2) (75.9, 80.3) (0.2, 0.7) (8.1, 9.9) (8.3, 10.2)

Rural 80.9 78.7 18.9 64.9 93.3 76.9 1.3 4.9 6.3

(75.2, 85.6) (59.5, 90.3) (12.0, 28.5) (55.0, 73.6) (81.8, 97.7) (67.2, 84.4) (0.6, 3.0) (3.8, 6.3) (5.0, 7.9)


Urban 30.7 47.9 7.0 52.8 82.6 71.8 0.4 8.2 8.1

(22.5, 40.3) (39.1, 56.9) (4.6, 10.7) (48.9, 56.6) (80.3, 84.7) (68.8, 74.6) (0.2, 0.6) (7.4, 9.0) (7.3, 9.0)

Rural 25.2 54.5 7.9 57.7 84.1 67.7 1.0 4.2 4.6

(18.3, 33.7) (27.3, 79.2) (4.2, 14.3) (45.9, 68.7) (70.2, 92.2) (53.9, 78.9) (0.5, 2.3) (3.2, 5.6) (3.5, 6.0)


Urban 58.4 31.3 8.5 16.2 16.9 15.3 0.1 2.0 2.3

(51.7, 64.8) (22.5, 41.8) (6.0, 11.7) (13.2, 19.7) (14.0, 20.2) (13.2, 17.8) (0.0, 0.2) (1.7, 2.3) (2.1, 2.6)

Rural 69.1 55.6 15.2 10.7 21.3 20.5 0.3 1.1 2.5

(60.3, 76.7) (27.6, 80.4) (9.4, 23.7) (5.9, 18.5) (12.9, 33.1) (13.8, 29.4) (0.1, 1.1) (0.7, 1.5) (1.8, 3.5)


Urban

59.4 31.0 8.5 27.9 44.1 34.6 0.2 4.1 4.4

(49.7, 68.4) (23.0, 40.4) (5.8, 12.3) (25.0, 31.0) (40.5, 47.8) (31.6, 37.8) (0.1, 0.3) (3.7, 4.6) (4.0, 4.8)

Rural

69.7 57.1 14.8 23.2 42.7 34.1 0.6 2.0 3.3

(62.8, 75.7) (29.8, 80.7) (9.1, 23.3) (14.1, 35.7) (31.2, 55.0) (21.8, 49.1) (0.2, 1.5) (1.3, 3.1) (2.4, 4.6)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











QA ACT - adults

Urban

37.9 66.1 9.1 49.5 77.0 67.4 0.3 7.7 7.8

(29.5, 47.1) (55.8, 75.0) (6.3, 13.0) (44.3, 54.8) (74.1, 79.7) (64.6, 70.1) (0.2, 0.6) (6.8, 8.7) (6.9, 8.7)

Rural 40.6 60.1 12.0 51.7 85.6 63.8 0.9 3.9 4.7

(31.4, 50.5) (32.6, 82.5) (6.6, 20.6) (40.0, 63.2) (71.2, 93.4) (52.8, 73.5) (0.4, 2.0) (3.0, 4.9) (3.7, 5.9)


Urban 4.7 23.2 2.2 39.5 85.6 50.6 0.1 6.1 5.9

(3.2, 6.8) (15.0, 34.0) (1.4, 3.5) (36.4, 42.8) (80.8, 89.4) (43.5, 57.6) (0.0, 0.2) (5.4, 7.0) (5.2, 6.8)

Rural 0.8 44.2 3.0 24.9 67.7 30.8 0.0 1.5 1.7

(0.2, 2.8) (18.1, 74.0) (0.9, 9.2) (18.5, 32.7) (50.7, 81.0) (19.3, 45.3) (0.0, 0.2) (1.1, 2.1) (1.2, 2.3)


Urban 72.1 70.2 13.0 65.3 94.4 83.9 0.4 9.7 9.9

(64.3, 78.7) (62.1, 77.2) (9.3, 17.9) (60.9, 69.5) (92.1, 96.0) (81.3, 86.2) (0.3, 0.7) (8.8, 10.7) (9.0, 10.9)

Rural 78.6 76.0 18.4 66.4 95.7 79.3 1.3 5.0 6.3

(71.8, 84.2) (56.6, 88.5) (11.7, 27.8) (57.2, 74.6) (77.2, 99.3) (69.6, 86.5) (0.6, 2.9) (3.9, 6.3) (5.1, 7.9)


Urban 60.9 43.7 10.5 36.8 61.0 63.7 1.0 7.2 7.4

(53.0, 68.2) (34.6, 53.2) (7.7, 14.1) (32.0, 41.8) (56.7, 65.2) (60.6, 66.7) (0.7, 1.5) (6.5, 8.1) (6.7, 8.2)

Rural 76.4 61.2 14.2 43.6 75.3 73.1 4.5 7.2 7.9

(69.0, 82.5) (35.5, 81.9) (8.7, 22.4) (31.6, 56.4) (62.8, 84.6) (61.1, 82.5) (2.9, 6.9) (5.6, 9.3) (6.4, 9.8)


Urban 12.4 18.4 3.6 17.4 50.2 51.9 0.8 5.3 5.2

(8.2, 18.3) (11.5, 28.2) (2.4, 5.3) (14.8, 20.3) (46.6, 53.7) (49.2, 54.6) (0.5, 1.4) (4.7, 6.0) (4.6, 5.9)

Rural 15.0 9.2 2.6 20.7 60.3 60.4 3.3 5.3 5.0

(8.7, 24.7) (2.2, 30.8) (1.6, 4.3) (14.7, 28.3) (50.4, 69.5) (46.5, 72.8) (2.1, 5.3) (4.0, 6.9) (3.8, 6.5)

Oral Quinine

Urban 35.0 22.0 5.3 11.4 19.5 20.6 0.0 2.1 2.2

(28.3, 42.3) (14.5, 32.1) (4.0, 7.0) (9.5, 13.6) (15.6, 24.1) (17.4, 24.3) (0.0, 0.1) (1.8, 2.4) (2.0, 2.6)

Rural 46.4 45.5 9.2 14.0 30.5 40.7 0.2 1.6 2.4

(38.4, 54.5) (20.8, 72.6) (5.2, 15.8) (6.6, 27.2) (19.1, 45.0) (27.4, 55.6) (0.1, 1.1) (1.1, 2.4) (1.7, 3.3)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Quinine IV/IM

Urban 43.8 31.5 6.9 22.3 9.7 7.4 0.0 1.6 1.9

(36.0, 51.8) (22.5, 42.2) (5.0, 9.5) (19.4, 25.4) (7.3, 12.7) (4.9, 11.1) - (1.4, 1.9) (1.6, 2.3)

Rural 62.0 52.7 11.7 24.0 31.6 24.8 0.0 1.3 2.3

(53.7, 69.6) (25.1, 78.8) (7.0, 19.0) (14.7, 36.6) (18.7, 48.3) (16.6, 35.4) (0.0, 0.2) (0.9, 1.9) (1.8, 3.1)


Urban 2.0 0.0 0.2 4.6 14.6 9.0 0.2 1.1 1.1

(0.9, 4.2) - (0.1, 0.5) (3.0, 7.2) (12.3, 17.4) (7.3, 11.0) (0.1, 0.3) (0.9, 1.4) (0.9, 1.3)

Rural 0.0 3.8 0.2 1.2 7.5 6.3 1.0 1.2 1.1

- (0.6, 21.1) (0.0, 1.5) (0.2, 6.6) (2.6, 19.6) (2.5, 15.4) (0.3, 3.5) (0.4, 3.5) (0.4, 3.2)


Urban 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0

- - - (0.0, 0.4) - - - - -

Rural 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

- - - - - - - - -


Urban 46.2 46.6 8.3 35.5 24.5 9.1 0.0 2.6 2.9

(40.9, 51.5) (38.1, 55.2) (6.0, 11.3) (32.6, 38.5) (19.8, 29.8) (6.7, 12.2) (0.0, 0.1) (2.2, 3.0) (2.5, 3.3)

Rural 54.2 50.4 10.5 20.8 22.3 7.2 0.0 0.7 1.7

(45.9, 62.3) (26.0, 74.5) (6.1, 17.5) (13.2, 31.2) (13.5, 34.5) (3.3, 14.9) - (0.5, 1.1) (1.3, 2.2)

Injectable artemether

Urban 6.4 34.4 3.2 31.2 24.0 8.9 0.0 2.4 2.4

(4.6, 8.9) (25.7, 44.3) (1.9, 5.3) (28.1, 34.5) (19.3, 29.4) (6.6, 11.8) (0.0, 0.1) (2.1, 2.7) (2.1, 2.8)

Rural 2.2 50.4 3.6 17.7 22.3 7.2 0.0 0.6 0.9

(0.7, 6.6) (26.0, 74.5) (1.2, 10.0) (12.4, 24.7) (13.5, 34.5) (3.3, 14.9) - (0.4, 1.0) (0.6, 1.4)

Injectable artesunate

Urban 43.9 22.0 6.2 7.6 4.4 1.6 0.0 0.5 0.8

(38.6, 49.4) (13.5, 33.7) (4.5, 8.5) (6.2, 9.4) (2.5, 7.4) (0.7, 3.4) - (0.4, 0.7) (0.7, 1.0)

Rural 53.8 0.0 7.2 3.1 2.7 0.0 0.0 0.1 0.8

(45.4, 62.1) - (4.4, 11.6) (0.5, 16.4) (0.5, 12.8) - - (0.0, 0.4) (0.6, 1.1)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Injectable artemotil

Urban 0.0 0.0 0.0 1.9 5.4 1.1 0.0 0.2 0.2

- - - (1.2, 3.1) (3.2, 9.1) (0.6, 2.1) - (0.1, 0.4) (0.1, 0.4)

Rural 0.0 0.0 0.0 0.0 2.4 0.0 0.0 0.0 0.0

- - - - (0.4, 13.7) - - - -


Urban 64.4 54.3 10.8 45.2 26.0 13.1 0.0 3.3 3.7

(58.5, 69.9) (44.6, 63.7) (7.9, 14.5) (42.5, 48.1) (21.3, 31.4) (9.8, 17.3) (0.0, 0.1) (2.9, 3.7) (3.3, 4.2)

Rural 81.4 68.3 15.3 38.3 38.1 25.9 0.0 1.7 3.0

(74.7, 86.6) (45.3, 84.9) (9.5, 23.8) (27.4, 50.6) (23.7, 54.9) (17.8, 36.1) (0.0, 0.2) (1.2, 2.3) (2.5, 3.7)


** The denominator includes 553 community health workers. Urban: 293 outlets. Rural: 260 outlets.




Table B2: Availability of antimalarials, among all outlets stocking at least one antimalarial, by outlet type, across urban/rural location




Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: Urban N=160 Rural N=297







Urban N=1,213 Rural N=403


Any ACT

Urban 85.6 93.5 83.8 93.5 99.9 93.1 32.0 87.7 87.4

(80.0, 89.9) (87.7, 96.7) (78.3, 88.2) (91.3, 95.2) (99.7, 99.9) (90.2, 95.2) (19.4, 47.8) (84.1, 90.6) (83.8, 90.3)

Rural 82.2 100.0 88.9 89.5 100.0 87.9 25.0 54.4 61.5

(76.6, 86.6) - (83.9, 92.5) (82.0, 94.1) - (75.8, 94.4) (11.1, 47.1) (41.1, 67.1) (48.8, 72.7)


Urban 85.6 93.5 83.8 91.5 97.9 91.0 32.0 85.9 85.7

(80.0, 89.9) (87.7, 96.7) (78.3, 88.2) (89.2, 93.3) (96.9, 98.6) (88.3, 93.1) (19.4, 47.8) (82.5, 88.7) (82.3, 88.5)

Rural 82.2 100.0 88.9 87.3 97.0 85.8 25.0 53.4 60.7

(76.6, 86.6) - (83.9, 92.5) (80.1, 92.2) (84.0, 99.5) (74.5, 92.6) (11.1, 47.1) (40.3, 66.1) (48.1, 72.0)


Urban 0.3 0.0 0.2 2.5 13.3 4.7 5.6 5.2 4.9

(0.1, 0.9) - (0.1, 0.5) (1.4, 4.7) (9.5, 18.5) (2.7, 8.2) (1.9, 15.2) (3.5, 7.7) (3.3, 7.1)

Rural 0.3 0.0 0.2 3.6 3.9 1.5 0.0 1.1 1.0

(0.1, 1.9) - (0.0, 1.2) (1.4, 9.3) (1.1, 12.7) (0.5, 5.0) - (0.6, 2.4) (0.5, 1.9)


Urban 0.0 0.0 0.0 7.3 17.9 6.7 0.0 7.6 7.0

- - - (5.6, 9.6) (14.9, 21.4) (5.5, 8.0) - (6.6, 8.6) (6.1, 8.0)

Rural 0.0 0.0 0.0 2.3 6.7 6.2 0.0 2.1 1.7

- - - (0.6, 8.2) (2.7, 15.4) (2.1, 17.1) - (0.8, 5.3) (0.7, 4.2)

DHAPPQ

Urban 4.6 29.8 13.3 33.5 77.0 39.0 5.6 38.6 36.7

(3.1, 6.9) (19.3, 43.1) (9.7, 18.0) (27.3, 40.4) (71.1, 82.0) (32.1, 46.5) (1.9, 15.2) (33.0, 44.6) (31.4, 42.2)

Rural 0.5 16.4 4.3 23.9 62.4 27.3 0.5 12.8 11.1

(0.1, 2.9) (5.5, 39.8) (1.9, 9.1) (15.4, 35.2) (45.2, 76.9) (15.2, 44.1) (0.1, 3.2) (8.3, 19.4) (7.3, 16.5)


Urban 85.3 93.5 83.7 82.4 90.1 84.3 29.2 78.8 79.1

(79.6, 89.6) (87.7, 96.7) (78.1, 88.0) (79.3, 85.2) (88.3, 91.7) (82.4, 86.1) (17.8, 44.1) (76.0, 81.3) (76.4, 81.6)

Rural 82.2 100.0 88.9 87.3 95.3 83.7 25.0 52.9 60.2

(76.6, 86.6) - (83.9, 92.5) (80.1, 92.2) (83.9, 98.8) (72.8, 90.7) (11.1, 47.1) (39.9, 65.5) (47.8, 71.5)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)










QA AL

Urban 85.3 93.5 83.7 81.5 88.3 83.8 29.2 78.0 78.5

(79.6, 89.6) (87.7, 96.7) (78.1, 88.0) (78.2, 84.4) (86.4, 90.1) (81.7, 85.8) (17.8, 44.1) (75.3, 80.5) (75.7, 81.0)

Rural 82.2 100.0 88.9 86.6 95.3 82.7 25.0 52.5 59.9

(76.6, 86.6) - (83.9, 92.5) (79.0, 91.7) (83.9, 98.8) (72.2, 89.8) (11.1, 47.1) (39.6, 65.0) (47.6, 71.1)


Urban 36.3 61.6 44.6 72.4 85.9 77.0 25.4 71.4 69.3

(27.5, 46.2) (50.5, 71.7) (36.5, 53.0) (67.6, 76.8) (83.9, 87.7) (74.0, 79.7) (15.3, 39.2) (68.5, 74.0) (66.3, 72.2)

Rural 25.6 69.2 37.2 77.1 86.0 72.7 19.7 45.2 43.5

(18.5, 34.3) (32.7, 91.2) (27.4, 48.2) (66.6, 85.0) (71.7, 93.7) (57.8, 83.9) (9.4, 36.9) (34.1, 56.7) (34.8, 52.7)


Urban 69.2 40.3 53.5 22.2 17.5 16.4 6.1 17.2 20.0

(62.4, 75.2) (29.3, 52.4) (46.4, 60.5) (19.1, 25.7) (14.7, 20.8) (14.1, 19.1) (3.3, 11.0) (15.6, 18.9) (18.6, 21.4)

Rural 70.2 70.6 71.7 14.3 21.8 22.1 5.3 11.5 23.8

(61.5, 77.6) (38.9, 90.0) (60.4, 80.8) (7.7, 25.0) (13.2, 33.6) (14.8, 31.6) (1.3, 18.5) (7.2, 17.8) (16.3, 33.4)


Urban

70.3 39.9 54.1 38.3 45.9 37.1 13.2 36.1 37.4

(60.9, 78.3) (29.6, 51.3) (46.0, 61.9) (34.2, 42.6) (42.2, 49.6) (34.0, 40.4) (8.3, 20.5) (34.2, 38.0) (35.6, 39.3)

Rural

70.7 72.6 69.8 31.0 43.6 36.7 10.4 21.5 31.4

(63.9, 76.8) (41.6, 90.8) (60.5, 77.8) (18.5, 47.0) (32.3, 55.7) (23.4, 52.3) (3.9, 24.9) (13.4, 32.6) (22.1, 42.4)

QA ACT - adults

Urban

44.9 85.0 57.8 68.0 80.1 72.3 22.6 66.8 66.1

(36.2, 54.0) (75.4, 91.3) (50.9, 64.5) (64.8, 71.1) (77.9, 82.1) (69.4, 75.0) (13.1, 36.2) (63.4, 70.1) (62.7, 69.4)

Rural 41.2 76.4 56.3 69.0 87.5 68.6 17.3 41.3 44.4

(31.9, 51.2) (37.2, 94.6) (42.0, 69.6) (56.7, 79.0) (72.6, 94.8) (56.2, 78.8) (8.2, 32.7) (32.6, 50.5) (35.7, 53.3)


Urban 5.6 29.8 13.8 54.3 89.0 54.2 5.6 53.5 50.4

(3.9, 7.9) (19.3, 43.1) (10.3, 18.4) (49.2, 59.2) (85.5, 91.8) (46.6, 61.6) (1.9, 15.2) (48.3, 58.6) (45.3, 55.5)

Rural 0.8 56.2 14.1 33.2 69.2 33.2 0.5 16.2 15.8

(0.2, 2.8) (22.6, 84.9) (5.3, 32.2) (24.4, 43.5) (52.5, 82.0) (20.1, 49.4) (0.1, 3.2) (10.7, 23.8) (11.0, 22.0)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Urban 85.4 90.3 82.6 89.7 98.1 90.0 29.7 84.6 84.5

(79.7, 89.7) (84.5, 94.1) (77.2, 86.9) (87.4, 91.6) (96.9, 98.9) (87.4, 92.1) (18.3, 44.2) (81.3, 87.4) (81.1, 87.3)

Rural 79.8 96.5 86.6 88.7 97.8 85.2 24.5 53.3 60.1

(73.0, 85.3) (81.5, 99.4) (80.4, 91.1) (80.9, 93.6) (87.2, 99.7) (73.4, 92.4) (10.9, 46.1) (40.4, 65.8) (47.8, 71.2)


Urban 72.1 56.3 66.6 50.5 63.4 68.3 74.0 63.0 63.3

(64.0, 79.0) (45.1, 66.8) (59.4, 73.1) (45.8, 55.2) (59.4, 67.2) (65.0, 71.4) (58.9, 85.0) (59.8, 66.2) (60.2, 66.3)

Rural 77.6 77.8 66.9 58.2 76.9 78.6 83.7 77.5 75.3

(70.2, 83.6) (51.5, 92.0) (55.0, 77.0) (44.0, 71.2) (64.6, 85.9) (66.7, 87.1) (65.9, 93.2) (67.1, 85.2) (66.9, 82.2)


Urban 14.7 23.7 22.5 23.8 52.1 55.6 60.1 46.3 44.4

(10.0, 21.1) (15.1, 35.2) (17.8, 28.1) (20.9, 27.0) (48.5, 55.8) (53.0, 58.2) (44.2, 74.1) (43.5, 49.1) (41.9, 47.1)

Rural 15.2 11.7 12.3 27.6 61.6 64.9 62.8 56.6 47.6

(8.8, 25.0) (2.8, 37.4) (7.3, 20.0) (19.2, 37.9) (51.4, 71.0) (50.3, 77.2) (43.5, 78.8) (45.6, 67.0) (38.3, 57.1)

Oral Quinine

Urban 41.5 28.4 33.6 15.6 20.2 22.1 2.8 17.9 19.1

(33.5, 49.9) (18.9, 40.2) (27.6, 40.2) (13.6, 17.9) (16.3, 24.8) (18.6, 26.1) (1.0, 7.8) (16.1, 20.0) (17.3, 21.2)

Rural 47.1 57.8 43.2 18.7 31.2 43.8 4.5 17.5 22.8

(39.0, 55.4) (29.0, 82.1) (31.9, 55.1) (9.1, 34.5) (19.7, 45.7) (30.1, 58.5) (0.9, 19.5) (11.7, 25.4) (16.4, 30.7)

Quinine IV/IM

Urban 51.8 40.6 43.8 30.6 10.1 8.0 0.0 14.1 16.4

(43.5, 60.1) (29.3, 53.0) (37.4, 50.5) (26.7, 34.8) (7.7, 13.2) (5.3, 11.9) - (11.9, 16.6) (13.9, 19.3)

Rural 62.9 67.0 55.2 32.0 32.3 26.7 0.5 13.7 22.1

(54.5, 70.6) (36.5, 87.7) (43.1, 66.7) (20.6, 46.1) (19.2, 48.9) (18.1, 37.5) (0.1, 3.2) (8.8, 20.6) (16.4, 29.1)


Urban 2.4 0.0 1.3 6.4 15.2 9.6 14.0 9.8 9.1

(1.1, 4.9) - (0.6, 2.8) (4.3, 9.3) (12.8, 18.0) (7.9, 11.7) (8.5, 22.1) (8.5, 11.3) (7.9, 10.6)

Rural 0.0 4.8 1.2 1.6 7.6 6.8 19.5 12.7 10.3

- (0.7, 26.6) (0.2, 6.6) (0.3, 8.9) (2.7, 20.1) (2.6, 16.5) (6.0, 47.9) (4.4, 31.4) (3.6, 26.3)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Urban 0.0 0.0 0.0 0.2 0.0 0.0 0.0 0.1 0.1

- - - (0.1, 0.6) - - - (0.0, 0.2) (0.0, 0.2)

Rural 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

- - - - - - - - -


Urban 54.7 59.9 52.4 48.7 25.5 9.7 2.8 22.5 24.8

(47.2, 61.9) (49.7, 69.3) (45.7, 59.0) (44.4, 53.1) (20.9, 30.7) (7.1, 13.1) (1.0, 7.8) (19.5, 25.8) (21.7, 28.1)

Rural 55.1 64.0 49.6 27.8 22.8 7.7 0.0 7.7 16.2

(46.5, 63.3) (35.5, 85.1) (38.9, 60.4) (18.2, 39.9) (14.0, 35.0) (3.6, 15.9) - (4.8, 12.0) (12.6, 20.7)

Injectable artemether

Urban 7.6 44.3 20.2 42.9 24.9 9.5 2.8 20.6 20.5

(5.3, 10.7) (32.8, 56.3) (14.8, 26.9) (39.3, 46.5) (20.3, 30.2) (7.1, 12.7) (1.0, 7.8) (18.0, 23.4) (18.0, 23.3)

Rural 2.2 64.0 16.8 23.7 22.8 7.7 0.0 6.9 8.9

(0.7, 6.7) (35.5, 85.1) (6.9, 35.6) (17.0, 32.0) (14.0, 35.0) (3.6, 15.9) - (4.4, 10.6) (5.9, 13.3)

Injectable artesunate

Urban 52.0 28.3 39.5 10.5 4.5 1.7 0.0 4.5 7.1

(44.5, 59.5) (17.8, 41.8) (32.1, 47.5) (8.2, 13.3) (2.7, 7.7) (0.8, 3.6) - (3.2, 6.1) (5.6, 9.0)

Rural 54.7 0.0 33.9 4.1 2.8 0.0 0.0 0.8 7.6

(46.0, 63.0) - (24.7, 44.5) (0.7, 20.8) (0.5, 13.0) - - (0.2, 4.4) (5.6, 10.2)

Injectable artemotil

Urban 0.0 0.0 0.0 2.6 5.7 1.2 0.0 2.1 1.9

- - - (1.6, 4.3) (3.4, 9.3) (0.7, 2.2) - (1.3, 3.3) (1.2, 3.0)

Rural 0.0 0.0 0.0 0.0 2.4 0.0 0.0 0.0 0.0

- - - - (0.4, 14.0) - - (0.0, 0.3) (0.0, 0.2)







Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Urban 76.3 69.9 68.2 62.1 27.1 14.1 2.8 28.7 31.7

(69.7, 81.8) (58.1, 79.5) (61.5, 74.2) (57.7, 66.4) (22.4, 32.3) (10.5, 18.6) (1.0, 7.8) (25.4, 32.2) (28.1, 35.6)

Rural 82.7 86.8 72.2 51.1 38.9 27.9 0.5 17.7 28.8

(76.0, 87.8) (62.7, 96.2) (60.0, 81.9) (38.5, 63.6) (24.4, 55.7) (19.4, 38.2) (0.1, 3.2) (12.1, 25.2) (22.5, 36.1)

* Antimalarial-stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet. The denominator includes urban and rural outlets that met screening criteria and completed full interviews. 67 outlets in the denominator had partial interviews. Urban: 48 outlets. Rural: 19 outlets.




