Scientific Papers

Assessing availability, prices, and market share of quality-assured malaria ACT and RDT in the private retail sector in Nigeria and Uganda | Malaria Journal

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Across the six retail audits, 2,658 PMRs were surveyed. The types and locations of PMRs surveyed varied in each country with drug shops being the vast majority in each country (78.4%) (Table 1).

Table 1 PMRs sampled in Nigeria and Uganda

Availability of WHO-PQ-ACTs

Nearly three-quarters of PMRs had WHO-PQ-ACTs in stock during the 2014/2016 baseline surveys in Nigeria and Uganda (Fig. 1). In Nigeria, WHO-PQ-ACTs were available in 72% (95% CI [67%–75%]) of sampled PMRs in 2016, 49% (95% CI [44%–54%]) in 2018, and in only 15% (95% CI [11%–19%]) of such PMRs in 2021. The difference in WHO-PQ-ACT availability between 2016 and 2018 was statistically significant (OR = 0.37, 95% CI [0.28–0.48]) as well as between 2016 and 2021 (OR = 0.07, 95% CI [0.05–0.09]). Across all three surveys in Nigeria, WHO-PQ-ACT availability was highest in pharmacies (84% in 2016; 74% in 2018; 20% in 2021) compared to drug shops (70% in 2016; 44% in 2018; 14% in 2021).

Fig. 1
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Availability of WHO-PQ-ACTs in Nigeria and Uganda 2014–2021

There was not a statistically significant decrease in WHO-PQ-ACT availability in pharmacies between 2016 and 2018, however, there was a statistically significant decrease between 2016 and 2021 (OR = 0.05, 95% CI [0.02–0.14]). In drug shops, there was a statistically significant decrease in WHO-PQ-ACT availability between 2016 and 2018 (OR = 0.33, 95% CI [0.24–0.44]), and between 2016 and 2021 (OR = 0.07, 95% CI [0.05–0.11]). In Uganda, WHO-PQ-ACTs were availablen in 71% of sampled PMRs (95% CI [67%–74%]) in 2014 and decreased to 64% of sampled PMRs (95% CI [59%–69%]) in 2018. In 2020, 52% of sampled PMRs in Uganda had WHO-PQ-ACTs in stock and availability was highest in pharmacies in 2014 (95%) and 2018 (73%), however in 2021 it was highest in clinics (76%) followed by drug shops (50%) and then pharmacies (41%). There was no statistically significant difference in WHO-PQ-ACT availability in Uganda between 2014 and 2018.

WHO-PQ-ACT availability also varied by geography and was higher in urban areas compared to rural areas in both countries in all surveys (Additional file 5).

Availability of non-WHO-PQ-ACTs

Availability of non-WHO-PQ-ACTs varied over time in Nigeria and Uganda in sampled PMRs (Fig. 2). In Nigeria, non-WHO-PQ-ACT availability increased from 13% in 2016 (95% CI [10%–16%]) to 56% in 2018 (95% CI [51%–61%]) to 54% in 2021 (95% CI [48%–59%]). Availability was higher in pharmacies compared to drug shops in all survey years (40% vs 9% in 2014; 87% vs 50% in 2018; 74% vs 52% in 2021). Although not a primary indicator, in Nigeria imitation green leaf logos on non-WHO-PQ-ACTs were found in 18% of the PMRs surveyed in 2018 and in 11% of observed ACTs in 2021. In Uganda, the availability of non-WHO-PQ-ACTs in sampled PMRs increased from 6% (95% CI [4%–8%]) in 2014 to 40% (95% CI [35%–45%]) in 2018. In 2020, 55% of PMRs in Uganda had non-WHO-PQ-ACTs in stock. Availability was highest in pharmacies in 2014 (50%) and 2018 (55%), however in 2021 availability was highest in private clinics (81%). Non-WHO-PQ-ACT availability remained higher in urban areas compared to rural areas in all audits in Uganda and Nigeria (Additional file 6).

Fig. 2
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Availability of Non-WHO-PQ-ACTs in Nigeria and Uganda 2014–2021

Price of WHO-PQ-ACTs

In Nigeria, retail prices were collected for 6,036 WHO-PQ-ACT treatment sales in the seven days prior to the survey in 2016. Retail prices were collected for 3,061 treatment sales in 2018 and 1,737 treatment sales in 2021. In Uganda, retail prices were collected for 7,195 treatment sales in the last seven days in 2014 and 2,201 treatment sales in 2018. In Nigeria, volume-weighted average price of WHO-PQ-ACTs increased from $0.48 (95% CI [$0.47–$0.49]) in 2016 to $1.31 (95% CI [$1.10–$1.53]) in 2018 and then declined to $0.68 (95% CI [$0.60–$0.77]) in 2021 (Fig. 3). Although overall volume-weighted average price of WHO-PQ-ACTs declined in 2021, this was only observed in Kano state (from $0.72 in 2018 to $0.63 in 2021); in Lagos state, the volume-weighted average price of WHO-PQ-ACTs increased from $1.59 in 2018 to $2.37 in 2021. (In Uganda, the volume-weighted average price of WHO-PQ-ACTs in Uganda increased from $0.99 (95% CI [$0.97–$1.00]) in 2014 to $1.23 (95% CI [$1.20–$1.26]) in 2018. The retail price of WHO-PQ-ACTs also varied by urban/rural setting and was higher in urban areas compared to rural areas in both countries and across all periods (Additional file 7).