Table B3: Antimalarial market composition, across urban/rural location





Facility

ALL Public / Not-

For-Profit

Private For-Profit

Facility

Registered Pharmacy


General Retailer

ALL Private

% % % % % % % % %

Urban, N= 1,029 5.6 0.5 2.6 8.7 25.4 16.0 41.0 8.9 91.3

(4.5, 6.8) (0.3, 1.2) (1.9, 3.4) (7.1, 10.5) (23.6, 27.3) (11.3, 22.2) (35.4, 46.8) (6.3, 12.6) (89.5, 92.9)

Rural, N=472 16.8 2.6 4.5 23.9 14.0 4.1 18.3 39.6 76.1

(12.6, 22.0) (1.0, 6.3) (2.3, 8.9) (17.9, 31.2) (10.6, 18.2) (2.1, 7.9) (12.8, 25.7) (28.3, 52.2) (68.8, 82.1)





Table B4a: Price of tablet formulation antimalarials, by outlet type, across urban/rural location

Private

For-Profit Facility


Private


(N of Antimalarials) Median [IQR]


Median [IQR] (N of Antimalarials)



Any ACT

Urban $2.25 $3.38 $2.25 $2.82 $2.70

[1.50-4.51] (530) [1.69-5.63] (1,961) [1.35-4.51] (1,230) [1.13-5.63] (48) [1.35-4.73] (3,769)

Rural $1.69 $1.80 $1.35 $1.35 $1.58

[1.13-3.38] (125) [1.13-3.94] (154) [1.13-2.93] (202) [1.13-1.69] (36) [1.13-2.82] (517)


Urban $1.69 $1.69 $1.69 $1.35 $1.69

[1.13-3.38] (383) [1.13-2.82] (1,017) [1.13-2.25] (816) [1.13-2.25] (38) [1.13-2.70] (2,254)

Rural $1.69 $1.35 $1.13 $1.35 $1.35

[1.13-2.25] (93) [1.13-1.69] (99) [1.13-1.58] (145) [1.13-1.69] (35) [1.13-1.69] (372)


Urban $5.63 $5.63 $5.07 $9.91 $5.63

[5.07-5.86] (10) [5.07-6.08] (74) [4.51-6.76] (16) [8.56-11.26] (2) [5.07-7.88] (102)

Rural $6.20 $4.73 $6.76 - $6.20

[5.07-6.20] (2) [4.51-4.73] (2) [3.94-7.88] (3) - [4.73-6.76] (7)


Urban $1.69 $1.35 $1.58 $1.13 $1.69

[1.13-2.25] (342) [1.13-1.80] (802) [1.13-2.03] (682) [1.13-1.50] (34) [1.13-2.25] (1,860)

Rural $1.69 $1.13 $1.13 $1.35 $1.13

[1.13-2.25] (91) [1.13-1.69] (87) [1.13-1.35] (136) [1.13-1.69] (35) [1.13-1.69] (349)

QA ACT with ‘green leaf’ logo

Urban $1.69 $1.35 $1.58 $1.13 $1.69

[1.13-2.25] (282) [1.13-2.03] (708) [1.13-2.25] (609) [1.13-1.69] (29) [1.13-2.25] (1,628)

Rural $1.50 $1.13 $1.13 $1.35 $1.13

[1.13-2.03] (78) [1.13-1.69] (76) [1.13-1.35] (116) [1.13-1.69] (32) [1.13-1.69] (302)



Private

For-Profit Facility


Private


(N of Antimalarials) Median [IQR]






Urban $1.69 $1.35 $1.50 $1.13 $1.35

[1.13-2.25] (59) [1.13-1.80] (94) [1.13-1.69] (72) [1.13-1.35] (5) [1.13-1.80] (230)

Rural $1.69 $1.13 $1.13 $1.69 $1.13

[1.13-2.25] (12) [1.13-1.35] (11) [0.90-1.35] (20) [1.69-1.69] (3) [1.01-1.69] (46)

QA AL

Urban $1.69 $1.35 $1.50 $1.13 $1.58

[1.13-2.25] (323) [1.13-1.80] (725) [1.13-1.80] (651) [1.13-1.50] (34) [1.13-2.25] (1,733)

Rural $1.69 $1.13 $1.13 $1.35 $1.13

[1.13-2.25] (87) [1.13-1.69] (84) [1.13-1.35] (130) [1.13-1.69] (35) [1.13-1.69] (336)


Urban $4.51 $5.07 $4.73 $6.76 $4.73

[3.38-5.68] (188) [3.38-9.12] (1,159) [3.83-7.88] (548) [3.38-11.26] (14) [3.38-7.88] (1,909)

Rural $3.94 $3.94 $3.94 $3.94 $3.94

[3.15-5.07] (34) [3.38-5.07] (67) [3.15-5.41] (66) (1) [3.15-5.07] (168)


Urban $0.79 $0.79 $0.56 $0.34 $0.56

[0.56-1.35] (71) [0.56-1.69] (428) [0.56-1.13] (392) [0.34-0.51] (47) [0.56-1.13] (938)

Rural $0.56 $0.56 $0.56 $0.34 $0.39

[0.34-0.56] (26) [0.45-0.84] (52) [0.45-0.68] (89) [0.34-0.45] (148) [0.34-0.56] (315)

Quinine

Urban $4.73 $3.78 $3.78 $1.14 $3.78

[2.37-7.10] (10) [3.31-4.73] (46) [2.37-4.73] (22) (1) [2.37-4.73] (79)

Rural $7.10 $3.78 $4.73 - $4.73

[2.37-7.10] (3) [2.84-4.73] (5) [4.73-4.73] (8) - [3.31-4.73] (16)


Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows: 73 any ACT tablets, 47 artemether lumefantrine tablets, 2 artesunate sulfadoxine pyrimethamine tablets, 46 QA ACT tablets, 39 QA ACT with AMFm logo tablets, 6 QA ACT without AMFm logo tablets, 41 QA artemether lumefantrine tablets, 27 non-QA ACT tablets, 7 sulfadoxine pyrimethamine tablets, 1 quinine tablet.




Table B4b: Price of pre-packaged antimalarials, by outlet type, across urban/rural location

Private

For-Profit Facility


Private

Median price of one pre-packaged therapy:

Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Adult QA AL

Urban $1.69 $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (185) [1.13-1.69] (404) [1.13-1.69] (382) [1.13-1.13] (19) [1.13-1.69] (990)

Rural $1.13 $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (55) [1.13-1.35] (48) [1.13-1.13] (78) [1.13-1.69] (23) [1.13-1.35] (204)

Pediatric QA AL*

Urban $0.68 $0.56 $0.56 $0.56 $0.56

[0.56-1.13] (49) [0.45-0.90] (147) [0.56-0.90] (116) [0.56-1.13] (6) [0.56-1.13] (318)

Rural $0.56 $0.56 $0.56 - $0.56

[0.56-1.13] (16) [0.34-0.56] (14) [0.56-0.68] (15) - [0.56-0.90] (45)

*QA AL is the pre-packaged regimen appropriate for a child under age five. Figures in this table are derived using audited products with price information. The numbers of antimalarials captured in audit sheets with missing price information are as follows:

27 adult QA AL, 5 pediatric QA AL




Table B5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across urban/rural location


ALL Public / Not- For-

Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)











Urban 96.2 91.1 79.1 80.2 21.5 18.2 0.0 33.0

(93.9, 97.6) (83.1, 95.5) (70.6, 85.7) (76.6, 83.4) (18.3, 25.1) (15.1, 21.9) - (29.6, 36.6)

Rural 92.4 91.0 69.5 55.1 13.4 7.5 0.0 10.7

(85.4, 96.2) (77.7, 96.7) (40.0, 88.6) (44.0, 65.8) (6.4, 25.9) (3.9, 13.9) - (7.1, 15.8)










Urban 70.6 62.7 66.2 8.0 6.4 0.0 22.5 25.8

(65.6, 75.2) (54.2, 70.5) (61.5, 70.6) (6.2, 10.4) (4.7, 8.6) - (20.0, 25.2) (23.4, 28.3)

Rural 54.1 38.2 44.8 10.8 2.7 0.0 8.1 14.6

(48.4, 59.8) (21.5, 58.3) (34.5, 55.6) (4.9, 22.0) (0.9, 7.8) - (5.1, 12.4) (10.6, 19.9)










Urban 61.8 44.8 30.8 15.8 14.2 0.0 16.7 18.9

(54.0, 69.0) (38.7, 51.1) (27.4, 34.4) (12.3, 20.0) (12.0, 16.6) - (14.7, 18.9) (17.3, 20.7)

Rural 72.7 55.7 24.3 4.4 4.8 0.0 5.0 16.1

(65.0, 79.3) (35.4, 74.3) (15.0, 36.9) (1.1, 16.7) (2.0, 10.6) - (2.9, 8.5) (11.9, 21.3)









Checkmark RDTs

Urban 0.2 0.1 0.6 1.4 0.0 0.0 0.3 0.3

(0.1, 0.5) (0.0, 0.3) (0.3, 1.5) (0.6, 3.4) - - (0.2, 0.6) (0.2, 0.6)

Rural 0.0 0.4 0.0 0.0 0.0 0.0 0.0 0.1

- (0.1, 2.3) - - - - - (0.0, 0.5)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months.

*** Results in this table are derived using responses captured among outlets with blood testing information. 6 antimalarial-stocking outlets had missing information about both availability of microscopy and availability of RDTs. 18 antimalarial-stocking outlets had partial information about blood testing availability and are included in the denominator of the indicator “any blood testing available.”




Table B7: Price of malaria blood testing, by outlet type, across urban/rural location

Private For-Profit


ALL Private


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]



Adult

Urban $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (222) [1.13-1.69] (50) [1.13-1.13] (27) [1.13-1.69] (299)

Rural $0.56 $0.56 $0.45 $0.56

[0.56-1.13] (41) [0.45-0.56] (5) [0.45-1.13] (3) [0.56-1.13] (49)


Urban $1.13 $1.13 $1.13 $1.13

[0.56-1.69] (222) [1.13-1.13] (50) [1.13-1.13] (27) [0.56-1.69] (299)

Rural $0.56 $0.56 $0.45 $0.56

[0.56-0.56] (41) [0.45-0.56] (5) [0.45-1.13] (3) [0.56-0.90] (49)


Adult

Urban $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (109) [1.13-1.13] (53) [1.13-1.69] (54) [1.13-1.69] (216)

Rural $1.13 $0.96 $0.56 $1.13

[0.56-1.13] (25) [0.79-1.13] (2) [0.56-1.13] (5) [0.56-1.13] (32)

Child under five

Urban $1.13 $1.13 $1.13 $1.13

[1.13-1.69] (108) [1.13-1.13] (51) [1.13-1.13] (54) [1.13-1.69] (213)

Rural $1.13 $0.73 $0.56 $1.13

[0.56-1.13] (25) [0.56-0.90] (2) [0.56-1.13] (5) [0.56-1.13] (32)



Table B7: Price of malaria blood testing, by outlet type, across urban/rural location

Private For-Profit


ALL Private

Median price excluding fees:**






Adult

Urban $0.17 $1.13 $0.79 $0.68

(1) [0.56-1.69] (12) [0.56-1.13] (20) [0.56-1.13] (33)

Rural - $0.90 $0.45 $0.45

- (1) (1) [0.45-0.45] (2)

Child under five

Urban $0.17 $0.68 $0.79 $0.68

(1) [0.56-1.69] (11) [0.56-1.13] (20) [0.56-1.13] (32)

Rural - $0.90 $0.45 $0.45

- (1) (1) [0.45-0.45] (2)

* Total price to the consumer including consultation and/or service fees. ** Price to the consumer for an RDT excluding consultation and/or service fees. Microscopic blood testing price information was not available for all outlets. There were 6 outlets with missing or “don’t know” responses. RDT price information was not available (missing or “don’t know” response) for: 31 adult RDTs and 34 child RDTs in median price to consumers and 244 adult RDTs and 245

child RDTs in median price excluding fees.




Table B8a: Antimalarial market share, urban

AETDs sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/ distributed:*


TOTAL Public

Private For-Profit

Facility

Registered Pharmacy




% % % % % % % %

1. Any ACT 5.7 7.3 9.6 32.7 20.4 1.1 63.8 71.2


Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.1 0.3 0.1 0.0 0.5 0.5

DHAPPQ 0.1 0.4 0.8 5.8 2.4 0.2 9.2 9.5








Oral Quinine 0.0 0.1 0.0 0.3 0.1 0.0 0.4 0.5

Quinine IV/IM 0.1 0.2 0.1 0.3 0.1 0.0 0.4 0.6








* A total of 30,012.7 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. *** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 5,313 antimalarials were audited. Of these, 230 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.




Table B8b: Antimalarial market share, rural



TOTAL Public

Private For-Profit

Facility

Registered Pharmacy




% % % % % % % %

1. Any ACT 15.0 21.3 9.3 4.4 22.5 7.4 43.6 64.9


Artesunate Sulfadoxine Pyrimethamine (ASSP) 0.0 0.0 0.1 0.0 0.1 0.0 0.1 0.1

DHAPPQ 0.0 0.2 0.7 0.5 1.5 0.1 2.7 2.9








Oral Quinine 0.8 1.8 0.0 0.0 0.1 0.0 0.2 1.9

Quinine IV/IM 0.3 0.3 0.2 0.0 0.2 0.0 0.5 0.8








* A total of 5,632.6 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category. *** Row sum – market share for the specified antimalarial medicine. **** Column sum – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column. A total of 1,338 antimalarials were audited. Of these, 95 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.




Table B9a: Antimalarial market share across outlets, urban



TOTAL Public / Not For-

Profit**

Private For-Profit

Facility Registered Pharmacy



% % % % % % %

1. Any ACT 85.3 86.4 81.9 67.9 69.2 53.0 69.8



DHAPPQ 0.8 4.5 7.1 12.0 8.1 8.3 10.0








Oral Quinine 0.7 0.7 0.4 0.6 0.4 0.0 0.5

Quinine IV/IM 2.2 1.9 0.8 0.5 0.2 0.0 0.4







OUTLET TYPE TOTAL**** 100.0 100.0 100.0 100.0 100.0 100.0 100.0

* AETDs reportedly sold or distributed in the previous seven days: 1,966.9 public health facility; 468.5 private-not-for-profit HF; 3,334.2 private for-profit HF; 15,226.0 Registered Pharmacy; 8665.3 Unregistered Pharmacy; 337.7 general retailer. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

Categories 1 through 4 sum to 100% within each column. A total of 5,313 antimalarials were audited. Of these, 230 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 19 public health facilities; 1 private not-for profit facilities; 63 private for-profit facilities; 49 registered pharmacies; 91 unregistered pharmacies; 7 general retailers.




Table B9b: Antimalarial market share across outlets, rural



TOTAL Public / Not For-

Profit**

Private For-Profit

Facility Registered Pharmacy



% % % % % % %

1. Any ACT 71.7 74.6 80.5 56.0 64.3 43.4 61.0



DHAPPQ 0.0 0.8 5.9 5.8 4.3 0.4 3.8








Oral Quinine 3.6 6.2 0.3 0.2 0.4 0.0 0.2

Quinine IV/IM 1.2 1.2 1.6 0.3 0.7 0.0 0.6







OUTLET TYPE TOTAL**** 100.0 100.0 100.0 100.0 100.0 100.0 100.0

* 5632.6 AETDs reportedly sold or distributed in the previous seven days: 916.9 public health facility; 72.5 CHW; 370.5 private-not-for-profit HF; 743.2 private for-profit HF; 562.5 Registered Pharmacy; 2,111.8 Unregistered Pharmacy; 855.2 general retailer. See Annex 11 for a description of AETD calculation and Annex 12 for AETD numbers by outlet type and drug category.

Categories 1 through 4 sum to 100% within each column. A total of 1,338 antimalarials were audited. Of these, 95 audited antimalarials were not included in market share calculations due to due to incomplete or inconsistent information, including the following number of antimalarials by outlet type: 8 public health facility; 1 community health worker;17 private for-profit; 12 registered pharmacy; 32 unregistered pharmacy; 25 general retailer.




Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location



Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Would refer a 2 year old child with symptoms of severe malaria to a health facility

- Urban N=16 Rural N=43

- Urban N=443 Rural N=47





Yes, would refer to health facility

Urban NA 100.0

NA 90.6 86.0 87.7 87.1 87.5

- (87.5, 93.0) (83.1, 88.5) (84.6, 90.2) (84.9, 89.1) (85.3, 89.5)

Rural NA 89.1

NA 90.6 80.2 88.8 86.8 87.0

(77.7, 95.0) (79.9, 95.9) (68.8, 88.1) (81.4, 93.4) (80.8, 91.1) (81.7, 91.0)

Would recommend that a client with a negative malaria blood test take an antimalarial









Yes – sometimes

Urban 26.5 32.7 31.2 30.4 31.2 12.5 29.3 29.7

(22.2, 31.3) (27.0, 39.0) (27.7, 34.9) (27.2, 33.8) (27.6, 35.1) (8.9, 17.3) (27.2, 31.6) (27.5, 32.0)

Rural 17.5 15.2 28.8 24.1 24.9 10.2 20.5 18.6

(12.8, 23.5) (8.5, 25.6) (19.9, 39.7) (13.2, 39.8) (15.2, 37.8) (5.6, 17.9) (15.9, 26.0) (13.9, 24.5)

Yes – always

Urban 6.1 4.5 6.6 2.8 1.5 1.8 3.4 3.5

(3.9, 9.4) (2.9, 6.9) (4.2, 10.0) (2.0, 4.0) (0.9, 2.4) (0.7, 4.7) (2.6, 4.5) (2.7, 4.6)

Rural 3.7 2.6 4.4 0.0 5.0 11.3 7.1 5.5

(1.8, 7.6) (1.5, 4.6) (1.6, 11.7) - (1.6, 14.5) (4.1, 27.7) (3.7, 13.1) (3.2, 9.4)

Circumstances cited for recommending antimalarial treatment to a client who tested negative for malaria:*









Patient has signs and symptoms of malaria.

Urban 98.3 93.8 86.8 90.9 84.0 100.0 86.6 87.4

(94.8, 99.4) (87.9, 97.0) (82.2, 90.3) (86.8, 93.8) (80.5, 87.0) - (83.3, 89.3) (84.0, 90.2)

Rural 98.9 96.2 95.9 83.9 96.2 56.3 84.2 87.3

(93.5, 99.8) (83.0, 99.2) (82.0, 99.2) (48.9, 96.6) (83.7, 99.2) (32.1, 77.7) (74.3, 90.7) (79.7, 92.4)



Table B12: Provider case management knowledge and practices, by outlet type, across urban/rural location



Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets


(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Provider doesn't trust the test results.

Urban 26.5 17.0 7.8 11.7 16.8 - 12.0 12.5

(16.1, 40.3) (10.2, 26.8) (5.5, 11.0) (8.0, 16.9) (12.9, 21.5) - (9.3, 15.2) (9.9, 15.7)

Rural 11.7 15.5 6.6 8.4 11.5 36.4 17.0 16.6

(5.6, 22.7) (5.6, 36.4) (1.8, 21.2) (1.4, 37.9) (2.3, 42.1) (9.8, 75.1) (7.5, 34.0) (8.6, 29.8)

When the patient asks for antimalarial treatment.

Urban 4.5 1.9 4.4 10.2 8.5 6.1 7.0 6.4

(1.6, 11.9) (0.6, 5.6) (2.4, 7.9) (7.3, 14.0) (6.2, 11.6) (1.9, 17.9) (5.2, 9.4) (4.8, 8.5)

Rural 12.6 6.3 2.4 8.4 - - 1.0 2.4

(6.7, 22.6) (2.8, 13.5) (0.4, 13.1) (1.4, 37.9) - - (0.2, 4.5) (1.0, 5.5)

Other (all other reasons)

Urban 90.6 84.5 87.2 83.2 76.2 82.8 81.7 82.0

(82.9, 95.1) (74.2, 91.1) (79.6, 92.3) (72.8, 90.1) (61.6, 86.5) (63.7, 93.0) (72.4, 88.3) (73.0, 88.5)

Rural 70.6 61.8 89.0 100.0 85.9 92.5 89.2 82.0

(42.9, 88.5) (33.5, 83.9) (71.3, 96.3) - (60.1, 96.1) (67.2, 98.7) (77.0, 95.3) (63.5, 92.3)

Provider questions were administered to one staff member working in each outlet eligible for a full interview (current/recent antimalarial-stocking outlets or outlets providing malaria blood testing). * No providers were missing information on circumstances for recommending antimalarials to clients who tested negative for malaria.




Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location



Profit*

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: Urban N=171 Rural N=300








Correctly state the national first-line

treatment for uncomplicated malaria

Urban 99.5 95.7 93.3 96.1 91.1 33.3 82.4 83.5

(98.8, 99.8) (93.0, 97.4) (91.9, 94.5) (93.6, 97.7) (89.1, 92.8) (25.0, 42.6) (77.5, 86.5) (79.0, 87.2)

Rural 98.2 96.3 91.1 96.5 90.4 27.3 51.2 61.1

(96.0, 99.2) (92.7, 98.2) (82.9, 95.6) (89.3, 98.9) (82.2, 95.1) (18.9, 37.5) (40.6, 61.8) (49.7, 71.4)

Correctly state the first-line dosing regimen for an adult

Urban 97.1 83.5 87.2 89.6 86.3 18.6 75.4 76.1

(94.8, 98.5) (75.4, 89.3) (84.9, 89.2) (87.5, 91.5) (83.8, 88.5) (11.2, 29.5) (69.3, 80.7) (70.1, 81.2)

Rural 95.1 91.3 89.7 93.2 85.7 16.5 43.4 53.8

(89.7, 97.7) (84.6, 95.2) (82.8, 94.1) (84.7, 97.2) (76.9, 91.6) (11.5, 23.3) (33.8, 53.5) (43.5, 63.9)

Correctly state the first-line dosing regimen for a child

Urban 87.7 78.4 71.6 81.3 73.3 9.5 62.8 64.1

(82.4, 91.5) (72.0, 83.6) (68.6, 74.4) (78.8, 83.6) (70.3, 76.1) (5.8, 15.2) (57.6, 67.7) (59.0, 68.8)

Rural 87.9 79.5 77.5 77.5 76.2 10.4 35.4 45.0

(82.9, 91.6) (68.7, 87.2) (64.4, 86.8) (62.7, 87.6) (63.3, 85.6) (6.4, 16.6) (26.6, 45.4) (35.9, 54.5)

Report an ACT as the most effective antimalarial medicine for an adult

Urban 96.7 92.9 91.3 95.6 89.1 37.7 81.7 82.6

(94.1, 98.1) (87.2, 96.1) (89.1, 93.1) (93.9, 96.8) (87.5, 90.5) (26.1, 51.0) (75.9, 86.3) (77.0, 87.1)

Rural 96.7 94.6 82.5 86.8 81.6 24.7 46.4 56.9

(92.9, 98.5) (89.7, 97.2) (73.8, 88.8) (77.5, 92.6) (73.8, 87.5) (13.3, 41.4) (33.9, 59.3) (44.1, 68.9)

Report an ACT as the most effective antimalarial medicine for a child

Urban 90.5 92.1 89.0 96.5 87.5 29.1 79.0 80.1

(86.0, 93.7) (89.2, 94.2) (86.8, 90.9) (95.0, 97.6) (85.3, 89.4) (18.9, 42.0) (72.8, 84.1) (74.4, 84.7)

Rural 97.7 91.3 81.8 93.7 77.6 18.2 41.5 52.4

(95.0, 99.0) (86.5, 94.5) (71.9, 88.8) (79.2, 98.3) (68.5, 84.7) (9.3, 32.7) (30.0, 54.1) (40.5, 64.0)



Table B13: Provider antimalarial treatment knowledge and practices, by outlet type, across urban/rural location



Profit*

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) Report an ACT as the antimalarial he/she most commonly recommends for adults

Urban 99.4 91.3 93.6 94.4 86.0 36.1 80.6 81.5

(98.7, 99.7) (87.2, 94.2) (91.7, 95.1) (92.3, 96.0) (84.0, 87.8) (25.7, 48.0) (75.5, 84.8) (76.6, 85.5)

Rural 97.8 98.4 91.5 90.7 84.7 21.3 46.4 57.7

(93.6, 99.3) (95.5, 99.4) (85.0, 95.3) (78.3, 96.4) (73.3, 91.8) (10.2, 39.2) (32.8, 60.6) (43.2, 71.1)

Report an ACT as the antimalarial he/she most commonly recommends for children

Urban 97.5 94.0 88.7 95.3 84.0 28.0 77.0 78.4

(94.7, 98.8) (91.7, 95.7) (86.7, 90.5) (93.0, 96.9) (81.1, 86.5) (17.9, 40.9) (71.6, 81.7) (73.5, 82.7)

Rural 98.4 96.8 84.4 90.9 77.7 16.8 41.1 53.2

(93.5, 99.6) (91.0, 98.9) (75.9, 90.3) (77.9, 96.6) (65.5, 86.5) (8.5, 30.5) (29.4, 53.9) (40.1, 66.0)

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was Kenya's first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators.




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

Table C1: Availability of antimalarials, among screened outlets, by type of public health facility

Hospital Public Health Centre Public Dispensary ALL

Public Health Facilities

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: N=44 N=152 N=289 N=485


87.5 98.9 90.7 92.5

(69.9, 95.5) (97.5, 99.5) (87.4, 93.3) (89.5, 94.7)

Any ACT 85.3 81.8 74.0 77.2

(68.9, 93.9) (75.1, 87.0) (68.3, 78.9) (72.7, 81.2)

Artemether Lumefantrine (AL) 85.3 81.8 74.0 77.2

(68.9, 93.9) (75.1, 87.0) (68.3, 78.9) (72.7, 81.2)

Quality Assured ACT (QA ACT) 85.3 81.8 73.8 77.1

(68.9, 93.9) (75.1, 87.0) (68.1, 78.8) (72.6, 81.1)

QA ACT AL 85.3 81.8 73.8 77.1

(68.9, 93.9) (75.1, 87.0) (68.1, 78.8) (72.6, 81.1)


44.3 24.1 26.0 27.5

(31.0, 58.5) (18.0, 31.6) (20.1, 32.8) (22.1, 33.7)


69.9 69.3 61.7 64.6

(54.6, 81.7) (61.3, 76.4) (54.5, 68.3) (58.8, 69.9)


11.2 2.5 0.9 2.5

(6.3, 19.1) (1.3, 4.7) (0.5, 1.6) (1.7, 3.5)

Any non-artemisinin therapy 71.1 77.1 66.6 69.8

(56.1, 82.5) (70.0, 82.9) (60.4, 72.3) (64.2, 74.9)

Sulfadoxine-Pyrimethamine 19.0 12.4 13.6 13.9

(11.9, 28.9) (7.8, 19.1) (8.9, 20.4) (9.7, 19.6)


76.6 84.1 69.7 74.2

(61.1, 87.2) (78.6, 88.4) (63.5, 75.3) (69.5, 78.4)

* The denominator includes outlets that met screening criteria for a full interview. There were 10 outlets that did not complete the interview (were not interviewed or completed a partial interview).




Table C2: Availability of antimalarials, among outlets stocking at least one antimalarial, by type of public health facility



%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: N=42 N=147 N=268 N=457


100.0 100.0 100.0 100.0

- - - -

Any ACT 97.4 82.7 81.5 83.5

(92.6, 99.1) (76.0, 87.8) (76.3, 85.8) (79.6, 86.8)

Artemether Lumefantrine (AL) 97.4 82.7 81.5 83.5

(92.6, 99.1) (76.0, 87.8) (76.3, 85.8) (79.6, 86.8)

Quality Assured ACT (QA ACT) 97.4 82.7 81.3 83.4

(92.6, 99.1) (76.0, 87.8) (76.1, 85.6) (79.5, 86.6)

QA ACT AL 97.4 82.7 81.3 83.4

(92.6, 99.1) (76.0, 87.8) (76.1, 85.6) (79.5, 86.6)


50.6 24.4 28.6 29.8

(35.9, 65.2) (18.2, 31.9) (22.2, 36.0) (24.0, 36.3)


79.8 70.1 68.0 69.8

(66.7, 88.6) (62.1, 77.1) (60.5, 74.6) (64.0, 75.0)


12.8 2.5 1.0 2.7

(7.3, 21.5) (1.3, 4.7) (0.6, 1.8) (1.9, 3.8)

Any non-artemisinin therapy 81.2 77.9 73.4 75.5

(69.3, 89.2) (70.8, 83.7) (67.4, 78.7) (70.1, 80.2)

Sulfadoxine-Pyrimethamine 21.7 12.5 15.0 15.0

(13.7, 32.5) (7.9, 19.3) (9.8, 22.4) (10.5, 21.1)


87.5 85.0 76.8 80.2

(76.9, 93.6) (79.5, 89.2) (70.3, 82.2) (75.6, 84.1)

* The denominator includes outlets that met screening criteria for a full interview. There were 9 outlets that did not complete the interview (were not interviewed or completed a partial interview).




Table C5: Availability of malaria blood testing among antimalarial-stocking outlets*, by type of public health facility



%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets** that stocked:

N=43 N=150 N=278 N=471

Any malaria blood testing 100.0 100.0 90.5 94.1

- - (84.3, 94.4) (90.1, 96.5)

N=43 N=150 N=277 N=470

Microscopic blood tests 100.0 88.3 42.5 60.9

- (78.3, 94.1) (37.1, 48.1) (56.8, 64.9)

N=43 N=150 N=277 N=470

Rapid diagnostic tests (RDTs) 23.7 68.2 75.9 68.2

(15.4, 34.6) (59.2, 76.1) (69.1, 81.6) (62.7, 73.3)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months.

** Results in this table are derived using responses captured among outlets with blood testing information. There were no antimalarial-stocking outlet with missing information about both availability of microscopy and availability of RDTs, and 3 antimalarial-stocking outlets had partial information about blood testing availability.




Table C12: Provider antimalarial treatment knowledge and practices, by type of public health facility



%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: N=43 N=150 N=278 N=471

Correctly state the national first-

line treatment for uncomplicated malaria

100.0 97.3 99.1 98.7

- (94.2, 98.7) (97.7, 99.7) (97.5, 99.3)

Correctly state the first-line dosing regimen for:

An adult 89.3 96.0 97.1 95.9

(58.6, 98.0) (92.4, 97.9) (95.2, 98.2) (92.9, 97.7)

A two-year old child 75.7 88.9 89.4 87.8

(56.3, 88.3) (83.8, 92.5) (85.8, 92.2) (84.4, 90.6)

Report an ACT as the most effective antimalarial medicine for

Adults 95.3 98.5 96.2 96.7

(87.2, 98.4) (96.7, 99.3) (93.2, 97.9) (94.6, 98.0)

Children 88.7 96.8 94.9 94.7

(77.3, 94.8) (94.2, 98.3) (91.8, 96.8) (92.6, 96.3)

Report an ACT as the antimalarial he/she most commonly recommends for:

Adults 97.9 98.6 98.5 98.5

(88.8, 99.6) (96.9, 99.4) (94.2, 99.6) (96.3, 99.4)

Children 91.3 98.8 98.9 98.0

(79.9, 96.5) (97.2, 99.5) (93.6, 99.8) (95.7, 99.1)

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was Kenya's first line treatment for uncomplicated malaria.

Numbers of providers (N) in this table are the total number of providers eligible for table indicators. There were no providers with missing information.




Results Section D: Core Indicators across Survey Round: 2010, 2011, 2014

Table D1: Availability of antimalarials, among all screened outlets, by outlet type, across survey round


ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: 2010 N=426 2011 N=442 2014 N=485

2010 N=1,806 2011 N=837

2014 N=1,096

2010 N=365 2011 N=308 2014 N=453

2010 N=236 2011 N=263 2014 N=503

2010 N=477 2011 N=503 2014 N=572

2010 N=10,669 2011 N=9,424 2014 N=9,950

2010 N=12,901 2011 N=10,546 2014 N=11,580

2010 N=13,897 2011 N=11,383 2014 N=12,676


2010 91.7 10.0 62.5 92.2 88.1 4.9 10.0 10.0

(84.7, 95.7) (6.3, 15.6) (46.9, 75.9) (86.2, 95.8) (83.9, 91.3) (3.4, 7.0) (8.5, 11.7) (8.5, 11.7)

2011 96.8 52.5 88.9 98.4 94.4 5.3 12.1 16.6

(92.0, 98.8) (26.3, 77.5) (81.3, 93.6) (95.9, 99.4) (91.1, 96.5) (4.1, 6.9) (10.7, 13.5) (15.2, 18.1)

2014 92.5 18.6 73.3 96.3 93.2 2.9 10.7 11.3

(89.5, 94.7) (14.2, 24.0) (68.5, 77.6) (94.2, 97.7) (91.7, 94.4) (2.1, 4.0) (9.8, 11.7) (10.4, 12.3)

Any ACT

2010 81.4 8.5 35.6 91.1 41.1 0.0 2.9 3.9

(68.5, 89.8) (5.1, 13.8) (27.6, 44.4) (85.8, 94.5) (35.0, 47.5) - (2.4, 3.5) (3.2, 4.6)

2011 94.0 51.1 74.3 93.7 84.7 1.3 7.6 12.5

(89.6, 96.6) (25.8, 75.9) (66.9, 80.5) (88.6, 96.6) (77.1, 90.2) (0.7, 2.2) (6.2, 9.1) (11.1, 14.0)

2014 77.2 16.2 67.9 96.2 85.8 0.8 8.3 8.8

(72.7, 81.2) (12.2, 21.1) (63.6, 71.8) (94.1, 97.5) (82.9, 88.3) (0.4, 1.4) (7.3, 9.3) (7.9, 9.8)


2010 81.4 8.4 32.0 89.1 39.8 0.0 2.8 3.7

(68.5, 89.8) (5.1, 13.6) (24.4, 40.6) (84.4, 92.5) (34.2, 45.6) - (2.3, 3.4) (3.1, 4.5)

2011 94.0 51.1 73.3 92.9 83.3 1.3 7.5 12.4

(89.6, 96.6) (25.8, 75.8) (66.0, 79.6) (87.3, 96.1) (75.8, 88.9) (0.7, 2.2) (6.2, 9.0) (11.1, 13.9)

2014 77.2 16.2 66.4 94.2 83.9 0.8 8.1 8.7

(72.7, 81.2) (12.2, 21.1) (62.2, 70.3) (91.7, 96.0) (81.1, 86.3) (0.4, 1.4) (7.2, 9.1) (7.8, 9.7)


2010 80.4 8.2 23.3 81.4 29.1 0.0 2.1 3.1

(66.0, 89.6) (5.0, 13.4) (17.0, 31.2) (76.8, 85.3) (24.1, 34.6) - (1.7, 2.6) (2.6, 3.8)

2011 93.9 51.0 69.4 89.7 81.5 1.2 7.2 12.2

(89.5, 96.5) (25.8, 75.7) (62.2, 75.8) (84.2, 93.4) (73.8, 87.3) (0.7, 2.2) (5.9, 8.8) (10.9, 13.6)

2014 77.1 16.1 61.2 87.1 78.5 0.8 7.5 8.2

(72.6, 81.1) (12.2, 21.1) (57.2, 65.2) (84.8, 89.1) (76.0, 80.8) (0.4, 1.3) (6.7, 8.5) (7.4, 9.1)





ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

QA ACT with “green leaf” logo

2010 1.2 0.1 8.4 45.7 9.1 0.0 0.8 0.7

(0.5, 2.7) (0.1, 0.3) (5.5, 12.6) (32.6, 59.5) (4.3, 18.5) - (0.5, 1.2) (0.4, 1.0)

2011 66.5 35.9 64.6 89.5 79.1 1.2 7.0 10.3

(53.9, 77.1) (19.6, 56.2) (57.6, 71.0) (83.9, 93.3) (71.0, 85.5) (0.7, 2.1) (5.7, 8.5) (8.9, 11.8)

2014 27.5 7.5 53.9 82.7 71.0 0.6 6.7 6.8

(22.1, 33.7) (5.1, 10.8) (50.0, 57.7) (80.5, 84.8) (67.5, 74.2) (0.4, 1.1) (6.0, 7.6) (6.0, 7.7)

QA ACT without “green leaf” logo

2010 80.0 8.2 17.6 74.1 22.6 0.0 1.7 2.7

(65.8, 89.3) (4.9, 13.3) (11.7, 25.8) (68.2, 79.2) (18.0, 27.9) - (1.2, 2.2) (2.2, 3.4)

2011 62.1 33.4 11.8 - 6.9 - 0.7 4.4

(49.7, 73.0) (17.2, 54.6) (7.6, 17.7) - (4.1, 11.4) - (0.6, 1.0) (3.5, 5.5)

2014 64.6 12.0 14.9 17.2 16.3 0.2 1.6 2.4

(58.8, 69.9) (8.8, 16.0) (12.3, 18.1) (14.4, 20.2) (14.1, 18.8) (0.1, 0.4) (1.4, 1.9) (2.1, 2.8)

Non-quality-assured ACT

2010 3.4 0.9 26.6 90.5 25.8 0.0 2.1 1.9

(1.9, 5.9) (0.4, 1.9) (19.5, 35.2) (85.3, 94.0) (18.3, 35.1) - (1.7, 2.5) (1.5, 2.3)

2011 6.1 3.5 29.3 86.8 37.3 0.1 3.4 3.4

(3.3, 11.0) (1.5, 8.0) (22.1, 37.7) (80.8, 91.1) (29.2, 46.2) (0.0, 0.2) (2.7, 4.3) (2.7, 4.3)

2014 2.5 2.6 36.2 84.4 46.7 0.1 4.5 4.3

(1.7, 3.5) (1.3, 5.2) (33.0, 39.6) (79.9, 88.1) (40.3, 53.1) (0.0, 0.1) (3.8, 5.2) (3.7, 5.1)


2010 87.3 8.2 52.0 72.9 80.0 4.9 9.3 9.1

(78.9, 92.7) (5.5, 12.0) (37.3, 66.4) (67.3, 77.9) (75.7, 83.7) (3.4, 7.0) (7.9, 10.9) (7.7, 10.7)

2011 91.3 49.5 66.8 83.4 75.4 4.5 9.8 14.3

(85.5, 94.9) (25.0, 74.3) (60.2, 72.8) (75.5, 89.1) (67.5, 81.9) (3.4, 5.9) (8.7, 11.0) (12.9, 15.7)

2014 69.8 12.4 38.1 62.0 65.6 2.3 7.2 7.6

(64.2, 74.9) (9.3, 16.5) (33.7, 42.7) (57.9, 65.9) (62.2, 68.8) (1.6, 3.4) (6.5, 8.1) (6.9, 8.5)





ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


2010 68.4 6.6 26.8 31.0 68.9 3.3 6.7 6.7

(56.8, 78.1) (4.3, 9.9) (19.1, 36.2) (21.9, 41.8) (61.2, 75.7) (2.2, 5.0) (5.3, 8.3) (5.3, 8.3)

2011 55.4 30.5 37.0 64.0 53.9 2.8 6.5 9.2

(43.3, 66.9) (15.9, 50.4) (28.6, 46.3) (52.9, 73.8) (46.7, 61.0) (2.1, 3.9) (5.6, 7.5) (8.0, 10.6)

2014 13.9 3.1 18.1 50.8 53.6 1.8 5.3 5.1

(9.7, 19.6) (2.2, 4.2) (15.7, 20.8) (47.5, 54.1) (50.1, 56.9) (1.2, 2.6) (4.7, 6.0) (4.6, 5.8)

Oral Quinine

2010 59.4 4.8 19.7 36.2 38.8 0.0 2.2 2.7

(50.9, 67.4) (3.1, 7.5) (13.8, 27.4) (26.9, 46.7) (31.7, 46.3) (0.0, 0.2) (1.7, 3.0) (2.1, 3.3)

2011 72.7 39.1 32.5 38.5 43.0 0.1 3.0 7.1

(64.6, 79.5) (20.3, 61.9) (24.4, 41.7) (29.4, 48.5) (32.1, 54.6) (0.0, 0.2) (2.3, 4.1) (6.1, 8.3)

2014 41.5 7.3 12.0 20.2 24.6 0.1 1.9 2.3

(36.1, 47.2) (5.1, 10.3) (9.6, 14.9) (16.5, 24.5) (20.2, 29.5) (0.0, 0.4) (1.6, 2.2) (2.0, 2.7)


2010 0.0 0.0 1.1 0.9 11.9 0.0 0.5 0.4

- - (0.2, 5.4) (0.2, 3.5) (2.8, 39.1) - (0.1, 2.7) (0.1, 2.4)

2011 0.0 0.0 0.5 1.2 0.0 0.0 0.0 0.0

- - (0.1, 3.5) (0.2, 7.8) - - (0.0, 0.1) (0.0, 0.1)

2014 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0

- - (0.0, 0.3) - - - - -


2010 3.6 0.4 16.3 56.5 8.0 0.0 1.0 0.9

(1.6, 7.6) (0.2, 0.8) (10.5, 24.5) (36.1, 74.9) (5.6, 11.3) - (0.7, 1.4) (0.6, 1.3)

2011 2.5 2.1 21.4 44.5 12.8 0.0 1.6 1.7

(1.2, 5.2) (1.0, 4.7) (15.2, 29.1) (30.6, 59.4) (7.5, 21.2) - (1.2, 2.2) (1.2, 2.3)

2014 50.8 9.4 32.2 24.3 8.7 0.0 1.9 2.5

(45.6, 56.0) (6.8, 12.9) (29.0, 35.5) (20.0, 29.2) (6.6, 11.3) (0.0, 0.1) (1.6, 2.2) (2.2, 2.8)





ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


2010 66.3 5.9 38.6 61.0 22.5 0.0 2.1 2.7

(55.1, 75.9) (3.8, 9.2) (25.0, 54.2) (38.5, 79.6) (18.4, 27.3) - (1.6, 2.6) (2.2, 3.3)

2011 77.3 42.2 47.7 48.6 25.2 0.0 2.8 7.3

(69.2, 83.8) (21.3, 66.2) (39.2, 56.4) (35.0, 62.3) (17.5, 34.8) - (2.2, 3.6) (6.1, 8.6)

2014 74.2 13.1 43.7 26.8 15.6 0.0 2.7 3.5

(69.5, 78.4) (9.9, 17.3) (40.3, 47.1) (22.3, 31.9) (12.1, 19.9) (0.0, 0.1) (2.4, 3.1) (3.1, 3.8)

* The denominator includes outlets that met screening criteria for a full interview but did not complete the interview (were not interviewed or completed a partial interview).

Source: ACTwatch Outlet Survey, Kenya, 2010, 2011, 2014.



Table D2: Availability of antimalarials, among outlets stocking at least one antimalarial, by outlet type, across survey round


ALL Public/Not-For-

Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of outlets* stocking: 2010 N=395 2011 N=428 2014 N=457

2010 N=455 2011 N=470 2014 N=517

2010 N=242 2011 N=272 2014 N=342

2010 N=216 2011 N=258 2014 N=487

2010 N=421 2011 N=475 2014 N=535

2010 N=553 2011 N=379 2014 N=252

2010 N=1,433 2011 N=1,384 2014 N=1,616

2010 N=1,888 2011 N=1,854 2014 N=2,133

Any ACT

2010 88.8 85.1 56.9 98.8 46.6 0.0 29.3 38.6

(79.0, 94.3) (74.6, 91.8) (48.6, 64.9) (95.1, 99.7) (39.9, 53.5) - (24.3, 34.7) (33.0, 44.5)

2011 97.1 97.3 83.6 95.3 89.8 24.2 62.8 75.1

(93.8, 98.7) (94.4, 98.7) (77.3, 88.4) (89.5, 97.9) (82.9, 94.1) (14.3, 37.8) (53.5, 71.2) (68.3, 80.8)

2014 83.5 86.8 92.6 99.9 92.1 27.0 77.1 78.3

(79.6, 86.8) (83.2, 89.8) (90.4, 94.3) (99.7, 99.9) (89.0, 94.3) (15.7, 42.5) (69.8, 83.1) (71.8, 83.7)


2010 88.8 83.5 51.1 96.6 45.1 0.0 27.8 37.1

(79.0, 94.3) (72.7, 90.6) (43.7, 58.5) (90.6, 98.8) (39.2, 51.2) - (22.5, 33.7) (31.3, 43.3)

2011 97.0 97.2 82.5 94.4 88.3 24.2 62.0 74.6

(93.8, 98.6) (94.3, 98.7) (76.3, 87.4) (88.9, 97.3) (81.5, 92.8) (14.3, 37.8) (52.9, 70.4) (67.9, 80.3)

2014 83.5 86.8 90.5 97.8 90.0 27.0 75.6 76.9

(79.6, 86.8) (83.2, 89.8) (88.4, 92.3) (96.8, 98.5) (87.1, 92.3) (15.7, 42.5) (68.5, 81.4) (70.6, 82.2)


2010 87.6 82.0 37.3 88.3 33.0 0.0 21.0 31.2

(76.2, 94.0) (70.8, 89.5) (30.8, 44.3) (82.7, 92.2) (27.5, 39.0) - (16.3, 26.7) (25.5, 37.6)

2011 96.9 97.1 78.1 91.2 86.4 23.3 59.9 73.2

(93.7, 98.5) (94.2, 98.6) (72.1, 83.2) (86.3, 94.5) (79.2, 91.3) (13.6, 36.9) (51.0, 68.2) (66.7, 78.8)

2014 83.4 86.8 83.6 90.5 84.2 26.2 70.5 72.5

(79.5, 86.6) (83.1, 89.7) (80.7, 86.1) (88.8, 92.0) (81.8, 86.3) (15.1, 41.6) (64.4, 76.0) (66.9, 77.5)


2010 1.3 1.3 13.4 49.6 10.4 0.0 7.7 6.7

(0.6, 2.9) (0.6, 2.7) (9.5, 18.5) (33.5, 65.7) (4.8, 21.1) - (4.9, 11.9) (4.4, 10.0)

2011 68.6 68.4 72.7 91.0 83.8 22.8 58.0 61.7

(56.8, 78.4) (56.9, 78.0) (66.8, 77.9) (85.9, 94.3) (76.1, 89.4) (13.4, 36.1) (49.2, 66.3) (54.1, 68.8)

2014 29.8 40.2 73.5 85.9 76.1 21.4 63.0 60.3

(24.0, 36.3) (33.5, 47.3) (69.1, 77.4) (83.9, 87.7) (72.6, 79.4) (12.9, 33.4) (57.6, 68.2) (55.5, 64.9)





ALL Public/Not-For-

Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


2010 87.2 81.3 28.2 80.3 25.7 0.0 16.7 27.5

(76.0, 93.6) (70.2, 88.9) (21.3, 36.4) (73.5, 85.7) (20.8, 31.2) - (12.0, 22.7) (21.8, 34.0)

2011 64.1 63.5 13.2 - 7.3 - 6.0 26.5

(50.8, 75.5) (50.8, 74.6) (8.5, 20.0) - (4.3, 12.2) - (4.5, 8.0) (21.6, 32.1)

2014 69.8 64.2 20.4 17.8 17.5 5.5 15.4 21.3

(64.0, 75.0) (56.7, 71.2) (17.2, 23.9) (15.1, 20.8) (15.1, 20.2) (2.2, 13.3) (13.3, 17.8) (18.5, 24.5)

Non-Quality Assured ACT (non-QA ACT)

2010 3.7 8.8 42.6 98.1 29.3 0.0 20.8 18.8

(2.0, 6.6) (4.9, 15.5) (34.8, 50.7) (93.6, 99.5) (20.5, 39.9) - (17.1, 25.1) (15.8, 22.3)

2011 6.3 6.6 33.0 88.3 39.6 1.2 28.3 20.6

(3.4, 11.6) (3.8, 11.3) (24.4, 42.9) (81.9, 92.6) (30.8, 49.1) (0.4, 3.9) (22.2, 35.4) (16.3, 25.6)

2014 2.7 14.0 49.4 87.7 50.1 2.0 41.6 38.3

(1.9, 3.8) (7.9, 23.5) (44.8, 54.0) (84.2, 90.5) (43.2, 57.0) (0.7, 5.2) (36.0, 47.5) (33.1, 43.7)


2010 95.2 81.7 83.2 79.0 90.8 100.0 93.4 91.4

(92.0, 97.2) (55.2, 94.2) (73.2, 90.0) (71.9, 84.8) (87.5, 93.3) (91.0, 95.2) (86.4, 94.7)

2011 94.3 94.2 75.1 84.8 79.9 84.0 81.3 85.9

(88.5, 97.2) (89.0, 97.1) (69.5, 80.0) (77.3, 90.1) (72.3, 85.8) (75.7, 89.9) (77.4, 84.6) (82.5, 88.7)

2014 75.5 66.8 52.3 64.3 70.3 80.9 67.6 67.5

(70.1, 80.2) (59.4, 73.4) (47.5, 57.0) (60.6, 67.9) (66.9, 73.6) (68.6, 89.1) (63.4, 71.6) (63.7, 71.1)


2010 74.6 65.4 42.9 33.6 78.2 68.5 67.0 66.7

(65.2, 82.1) (47.7, 79.6) (31.9, 54.6) (24.8, 43.7) (70.9, 84.2) (56.2, 78.7) (59.0, 74.1) (59.0, 73.7)

2011 57.2 58.0 41.7 65.1 57.1 53.5 53.8 55.3

(45.2, 68.5) (46.4, 68.7) (32.2, 51.8) (54.0, 74.7) (49.4, 64.5) (45.4, 61.4) (49.0, 58.5) (50.2, 60.3)

2014 15.0 16.5 24.7 52.8 57.5 62.0 49.6 45.6

(10.5, 21.1) (12.6, 21.3) (21.7, 28.0) (49.4, 56.2) (54.0, 60.8) (48.0, 74.3) (45.5, 53.6) (41.9, 49.3)





ALL Public/Not-For-

Profit**

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Oral Quinine

2010 64.7 48.0 31.6 39.3 44.0 0.7 22.6 26.8

(56.5, 72.2) (34.9, 61.4) (23.7, 40.6) (27.8, 52.0) (35.6, 52.8) (0.1, 5.2) (17.0, 29.2) (22.0, 32.3)

2011 75.1 74.5 36.5 39.2 45.5 1.1 25.2 42.8

(68.1, 80.9) (67.9, 80.1) (28.5, 45.5) (30.2, 49.0) (34.4, 57.1) (0.3, 3.3) (19.5, 32.0) (38.0, 47.8)

2014 44.9 39.2 16.3 21.0 26.4 4.0 17.8 20.4

(39.0, 50.9) (31.9, 47.0) (13.3, 19.8) (17.3, 25.2) (21.7, 31.7) (1.1, 13.1) (15.5, 20.4) (17.8, 23.3)


2010 0.0 0.0 1.8 1.0 13.5 0.0 5.2 4.4

- - (0.4, 8.4) (0.3, 3.7) (3.1, 42.9) - (1.0, 23.9) (0.8, 20.7)

2011 0.0 0.0 0.6 1.2 0.0 0.0 0.2 0.2

- - (0.1, 4.0) (0.2, 7.9) - - (0.1, 1.0) (0.0, 0.6)

2014 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.0

- - (0.1, 0.4) - - - (0.0, 0.1) (0.0, 0.1)


2010 3.9 4.2 26.1 61.3 9.1 0.0 9.6 8.7

(1.7, 8.7) (2.3, 7.5) (19.1, 34.7) (36.2, 81.6) (6.4, 12.7) - (6.5, 13.9) (5.9, 12.6)

2011 2.6 4.1 24.0 45.3 13.6 0.0 13.5 10.1

(1.3, 5.3) (2.3, 7.0) (17.0, 32.8) (31.1, 60.3) (7.9, 22.5) - (9.8, 18.4) (7.6, 13.4)

2014 54.9 50.7 43.9 25.3 9.3 0.8 17.8 21.8

(49.0, 60.7) (43.9, 57.6) (39.8, 48.1) (21.1, 30.0) (7.1, 12.2) (0.3, 2.4) (15.3, 20.6) (19.3, 24.5)


2010 72.3 59.1 61.7 66.2 25.6 0.0 20.9 27.3

(61.5, 81.0) (43.1, 73.4) (47.4, 74.3) (37.9, 86.2) (21.1, 30.6) - (15.8, 27.1) (22.0, 33.4)

2011 79.9 80.2 53.7 49.4 26.7 0.0 23.3 43.6

(70.7, 86.7) (72.0, 86.5) (45.3, 62.0) (35.6, 63.3) (18.6, 36.6) - (18.7, 28.6) (37.9, 49.5)

2014 80.2 70.6 59.6 27.9 16.8 1.2 25.2 30.7

(75.6, 84.1) (63.2, 77.0) (55.3, 63.7) (23.5, 32.7) (13.0, 21.4) (0.4, 3.1) (22.1, 28.6) (27.5, 34.2)

* Antimalarial‐stocking outlets have at least one antimalarial in stock on the day of the survey, verified by presence of at least one antimalarial recorded in the antimalarial audit sheet.




Table D3: Antimalarial market composition, across survey round



ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private

% % % % % % %

2010, N=1,471 outlets 11.2 17.2 12.0 2.5 30.6 37.5 82.8

(8.3, 15.1) (11.7, 24.6) (8.3, 17.1) (1.4, 4.7) (18.9, 45.5) (27.8, 48.3) (75.4, 88.3)

2011, N=1,348 outlets 13.0 16.4 18.8 3.3 30.1 31.5 83.6

(10.2, 16.3) (13.3, 20.0) (14.5, 24.0) (1.9, 5.7) (24.9, 35.9) (24.3, 39.6) (80.0, 86.7)

2014, N=1,501 outlets 9.5 14.0 21.4 11.8 33.0 19.8 86.0

(7.9, 11.4) (11.7, 16.8) (19.3, 23.6) (8.6, 16.0) (28.3, 38.0) (14.5, 26.4) (83.2, 88.3)





Table D4: Price of tablet formulation antimalarials in 2010 USD, by outlet type, across survey round

Private

For-Profit Facility


Private



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Any ACT

2010 $3.45 $4.90 $4.03 - $4.03

[0.92-5.18] (308) [3.24-7.25] (1,173) [2.30-5.83] (702) - [2.30-6.10] (2,183)

2011 $0.58 $3.45 $0.81 $0.46 $0.92

[0.46-2.30] (479) [0.61-5.18] (1,363) [0.46-3.68] (1,356) [0.46-0.46] (114) [0.46-4.03] (3,312)

2014 $2.63 $3.94 $2.63 $1.97 $2.63

[1.58-5.25] (655) [1.84-6.56] (2,115) [1.40-5.25] (1,432) [1.31-3.94] (84) [1.58-5.25] (4,286)

Quality-assured ACT (QA ACT)

2010 $1.15 $4.61 $2.30 - $2.30

[0.00-3.45] (138) [1.15-5.99] (331) [1.38-5.53] (273) - [1.15-5.53] (742)

2011 $0.58 $0.61 $0.58 $0.46 $0.52

[0.46-1.15] (342) [0.46-1.38] (671) [0.46-0.92] (882) [0.46-0.46] (111) [0.46-0.92] (2,006)

2014 $1.97 $1.58 $1.58 $1.40 $1.75

[1.31-2.63] (433) [1.31-2.10] (889) [1.31-2.10] (818) [1.31-1.97] (69) [1.31-2.63] (2,209)


2010 $1.15 $0.92 $1.15 - $1.15

[0.92-1.38] (39) [0.69-1.15] (98) [0.92-2.30] (108) - [0.81-1.73] (245)

2011 $0.58 $0.61 $0.52 $0.46 $0.46

[0.46-1.15] (303) [0.46-1.20] (641) [0.46-0.92] (840) [0.46-0.46] (108) [0.46-0.92] (1,892)

2014 $1.97 $1.58 $1.58 $1.31 $1.75

[1.31-2.63] (360) [1.31-2.10] (784) [1.31-2.10] (725) [1.31-1.97] (61) [1.31-2.63] (1,930)


2010 $1.15 $5.76 $3.45 - $3.45

[0.00-4.61] (99) [4.03-6.91] (232) [2.30-5.76] (165) - [1.84-5.76] (496)

2011 $0.00 $2.30 $0.69 $0.46 $0.58

[0.00-0.92] (39) [1.15-11.05] (30) [0.46-2.30] (42) [0.46-0.69] (3) [0.00-1.84] (114)

2014 $1.97 $1.40 $1.58 $1.97 $1.58

[1.31-2.63] (71) [1.31-2.10] (105) [1.31-1.97] (92) [1.31-1.97] (8) [1.31-1.97] (276)




Private

For-Profit Facility


Private



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Non-quality assured ACT

2010 $4.53 $5.07 $4.61 - $4.61

[3.22-6.45] (170) [3.68-9.21] (842) [3.45-6.33] (429) - [3.45-6.91] (1,441)

2011 $4.61 $5.18 $4.61 $0.46 $4.61

[3.45-6.91] (137) [4.03-8.63] (692) [4.03-5.76] (474) [0.46-0.46] (3) [3.80-7.25] (1,306)

2014 $5.25 $5.61 $5.25 $6.56 $5.25

[3.94-6.56] (222) [3.94-10.59] (1,226) [4.07-9.19] (614) [3.94-13.13] (15) [3.94-8.40] (2,077)


2010 $0.81 $0.69 $0.69 $0.35 $0.46

[0.40-1.21] (109) [0.35-1.04] (175) [0.46-1.04] (533) [0.35-0.46] (417) [0.35-0.86] (1,235)

2011 $0.58 $0.92 $0.58 $0.35 $0.46

[0.35-0.92] (116) [0.52-1.73] (268) [0.40-1.15] (395) [0.35-0.46] (198) [0.35-1.04] (977)

2014 $0.66 $0.79 $0.66 $0.39 $0.66

[0.53-1.31] (97) [0.66-1.97] (480) [0.66-1.31] (481) [0.39-0.53] (195) [0.46-1.05] (1,253)

Pre-packaged adult QA AL

2010 $1.15 $4.84 $2.53 - $2.53

[0.69-3.45] (98) [1.15-5.99] (286) [1.15-5.76] (238) - [1.15-5.76] (622)

2011 $0.46 $0.46 $0.46 $0.46 $0.46

[0.46-0.69] (227) [0.46-0.52] (321) [0.46-0.58] (533) [0.46-0.46] (95) [0.46-0.58] (1,176)

2014 $1.84 $1.31 $1.31 $1.31 $1.31

[1.31-1.97] (255) [1.31-1.97] (504) [1.31-1.97] (488) [1.31-1.97] (42) [1.31-1.97] (1,289)




Private

For-Profit Facility


Private



Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]


Pre-packaged Pediatric QA AL

2010 $0.00 $1.97 $0.66 - $0.66

[0.00-0.66] (11) [1.58-2.63] (13) [0.53-0.66] (9) - [0.53-1.97] (33)

2011 $0.53 $0.53 $0.53 $0.53 $0.53

[0.00-0.66] (34) [0.39-0.53] (131) [0.39-0.53] (116) [0.20-0.53] (7) [0.39-0.53] (288)

2014 $0.79 $0.66 $0.66 $0.66 $0.66

[0.66-1.31] (67) [0.53-1.05] (171) [0.66-1.05] (134) [0.66-1.31] (6) [0.66-1.31] (378)


Figures in this table are derived using audited products with price information.




Table D5: Availability of malaria blood testing among antimalarial-stocking outlets*, by outlet type, across survey round


ALL Public

Private For-Profit

Facility

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)


2010 N=404 2011 N=432 2014 N=471

2010 N=506 2011 N=477 2014 N=573

2010 N=270 2011 N=281 2014 N=375

2010 N=213 2011 N=256 2014 N=490

2010 N=444 2011 N=491 2014 N=556

2010 N=1,100 2011 N=575 2014 N=405

2010 N=2,030 2011 N=1,603 2014 N=1,826

2010 N=2,536 2011 N=2,080 2014 N=2,399


2010 45.5 31.8 52.8 12.7 10.5 0.0 9.0 12.7

(39.0, 52.1) (20.9, 45.2) (41.2, 64.1) (7.5, 20.7) (7.7, 14.1) - (7.4, 10.9) (10.7, 15.0)

2011 55.4 57.2 44.5 18.0 7.1 0.0 10.4 25.5

(48.2, 62.4) (50.5, 63.7) (34.7, 54.7) (11.5, 27.1) (4.8, 10.6) - (8.1, 13.3) (22.1, 29.3)

2014 94.1 73.3 74.3 21.0 16.2 0.0 25.3 31.7

(90.1, 96.5) (53.0, 86.9) (70.1, 78.0) (18.0, 24.4) (13.1, 19.7) - (21.4, 29.6) (28.1, 35.5)

2010 N=404 2011 N=432 2014 N=470

2010 N=506 2011 N=477 2014 N=571

2010 N=270 2011 N=280 2014 N=375

2010 N=213 2011 N=256 2014 N=490

2010 N=443 2011 N=488 2014 N=555

2010 N=1,098 2011 N=571 2014 N=403

2010 N=2,027 2011 N=1,595 2014 N=1,823

2010 N=2,533 2011 N=2,072 2014 N=2,394


2010 40.5 29.5 48.5 7.7 8.9 0.0 7.9 11.4

(33.6, 47.8) (19.6, 41.7) (37.7, 59.4) (2.9, 19.2) (5.8, 13.3) - (6.4, 9.8) (9.7, 13.5)

2011 41.6 44.5 40.2 12.2 6.0 0.0 8.9 20.4

(33.2, 50.5) (36.0, 53.3) (30.4, 50.8) (6.3, 22.5) (3.8, 9.2) - (6.9, 11.4) (17.5, 23.6)

2014 60.9 47.3 61.1 8.2 5.7 0.0 17.4 21.5

(56.8, 64.9) (33.5, 61.6) (56.7, 65.4) (6.5, 10.4) (4.1, 7.7) - (14.8, 20.5) (18.7, 24.4)

2010 N=403 2011 N=432 2014 N=470

2010 N=505 2011 N=477 2014 N=571

2010 N=269 2011 N=281 2014 N=375

2010 N=213 2011 N=256 2014 N=490

2010 N=443 2011 N=491 2014 N=555

2010 N=1,091 2011 N=575 2014 N=403

2010 N=2,019 2011 N=1,603 2014 N=1,823

2010 N=2,524 2011 N=2,080 2014 N=2,394


2010 6.0 5.1 6.7 5.6 1.9 0.0 1.4 2.0

(2.9, 12.1) (2.3, 10.9) (3.2, 13.6) (3.6, 8.5) (0.5, 6.5) - (0.8, 2.5) (1.3, 3.0)

2011 19.4 18.4 6.7 6.7 1.8 0.0 2.1 7.4

(9.9, 34.4) (9.6, 32.3) (3.7, 11.8) (3.2, 13.6) (0.8, 3.7) - (1.3, 3.4) (4.2, 12.7)

2014 68.2 51.7 29.2 15.0 12.3 0.0 12.6 17.8

(62.7, 73.3) (39.7, 63.5) (25.7, 33.0) (11.8, 18.9) (10.2, 14.8) - (10.5, 15.0) (15.7, 20.1)

* Blood testing availability is reported among outlets that either had antimalarials in stock on the day of the survey or reportedly stocked antimalarials in the previous 3 months. ** Results in this table are derived using responses captured among outlets with blood testing information.




Table D7: Price of malaria blood testing in 2010 USD, by outlet type, across survey round

Private For-Profit


ALL Private


Median [IQR]


Median [IQR]


Median [IQR]


Median [IQR]



Adult

2010 $0.66 $0.66 $0.66 $0.66

[0.66-1.31] (159) [0.53-1.31] (27) [0.66-1.31] (34) [0.66-1.31] (220)

2011 $0.58 $1.15 $0.58 $0.58

[0.58-1.15] (157) [0.58-1.15] (26) [0.58-0.92] (31) [0.58-1.15] (214)

2014 $1.31 $1.31 $1.31 $1.31

[0.66-1.31] (263) [1.31-1.31] (55) [1.31-1.31] (30) [0.66-1.31] (348)


2010 $0.66 $0.66 $0.66 $0.66

[0.66-1.31] (160) [0.53-1.31] (26) [0.66-1.31] (34) [0.66-1.31] (220)

2011 $0.58 $0.58 $0.58 $0.58

[0.46-0.81] (156) [0.58-1.15] (25) [0.58-0.92] (31) [0.58-1.15] (212)

2014 $1.31 $1.31 $1.31 $1.31

[0.66-1.31] (263) [1.31-1.31] (55) [1.31-1.31] (30) [0.66-1.31] (348)


Adult

2010 $0.00 $0.92 $1.31 $1.31

[0.00-1.31] (21) [0.92-2.63] (16) [1.31-1.31] (8) [0.00-1.31] (45)

2011 $0.58 $1.73 $1.15 $1.15

[0.35-1.15] (23) [1.15-1.73] (29) [0.58-1.73] (15) [0.58-1.73] (67)

2014 $1.31 $1.31 $1.31 $1.31

[1.31-1.97] (134) [1.31-1.31] (55) [1.31-1.97] (59) [1.31-1.97] (248)

Child under five

2010 $0.00 $0.92 $1.31 $1.31

[0.00-1.31] (21) [0.92-2.63] (16) [1.31-1.31] (8) [0.00-1.31] (45)

2011 $0.58 $1.15 $1.15 $1.15

[0.23-1.15] (23) [1.15-1.73] (28) [0.58-1.38] (15) [0.58-1.38] (66)

2014 $1.31 $1.31 $1.31 $1.31

[1.31-1.97] (133) [1.31-1.31] (53) [1.31-1.31] (59) [1.31-1.97] (245)

* Total price to the consumer including consultation and/or service fees.




Table D8: Antimalarial market share, across survey round

AETDs sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/ distributed:


TOTAL Public/Not For-

Profit

Private For-Profit

Facility

Registered Pharmacy



ANTI-MALARIAL TOTAL*

% % % % % % % %

2010

1. Any ACT 15.9 18.1 4.3 4.7 6.3 0.0 15.3 33.4








OUTLET TYPE TOTAL*** 26.4 33.0 11.0 9.2 40.6 6.1 67.0 100.0

2011

1. Any ACT 15.6 17.9 10.1 3.2 28.1 2.5 43.8 61.7









2014

1. Any ACT 7.5 10.0 9.6 27.4 20.8 2.3 60.0 70.0









* Row sum – market share for the specified antimalarial medicine. *** Column sum (within each survey round) – market share for the specified outlet type. Categories 1 through 4 sum to 100% in the far-right column – antimalarial total column (within in survey round).




Table D9: Antimalarial market share, across outlet type, across survey round

AETDs sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/ distributed:


TOTAL Public / Not-For-

Profit

Private For-Profit

Facility

Registered Pharmacy



% % % % % % %

2010

1. Any ACT 60.4 54.9 39.0 51.3 15.4 0.0 22.8








2011

1. Any ACT 46.1 48.8 64.9 55.9 75.1 52.8 69.2








2014

1. Any ACT 79.5 81.2 81.7 67.4 68.1 46.7 68.4








Categories 1 through 4 sum to 100% within each column (within each survey round).




Table D12: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round


ALL Public / Not for-

profit

Private for-profit

HF

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: 2010 N=407 2011 N=432 2014 N=471

2010 N=509 2011 N=477 2014 N=573

2010 N=270 2011 N=282 2014 N=375

2010 N=216 2011 N=259 2014 N=492

2010 N=444 2011 N=492 2014 N=557

2010 N=1,112 2011 N=576 2014 N=408

2010 N=2,045 2011 N=1,609 2014 N=1,832

2010 N=2,554 2011 N=2,086 2014 N=2,405

Correctly state the national

first-line treatment for uncomplicated malaria

2010 96.7 83.0 77.3 97.3 61.9 15.5 36.8 44.3

(94.2, 98.2) (71.2, 90.6) (68.0, 84.5) (92.1, 99.1) (48.8, 73.4) (11.1, 21.1) (32.6, 41.2) (39.5, 49.1)

2011 97.6 97.0 86.4 90.9 84.5 29.9 58.6 71.0

(95.0, 98.9) (94.6, 98.4) (77.3, 92.2) (85.1, 94.6) (78.4, 89.1) (20.5, 41.2) (50.6, 66.2) (65.1, 76.3)

2014 98.7 96.1 92.8 96.2 91.0 29.3 71.5 74.8

(97.5, 99.3) (93.9, 97.5) (90.9, 94.3) (93.9, 97.6) (88.9, 92.7) (22.9, 36.6) (64.4, 77.7) (68.4, 80.3)

Correctly state the first-line dosing regimen for*:

An adult

2010 68.1 43.7 31.0 85.1 27.0 - 12.9 17.9

(57.1, 77.4) (30.1, 58.3) (24.9, 37.9) (77.4, 90.5) (22.5, 32.1) - (9.8, 16.9) (14.7, 21.7)

2011 85.5 85.8 69.8 80.0 76.9 11.8 44.1 57.5

(78.9, 90.3) (79.8, 90.3) (61.9, 76.7) (73.1, 85.4) (70.1, 82.5) (7.6, 18.0) (38.0, 50.5) (51.8, 63.1)

2014 95.9 88.4 87.8 89.9 86.2 17.3 64.2 67.4

(92.9, 97.7) (84.1, 91.6) (85.7, 89.7) (87.9, 91.6) (83.8, 88.3) (12.9, 22.6) (57.0, 70.8) (61.0, 73.3)

A two-year old child

2010 64.4 42.8 20.4 68.8 14.5 - 8.0 13.6

(54.0, 73.6) (32.3, 54.0) (14.1, 28.6) (54.7, 80.1) (10.9, 19.0) - (10.7, 17.1) (15.0, 24.9)

2011 83.7 83.3 49.4 63.7 52.6 5.4 30.0 47.1

(76.1, 89.2) (76.7, 88.3) (41.7, 57.1) (54.3, 72.2) (45.8, 59.4) (3.0, 9.6) (24.7, 35.9) (41.6, 52.8)

2014 87.8 79.1 73.0 81.1 73.9 10.1 53.2 56.7

(84.4, 90.6) (72.4, 84.4) (69.4, 76.3) (78.6, 83.3) (70.6, 76.9) (7.0, 14.3) (47.0, 59.3) (51.0, 62.2)



Table D12: Provider antimalarial treatment knowledge and practices, by outlet type, across survey round



profit

Private for-profit

HF

Registered Pharmacy



Private ALL

Outlets

%

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI) %

(95% CI)

Proportion of providers who: 2010 N=407 2011 N=432 2014 N=471

2010 N=509 2011 N=477 2014 N=573

2010 N=270 2011 N=282 2014 N=375

2010 N=216 2011 N=259 2014 N=492

2010 N=444 2011 N=492 2014 N=557

2010 N=1,112 2011 N=576 2014 N=408

2010 N=2,045 2011 N=1,609 2014 N=1,832

2010 N=2,554 2011 N=2,086 2014 N=2,405

Report an ACT as the most effective

antimalarial medicine

For adults

2010 84.6 66.5 50.6 89.4 38.3 4.7 21.0 28.3

(79.6, 88.5) (57.7, 74.4) (42.2, 58.8) (83.7, 93.3) (26.0, 52.3) (2.9, 7.5) (17.6, 24.8) (24.0, 33.1)

2011 95.7 94.8 82.7 89.8 88.1 25.7 56.8 69.0

(92.5, 97.5) (91.6, 96.8) (76.1, 87.8) (81.4, 94.7) (81.5, 92.6) (16.8, 37.2) (48.3, 64.9) (62.5, 74.9)

2014 96.7 93.9 89.2 95.0 87.6 29.1 69.3 72.6

(94.6, 98.0) (90.6, 96.2) (86.7, 91.3) (93.3, 96.2) (85.7, 89.3) (19.7, 40.7) (61.2, 76.4) (65.3, 78.9)

For children

2010 87.7 68.9 42.1 88.2 35.3 3.9 18.8 26.8

(83.0, 91.3) (55.5, 79.7) (34.1, 50.4) (82.3, 92.3) (26.4, 45.3) (2.4, 6.5) (15.5, 22.6) (22.2, 32.0)

2011 95.3 94.7 79.2 96.3 75.8 18.6 50.2 64.5

(91.0, 97.6) (90.5, 97.1) (72.1, 84.9) (92.3, 98.3) (67.1, 82.8) (12.1, 27.5) (42.4, 57.9) (58.4, 70.2)

2014 94.7 91.6 87.3 96.3 85.6 21.9 65.8 69.3

(92.6, 96.3) (88.6, 93.8) (84.5, 89.6) (94.8, 97.4) (83.0, 87.8) (14.4, 31.8) (57.7, 73.2) (62.1, 75.7)

At the time of the 2014 Kenya ACTwatch outlet survey, artemether lumefantrine was Kenya's first line treatment for uncomplicated malaria. Numbers of providers (N) in this table are the total number of providers eligible for table indicators. * In 2010 and 2011, this question was only administered in QA ACT-stocking outlets.




Annex 1: ACTwatch Background ACTwatch is a multi-country research project implemented by PSI (www.psi.org). Standardized tools and approaches are employed to provide comparable data across countries and over time. Project countries include: Benin, Cambodia, the Democratic Republic of Congo, Kenya, Laos, Madagascar, Myanmar, Nigeria, Tanzania (currently mainland only, previous work in Zanzibar), Thailand, Uganda, Vietnam, and Zambia. The project was launched in 2008 with funding from the Bill and Melinda Gates Foundation (BMGF), and is currently funded through 2016 by the BMGF, UNITAID, and DFID. ACTwatch is designed to provide timely, relevant, and high quality antimalarial market evidence.2 The goal of providing this market evidence is to inform and monitor national and global policy, strategy, and funding decisions for improving malaria case management. ACTwatch is monitoring antimalarial markets in the context of policy shifts and investments in the scale-up of first-line ACT and blood testing using RDTs. This has included adaptation of project methods for the evaluation of the Affordable Medicines Facility-malaria (AMFm) pilot.3 The project implements a set of research tools designed to: 1) Provide a picture of the total market for malaria case management including: all providers carrying antimalarials

and RDTs and providing case management services; the relative antimalarial market share for each provider type; the antimalarial supply chain; and price markups within the supply chain for antimalarials and RDTs.

2) Monitor the readiness of market components for appropriate malaria case management, including: availability

of antimalarials and malaria blood testing; consumer price of antimalarial treatment and malaria blood testing; and provider qualifications, training and knowledge.

3) Monitor the performance of market components for appropriate malaria case management, including: the

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

ACTwatch research tools for malaria market monitoring include: 1. Outlet surveys Outlet surveys entail collecting quantitative data from all outlets and providers with the potential to sell or distribute antimalarials and/or provide malaria blood testing. These include health facilities, community health workers, pharmacies, Unregistered Pharmacies, retail outlets, market stalls, and mobile providers. A screening process identifies outlets that provide antimalarials and/or malaria blood testing. Among these eligible outlets, service providers are interviewed and all antimalarials and RDTs are audited. The audit collects information about each antimalarial and RDT in stock (e.g. brand name, drug active ingredients and strengths, manufacturer, etc.) and retailer reports on consumer price and sale/distribution volumes for each product. A representative sample of outlets is identified within target study domains such that findings from the outlet survey provide estimates of antimalarial and RDT availability, price, and relative market share across the entire market as well as within key market segments.4

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


http://www.psi.org/


From 2008 through 2014, ACTwatch conducted 35 national outlet surveys across the 10 project countries.5 Reports are available at www.actwatch.info, and peer-reviewed publications have appeared in Malaria Journal and The Lancet.6 2. Supply chain studies Supply chain studies employ quantitative and qualitative research methods to effectively map the antimalarial supply chain in a given country. The supply chain is mapped from the antimalarial outlets (service delivery points) identified during an outlet survey to national importers and distributors with identification of all mid-level distributers in between. Retail prices are documented along the supply chain to facilitate calculation of commodity mark-ups. From 2008 through 2012, ACTwatch conducted 8 national supply chain studies. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in PLoS One.7 3. Population-based surveys Population-based surveys are conducted among consumers to document fever treatment-seeking behavior. A representative sample of the target population (caregivers of children and/or adults according to burden and risk) is identified, and a screening tool is used to identify individuals who have recently experienced fever. The surveys investigate the extent to which health care was sought, as well as common sources of care received. Respondent reports of malaria blood testing and antimalarials acquired are documented and summarized. The survey includes measures of demographic and other individual, household/family, and community characteristics that can be used to develop consumer profiles as well as monitor equity in access to malaria case management. From 2008 through 2012, ACTwatch conducted 14 household surveys focused on fever treatment-seeking behavior. Reports are available at www.actwatch.info, and a peer-reviewed publication has appeared in Malaria Journal.8

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

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

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

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






ACTwatch in Kenya PSI conducted two rounds of outlet surveys in 2010 and 2011 in Kenya as part of the Independent Evaluation of the AMFm through support from the Global Fund. A follow-up outlet survey was conducted in 2014.



Annex 2: Kenya Background The Republic of Kenya is a country in East Africa and is bordered by Ethiopia, Sudan, Uganda, Tanzania and Somalia. It covers an area of 582,646 square kilometers, of which about 80% of the land area is arid and semi‐arid and only 20% is arable.9 It is divided into eight provinces, which are further subdivided into districts, divisions, locations, and sub‐locations. According to the 2009 census, the population of Kenya was 38.6 million,10 and more recent World Bank figures estimate the population reached 44.86 million in 2014.11 In 2009, 42.9% of the population was aged below 15 years, and 67.7% lived in rural areas.12 Kenya is a lower middle-income country with a gross domestic product per capita of US $ 1,358.3 per capita in 2014, and an economy that is predominantly agrarian.13 The human development index is 0.535, ranking the country 147th out of 187 countries. Kenya experiences strong regional disparities in poverty as well as high rates of inequality of income distribution, particularly in urban areas.

Health care system

Kenya’s health care system consists of a network of more than 6,700 health facilities countrywide, with the public sector accounting for half of facilities.14 There has been a general increase in the number of healthcare personnel over the years and there was an average of 20.7 doctors and 159.3 nurses for every 100,000 persons by 2013.15 The public sector accounts for 60% of total health personnel, of whom about 70% are concentrated in hospitals.16 Kenya has two line of ministries responsible for health care delivery – the Ministry of Medical Services (MOMS) and the Ministry of Public Health and Sanitation (MOPHS) that together have the mandate to implement the National Health Sector Strategic Plan. Health services delivery is now organized with a focus on community delivery systems with community health units responsible for services at the community level. Community health units refer to primary care services provided at dispensaries and health centers at the sub-county level. Referral services are available at the county and national levels.17

The private for‐profit health sector is comprised of private hospitals, clinics, dispensaries and drug outlets and accounts

for about one-third of health facilities in the country.18

Malaria risk and burden

Approximately 75 percent of Kenya’s population resides in areas with malaria transmission (population of 33.7 million

people), with 36 percent residing in areas of high transmission and 40% residing in areas of low transmission. In recent

years, Kenya has experienced significant declines in malaria admissions and deaths at the national level. High malaria

transmission is concentrated in the endemic areas around Lake Victoria.19

9 MOPHS. (2009). Towards a malaria-free Kenya: National Malaria strategy 2009-2017. Available: http://www.c-hubonline.org/sites/default/files/resources/main/Kenya_National_Malaria_Strategy_2009-2017.pdf. 10 KNBS. (2010). The 2009 Kenya Population and Housing Census: Volume 1c. Nairobi, Kenya: KNBS. 11 The World Bank (2015). Available: http://data.worldbank.org/indicator/SP.POP.TOTL/countries/KE?display=graph. 12Kenya National Bureau of Statistics (KNBS). (2010). The 2009 Kenya population and Housing Census: Volume 1c. Nairobi, Kenya: KNBS. 13 The World Bank (2015). Available: http://data.worldbank.org/indicator/NY.GDP.PCAP.CD. 14 Division of Malaria Control [Ministry of Public Health and Sanitation]. (2010). National guidelines for the diagnosis, treatment and prevention of malaria in Kenya. Nairobi, Kenya: DOMC. 15 Ministry of Health. (2014). Kenya Health Policy 2014-2030: Towards attaining the highest standard of health. Nairobi, Kenya: Ministry of Health 16 Wamai R. G. (2009). The Kenya Health System – Analysis of the situation and enduring challenges. JMAJ 52(2): 134–140 17 Ministry of Health. (2014). Kenya Health Policy 2014-2030: Towards attaining the highest standard of health. Nairobi, Kenya: Ministry of Health 18 DOMC [MOPHS]. (2010). National guidelines for the diagnosis, treatment and prevention of malaria in Kenya. Nairobi, Kenya: DOMC 19 WHO. (2014). World Malaria Report 2014. WHO: Geneva.


http://www.c-hubonline.org/sites/default/files/resources/main/Kenya_National_Malaria_Strategy_2009-2017.pdf


http://data.worldbank.org/indicator/SP.POP.TOTL/countries/KE?display=graph

http://data.worldbank.org/indicator/NY.GDP.PCAP.CD


Figure X1: Map of confirmed cases per 1000 population / parasite prevalence

Source: Noor et al. (2009). The risks of malaria infection in Kenya in 2009, p. 9.

Kenya has four malaria epidemiological zones that are largely defined by altitude, rainfall patterns and temperature.

These areas include:

1. Endemic areas around Lake Victoria in Western Kenya and in the Coastal regions. Transmission in these areas is

intense throughout the year, but peaks from June to August and again in late November following the rainy seasons.

2. Seasonal transmission areas. These are arid and semi‐arid areas of the northern and south-eastern parts of the

country, which experience short periods of intense transmission during the rainy season.

3. Epidemic prone areas of Western highlands of Kenya. Malaria transmission here is seasonal with considerable year‐

to‐year variation. Case fatality rates during an epidemic can be up to ten times greater than those experienced in

regions where malaria occurs regularly.

4. Low risk malaria areas. This zone covers the central highlands of Kenya including Nairobi, where temperatures are

too low to allow completion of the sporogenic cycle of the malaria parasite in the vector.

Malaria case management guidelines

Diagnosis

The national guidelines for malaria case management were updated in 2010 to recommend universal parasitological

testing of all febrile patients in all areas of the country (regardless of endemicity) with malaria microscopy or RDTs.

However, the guidelines noted that where confirmatory testing is not available, suspected malaria cases should not

be denied antimalarial treatment.20 The first nationwide distribution of RDTs took place in 2012, following initial sub-

20 MOPHS (2010) National Guidelines for Diagnosis, Treatment and Prevention of Malaria for Health Workers. Third Edition. Ministry of Public Health and Sanitation & Ministry of Medical Services, Division of Malaria Control, Nairobi.



national pilot projects implemented since 2006.21 A major RDT stockout occurred in 2013 after a central warehouse

fire in January destroyed over 4.2 million RDTs. A PMI procurement of 4.5 million RDTs arrived in March 2014 and RDTs

were rolled out to community, dispensary and health centers.22 Access to diagnostic testing services is being expanded

through the provision of RDTs to facilities that do not have microscopy. It is expected that with increased access to

RDTs, provided through a Global Fund Round 10 Grant, rational use of ACTs will improve – thereby increasing access

by decreasing demand.23

Treatment

In 2004, Kenya changed its first-line treatment policy for uncomplicated malaria from SP to artemether lumefantrine

(AL) 20/120.24 In 2010, the treatment policy was revised to recommend dihydroartemisinin piperaquine (DHA PPQ)

for the second-line treatment and the use of AL during the second and third trimesters of pregnancy.25

Results of nationally representative biannual surveys to monitor outpatient malaria case management by the DOMC

between 2010 and 2013 showed that availability of at least one AL pack was relatively high (range: 89.1%–97.2%),

however, facilities less commonly had all four packs in stock (range: 45.4–71.5%).26

Financing and major initiatives to improve case management

In the Kenya Malaria Strategy 2009-2017, the malaria case management objective is to have 100 percent of all suspected malaria cases presenting to a health provider managed according to the national malaria treatment guidelines by 2017. Strategies to achieve this objective include: 27

1) Capacity building of health workers in malaria diagnosis and treatment at health facilities

2) Access to affordable malaria medicines and diagnostics through the private sector

3) Strengthening community case management of malaria using the community strategy through community

health workers

4) Ensuring commodity security of antimalarials and diagnostics in the public sector

Kenya has implemented strategies to increase access to malaria blood testing and appropriate treatment with funding through the Affordable Medicines Facility, malaria (AMFm) and Global Fund Round 10 as well as support from DFID and the US President’s Malaria Initiative (PMI). The AMFm provided first-line buyers in the public and private sector with access to highly subsidized (co-paid) quality-assured ACTs. Medicines subsidized through the AMFm are marked with a ‘green leaf’ logo on the packaging. Phase 1 of the AMFm was implemented from 2010-2012. Kenya signed the AMFm grant in July 2010. Copaid ACTs arrived in-country for the private sector by August of 2010 and for the public sector by June of 2011. By the end of 2011, the number of copaid QA ACT treatments delivered to Kenya was approximately 14.35 million in the public sector and 14.1 million in the private sector. The independent evaluation of the AMFm in Kenya showed a successful increase in availability and market share for quality-assured ACTs. The median price for QA ACTs in the private sector fell dramatically between baseline and endline and the price was equal to that

21 Zurovac D, Githinji S, Memusi D, et al. (2014). Major improvements in the quality of malaria case-management under the “test and treat” policy in Kenya.

PLoS One, 9(3): e92782. 22 PMI. (2015). Malaria Operational Plan 2015. Available: http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-

15/fy-2015-kenya-malaria-operational-plan.pdf?sfvrsn=3. 23 Key informant interviews conducted in December 2014. 24 Amin AA, Zurovac D, Kangwana BB, Greenfeld J, Otieno DN, et al. (2007) The challenges of changing national malaria drug policy to artemisinin-based combinations in Kenya. Malar J 6: 72. 25 MOPHS. (2010). National Guidelines for Diagnosis, Treatment and Prevention of Malaria for Health Workers. Third Edition. Ministry of Public Health and Sanitation & Ministry of Medical Services, Division of Malaria Control, Nairobi. 26 Zurovac D, Githinji S, Memusi D, et al. (2014). Major improvements in the quality of malaria case-management under the “test and treat” policy in Kenya. PLoS One, 9(3): e92782. 27 MOPHS. (2009). Towards a malaria-free Kenya: National Malaria strategy 2009-2017. Available: http://www.c-hubonline.org/sites/default/files/resources/main/Kenya_National_Malaria_Strategy_2009-2017.pdf.


http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-15/fy-2015-kenya-malaria-operational-plan.pdf?sfvrsn=3





of the most popular non-artemisinin therapy, SP.28 Transitional funding was provided by DFID in Kenya for co-paid ACTs through 2014. Kenya switched from a combined “push-pull” procurement system to a “pull” system based on AL consumption in 2012. This shift has been supported with activities to strengthen logistics and management information systems as well as various approaches to mitigate stock-outs as peripheral levels.29 Kenya has not experienced a stockout of AL at the central level for more than three years, which is an improvement over previous years when nationwide stockouts occurred regularly.30

28 AMFm Independent Evaluation Team. (2012). Independent evaluation of Phase 1 of the Affordable Medicines Facility – malaria (AMFm), multi-country

independent evaluation report: Final report. Calverton MD and London: ICF International and London School of Tropical Medicine and Hygiene. 29 Zurovac D, Githinji S, Memusi D, et al. (2014). Major improvements in the quality of malaria case-management under the “test and treat” policy in Kenya. PLoS One, 9(3): e92782. 30 PMI. (2015). Malaria Operational Plan 2015. Available: http://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-

15/fy-2015-kenya-malaria-operational-plan.pdf?sfvrsn=3.





Annex 3: Outlet Survey Methods

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

Public health facilities National referral hospital, provincial general hospitals, health centers or sub-health centers and dispensaries. There are over 3,000 MOH public health facilities in Kenya.

Private not for-profit health facilities

Hospitals, clinics, and dispensaries operated by NGO, CBO, or faith-based organizations. There are over 1,100 private not for-profit facilities in Kenya.

Community health workers

Community-based health workers

Private for-profit health facilities

Private hospitals, clinics, dispensaries, and diagnostic laboratories. There are over 3,100 private for-profit health facilities in Kenya.

Registered pharmacies/chemists

Pharmacies/Chemists are licensed and regulated by the Registered Pharmacy and Poisons Board and include Pharmacist Premises. By 2013, there were over 4,100 registered Pharmacies/Chemists in Kenya.

Unregistered pharmacies Small businesses that are not registered with the Registered Pharmacy and Poisons Board, but sell various classes of prescription and over-the-counter medicine at commercial prices.

General retailers Supermarkets, duka, kiosks, market stalls, and petrol stations.

Itinerant drug vendors Mobile providers typically working within a radius of their home. They are not registered with any national regulatory authority.

Stratification The Kenya 2014 outlet survey is stratified to provide estimates for urban and rural domains. Urban and rural designations for all sub-counties in the sampling frame were obtained from the 1999 National Census classification of enumeration areas. Locations with 65% or greater population living in areas classified as urban or peri-urban were classified as urban. All other locations were classified s rural.

Eligibility Criteria All outlets with the potential to sell or distribute antimalarials were included in the census screening. Outlets were eligible for a provider interview and malaria product audit if they met at least one of three study criteria: 1) one or more antimalarials reportedly in stock the day of the survey; 2) one or more antimalarials reportedly in stock within the three months preceding the survey; and/or 3) provides malaria blood testing (microscopy or RDT). Outlets that do not serve the general public (e.g. military facilities) were excluded from the study. Sample Size The outlet survey was powered to detect a 20 percentage point increase between 2011 and 2014 within each research domain (and nationally) in the indicator, the proportion of outlets that have quality-assured ACT in stock among all outlets with antimalarials in stock at the time of the survey. The required sample size for each research domain (urban



and rural strata) was calculated in three steps: 1) determine the required number of antimalarial-stocking outlets; 2) determine the number of outlets to be enumerated to arrive at this number of antimalarial-stocking outlets; and 3) determine the number of clusters for the census to arrive at this number of outlets.

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

where:

n= desired sample size

P1= the proportion of antimalarial-stocking outlets with quality assured ACT in stock in 2011

P2= the expected proportion of antimalarial-stocking outlets with quality-assured ACT in stock in 2014

P= (P1+P2)/2

Zα/2= The standard normal deviate value for a α type I error (two-sided)

Z1-β= The standard normal deviate value for a β type type II error

Deff= design effect anticipated due to the cluster survey design. Design effects observed during the 2011 study were used for sample size calculations.

The required size for the 2014 survey was calculated based on the following values of P1 and deff, estimated from the 2011 AMFm Independent Evaluation outlet survey:

Urban Domain Rural Domain

P1 0.719 0.634 deff 6.5 6.4

In addition, the following values for key parameters were used: Zα/2 = 1.96, corresponding to an α (type I) error of 5% with a two-sided test Z1-β = 0.84, corresponding to a test power of 80% (or a type II error of 20%) The required numbers of antimalarial stocking outlets, calculated using the above formula, are 594 outlets in the urban domain and 617 outlets in the rural domain. The same formula was used to calculate the number of public health facilities and pharmacies required to detect change over time within each of these outlet types, in urban and rural areas. In 2011, QA ACT availability within these outlet types was observed as follows: urban public health facility: 0.920; rural public health facility: 0.974; urban Registered Pharmacy: 0.933. With a design effect of 2.0 in all cases, 114 urban and 84 rural public health facilities are required, and 107 urban pharmacies and 127 rural pharmacies are required.

n = deff Za 2P(1- P) + Z1-b P1(1- P1)+ P2(1- P2 )éë

ùû

2

(P2 - P1)2



Required number of antimalarial-stocking outlets The following formula was used to calculate the required number of enumerated outlets:

where: N = the required number of outlets enumerated n = the number of antimalarial stocking outlets Pam= the proportion of outlets having any antimalarial in stock at the time of the survey among all outlets enumerated The table below presents the estimates for Pam from the 2010 outlet survey and the required gross sample sizes calculated using the above formula.


n 594 617 Pam 0.15 0.18 N 3,960 3,427

Thus a total of 3,960 outlets in the urban domain and 3,428 outlets in the rural domain must be interviewed in order to detect a 20 percentage point change in QA ACT availability between the 2014 and 2016 outlet surveys. During the 2011 national outlet survey, 90% of urban outlets and 79% of rural outlets enumerated were successfully screened, with reasons for non-participation including outlet temporary or permanent closure, non-availability due to busy providers, and refusal. Taking these non-participation rates into account, the total number of outlets required for enumeration is: 4,362 urban and 4,343 rural.

Required number of clusters (location) The primary sampling approach entails sampling a set of administrative units (geographic clusters) with a corresponding population of approximately 10,000 to 15,000 inhabitants. The appropriate administrative unit in Kenya corresponding to this desired population size is location. The desired number of clusters (wards) is selected with probability of cluster selection proportionate to size (PPS). A census of all outlets with the potential to sell or distribute antimalarials will be conducted in sampled wards. The average number of outlets screened per cluster from the 2011 outlet survey was used to estimate the number of clusters required in 2014 to achieve the desired sample size. The following formula was used to calculate the required number of clusters:

𝐶 = 𝑁/�̅� where: C = the required number of clusters N = the number of enumerated outlets O̅ = the mean number of outlets per cluster The table below presents the estimates for O̅ from the 2010/11 outlet survey and the required number of clusters required using the above formula.


N 4,362 4,343

O̅ 320.1 160.9 C 14 27

The 2011 survey findings suggest that on average, each urban location will have 2.3 public health facilities and 2.5 pharmacies. In order to achieve a sufficiently large sample size of urban public health facilities and pharmacies using the census Location plus Division booster strategy, the optimal number of urban Locations was calculated at 26.

N =n /Pam



Thus a total of 26 urban and 27 rural clusters will be censused in order to detect a 20 percentage point change in QA ACT availability between the 2014 and 2016 outlet surveys, and to achieve sufficient sample sizes for public health facilities and pharmacies to allow for estimates within these key outlet types. Applying the above parameters to the stated formula yields the following required sample sizes: urban: 268; rural 813; total: 1,081.

Sampling The primary sampling approach taken for outlet surveys entails sampling a set of administrative units (geographic clusters) with a corresponding population of approximately 10,000 to 15,000 inhabitants. The appropriate administrative unit in Kenya corresponding to this desired population size is Location. A representative sample of Locations was selected and a census of all outlets with the potential to sell or distribute antimalarials was conducted in sampled Locations. A ‘booster’ sample was used to increase the sample size for certain outlet types. The booster sample was drawn from the Divisions in which sampled Locations were located. Within booster sample Divisions, a census of the following outlet types was conducted: public health facilities and registered pharmacies. The sampling frame was generated using information from the 1999 National Census. Locations were defined as urban or rural according to information in the sampling frame provided at enumeration area (EA) level. The National Census classified EAs as urban, peri-urban, or rural. At the Location level, Locations with 65% or greater population living in areas classified as urban or peri-urban were classified as urban. All other locations were classified as rural. Clusters with recent documented security risks were excluded from sampling framework and these included all clusters in former North-Eastern Province and as well as clusters in former Coast Provinces (Tana River and Lamu). A representative sample of Locations was selected in each research domain (urban and rural areas) using one-stage cluster sampling. Two lists were prepared: a list of all urban Locations and a list of all rural Locations. The lists were sorted alphabetically by Province, District, Division, and Location and 26 urban and 27 rural Locations were sampled with probability proportional to population size (PPS). Selected/sampled locations with high population size of >40,000 persons were segmented into smaller units (sub-locations) and one sub-location was selected for the survey. The list of selected Locations is included in Annex 4. In these sampled locations, a census was conducted among all outlets with potential to stock antimalarials or/and provide malaria blood testing. In addition to the census of selected Locations, a booster sample was employed for pharmacies and public health facilities to reach the desired sample size for these key market segments. The booster strategy for public health facilities and pharmacies was to census all facilities and pharmacies within the Division of the sampled Location (i.e. expand the geographic scope for the census).

Data Collection Interviewers, supervisors, and quality controllers received training that included an orientation to the study, questionnaire and use of PDAs, classroom training on completing antimalarial and RDT audits, and a field exercise. Following training, data collection was implemented from November 7 to December 22, 2014. For all interviews, a structured questionnaire was administered using paper questionnaires (see Annex 6). A series of screening questions were administered at all outlets to determine eligibility for the survey. Outlets where antimalarial medicines were reportedly sold and/or malaria blood testing was reportedly provided were invited to participate in the survey. Following informed consent procedures, an audit of all available antimalarial medicines and RDTs was conducted. Antimalarial audit information included formulation, package size, brand name, active ingredients and strengths, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. RDT audit information included brand name, manufacturer, country of manufacture, reported sale/distribution in the week preceding the survey, retail price, and wholesale price. Detailed descriptions of antimalarials and RDTs audited are provided in Annex 7 and Annex 8. In addition to the product audit, a series of questions was administered to the senior-most provider regarding malaria case management knowledge and practices as well as provider training and qualifications. Geo-coordinates were recorded for each outlet using a handheld Global Positioning System (GPS) unit.



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

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

Protection of Human Subjects Ethical approval was obtained from the Kenyatta National Hospital Ethics and Research Committee (KNH ERC) prior to conducting the study. The PSI Research Ethics Board ceded review to the committee in Kenya. Provider interviews and product audits were completed only after administration of a standard informed consent form and provider consent to participate in the study. Providers had the option to end the interview at any point during the study. Standard measures were employed to maintain provider confidentiality and anonymity.



Annex 4: Sampled Locations

Table X1. Sampled locations Province District Division Location Urban/Rural Population

CENTRAL KIAMBU KIKUYU KINOO - Uthiru Sub-Loc urban 15,145

CENTRAL KIAMBU KIKUYU KINOO - Gitiba Sub-Loc urban 3,766

CENTRAL KIAMBU KIKUYU KINOO - Kinoo Sub-Loc urban 14,474

CENTRAL KIAMBU KIKUYU KINOO - Thogoto Sub-Loc urban 11,726

CENTRAL KIAMBU KIKUYU KABETE urban 30,899

CENTRAL KIAMBU KIKUYU KARAI rural 27,951

CENTRAL KIAMBU KIKUYU KIKUYU rural 33,907

CENTRAL KIAMBU KIKUYU MUGUGA rural 33,103

CENTRAL KIAMBU KIKUYU NYATHUNA rural 23,994

CENTRAL KIRINYAGA CENTRAL KUTUS rural 12,258

CENTRAL KIRINYAGA CENTRAL INOI rural 25,826

CENTRAL KIRINYAGA CENTRAL KERUGOYA rural 22,717

CENTRAL KIRINYAGA CENTRAL KOROMA rural 12,834

CENTRAL MURANG'A KAHURO MUGOIRI rural 31,413

CENTRAL MURANG'A KAHURO KAHUHIA rural 14,818

CENTRAL MURANG'A KAHURO MURARANDIA rural 29,995

CENTRAL MURANG'A KAHURO WEITHAGA rural 16,493

CENTRAL NYERI KIENI EAST GAKAWA rural 22,797

CENTRAL NYERI KIENI EAST KABARU rural 19,203

CENTRAL NYERI KIENI EAST KIAMATHAGE rural 10,678

CENTRAL NYERI KIENI EAST NAROMORU rural 17,667

CENTRAL NYERI KIENI EAST THIGU rural 10,522

CENTRAL THIKA KAKUZI MITUMBIRI rural 19,304

CENTRAL THIKA KAKUZI ITHANGA rural 18,199

CENTRAL THIKA KAKUZI KAKUZI rural 26,026

CENTRAL THIKA KAKUZI SAMURU rural 8,389

CENTRAL THIKA MUNICIPALITY THIKA MUNICIPAL- Komu Sub-Loc urban 54,120

CENTRAL THIKA MUNICIPALITY THIKA MUNICIPAL - Biashara Sub-Loc urban 10,607

CENTRAL THIKA MUNICIPALITY THIKA MUNICIPAL - Karimeni Sub-Loc urban 4,648

CENTRAL THIKA MUNICIPALITY THIKA MUNICIPAL - Majengo Sub-Loc urban 17,593

CENTRAL THIKA MUNICIPALITY GATUANYAGA rural 17,875

COAST KWALE KUBO MWALUPHAMBA rural 16,648

COAST KWALE KUBO LUKORE rural 2,619

COAST KWALE KUBO MAJIMBONI rural 6,170

COAST KWALE KUBO MANGAWANI rural 7,444

COAST KWALE KUBO MKONGANI rural 13,070

COAST KWALE KUBO MWALUVANGA rural 2,892

COAST KWALE MSAMBWENI DIANI - Gombato Sub-Loc urban 18,045

COAST KWALE MSAMBWENI DIANI - Bongwe Sub-Loc urban 7,962

COAST KWALE MSAMBWENI DIANI - Ukunda Sub-Loc urban 23,936

COAST KWALE MSAMBWENI DZOMBO rural 30,226

COAST KWALE MSAMBWENI KIKONENI rural 14,691

COAST KWALE MSAMBWENI KINGWEDE/SHIRAZ rural 8,912

COAST KWALE MSAMBWENI KINONDO rural 18,121

COAST KWALE MSAMBWENI LUNGA rural 16,848

COAST KWALE MSAMBWENI MIVUMONI rural 8,639

COAST KWALE MSAMBWENI MSAMBWENI urban 14,381

COAST KWALE MSAMBWENI MWERENI rural 26,736

COAST KWALE MSAMBWENI PONGWE/KIDIMU rural 12,372

COAST KWALE MSAMBWENI VANGA rural 11,473

COAST MOMBASA CHANGAMWE PORT REITZ urban 53,401

COAST MOMBASA CHANGAMWE CHANGAMWE urban 11,314

COAST MOMBASA CHANGAMWE KIPEVU urban 44,583

COAST MOMBASA CHANGAMWE MIKINDANI urban 32,267

COAST MOMBASA CHANGAMWE MIRITINI urban 29,953

COAST MOMBASA KISAUNI KISAUNI - Kisauni Sub-Loc urban 51,508

COAST MOMBASA KISAUNI KISAUNI - Junda Sub-Loc urban 13,454



COAST MOMBASA KISAUNI KISAUNI - Magogoni Sub-Loc urban 45,565

COAST MOMBASA KISAUNI BAMBURI urban 39,687

COAST MOMBASA KISAUNI KONGOWEA urban 86,581

COAST MOMBASA LIKONI LIKONI - Likoni Sub-Loc urban 15,054

COAST MOMBASA LIKONI LIKONI - Bofu Sub-Loc urban 24,924

COAST MOMBASA LIKONI LIKONI - Timbwani Sub-Loc urban 18,584

COAST MOMBASA LIKONI MTONGWE urban 20,507

COAST MOMBASA LIKONI SHIKA ADABU urban 14,270

EASTERN EMBU MANYATTA NGANDORI rural 22,342

EASTERN EMBU MANYATTA GATURI NORTH rural 12,324

EASTERN EMBU MANYATTA NGINDA rural 27,836

EASTERN EMBU MANYATTA RUGURU rural 9,022

EASTERN ISIOLO CENTRAL ISIOLO EAST urban 10,416

EASTERN ISIOLO CENTRAL CENTRAL urban 23,084

EASTERN ISIOLO CENTRAL ISIOLO WEST rural 11,409

EASTERN ISIOLO CENTRAL NGARE MARA rural 6,334

EASTERN MACHAKOS KANGUNDO KANZALU rural 18,381

EASTERN MACHAKOS KANGUNDO KAKUYUNI rural 15,776

EASTERN MACHAKOS KANGUNDO KANGUNDO rural 28,306

EASTERN MACHAKOS KANGUNDO KAWETHEI rural 15,644

EASTERN MACHAKOS KANGUNDO KIVAANI rural 13,130

EASTERN MAKUENI KATHONZWENI KITISE rural 8,495

EASTERN MAKUENI KATHONZWENI KANTHUNI rural 7,787

EASTERN MAKUENI KATHONZWENI KATHONZWENI rural 17,998

EASTERN MAKUENI KATHONZWENI KITHUKI rural 9,605

EASTERN MAKUENI KATHONZWENI MAVINDINI rural 12,810

EASTERN MAKUENI KATHONZWENI MBUVO rural 8,997

EASTERN MBEERE GACHOKA MAVURIA rural 17,259

EASTERN MBEERE GACHOKA KIAMBERE rural 10,860

EASTERN MBEERE GACHOKA KIANJIRU rural 17,479

EASTERN MBEERE GACHOKA MBETI SOUTH rural 13,953

EASTERN MERU CENTRAL MIRIGA MIERU E. THUURA urban 9,608

EASTERN MERU CENTRAL MIRIGA MIERU E. CHUGU urban 12,759

EASTERN MERU CENTRAL MIRIGA MIERU E. GIAKI rural 7,540

EASTERN MERU CENTRAL MIRIGA MIERU E. KIBURINE rural 6,619

EASTERN MERU CENTRAL MIRIGA MIERU E. MULATHANKARI urban 11,103

EASTERN MERU CENTRAL MIRIGA MIERU E. MUNITHU urban 9,444

EASTERN MERU NORTH MUTUATI KABACHI rural 34,110

EASTERN MERU NORTH MUTUATI NAATHU rural 22,221

EASTERN NITHI (MERU S.) MWIMBI GANGA rural 16,170

EASTERN NITHI (MERU S.) MWIMBI CHOGORIA rural 14,587

EASTERN NITHI (MERU S.) MWIMBI KIERA rural 9,042

EASTERN NITHI (MERU S.) MWIMBI MAARA rural 10,907

EASTERN NITHI (MERU S.) MWIMBI MURUGI rural 13,368

NAIROBI NAIROBI CENTRAL MATHARE - Mathare Sub-Loc urban 25,501

NAIROBI NAIROBI CENTRAL MATHARE - Mabatini Sub-Loc urban 17,260

NAIROBI NAIROBI CENTRAL MATHARE - Mlango Kubwa Sub-Loc urban 25,986

NAIROBI NAIROBI CENTRAL HURUMA urban 87,386

NAIROBI NAIROBI CENTRAL KARIOKOR urban 33,975

NAIROBI NAIROBI CENTRAL NGARA urban 24,158

NAIROBI NAIROBI CENTRAL STAREHE urban 14,151

NAIROBI NAIROBI DAGORETTI MUTUINI urban 14,534

NAIROBI NAIROBI DAGORETTI KAWANGWARE urban 86,884

NAIROBI NAIROBI DAGORETTI KENYATTA/GOLF C urban 28,528

NAIROBI NAIROBI DAGORETTI RIRUTA urban 65,987

NAIROBI NAIROBI DAGORETTI UTHIRU/RUTHMITU urban 23,250

NAIROBI NAIROBI DAGORETTI WAITHAKA urban 20,142

NAIROBI NAIROBI EMBAKASI EMBAKASI urban 22,982

NAIROBI NAIROBI EMBAKASI UMOJA - Savannah Sub-Loc urban 30,206

NAIROBI NAIROBI EMBAKASI UMOJA - Umoja Sub-Loc urban 62,666

NAIROBI NAIROBI EMBAKASI DANDORA urban 109,438

NAIROBI NAIROBI EMBAKASI KARIOBANGI S. urban 17,467

NAIROBI NAIROBI EMBAKASI KAYOLE urban 98,125



NAIROBI NAIROBI EMBAKASI MUKURU KWA NJEN urban 62,271

NAIROBI NAIROBI EMBAKASI NJIRU urban 17,730

NAIROBI NAIROBI EMBAKASI RUAI urban 12,461

NAIROBI NAIROBI KASARANI KARIOBANGI - Kariobangi North Sub-Loc urban 31,905

NAIROBI NAIROBI KASARANI KARIOBANGI - Baba Dogo Sub-Loc urban 39,373

NAIROBI NAIROBI KASARANI GITHURAI urban 48,168

NAIROBI NAIROBI KASARANI KAHAWA urban 32,272

NAIROBI NAIROBI KASARANI KASARANI urban 37,620

NAIROBI NAIROBI KASARANI KOROGOCHO urban 44,141

NAIROBI NAIROBI KASARANI ROYSAMBU urban 27,492

NAIROBI NAIROBI KASARANI RUARAKA urban 79,079

NAIROBI NAIROBI KIBERA KIBERA - Makina Sub-Loc urban 32,450

NAIROBI NAIROBI KIBERA KIBERA - Kibera Sub-Loc urban 16,082

NAIROBI NAIROBI KIBERA KIBERA - Lindi Sub-Loc urban 17,859

NAIROBI NAIROBI KIBERA KIBERA - Silanga Sub-Loc urban 16,643

NAIROBI NAIROBI KIBERA SERA NGOMBE - Olympic Sub-Loc urban 21,454

NAIROBI NAIROBI KIBERA SERA NGOMBE - Gatwikira Sub-Loc urban 24,209

NAIROBI NAIROBI KIBERA KAREN urban 8,879

NAIROBI NAIROBI KIBERA LAINI SABA urban 51,896

NAIROBI NAIROBI KIBERA LANGATA urban 16,015

NAIROBI NAIROBI KIBERA MUGUMOINI urban 29,604

NAIROBI NAIROBI KIBERA NAIROBI WEST urban 41,868

NAIROBI NAIROBI PUMWANI BAHATI urban 39,098

NAIROBI NAIROBI PUMWANI EASTLEIGH NORTH urban 66,758

NAIROBI NAIROBI PUMWANI EASTLEIGH SOUTH urban 50,390

NAIROBI NAIROBI PUMWANI KAMUKUNJI urban 18,154

NAIROBI NAIROBI PUMWANI PUMWANI urban 20,074

NAIROBI NAIROBI WESTLANDS HIGHRIDGE - Karura Sub-Loc urban 14,826

NAIROBI NAIROBI WESTLANDS HIGHRIDGE - Highridge Sub-Loc urban 25,050

NAIROBI NAIROBI WESTLANDS HIGHRIDGE - Muthaiga Sub-Loc urban 6,723

NAIROBI NAIROBI WESTLANDS KANGEMI urban 59,125

NAIROBI NAIROBI WESTLANDS KILIMANI urban 44,312

NAIROBI NAIROBI WESTLANDS KITISURU urban 27,790

NAIROBI NAIROBI WESTLANDS LAVINGTON urban 18,818

NAIROBI NAIROBI WESTLANDS PARKLANDS urban 11,365

NYANZA GUCHA(S. KISII) OGEMBO SENGERA rural 30,933

NYANZA GUCHA(S. KISII) OGEMBO M/CHACHE rural 47,827

NYANZA KISII CENTRAL TOWNSHIP TOWNSHIP urban 34,956

NYANZA KISUMU KADIBO KOMBURA rural 11,759

NYANZA KISUMU KADIBO BWANDA rural 7,620

NYANZA KISUMU KADIBO KAWINO rural 12,119

NYANZA KISUMU KADIBO KOCHIENG' rural 17,284

NYANZA KISUMU WINAM S.W. KISUMU urban 18,845

NYANZA KISUMU WINAM CENTRAL KISUMU urban 15,028

NYANZA KISUMU WINAM CENTRAL KOLWA urban 19,615

NYANZA KISUMU WINAM EAST KAJULU urban 11,919

NYANZA KISUMU WINAM EAST KISUMU urban 27,633

NYANZA KISUMU WINAM EAST KOLWA urban 15,580

NYANZA KISUMU WINAM KONDELE urban 69,225

NYANZA KISUMU WINAM MIWANI rural 8,142

NYANZA KISUMU WINAM NORTH KISUMU urban 16,210

NYANZA KISUMU WINAM TOWNSHIP urban 40,083

NYANZA KISUMU WINAM WEST KAJULU urban 17,174

NYANZA KISUMU WINAM WEST KOLWA urban 66,953

NYANZA N.KISII(NYAMIRA EKERENYO EKERENYO - Boisanga II Sub-Loc rural 7,216

NYANZA N.KISII(NYAMIRA EKERENYO EKERENYO - Boisanga I Sub-Loc rural 9,808

NYANZA N.KISII(NYAMIRA EKERENYO EKERENYO - Bokurati I Sub-Loc rural 6,765

NYANZA N.KISII(NYAMIRA EKERENYO EKERENYO - Bokurati II Sub-Loc rural 4,767

NYANZA N.KISII(NYAMIRA EKERENYO EKERENYO - Ikonge Sub-Loc rural 14,710

NYANZA N.KISII(NYAMIRA EKERENYO BOMWAGAMO rural 14,143

NYANZA N.KISII(NYAMIRA EKERENYO KIABONYORU rural 35,179

NYANZA N.KISII(NYAMIRA EKERENYO N. MUG. CHACHE rural 40,720

NYANZA N.KISII(NYAMIRA NYAMIRA BONYAMATUTA CHA urban 21,903



NYANZA N.KISII(NYAMIRA NYAMIRA BOGICHORA rural 16,789

NYANZA N.KISII(NYAMIRA NYAMIRA BONYAMATUTA MAS urban 15,963

NYANZA N.KISII(NYAMIRA NYAMIRA BOSAMARO CHACHE rural 16,937

NYANZA N.KISII(NYAMIRA NYAMIRA BOSAMARO MASABA rural 15,739

NYANZA N.KISII(NYAMIRA NYAMIRA KEERA urban 19,120

NYANZA N.KISII(NYAMIRA NYAMIRA W. MUGIRANGO urban 27,168

NYANZA RACHUONYO KASIPUL KONUONGA rural 8,268

NYANZA RACHUONYO KASIPUL EAST KAMAGAK urban 12,991

NYANZA RACHUONYO KASIPUL KACHIEN rural 7,583

NYANZA RACHUONYO KASIPUL KAKELO rural 14,658

NYANZA RACHUONYO KASIPUL KODERA rural 13,018

NYANZA RACHUONYO KASIPUL KOJWACH rural 15,941

NYANZA RACHUONYO KASIPUL KOKECH urban 7,929

NYANZA RACHUONYO KASIPUL KOKWANYO rural 8,659

NYANZA RACHUONYO KASIPUL KOWIDI urban 12,165

NYANZA RACHUONYO KASIPUL NORTH KAMAGAK rural 13,313

NYANZA RACHUONYO KASIPUL WEST KAMAGAK urban 15,626

R/VALLEY BARINGO KOLLOWA TIRIOKO rural 2,249

R/VALLEY BARINGO KOLLOWA KOLLOWA rural 5,199

R/VALLEY BARINGO KOLLOWA LOIWAT rural 3,049

R/VALLEY BARINGO KOLLOWA NGORON rural 4,484

R/VALLEY BURET SOTIK KAMUNGEI rural 14,717

R/VALLEY BURET SOTIK CHEMAGEL rural 22,860

R/VALLEY BURET SOTIK KAPLETUNDO rural 8,661

R/VALLEY BURET SOTIK KIMOLWET rural 7,433

R/VALLEY BURET SOTIK MANARET rural 6,491

R/VALLEY KAJIADO NGONG ONGATA RONGAI urban 23,849

R/VALLEY KAJIADO NGONG C. KEEKONYOKIE rural 9,216

R/VALLEY KAJIADO NGONG KISERIAN rural 16,441

R/VALLEY KAJIADO NGONG MOSIRO rural 3,200

R/VALLEY KAJIADO NGONG N. KEEKONYOIKE rural 12,007

R/VALLEY KAJIADO NGONG NGONG urban 15,767

R/VALLEY KAJIADO NGONG NKAIMORONYA rural 36,242

R/VALLEY KAJIADO NGONG OLOOLUA rural 17,734

R/VALLEY KAJIADO NGONG S. KEEKONYOKIE rural 12,680

R/VALLEY KERICHO KIPKELION CHEPSEON rural 10,832

R/VALLEY KERICHO KIPKELION BARSIELE rural 4,253

R/VALLEY KERICHO KIPKELION KAMASIAN rural 10,702

R/VALLEY KERICHO KIPKELION KAPSEGER rural 9,206

R/VALLEY KERICHO KIPKELION KIMUGUL rural 9,494

R/VALLEY KERICHO KIPKELION KIPCHORAN rural 6,873

R/VALLEY KERICHO KIPKELION KIPSEGI rural 8,360

R/VALLEY KERICHO KIPKELION LESIRWA rural 4,420

R/VALLEY NAKURU BAHATI DUNDORI rural 35,384

R/VALLEY NAKURU BAHATI BAHATI rural 53,746

R/VALLEY NAKURU BAHATI KABAZI rural 26,815

R/VALLEY NAKURU BAHATI SOLAI rural 28,359

R/VALLEY NAKURU NAKURU MUNI. CENTRAL - Afraha Sub-Loc urban 27,706

R/VALLEY NAKURU NAKURU MUNI. CENTRAL - Baharini Sub-Loc urban 51,491

R/VALLEY NAKURU NAKURU MUNI. BARUTI urban 9,331

R/VALLEY NAKURU NAKURU MUNI. KAPTEMBWO urban 109,956

R/VALLEY NAKURU NAKURU MUNI. LAKE NAKURU urban 763

R/VALLEY NAKURU NAKURU MUNI. LANET urban 36,648

R/VALLEY NAKURU RONGAI RONGAI rural 15,367

R/VALLEY NAKURU RONGAI BOROR rural 10,687

R/VALLEY NAKURU RONGAI KAMPI YA MOTO rural 18,353

R/VALLEY NAKURU RONGAI LENGINET rural 16,959

R/VALLEY NAKURU RONGAI MAKONGENI rural 15,529

R/VALLEY NAROK CENTRAL LOWER MELILI urban 29,599

R/VALLEY NAROK CENTRAL NKARETA rural 11,295

R/VALLEY NAROK MULOT SOGOO rural 17,943

R/VALLEY NAROK MULOT ENELERAI rural 8,832

R/VALLEY NAROK MULOT ILMOTIOK rural 10,960



R/VALLEY NAROK MULOT MULOT rural 17,330

R/VALLEY NAROK MULOT SAGAMIAN rural 12,853

R/VALLEY TRANS NZOIA KWANZA KAPOMBOI rural 31,051

R/VALLEY TRANS NZOIA KWANZA KAISAGAT rural 22,452

R/VALLEY TRANS NZOIA KWANZA KWANZA rural 34,862

R/VALLEY UASIN GISHU KESSES TARAKWA urban 13,863

R/VALLEY UASIN GISHU KESSES CHEPTIRET rural 6,196

R/VALLEY UASIN GISHU KESSES CHUIYAT rural 5,381

R/VALLEY UASIN GISHU KESSES KAPKOI rural 4,034

R/VALLEY UASIN GISHU KESSES KESSES rural 13,311

R/VALLEY UASIN GISHU KESSES KIPCHAMO urban 6,159

R/VALLEY UASIN GISHU KESSES MEGUN rural 8,364

R/VALLEY UASIN GISHU KESSES OL'LEINGUSE rural 12,754

R/VALLEY UASIN GISHU KESSES TIMBOROA rural 10,009

R/VALLEY UASIN GISHU KESSES TULWET rural 4,645

R/VALLEY UASIN GISHU SOY SEGERO rural 10,082

R/VALLEY UASIN GISHU SOY KIBULGENY urban 39,925

R/VALLEY UASIN GISHU SOY KIPLOMBE rural 18,002

R/VALLEY UASIN GISHU SOY KIPSOMBA rural 15,747

R/VALLEY UASIN GISHU SOY KOISAGAT rural 15,686

R/VALLEY UASIN GISHU SOY MOI'S BRIDGE rural 36,018

R/VALLEY UASIN GISHU SOY SIRIKWA rural 5,457

R/VALLEY UASIN GISHU SOY SOY rural 14,617

R/VALLEY UASIN GISHU SOY ZIWA rural 7,883

WESTERN BUNGOMA KIMILILI KIMILILI urban 26,886

WESTERN BUNGOMA KIMILILI KAMUKUYWA rural 24,241

WESTERN BUNGOMA KIMILILI KIBINGEI urban 26,825

WESTERN BUNGOMA KIMILILI MAENI urban 17,598

WESTERN BUNGOMA NDIVISI CHETAMBE rural 17,723

WESTERN BUNGOMA NDIVISI LUKUSI rural 13,803

WESTERN BUNGOMA NDIVISI NAMARAMBI rural 14,969

WESTERN BUNGOMA NDIVISI NDIVISI rural 11,546

WESTERN BUTERE/MUMIAS KHWISERO WEST KISA rural 9,747

WESTERN BUTERE/MUMIAS KHWISERO CENTRAL KISA rural 16,584

WESTERN BUTERE/MUMIAS KHWISERO EAST KISA rural 10,009

WESTERN BUTERE/MUMIAS KHWISERO KISA SOUTH rural 9,359

WESTERN BUTERE/MUMIAS KHWISERO MULWANDA rural 19,546

WESTERN BUTERE/MUMIAS KHWISERO NORTH KISA rural 14,081

WESTERN BUTERE/MUMIAS KHWISERO SHIROMBE rural 8,742

WESTERN KAKAMEGA MUNICIPALITY BUKHUNGU urban 36,511

WESTERN KAKAMEGA MUNICIPALITY SHIEYWE urban 35,048

WESTERN LUGARI LIKUYANI LIKUYANI rural 19,824

WESTERN LUGARI LIKUYANI KONGONI rural 33,530

WESTERN LUGARI LIKUYANI NZOIA rural 22,269

WESTERN LUGARI LIKUYANI SINOKO rural 15,922

WESTERN VIHIGA TIRIKI WEST GISAMBAI rural 19,884

WESTERN VIHIGA TIRIKI WEST BANJA rural 21,871

WESTERN VIHIGA TIRIKI WEST JEPKOYAI rural 17,515

WESTERN VIHIGA TIRIKI WEST TAMBUA rural 17,070



Annex 5: Detailed Sample Description

Table X2: Detailed sample description


Community Health

Workers

Private Not For-Profit Facilities

Private for-profit

Health Facility

Registered Pharmacy



Outlets

Number of outlets screened (Figure 1 Box B) 485 553 58 453 503 572 9950 12676

Urban 182 293 34 351 454 469 6342 8224

Census 60 293 34 351 179 469 6342 7827

Booster 122 0 0 0 275 0 0 397

Rural 303 260 24 102 49 103 3608 4452

Census 68 260 24 102 23 103 3608 4191

Booster 235 0 0 0 26 0 0 261

Number of outlets eligible and interviewed (Figure 1 Box D) 477 58 50 407 492 557 408 2449

Urban 175 14 29 314 444 458 125 1559

Census 57 14 29 314 175 458 125 1172

Booster 118 0 0 0 269 0 0 387

Rural 302 44 21 93 48 99 283 890

Census 67 44 21 93 22 99 283 629

Booster 235 0 0 0 26 0 0 261

Number of outlets eligible but not interviewed (interview non-participation) 0 1 0 7 8 6 6 28

Urban 0 0 0 7 8 6 0 21

Census 0 0 0 7 3 6 0 16

Booster 0 0 0 0 5 0 0 5

Rural 0 1 0 0 0 0 6 7

Census 0 1 0 0 0 0 6 7

Booster 0 0 0 0 0 0 0 0

Number of interviewed outlets with at least one antimalarial in stock on the day of the survey (Figure 1, Box D1) 457 17 43 342 487 536 251 2133

Urban 160 3 27 262 439 441 71 1403

Census 52 3 27 262 173 441 71 1029

Booster 108 0 0 0 266 0 0 374

Rural 297 14 16 80 48 95 180 730

Census 65 14 16 80 22 95 180 472

Booster 232 0 0 0 26 0 0 258 Number of interviewed outlets with at least one antimalarial in stock on the day of the survey or at least one antimalarial 471 52 50 375 492 557 408 2405



Table X2: Detailed sample description


Community Health

Workers

Private Not For-Profit Facilities

Private for-profit

Health Facility

Registered Pharmacy



Outlets

Reportedly in stock in the previous 3 months (Figure 1 sum of Box 1 and Box 2)

Urban 171 12 29 285 444 458 125 1524

Census 55 12 29 285 175 458 125 1139

Booster 116 0 0 0 269 0 0 385

Rural 300 40 21 90 48 99 283 881

Census 65 40 21 90 22 99 283 620

Booster 235 0 0 0 26 0 0 261

Number of interviewed outlets that provide malaria blood testing, but do not stock antimalarial medicines (Figure 1 Box D3) 6 6 0 32 0 0 0 44

Urban 4 2 0 29 0 0 0 35

Census 2 2 0 29 0 0 0 33

Booster 2 0 0 0 0 0 0 2

Rural 2 4 0 3 0 0 0 9

Census 2 4 0 3 0 0 0 9

Booster 0 0 0 0 0 0 0 0 Proportion of eligible and interviewed antimalarial-stocking outlets with at least one provider with a health-related qualification* 99.78 88.24 100.00 99.12 99.38 97.19 7.29 88.09

Urban 100.00 66.67 100.00 98.85 99.54 98.63 7.14 94.49

Census 100.00 66.67 100.00 98.85 100.00 98.63 7.14 92.68

Booster 100.00 - - - 99.25 - - 99.46

Rural 99.66 92.86 100.00 100.00 97.92 90.53 7.34 75.76

Census 100.00 92.86 100.00 100.00 100.00 90.53 7.34 62.82

Booster 99.57 - - - 96.15 - - 99.22

* Health-related qualifications include: medical doctor, pharmacist, nurse, midwife, laboratory technician, registered pharmacy technician, community health assistant, and community health worker




Annex 6: Questionnaire

ACTwatch Outlet Survey KENYA 2014

Section 1: Census Information

Interviewer completes this section for all outlets.

Outlet ID Interviewer-Dist- Div-Loc -Outlet ID [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]

C1. Today’s date (dd/mm/yyyy) [___|___]-[___|___]-[_2_|_0_|_1_|_4_]

C2. Interviewer’s name [_____________________________________________] C2a. Interviewer’s code [___|___]

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

C4. Division

[__________________________________________________________________]

C4a. Division code

[___|___|___]

C5. Location name

[__________________________________________________________________]

C5a. Location code

[___|___|___|___]

C6. Name of outlet If no name, record “no name” or owner’s name

[__________________________________________________________________]

C6a. Outlet code

[___|___|___]

C7. Type of Outlet 01 = Public National Referral Hospital 02 = Public County Referral Hospital 03 = Public Sub-County Hospital 04 = Public Health Centre/ Sub-Health Centre 05 = Public Dispensary/ Clinic 06 = Community Health Worker 07 = Registered Pharmacy/Chemist 08 = Unregistered Registered Pharmacy/Chemist 09 = Private Hospital/Nursing Home

10 = Private Clinic/Dispensary

11 = NGO Hospital 12 = NGO/CBO Clinic/Dispensary 13 = Mission/Faith-based Hospital 14 = Mission/Faith-based Clinic/Dispensary 15 = Supermarket/ Chain Store 16 = Duka/Kiosk/Market Stall/Petrol Station/Convenience Store 17 = Hawker 18 = Private Diagnostic Lab (Lab only) 19 = NGO/Mission Diagnostic Lab (Lab only) 96 = Other (specify) [____________________________________]

[___|___]

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

C8a. Is this outlet listed as part of PS/K private sector RDT project? (Refer to PS/K list) 1 = Yes 0 = No [___]

Hello, my name is __________, I work for IPSOS on behalf of Population Services International. We are conducting a study on the availability of antimalarial medicines and diagnostic testing services. The results will be used to improve the availability of appropriate antimalarial treatment in Kenya. I would like to ask you a few questions to see if you could be part of the survey.

Section 2: Screening & Eligibility S1. Do you have any medicines in stock today?

1 = Yes Go to S3 0 = No

[___]

S2. Are there any medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes Go to S4 0 = No Go to S5 8 = Don’t know Go to S5

[___]

S3. Do you have any antimalarial medicines in stock today?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to Section 3: Antimalarial Audit.

0 = No Verify with prompt card. Go to S4

[___]

S4. Are there any antimalarial medicines that are out of stock today, but that you stocked in the past 3 months?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to A16. 0 = No Verify with prompt card. Go to S5 8 = Don’t know Verify with prompt card. Go to S5

[___]

S5. Are you offering any diagnostic services or selling any diagnostic tests here today?

1 = Yes Go to S6 0 = No Verify with prompt card. Record details in C9 then complete Sec 7: ORS & Zinc then Sec X: Ending Interview

[___]



S6. Are any of these services or tests for suspected malaria?

1 = Yes Provide information sheet & gain consent. Record start time in C9. Proceed to Section 4: Diagnostic Audit

0 = No Verify with prompt card. Record details in C9 then complete Sec 7: ORS & Zinc and Sec X: Ending Interview

[___]

Before proceeding to the full interview ensure you have given the respondent a study information sheet, explained the study and obtained informed consent.

C9. Result of Visit(s)

Date (dd/mm/yy)

Visit 1 Visit 2 Visit 3

[___|___]-[___|___]-[_1_|_4_] [___|___]-[___|___]-[_1_|_4_] [___|___]-[___|___]-[_1_|_4_] Time started

(use 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Time completed

(use 24hr clock) [___|___]:[___|___] [___|___]:[___|___] [___|___]:[___|___] Result

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

01 = Outlet eligible & survey completed go to E1

02 = Outlet ineligible: does not meet any screening criteria go to E1

03 = Interview interrupted go to C11

04 = Respondent not available/time not convenient go to C11

05 = Outlet not open at the time go to C11

06 = Outlet closed permanently go to E1

96 = Other (specify):[_____________________________________________________________]

97 = Refused go to C10

C10. If the provider refused, why?

1 = Client load Ask respondent for a time they would prefer to be interviewed and note in C11 2 = Thinks it’s an inspection / nervous about license go to E1 3 = Not interested go to E1 6 = Other (specify):[___________________________________________________________________] 7 = Refuses to give reason go to E1

[___]

C11. Use this space to record call back details. If it is not possible to complete the interview at another time, go to E1.

Section 7: ORS & Zinc: Read to the provider: I have just a few questions for you about availability of treatments for

diarrhea. ORS1. Do you have any oral rehydration salts, also known as ORS in stock today? Verify with prompt card.

1 = Yes 0 = No

[___]

ORS2. Do you have any zinc tablets for treatment of diarrhea in children in stock today? Verify with prompt card.

1 = Yes 0 = No Go to C9 – Results of visit

[___]

ORS3. Which strength of zinc tablets for treatment of diarrhea in children do you have in stock today?

Read list, circle ALL that apply 10mg

20mg

Other, specify :[______________________________]

A B C

ORS4. Do you have any ORS that is packaged together with zinc treatment for diarrhea in children in stock today? Verify with prompt card

1 = Yes 0 = No

[___]



THANK THE PROVIDER AND END INTERVIEW

Section X: Ending the interview

E1. Name of interviewee:

5 = Not applicable, no respondent; 7 = Refused [___]

E2. Physical address or location identifiers of outlet (not PO box) (Give detailed description that will help supervisor to find the outlet)

E3. Telephone number 9999999995 = Not applicable: no respondent

or has no telephone 9999999997 = Refused

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

E4.Latitude: [__] -[___|___|___] .[___|___|___|___|___] E5.Longitude: [_E_]-[___|___|___] .[___|___|___|___|___]

E7. Additional observations by interviewer (if any)



Section 3: Antimalarial Audit

A0. Read to the provider: Can you please show us the full range of antimalarials that you currently have in stock? Do you currently have any of the following? Prompt entire list using antimalarial prompt card; No response to be recorded.

Artemether lumefantrine, such as Lonart, Artefan, Coartem

Artemisinin combination therapies, such as Duo-Cotexcin, Co-arinate, P-Alaxin

Artemisinin monotherapies, such as, Arinate, Artemedine

Artemether such as, Gvither

SP, such as Fansidar, Metakelfin, Ekelfin, Orodar

Amodiaquine, such as, Malaratab, Loquin

Quinine, such as, Quinitab, Quinimax, Falciquin

Mefloquine, such as Mephaquin, Meflotas, Mequin

Chloroquine, such as, Falcin, Maladrin

Syrups or suspensions, such as, Falcidin, Amoquin

Injectables, such as, Larither, Paluther, Quinine

Granules or powders, such as Artequin, Paediatric

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

Proceed to the antimalarial audit. Different antimalarial audit sheets will be used to record the antimalarial information based on the dosage form of the medicine. Separate the antimalarials into two piles:

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

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

If additional audit sheets are used, add these sheets after the ones provided and staple the questionnaire again. All pages should be in order before you move onto the next outlet. Number each drug by assigning a Product Number (starting from 1 for TSG drugs and again from 1 for NT drugs). Number each audit sheet used in the spaces provided at the bottom of the page.

ADDITIONAL NOTES ON THE SUB-OUTLET CODE

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

SUB-OUTLET CODES

X ALL outlets that have only ONE dispensing/distribution point for medicines/diagnostics

A Outpatient department / dispensary/Main Registered Pharmacy (if used by all patients)

B Adult outpatient department / adult dispensary / adult clinic

C Child outpatient department / child dispensary / child clinic

D Antenatal / maternity clinic/MCH

E ART / HIV/AIDS clinic/Comprehensive Care Clinic (CCC)

G Private dispensing unit within a public health facility

L Laboratory (for RDT audit)

Z Other (specify the type in the space for audit comments –TSG 15 or NT 15)


TABLET, SUPPOSITORY & GRANULE DRUG AUDIT SHEET (TSG)OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Tablet Audit Sheet [__|__] of [__|__]

Sub-outlet code [_____] _______ Product number [__|__|__]

[__|__]

[__|__]

[__|__]

1. Generic name

2. Strength [__|__|__].[__]mg [__|__|__].[__]mg [__|__|__].[__]mg

2a. Is this base strength? [__] 1 = Yes [__] 0 = No 8 = Don’t know [__] If no, specify salt: [________________________]

3. Dosage form/formulation 1 = Tablet

2 = Suppository

3 = Granule

[___]

4. Brand name (Include weight and age information)

[__|__]

5. Manufacturer

6. Country of manufacture

7. Package size There are a total of [___|___|___|___] tablets/ suppositories/ granule sachets in each:

1 = Package

2 = Pot/tin

[___]

8. Is product a fixed-dose combination (FDC) 1 = Yes

0 = No

8 = Don’t

know

[___]

9. Does product have the AMFm logo? 1 = Yes

0 = No

8 = Don’t

know

[___]

10. Amount sold/distributed in the last 7 days to individual consumers (Record # of packages / tins described in Q7 OR record the total # of tablets / suppositories / granule packs sold) This outlet sold [___|___|___] packages/ tins in the last 7 days OR This outlet sold [___|___|___] tablets/ suppositories or granule sachets in the last 7 days Not applicable = 995; Refused = 997; Don’t know = 998

11. Stocked out at any point in the past 3 months? 1 = Yes

0 = No

8 = Don’t

know

[___] [__|__|__]

12. Retail selling price [___|___|___] tablets, suppositories or granule sachets cost an individual customer [___|___|___|___] KSH

13. Wholesale purchase price For the outlet’s most recent wholesale purchase [___|___|___|___] tablets, suppositories or granule sachets cost [___|___|___|___|___] KSH

14. Why do you stock this medicine [SHOW PRODUCT]? Do not read list. Circle ALL responses given

Free supply A

Profitable B

Recommended by the government C

Low price D

Customer demand or preference E

Positive brand reputation F

Often prescribed by doctors G

Most effective for treating malaria H

Don’t know X

Other Z

specify [_________________________________]

15. Comments

Free = 0000 Refused = 9997

Don’t know = 9998

Free = 00000 Refused = 99997

Don’t know = 99998


NON-TABLET DRUG AUDIT SHEET (NT): SYRUP, SUSPENSION, INJECTIONS & OTHERS OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Sub-outlet code [_____] _______ Product number [__|__|__]

[__|__]

[__|__]

[__|__]

1. Generic name

2. Strength [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__|__|__|__].[__]mg/[__|__|__] .[__]mL [__|__|__|__].[__]mg/[__|__|__] .[__]mL (Note: no mL recorded for powder injection)

2a. Is this base strength? [__] 1 = Yes [__] 0 = No 8 = Don’t know [__] If no, specify salt: [______________________]

3. Dosage form/formulation 1 = Syrup

2 = Suspension

3=Liquid injection

4 =Powder injection

5 = Drops

6 = Other (specify) [___________]

[___] [__|__]

4. Brand name (Include weight and age information)

5. Manufacturer 6. Country of manufacture

7. Package size There are a total of [___|___|___|___].[__] mL (or mg for powder injections) in each:

1 = Bottle

2 = Ampoule/vial

[___]

9. Does this product have the AMFm logo? 1 = Yes

0 = No

8 = Don’t

know

[___]

10. Amount sold/ distributed in the last 7 days to individual consumers This outlet sold [___|___|___|___] bottles, ampoules or vials in the last 7 days Refused = 9997; Don’t know = 9998

11. Stocked out at any point in the past 3 months? 1 = Yes

0 = No

8 = Don’t know

[___] [__|__|__]

12. Retail selling price [___|___|___] bottles ampoules or vials cost an individual customer [___|___|___|___] KSH

13. Wholesale purchase price For the outlet’s most recent wholesale purchase: [___|___|___|___] bottles, ampoules or vials cost [___|___|___|___|___] KSH

14. Why do you stock this medicine [SHOW PRODUCT]? Do not read list. Circle ALL responses given

Free supply A

Profitable B


Low price D



Often prescribed by doctors G

Most effective for treating malaria H

Don’t know X

Other Z

specify [_________________________________]

15. Comments

Free = 0000 Refused = 9997

Don’t know = 9998

Free = 00000 Refused = 99997

Don’t know = 99998

Non-Tablet Audit Sheet [___|___] of [___|___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Antimalarials recently in stock

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

1 = Yes go to A17 0 = No go to Section 4: Diagnostic Audit 8 = Don’t know go to Section 4: Diagnostic Audit

[___]

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

1 = Yes, specify

[_______________________________________] [_______________________________________]

[_______________________________________] [_______________________________________]

[_______________________________________] [_______________________________________]

[_______________________________________] [_______________________________________]

[_______________________________________] [_______________________________________]

0 = No, provider can’t remember

[___]

Interviewer: Go to Section 4: Diagnostic Audit


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Section 4: Diagnostic Audit This section is about availability of malaria blood testing. Completing the questions may require speaking with more than 1 staff member at the outlet. If the respondent does not know the answer to a question in this section, ask to speak with another staff member who can provide the information.

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

1 = Yes 0 = No 8 = Don’t know

[___]

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


[___]

D2a. How does this facility dispose used sharps such as needles? Do not read list. Circle ALL responses given

Pay another facility to incinerate A

Incinerate within the facility B Bury C

Other(specify)[___________________________________] D

D3. Is malaria microscopic testing available here today?

1 = Yes 0 = No go to D7

[___]

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

997 = Refused 998 = Don’t know

[___|___|___]

D5. What is the total cost for a microscopic test for malaria for an adult: [___|___|___|___] KSH

Free = 0000; NA =9995; Refused = 9997; Don’t know=9998

D6. What is the total cost for a microscopic test for malaria for a child under five: [___|___|___|___] KSH

Free = 0000; NA = 9995; Refused = 9997; Don’t know=9998

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

Are malaria RDTs available here today?

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

[___]

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

SD Bioline, SD Malaria Antigen, U-Test Malaria

Wondfo One Step, Nova Test

First Response, ParaCheck, CareStart

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

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

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


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


Sub-outlet code [_____] Product number [__|__|__]

1. Brand name

2. Antigen test

(circle ALL that apply)

Not indicated Z

HRP2 A

pLDH B

Aldolase C

3. Parasite species (circle ALL that apply)

Not indicated Z

Pf A

Pv B

Po C

pm D

pan E

vom/Pvom F

Other G

Specify [_____________________]

4. Manufacturer

5. Country of Manufacture

6. Lot Number 7a. Is this a self test kit, with each test kit co-packaged with its own buffer, pipette and lancet? 1 = Yes 0 = No 8 = Don’t know [___]

Not indicated = 998

7. Does the product have a checkmark logo? Show prompt card. 1=Yes 0=No go to 12 8=Don’t know go to 12 [___]

8. What is the name of your supply company for this product? Record name. [_________________________________]

9. When did you first receive or place an order for this product? Record month and year. [___|___| - |__2_|_0_|___|___] Month - Year

10. What was the date of your most recent order for this product? Record month and year. [___|___| - |_2_|_0_|___|___] Month - Year

11. How many RDT cassettes did you purchase/receive for your most recent order ? [___|___|___|___] Refused = 9997 ; Don’t know = 9998

12. Number of tests sold/ distributed /used in the last 7 days to individual consumers (Record total # of tests) This outlet sold or distributed [___|___|___|___] tests in the last 7 days

Refused = 9997; Don’t know=9998

13. Has this test been stocked out at any point in the past 3 months? 1 = Yes 0 = No 8 = Don’t know

[___]

14a. Do you or other staff use this brand of RDT to test clients here at this facility/outlet?

1 = Yes 0 = No go to 15a 8 = Don’t know go to 15a

[___]

14b. If yes, what is the total cost for an adult to have a test conducted with this RDT, including RDT cost and service fee?

[___|___|___|___] KSH

14c. If yes, what is the total cost for a child under the age of five to have a test conducted with this RDT, including RDT cost and service fee?

[___|___|___|___] KSH

15a. Does this facility/outlet provide this brand of RDT for clients to take away for testing somewhere else?

1 = Yes 0 = No go to 16 8 = Don’t know go to 16 [___]

15b. If yes, what is cost of this RDT for an adult? [___|___|___|___] KSH 15c. If yes, what is the cost of this RDT for a child under the age of five? [___|___|___|___] KSH

16. Wholesale purchase price For the outlet’s most recent wholesale purchase: [___|___|___|___] tests

cost [___|___|___|___|___] KSH Free = 00000

NA = 99995 Refused = 99997

Don’t know=99998

17. Why do you stock this RDT [SHOW RDT]? Do not read list Circle ALL responses given

Free supply A

Profitable B


Low price D



Don’t know X

Other Z

specify [_______________________________]

18. Comment

Free = 0000; NA = 9995; Refused = 9997; Don’t know=9998


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


RDT stock outs

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

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

[___]

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

1 = Yes, specify

[____________________________________________________________________________]

[____________________________________________________________________________]

[____________________________________________________________________________]

0 = No

[___]

D11. Does this facility/outlet provide medicines or prescription for medicines? 1 = Yes go to Section 5: Provider Module 0 = No Confirm response in S3 or S4 is not equal to 1 and outlet type recorded in C7

is 18 or 19 (“lab only”). Go to Section 7: ORS and ZINC and then Go to Section 6: Audit Tracking Sheet.

[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Section 5: Provider Module This section is for the senior-most staff member who is responsible for providing treatment, prescriptions or medicines to clients/patients.

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

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

responsibilities.

|___]

P2. For how many years have you worked in this outlet/facility? If less than 1 year, enter 01

[___|___]

P3. What age are you today? Write age in years 97 = Refused 98 = Don’t know

[___|___]

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

1 = Male 2 = Female

[___|___]

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

1 = No formal education 2 = Some primary school 3 = Completed primary school 4 = Some secondary school 5 = Completed secondary school 6 = Some university/college 7 = Completed a university/college degree

[___]

P6. Have you received any training in the last 12 months that included a component on malaria diagnosis, including malaria rapid diagnostic tests or microscopy?

Include pre-service training and stand-alone workshops.


[___]

P7. Have you received any training in the last 12 months on the national treatment guidelines for malaria? Include pre-service training and stand-alone workshops.


[___]

P8. Do you have any of the following health qualifications? Read list. Record 1 for yes, 0 for no

I. Pharmacist [___]

II. Medical doctor [___]

III. Clinical Officer [___]

IV. Nurse / Nursing Officer [___]

V. Midwife [___]

VI. Laboratory technician / Lab assistant [___]

VII. Pharmaceutical technologist [___]

VIII. Registered Pharmacy technician [___]

IX. Public Health Technician/Officer [___]

X. Medical assistant / Nursing Assistant / Nursing Aid [___]

XI. Community based distributor/Community Health Worker [___]

XII. Other 1: specify [______________________________] [___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P9. Not including yourself, do any other people working in this outlet or facility have the following health qualifications? Read list. Record 1 for yes, 0 for no, 8 for don’t know

I. Pharmacist [___]

II. Medical doctor [___]

III. Clinical Officer [___]

IV. Nurse / Nursing Officer [___]

V. Midwife [___]

VI. Laboratory technician / Lab assistant [___]

VII. Pharmaceutical technologist [___]

VIII. Registered Pharmacy technician [___]

IX. Public Health Technician/Officer [___]

X. Medical assistant / Nursing Assistant / Nursing Aid [___]

XI. Community based distributor/Community Health Worker [___]

XII. Other 1: specify [______________________________] [___]

XIII. Other 2: specify [______________________________] [___]

XIV. Other 3: specify [______________________________] [___]

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

P10. In your opinion, for treating uncomplicated malaria in adults, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock.

Generic or brand name

Dosage form/formulation

01 = Tablet 02 = Suppository 03 = Granule

04 = Syrup 05 = Suspension 06 = IM/IV Injection (liquid or powder)

07 = Drops 95 = None specified 98 = Don’t know

[______________________________________]

Don’t know = 98

[___|___]

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

Ask the provider to show you the medicine if it is in stock.






[_______________________________________]

Don’t know = 98 [___|___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P12. What antimalarial medicine for treating uncomplicated malaria in adults do you most often recommend to customers? Ask the provider to show you the medicine if it is in stock.






[______________________________________]

Don’t know = 98

[___|___]

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







[______________________________________]

Don’t know = 98

[___|___]

P14. In your opinion, for treating severe malaria in children under five, what is the most effective antimalarial medicine? Ask the provider to show you the medicine if it is in stock.






[_____________________________________]

Don’t know = 98

[___|___]

P15. What antimalarial medicine for treating severe malaria in children under five do you most often recommend to customers?







[_____________________________________]

Don’t know = 98

[___|___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P16. Please name the first line medicine recommended by the government to treat uncomplicated malaria. Do not read list. Only one response allowed.

01 = Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem) …………………………… Go to P17

02 = ACT................................................................................................................................ Go to P17

03 = ACTm............................................................................................................................. Go to P17

04 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop)

05 = Dihydroartemisinin Piperaquine (Duo-cotecxin, P-alaxin)

06 = Amodiaquine

07 = Artemether

08 = Artemisinin

09 = Artesunate Go to P19

10 = Chloroquine

11 = Quinine

12 = Sulfadoxine Pyrimethamine (Fansidar, SP, Orodar, Ekelfin, Metakelfin)

96 = Other specify: [______________________________________________]

98 = Don’t know

[___|___]

P17. Please explain the government recommended treatment regimen for this drug for an adult (60kg)

Read the following 3 questions to the provider

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___]

Non-tablet = 94

NA = 95

Don’t know = 98

If respondent has the medicine available use the package to complete the table below. If the medicine is not available ask respondent to identify from prompt card. If identification not possible, ask respondent to recall medicine details.

Generic name Strength in mg Brand name

[__|__]

_______________________________

_______________________________

_______________________________

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

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

[__|__|__].[__]mg Don’t know=999.8

[__|__]

[__|__]

[___|___]

Manufacturer

Don’t know = 98

Is this drug a fixed-dose combination


[___]


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P18. Please explain the government recommended treatment regimen for this drug for a 2-year old child (10kg) Read the

following 3 questions to the provider

I. How many tablets should they take at a time? [___|___].[___|___] II. How many times per day? [___|___] III. Over how many days? [___|___]

Non-tablet = 94

NA = 95

Don’t know = 98

If respondent has the medicine available use the package to complete the table below. If the medicine is not available ask respondent to identify from prompt card.

If identification not possible, ask respondent to recall medicine details.

Generic name Strength in mg Brand name

[__|__]

_______________________________

_______________________________

_______________________________

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

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

[__|__|__].[__]mg Don’t know=999.8

[__|__]

[__|__]

[___|___]

Manufacturer

Don’t know = 98

Is this drug a fixed-dose combination


[___]

P19. Please name the medicine recommended by the government to treat severe malaria. Do not read list. Only one response allowed.

01 = Artesunate (Artesun, Larinate) ……………………………………………………………………………. Go to P20

02 = Artemether (Artenam, Paluther., Artesiane, Larither) ...................... Go to P20

03 = Quinine...................................................................................................................... Go to P20

04 = ACT/ACTm

05= Artemether Lumefantrine (Lonart, Artefan, Lumartem, Coartem)

06 = Artesunate Amodiaquine (DUAC, Coarsucam, Winthrop)

07 = Dihydroartemisinin Piperaquine (Duo-cotecxin, P-alaxin) Go to P21

08 = Chloroquine

09 = Sulfadoxine Pyrimethamine (Fansidar, SP, Orodar, Ekelfin, Metakelfin)

96 = Other (specify): [ _________________________________________]

98 = Don’t know

[___|___]

P20. What is the dosage form/formulation medicine recommended by the government to treat severe malaria? Do not read dosage form options

[___|___]


04 = Syrup 05 = Suspension 06 = IM/IV Injection (Liquid or powder)



OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P21. Malaria rapid diagnostic tests, also called RDTs, are small, individually wrapped blood tests that are able to quickly diagnose whether a person has malaria. Show RDT images in prompt card

Have you ever seen or heard of malaria RDTs?

1 = Yes Go to P22 0 = No Go to P29 8 = Don’t know Go to P29

[___]

P22. Have you ever tested a client for malaria using an RDT?


[___]

P23. Would you ever recommend a patient/customer take an antimalarial if a blood test using a rapid diagnostic test produced a negative test result for malaria? Read list. Record only one response.

1 = Yes, Sometimes 2 = Yes, Always 3 = No, Never go to P25 8 = Don’t know go to P25

[___]

P24. Under what circumstances would you recommend a patient/customer take an antimalarial following a negative RDT test for malaria? Do not read list. Prompt “anything else” until the respondent is finished. Circle ALL responses given

When they have signs/symptoms of malaria A

When they ask for antimalarial treatment B

When they are a child C

When they are an adult D

When they are a pregnant woman E

When I do not trust/believe the test F

When I know the patient/customer G

Other (specify) [_______________________________________________] X

P25. Have you ever seen or heard about the RDT with a checkmark logo before? Show the RDT with the checkmark logo

1= Yes 0= No go to P29 98= Don’t know go to P29

[___]

P26. Where did you see or hear about the RDT with a checkmark logo? Do not read list. Circle ALL that apply

I attended a training A

My colleague in this outlet attended a training B

Brochure/booklet/job aid C

Billboard D

Poster E

Distributor/supplier F

From the RDT product G

Radio H

Colleague I

Nearby facility J

Other (specify): [___________________________________________] K


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


P27. Do you have any posters, brochures, or other job aids available here that describe malaria testing with an RDT? 1=Yes 0=No go to P29 8=Don’t know go to P29

[___]

P28. Ask to see the materials. Does the RDT with the checkmark logo appear on any of the materials? 1=Yes 0=No 8=Don’t know

[___]

P29. What are the danger signs of severe illness in a child under 5? Do not read list. Prompt “anything else” until the respondent is finished. Circle ALL responses given

Unable to drink /unable to breastfeed A

Vomits everything B

Convulsions C

Lethargic or unconscious D

Don’t know Z

Other (specify) [__________________________________________________________]

X

P30. What would you do if a 2-year old child was brought to this outlet with the danger signs of severe illness? Do not read list. Only one response allowed.

01 = Seek advice/help from someone in this facility

02 = Treat the child in this facility

03 = Refer to a health facility (clinic, hospital) with or without treating here

04 = Refer to a non health facility outlet (not a clinic or hospital) with or without treating here

05 = Send them away/home without medicine

06 = Send them away/home with medicine

96 = Other – specify: [__________________________________________________________]

98 = Don’t know

[___|___]

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


OUTLET ID: [___|___]-[___|___]-[___|___|___]-[___|___|___|___]-[___|___|___]


Section 6: Audit Tracking Sheet

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

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

[___]

T2. Total number of TABLET/SUPPOSITORY/GRANULE audit sheets completed

[___|___]

T3. Did you complete audit sheet information for all available TABLETS/SUPPOSITORIES/GRANULES? 1 = Yes, audit complete 0 = No, audit not complete

[___]

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


[___]

T5. Total number of NON-TABLET audit sheets completed

[___|___]

T6. Did you complete audit sheet information for all available NON-TABLETS? 1 = Yes, audit complete 0 = No, audit not complete

[___]

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


[___]

T8. Total number of RDT audit sheets completed

[___|___]

T9. Did you complete audit sheet information for all available RDT? 1 = Yes, audit complete 0 = No, audit not complete

[___]

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

THANK THE PROVIDER FOR THEIR PARTICIPATION

Return to C9 and record the final status of the interview and time completed. Then complete Section 7: ORS

and Zinc and Section X: Ending the Interview.



Annex 7: Antimalarial Reference

Table X3: Number of antimalarials audited



Private-not-for-

profit


profit

Private for-

profit HF

Registered Pharmacy


General retailer

Total Private

ALL Outlets

Urban 622 3 102 727 1124 3401 2181 110 6816 7543

Census 215 3 102 320 1124 1530 2181 110 4945 5265

Booster 407 0 0 407 0 1871 0 0 1871 2278

Rural 1108 31 61 1200 237 294 410 215 1156 2356

Census 251 31 61 343 237 129 410 215 991 1334

Booster 857 0 0 857 0 165 0 0 165 1022

TOTAL 1730 34 163 1927 1361 3695 2591 325 7972 9899


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

Quality-Assured ACT (QA ACT)

QA ACTs are ACTs that comply with the Global Fund to Fight AIDS, Tuberculosis and Malaria’s Quality Assurance Policy. A QA ACT is any ACT that appeared on the Global Fund's indicative list of antimalarials meeting the Global Fund's quality assurance policy* prior to data collection, or that previously had C-status in an earlier Global Fund quality assurance policy and was used in a program supplying subsidized ACTs. QA ACTs also include ACTs that have been granted regulatory approval by the European Medicines Agency (EMA)** – specifically Eurartesim® and Pyramax®.

Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets

Winthrop Infant 2-11 months # Coartem Dispersible 5-14kg ^#

Winthrop Toddler 1-5 years # Coartem Dispersible 15-25kg ^#

Winthrop Child 6-13 years # Coartem 20/120 25-35 Kg ^#

Winthrop Adult +14 years # Coartem 20/120 35 Kg+ ^#

Artesun- Plus 2-11 months # Combiart 20/120 ^#

Artesun- Plus 1-5 years # Combiart 20/120 5-15 Kg#

Artesun- Plus >14 years # Lumartem 15 To <25kg (Cipla Pharma LTD) #

Lumartem 35kg and above (Cipla Pharma LTD) ^#

Artemether Lumefantrine Tablets Lumerax 20/120 #

Artefan 20/120 5-14kg Dispersible ^# Lumet #

Artefan 20/120 15-24kg Dispersible ^#

Artefan 20/120 25-34kg ^#

Artefan 20/120 35+ Kg Adults ^#

Artemether + Lumefantrine <3years (IPCA Laboratories LTD) ^#

Artemether + Lumefantrine 3-8years (IPCA Laboratories LTD) ^#


Artemether + Lumefantrine >14 years (IPCA Laboratories LTD) ^#

Co-Falcinum 5-14 Kg ^

Co-Falcinum 15-24 Kg ^#

Co-Falcinum 25-34 Kg #

Co-Falcinum 35Kg and above ^#

Non-Quality-Assured ACT

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

Artemether Lumefantrine Tablets Dihydroartemisinin Piperaquine Tablets

Altem # Co-malasinin 40/320 #

Artefan 40/240 # D-artepp 40mg/320mg #



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

Artefan 80/480 # Darte-q #

Coartem 80/480 35 kg + # Duo-cotexcin Children 5-20kg #

Co-corither DS 35kg + # Duo-cotecxin 40/320 ^#

Cofantrine Forte # Duotab ^#

Co-max # Malacur 40/320 #

Lamitar AM ^ P-Alaxin 40/320 ^#

Lonart Tablets # Ridmal 40/320 #

Lonart DS ^#

Lonart Forte # Artemether Lumefantrine Suspension

Lum-artem 20/120 (Dawa Limited) # Artefan Suspension ^#

Lumesoft plus # Co-Artesiane Pediatric ^#

Luteriam # Co-corither Pediatric #

Lumether # Co-max #

Lonart 20/120 Pediatric ^#

Artesunate Sulfadoxine Pyrimethamine Tablets Lum-artem Children 1-5 Years (Dawa Limited) #

Co-arinate FDC Adult ^# Lumether #

Co-arinate FDC Junior #

Dihydroartemisinin Piperaquin Suspension

Artemisinin Naphthoquine Tablets Malacur for Infants and Children ^#

Arco ^# P-Alaxin Pediatric Suspension ^#

Artemisinin Piperaquine Tablets Artemether Lumefantrine Suppository

Artequick ^# Lonart #

Artesunate Amodiaquine Tablets Dihydroartemisinin Piperaquin Granules

Arenax # Darte-q paediatric #

Artesunate Mefloquine Tablets Artesunate Mefloquine Granules

Artequin 300/375 child # Artequin paediatric #

Artequin 600/750 adult ^#

* http://www.theglobalfund.org/en/procurement/quality/pharmaceutical **http://www.ema.europa.eu/ ^ Product audited in the public sector # Product audited in the private sector


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


Table X5: Nationally Registered ACTs

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

Artesunate Amodiaquine Tablets Artemether Lumefantrine Tablets

Winthrop Adult +14 Years # Coartem Dispersible 5-14kg ^#

Winthrop Child 6-13 Years # Coartem Dispersible 15-25kg ^#

Winthrop Infant 2-11 Months # Coartem 20/120 25-35 Kg ^#

Winthrop Toddler 1-5 Years # Coartem 20/120 35 Kg+ ^#

Co-falcinum 5-14kg ^#

Artesunate Sulfadoxine Pyrimethamine Tablets Co-falcinum 15-24kg ^#

Co-arinate FDC Adult ^# Co-falcinum 25-34kg #

Co-arinate FDC Junior # Co-falcinum 35kg And Adults ^#

Co-max #

Artemisinin Piperaquine Tablets Lonart #

Artequick ^# Lonart Ds ^#

Lonart Forte #

Dihydroartemisinin Piperaquine Tablets Lum-Artem 20/120 (Dawa Limited) #

D-Artepp 40mg/320mg # Lumartem 15 To <25kg (Cipla Pharma LTD) #

Malacur 40/320 # Lumartem 35kg And Above (Cipla Pharma LTD) ^#

P-Alaxin 40/320 ^# Lumerax 20/120 ^#

Ridmal 40/320 #

Artemether Lumefantrine Suspensions

Artesunate Mefloquine Tablets Artefan Suspension ^#

Artequin 300/375 Child # Lonart Paediatric ^#

Artequin 600/750 Adult ^# Lum-artem Children 1-5 Years (Dawa Limited) #

Artemether Lumefantrine Tablets Dihydroartemisinin Piperaquine Suspensions

Altem # P-Alaxin Pediatric Suspension ^#



Artefan 20/120 25-34kg ^#

Artefan 20/120 35+ Kg Adults ^#

Artefan 40/240 #

Artefan 80/480 #

Artemether + Lumefantrine <3years (IPCA Laboratories LTD) ^#



Artemether + Lumefantrine >14 years (IPCA Laboratories LTD) ^# ^ Product audited in the public sector # Product audited in the private sector



Table X6: Severe Malaria Treatment

WHO recommends parenteral artesunate as first-line treatment in the management of severe falciparum malaria, with artemether or quinine injections as acceptable alternatives if parenteral artesunate is not available*. If complete treatment for severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment. The following are options for pre-referral treatment: rectal artesunate, injectable quinine, injectable artesunate, injectable artemether, and injectable arteether/artemotil.

Quinine Liquid Injection (Manufacturer) Artemether Liquid Injection (Manufacturer)

Agenquine Injection (Shandong Xier Kangali Pharmaceutical Co. Ltd) ^# Artenam 100 (Arenco Pharmaceutical) ^#

Kwinil (Intas Pharmaceuticals Ltd) # Artenam 40 Paediatric (Arenco Pharmaceutical) #

Laquine Injection (Cosme Limited) ^# Artesiane 100 (Dafra Pharma Gmbh) ^#

Megaquin Injection (Royal Group) # Artesiane 80 (Dafra Pharma Gmbh) ^#

Mosqun Injection (Indus Pharma (Pvt) Ltd) ^# Artesiane 40 (Dafra Pharma Gmbh) #

Quinine Dihydrochloride (Laborate Pharmaceutical) ^# Corither AB (Coral Laboratories Ltd) #

Quimed Injection (Syner-Med Pharmaceutical Ltd) ^# Falcinum 40 (Cipla Ltd) #

Quinine Dihydrochloride (Rotexmedica Gmbh Arzneimittelwerk) ^#

Falcinum 80 (Cipla Ltd) #

Quinine Dihydrochloride (Intas Pharmaceutical Ltd) # Glinther (Guilin Pharmaceutical Co Ltd) #

Quinine Dihydrochloride (Gland Pharma Ltd) ^# Gvither 20 Injection (Bliss Gvs Pharma Ltd) ^#

Quinine Dihydrochloride (Systochem Laboratories Ltd) # Gvither 40 Injection (Bliss Gvs Pharma Ltd) ^#

S-Quin Injection (Swiss Parenteral Pvt Ltd) ^# Gvither Forte Injection (Bliss Gvs Pharma Ltd) ^#

Indomal Injection (Indus Pharma (Pvt) Ltd) #

Arteether/Artemotil Liquid Injection (Manufacturer) Larither 40 (IPCA Laboratories Ltd) ^#

Artimal (Indi Pharma Pvt Ltd) # Larither 80 (IPCA Laboratories Ltd) ^#

Emal Injection (Themis Medicare Ltd) # Malgo 80mg (Ccl Pharmacetical (Pvt) Ltd)#

Malither Injection (Themis Medicare Ltd) #

Artesunate Powder Injection (Manufacturer) Syn-Mal 80mg (Swiss Parenteral Pvt Ltd) #

Artesun 120mg (Guilin Pharmaceutical Co Ltd) ^# Tether 80mg (Luckon Pharmaceuticals) #

Artesun 30mg (Guilin Pharmaceutical Co Ltd) #

Artesun 60mg (Guilin Pharmaceutical Co Ltd) ^#

Artemether Liquid Injection (Manufacturer)

Artem (Kunming Pharmaceutical Corp) #

Artemal-M Injection (Plethico Pharma Ltd) ^#

Artemedine (Kunming Pharmaceutical Corp) #

Artemether Injection (Jiangsu Ruinian Qianjin Pharmaceutical Co, Ltd) #

* Guidelines for the treatment of malaria, 2nd edition – revision 1.WHO. Geneva: 2010. ^ Product audited in the public sector # Product audited in the private sector



Annex 8: RDT Reference

Table X7: Number of RDTs audited



Private Not-for-Profit Facility

Private for-profit

HF

Registered Pharmacy


General retailer ALL

Outlets

Urban 113 3 11 111 67 67 0 372

Census 35 3 11 111 21 67 0 248

Booster 78 0 0 0 46 0 0 124

Rural 221 19 8 25 3 6 0 282

Census 49 19 8 25 1 6 0 108

Booster 172 0 0 0 2 0 0 174

TOTAL 334 22 19 136 70 73 0 654




Table X8: RDT Brand Names and Manufacturers*

Brand Name Manufacturer

A Con # A Con Laboratories Inc

Abon ^# Abon Biopharm (Hangzhou) Co. Ltd

Artron # Artron Laboratories Inc

Carestart ^# Access Bio Inc.

Dvg Deangel Biological # Hang Zhou Deangel Biological Engineering Co Ltd

Ezdx ^# Advy Chemical

First Response # Premier Medical Corporation Ltd

Humasis ^# Humasis Co. Ltd

Ict # Ict Diagnostics

Immunoquick ^ Biosynex

Makesure # Hll Lifecare Limited

Malacur # Blue Cross Bio-Medical (Beijing)Co Ltd

Malaria Self Test # Ict Diagnostics

Malarigen # Aspen Laboratories Pvt Ltd

One Step Malaria (P.F.) Test # Blue Cross Bio-Medical (Beijing)Co Ltd

One Step Malaria (P.F.) Test # Humasis Co. Ltd

One Step Test ^ Intec Products Inc.

Onsite # Ctk Biotech Inc.

Paracheck ^# Orchid Biomedical Systems

Parahit # Signature Healthcare Ltd

Parascreen # Zephyr Biomedicals

Sd Bioline ^# Standard Diagnostics Inc.

Wondfo # Wondfo Biotech Co Ltd

* 654 RDTs were audited. No RDTs were missing brand name information (missing or don’t know). 8 were missing manufacturer name (missing or don’t know).

^ Product audited in the public sector # Product audited in the private sector



Annex 9. Sampling Weights Sampling weights were applied for analysis of the Kenya 2014 outlet survey data to account for variations in probability of selection as a result of the sampling design: 1) Stratification: Disproportionate allocation stratification was used to ensure adequate sample size within the urban

and rural domains to allow for domain-specific estimates. The research domains were based on national designation of urban and rural wards. A representative sample was selected within each domain.

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

3) Booster sample – public health facilities (PHFs) and pharmacies: The geographic area for the outlet census was

extended to the division level for public health facilities and pharmacies. All public health facilities and pharmacies within divisions in which the selected locations were located were included in the study.

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

𝑊𝑖 =1

a × Mα

∑ Mα

Where:

Mα = estimated cluster (population size)

ΣMα = sum of estimated cluster sizes (population size) in the entire stratum

a = number of clusters selected within the stratum

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

of outlet type.

Market share was calculated using the full census data at the location level only (i.e. the booster sample was not

included in market share calculations). Ward sampling weights were created using the sampling weight formula (Wi),

where:

Mα = estimated ward population size

ΣMα = sum of estimated location population size in the entire stratum

a = number of locations selected within the stratum

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

1. Public health facilities and pharmacies: Given that PHFs and pharmacies were included in the sample through a

division-wide census, the weights applied to PHFs and pharmacies for all indicators other than market share were

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

Mα = estimated division population size

ΣMα = sum of estimated division population size in the entire stratum

a = number of divisions selected within the stratum



The population estimates used to select wards with PPS and to create sampling weights were obtained from the 1999

National Census. A sampling frame with population sizes was used for selecting the sample because accurate estimates

on the total number of outlets per geographic/administrative unit that may be eligible for a medicine outlet survey do

not exist. The major assumption in using population figures for sampling and weighting is that distribution of outlets

and/or distribution of medicines moving through outlets in a given cluster is correlated with population size.



Annex 10: Indicator Definitions Table definitions below are reflective of the corresponding table numbers in each results section above (Table 1 definition corresponds to Table A1, Table B1, Table C1, etc.)

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

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

Denominator Number of outlets screened.

Calculation Numerator divided by denominator.

Handling missing values

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

Notes and considerations

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

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

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

Denominator Number of outlets with at least 1 antimalarial audited.



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


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



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

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

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

Calculation Numerator for each outlet type divided by the denominator.


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


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

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

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


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


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

A. Table 4b reports the median price of one injection of an antimalarial that should be used for severe malaria

treatment only (artemether injection, quinine injection). The inter-quartile range (IQR) is provided as a measure of dispersion.

B. Table 4b also provides the median price of two pre-packaged QA ACT therapies: pediatric appropriate for a 10kg child (2 years of age), and adult appropriate for a 60kg adult. The inter-quartile range (IQR) is provided as a measure of dispersion.




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


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



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

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

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



Antimalarial-stocking outlets with missing information about both availability of microscopy and availability of RDTs are excluded from this table. The number of such outlets is provided in a footnote.

Outlets with partial information about availability of blood testing (information about microcopy or RDTs) are included in the denominator of the indicator “any blood testing available.” The number of such outlets is provided in a footnote.

Indicators for RDT and microscopy availability exclude outlets with missing availability information respectively (i.e. outlets missing information about microscopy availability are excluded from the microscopy indicator).


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




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

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

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

Calculation Numerator for each outlet type divided by the denominator.


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


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

Table 7: Price of malaria blood testing A. Table 7 reports the median price of blood testing to consumers including any consultation or service fees. The

inter-quartile range (IQR) is provided as a measure of dispersion.

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


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






Table 8: Antimalarial market share Antimalarial market share is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by outlet type and antimalarial type as a percentage of all AETDs sold/distributed in the previous week. Expressed as a percentage, market share is the amount of a specific antimalarial sold/distributed by a specific outlet type relative to the entire antimalarial market (all antimalarial types sold/distributed by all outlet types). Totals are reported per antimalarial medicine type and per outlet type. Across antimalarial medicine types and outlet types, percentages in the entire table sum to 100% (the total market).

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

Denominator Total number of AETDs sold/distributed.



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


See Annex 11 for a description of AETD calculation.

Table 9: Antimalarial market share across outlet type Antimalarial market share across outlet type is the amount of adult equivalent treatment doses (AETD) reportedly sold or distributed in the previous week by antimalarial type within each outlet type as a percentage of all AETDs sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific antimalarial sold/distributed relative to the entire antimalarial market segment for the specified outlet type (all antimalarial types sold/distributed by the specific outlet type). Totals are reported per antimalarial medicine type for each outlet type. Across antimalarial medicine types within each outlet type, percentages sum to 100%.

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

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



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


See Annex 11 for a description of AETD calculation.



Table 10: Malaria blood testing market share Malaria blood testing market share is the number of malaria blood tests reportedly sold or distributed in the previous week by outlet type and malaria blood test type (RDT, microscopy) as a percentage of all malaria blood tests sold/distributed in the previous week. Expressed as a percentage, market share is the number of a specific malaria blood test type by a specific outlet type relative to the entire malaria blood testing market (all malaria blood tests sold/distributed by all outlet types). Totals are reported per test type and per outlet type. Across malaria blood test types and outlet types, percentages in the entire table sum to 100% (the total market).

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

Denominator Total number of malaria blood tests sold/distributed.



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


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

Table 11: Malaria blood testing market share across outlet type Malaria blood testing market share across outlet type is the number of malaria blood tests reportedly sold or distributed in the previous week by blood test type within each outlet type as a percentage of all blood tests sold/distributed in the previous week within the specified outlet type. Expressed as a percentage, outlet-type market share is the amount of a specific malaria blood test sold/distributed relative to the entire blood testing market segment for the specified outlet type (all malaria tests sold/distributed by the specific outlet type). Totals are reported per test type for each outlet type. Across malaria blood test types within each outlet type, percentages sum to 100%. The market share for each RDT manufacturer is also reported across outlet type. Within each outlet type, the number of RDTs for a specific manufacturer sold/distributed relative to all RDTs distributed within that outlet type is reported as a percentage. Totals for RDT market share across all manufacturers sums to 100% within each outlet type.

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

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



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


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



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

Numerator A. Referral: respondents who indicated that they would refer to a health facility (response option #3). Note this numerator excludes providers located in a public or private health facility.

B. Recommends antimalarials to test-negative clients: respondents who indicated “yes, always,” or “yes, sometimes.”

C. Circumstances for recommending an antimalarial: individual indicators for the most common responses provided to this open-ended question. Note this numerator excludes providers who did not respond to the previous question about recommending antimalarials to test-negative clients with “yes, always” or “yes, sometimes.”

Denominator A. Referral: respondents who provided a response to this question, including “don’t know.” Note this denominator excludes providers located in a public or private health facility.

B. Recommends antimalarials to test-negative clients: respondents who provided a response to this question, including “don’t know.”

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



A. Providers missing a response to this question will be excluded from the indicator. B. Providers missing a response to this question will be excluded from the indicator.

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


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



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

Numerator A. State first-line: providers who responded to p17 with a generic or brand name consistent with a national first-line treatment, or responded to p17 with “ACT,” or “ACTm” and in p18 provided a generic or brand name consistent with a national first-line treatment. In other words, providers must specifically name the first-line treatment using generic or brand name language in either p17 or p18.

B. First-line regimen, adult: providers who correctly stated the first-line generic ingredients and strengths in p18, and correctly stated: number of days, times per day, and tablets per dose to be taken.

C. ACT most effective, adult & child: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect.

D. ACT most often recommended, adult & child: Any response for this open-ended question whereby: 1) one medicine or a set of medicines to be used in combination is mentioned only i.e. multiple antimalarial medicines mentioned will be counted as incorrect; and 2) the combination of medicines is an ACT – defined either by using a brand name, generic name, “ACT,” or “ACTm.” If the provider mentions a correct ACT response and also mentioned an anti-pyretic (e.g. paracetamol), this response will be counted as correct. However, if the provider mentions a correct ACT response and also mentioned other drugs – such as an antibiotic – this answer will be counted as incorrect.

Denominator A. State first-line: All providers who responded to p17 – please name the first-line medicine.

B. First-line regimen, adult: All providers who responded to p17 (starting the series on first-line knowledge).

C. ACT most effective, adult & child: All providers who responded to p13/14, including providers who responded with “don’t know,” who provided names of non-antimalarial medicines, and who responded with more than one antimalarial medicine not intended to be used as combination therapy.

D. ACT most often recommended, adult & child: All providers who responded to p13/14, including providers who responded with “don’t know,” who provided names of non-antimalarial medicines, and who responded with more than one antimalarial medicine not intended to be used as combination therapy.



A. Providers missing a response to this question will be excluded from this indicator. B. Providers with partial information for the regimen questions will be included in the

denominator (i.e. missing treated as not mentioned). C. Providers missing a response to this question will be excluded from the indicator. D. Providers missing a response to this question will be excluded from the indicator.



Annex 11. Adult Equivalent Treatment Dose (AETD) Definition Antimalarial medicines are manufactured using a variety of active pharmaceutical ingredients, dosage forms, strengths, and package sizes. ACTwatch uses the adult equivalent treatment dose (AETD) as a standard unit for price and sale/distribution analyses. One AETD is defined as the number of milligrams (mg) of an antimalarial drug required to treat an adult weighing 60 kilograms (kg). For each antimalarial generic, the AETD is defined as the number of mg recommended in treatment guidelines for uncomplicated malaria in areas of low drug resistance issued by the WHO. Where WHO treatment guidelines do not cover a specific generic, the AETD is defined based on peer-reviewed research or the product manufacturer’s recommended treatment course for a 60kg adult. Table X9 lists AETD definitions used in this report. While it is recognized that the use of AETDs may over-simplify and ignore many of the complexities of medicine consumption and use, this analytical approach was selected because it standardizes medication dosing across drug types and across countries (which may sometimes vary) thus permitting comparisons on both prices and volumes calculated on the basis of an AETD. Additional considerations:

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

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

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

Calculation Information collected on drug strength and unit size as listed on the product packaging was used to calculate the total amount of each active ingredient found in the package. The number of AETDs in a unit was calculated.31 The number of AETDs in a monotherapy is calculated by dividing the total amount of active ingredient contained in the unit by the AETD (i.e. the total number of mg required to treat a 60kg adult). The number of AETDs for a combination therapy was calculated by dividing the total amount of the active ingredient that was used as the basis for the AETD by the AETD.

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



Table X9: Adult Equivalent Treatment Dose Definitions

Antimalarial Generic [Ingredient used for AETD

mg dose value]

Dose used for calculating 1

AETD (mg required to treat a 60kg adult)

Source

Amodiaquine 1800mg WHO Model Formulary, 2008

Arteether / Artemotil 1050mg WHO Use of Antimalarials, 2001

Artemether 960mg WHO Use of Antimalarials, 2001

Artemether-Lumefantrine

[Artemether] 480mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Artemisinin-Naphthoquine

[Artemisinin] 2400mg WHO Use of Antimalarials, 2001

Artemisinin-Piperaquine

[Artemisinin] 504mg

Thanh NX, Trung TN, Phong NC, et al. 2012. The efficacy and tolerability of

artemisinin-piperaquine (Artequick®) versus artesunate-amodiaquine

(Coarsucam™) for the treatment of uncomplicated Plasmodium falciparum

malaria in south-central Vietnam. Malaria Journal, 11:217.

Artesunate 960mg WHO Use of Antimalarials, 2001

Artesunate-Amodiaquine

[Artesunate] 600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Artesunate-Mefloquine

[Artesunate] 600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Artesunate- Sulfadoxine-

Pyrimethamine

[Artesunate]

600mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Atovaquone-Proguanil

[Atovaquone] 3000mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Chloroquine 1500mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Dihydroartemisinin 480mg Manufacturer Guidelines

(Cotecxin – Holleypharm; MALUether – Euromedi)

Dihydroartemisinin-

Piperaquine

[Dihydroartemisinin]

360mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Hydroxychloroquine

2000mg

Manufacturer Guidelines

(Plaquenil – Sanofi Aventis)

Mefloquine 1000mg

WHO Model Formulary, 2008

Primaquine 45mg WHO Guidelines for the treatment of malaria 2nd edition, 2010

Quinine 10408mg WHO Model Formulary, 2008

Sulfadoxine-Pyrimethamine 1500mg WHO Model Formulary, 2008



Annex 12: Antimalarial Volumes

Table X10: Antimalarial volumes, by outlet type

AETDs sold or distributed in the previous week by outlet type and antimalarial type:*



Profit

Private For-Profit

Facility

Registered Pharmacy


General retailer TOTAL Private

ALL Outlets

# AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI)

1. Any ACT

21411.6 28666.5 27435.0 78548.2 59694.7 6544.4 172222.4 200888.9

(13047.2, 29776.0) (18967.7, 38365.3) (21378.1, 33491.9) (42642.3, 114454.2) (46432.0, 72957.5) (1884.3, 11204.5)

(127704.1, 216740.6) (150901.5, 250876.3)

Artemether Lumefantrine

(AL)

21261.1 27600.4 23935.1 60267.8 51031.6 5977.0 141211.5 168811.9

(12897.3, 29624.9) (17928.4, 37272.4) (18522.7, 29347.4) (33035.0, 87500.5) (40267.7, 61795.6) (1564.2, 10389.8) (107245.6, 175177.4) (129203.6, 208420.2)


0.0 0.0 205.6 707.8 297.9 32.8 1244.1 1244.1

- - (3.7, 407.4) (73.1, 1342.6) (95.9, 499.9) - (522.4, 1965.7) (522.4, 1965.7)

DHAPPQ 130.1 1024.1 2311.0 13669.1 6353.7 440.4 22774.3 23798.4

- (341.7, 1706.5) (1590.0, 3032.0) (6867.4, 20470.9) (4043.9, 8663.5) - (14604.5, 30944.1) (15505.5, 32091.2)


21244.7 27016.3 19800.2 49868.4 46666.4 5040.7 121375.7 148392.0

(12879.6, 29609.8) (17321.9, 36710.6) (15361.3, 24239.1) (28025.3, 71711.5) (37148.6, 56184.2) (889.6, 9191.9) (93393.8, 149357.7) (114362.3, 182421.7)

QA ACT with the “green leaf” logo

11032.2 13824.4 15887.0 40544.7 40384.9 3989.8 100806.5 114630.9

(5913.8, 16150.7) (8141.5, 19507.4) (12318.9, 19455.2) (24672.0, 56417.5) (32093.7, 48676.1) (0.0, 8054.1) (79164.4, 122448.6) (89053.6, 140208.3)

QA ACT without the “green leaf” logo

10212.5 13159.0 3913.1 9323.7 6281.5 1050.9 20569.2 33728.3

(5840.2, 14584.7) (7658.8, 18659.3) (2794.9, 5031.4) (3002.8, 15644.5) (3839.3, 8723.7) (0.0, 3039.3) (13184.2, 27954.3) (23609.8, 43846.8)


166.9 1650.3 7634.8 28679.8 13028.4 1503.7 50846.7 52496.9

- (818.8, 2481.8) (5550.7, 9719.0) (13958.9, 43400.7) (8498.5, 17558.3) - (32850.7, 68842.6) (34187.7, 70806.1)


(12315.6, 29025.0) (17843.6, 37010.7) (19374.9, 30526.4) (31687.6, 92619.5) (40545.4, 63585.9) (1573.4, 9831.4) (107490.9, 182253.6) (129816.7, 214782.1)

2. Any non-artemisinin therapy

5220.5 6015.5 5155.7 36232.2 27276.3 7471.1 76135.3 82150.7

(2764.1, 7676.8) (3456.3, 8574.6) (4151.4, 6160.1) (20344.5, 52119.9) (21134.1, 33418.4) (4659.6, 10282.6) (57265.1, 95005.4) (62899.2, 101402.3)


(2426.5, 5857.8) (2407.6, 6111.7) (3651.8, 5338.9) (19667.0, 48294.6) (19826.2, 31620.3) (4602.5, 9930.7) (54206.1, 88725.7) (58320.0, 93131.1)

Oral Quinine 514.3 1094.6 130.2 635.0 315.8 0.0 1081.0 2175.6

(100.1, 928.5) (97.0, 2092.2) (65.7, 194.6) (146.3, 1123.7) (209.6, 422.0) - (570.3, 1591.7) (1046.2, 3305.0)

Quinine IV/IM 477.3 553.6 318.3 604.7 272.8 2.3 1198.1 1751.7

(196.7, 757.8) (268.1, 839.1) (210.6, 426.1) (0.0, 1217.8) (149.9, 395.6) - (511.1, 1885.1) (970.0, 2533.4)



Table X10: Antimalarial volumes, by outlet type

AETDs sold or distributed in the previous week by outlet type and antimalarial type:*



Profit

Private For-Profit

Facility

Registered Pharmacy


General retailer TOTAL Private

ALL Outlets

# AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI) # AETD (95% CI)

3. Oral artemisinin monotherapy

0.0 0.0 22.1 0.0 0.0 0.0 22.1 22.1

- - - - - - - -

4. Non-oral artemisinin monotherapy

296.2 606.3 978.2 1711.9 645.4 0.0 3335.4 3941.7

(148.1, 444.2) (306.2, 906.4) (680.7, 1275.6) - (150.9, 1139.8) - (1722.6, 4948.3) (2125.8, 5757.6)


(129.2, 425.6) (130.1, 434.5) - (0.0, 146.0) (0.0, 700.5) - - (300.5, 1161.0)


- (43.1, 604.9) (488.0, 954.8) - (162.7, 683.1) - (1429.9, 4137.8) (1628.3, 4587.4)


- - (3.3, 143.6) (9.4, 41.9) (0.0, 8.4) - (24.2, 182.2) (24.2, 182.2)

5. Any treatment for severe malaria

773.5 1159.9 1296.5 2316.6 918.1 2.3 4533.5 5693.4

(461.0, 1085.9) (741.2, 1578.6) (930.7, 1662.4) (728.9, 3904.4) (375.4, 1460.9) - (2291.7, 6775.4) (3206.9, 8179.9)


(17583.9, 36272.6) (24494.8, 46081.6) (26918.9, 40263.1) (65563.6, 167421.0)

(68865.8, 106366.9) (8030.8, 20000.2)

(188246.2, 315184.1) (217361.4, 356645.4)

* A total of 35645.3 AETDs were reportedly sold or distributed in the previous seven days. See Annex 11 for a description of AETD calculation. At the time of the 2014 ACTwatch outlet survey artemether lumefantrine was Kenya's first line treatment for uncomplicated malaria. A total of 6,651 antimalarials were audited in the census clusters. Of these, 325 audited antimalarials were not included in market share calculations due to incomplete or inconsistent information.





Documents

ACTwatch Study Reference Document Republic of …... Page 1 Released 23 February 2016 Suggested citation ACTwatch Group and Population Services Kenya (PSK). (2015). ACTwatch Study