Fig. 3
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Average Retail Price of WHO-PQ-ACTs in Nigeria and Uganda 2014–2021

Price of non-WHO-PQ-ACTs

In Nigeria, in 2016, retail prices were collected for 528 treatment sales in the seven days prior to the survey, 2,938 treatment sales in 2018, and 9,197 treatment sales in 2021. In Uganda, retail prices for non-WHO-PQ-ACT were collected for 243 treatment sales in 2014 and 536 treatment sales in 2018. In Nigeria, volume-weighted average prices of non-WHO-PQ-ACTs slightly increased from $1.45 (95% CI [$1.37–$1.52]) in 2016 to $1.47 (95% CI [$1.25–$1.68]) in 2018 and then declined to $1.08 (95% CI [$0.88–$1.29]) in 2021 (Additional file 8). Similarly in Uganda, the volume-weighted average price of non-WHO-PQ-ACTs fell from $3.64 in 2014 (95% CI [$3.37–$3.91]) to $2.05 (95% CI [$1.97–$2.14]) in 2018 to an unweighted average price of $1.38 in 2020. The retail price of non-WHO-PQ-ACTs also varied by urban/rural setting and was higher in urban areas compared to rural areas in both countries across all periods (Fig. 4).

Fig. 4
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Average Retail Price of non-WHO-PQ-ACTs in Nigeria and Uganda 2014–2021

Market share of WHO-PQ-ACTs among all ACTs and among all anti-malarials

Over 90% of ACT sales in the seven days prior to the survey were WHO-PQ-ACTs during the 2014/2016 baseline surveys in Nigeria and Uganda. In subsequent years, this proportion declined in both Uganda and Nigeria (Fig. 5). In Nigeria this proportion decreased from 92% in 2016 (95% CI [87%–96%]) to 51% in 2018 (95% CI [40%–61%]) to 16% in 2021 (95% CI [4%–28%]. In Uganda, the proportion decreased from 97% in 2014 (95% CI [95%–99%]) to 80% in 2018 (95% CI [73%–88%]) (Additional file 9).

Fig. 5
figure 5

Market share of WHO-PQ-ACTs among ACTs sold in Nigeria and Uganda 2014–2021

The market share of WHO-PQ-ACTs, non-WHO-PQ-ACTs, and non-artemisinin-based anti-malarials among all anti-malarials sold was also assessed. In Nigeria, in 2018, non-artemisinin-based anti-malarials had the highest market share (40%, 95% CI [25%–54%]) compared to non-WHO-PQ-ACTs (31%, 95% CI [23%–38%]) and WHO-PQ-ACTs (30%, 95% CI [19%–41%]). In 2021, market share shifted to mostly non-WHO-PQ-ACTs (80%, 95% CI [69%–91%]), followed by WHO-PQ-ACT market share (16%, 95% CI [4%, 27%]) and non-ACT market share to 5% (95% CI [0%–11%]). In Uganda, WHO-PQ-ACT market share was highest in 2014 (50%, 95% CI [37%–63%]), followed by non-artemisinin-based market share (38%, 95% CI [25%–50%]) and then non-WHO-PQ-ACT (12%, 95% CI [8%–17%]) [Fig. 6].

Fig. 6
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Market share of WHO-PQ-ACTs among all antimalarials sold in Nigeria and Uganda 2018–2021

Availability of RDTs

RDT availability either increased or remained the same over time in Nigeria and Uganda in sampled PMRs. In Nigeria, RDTs were available in 17% of sampled PMRs (95% CI [14%–21%]) in 2016, 12% of sampled PMRs in 2018 (95% CI [9%–16%]) and 18% of sampled PMRs (95% CI [14%–23%]) in 2021 (Additional file 10). In Uganda, RDT were available in 37% of sampled PMRs (95% CI [32%–42%]) in 2018 and increased to 56% in 2020 (Fig. 7). RDT availability also varied by urban/rural settings. In Nigeria, RDT availability was higher in rural areas compared to urban areas across all periods, unlike Uganda where RDT availability was higher in urban areas compared to rural areas in 2018. No RDT data was collected in Uganda in 2014 and data were not stratified by geography in 2020.

Fig. 7
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RDT Availability in Nigeria and Uganda 2016–2021

Prices of RDTs

In Nigeria, the volume-weighted mean price of RDTs decreased from $0.66 in 2016 (95% CI [$0.66–$0.66]) to $0.21 in 2018 (95% CI [$0.13–$0.30]), but then increased to $0.31 in 2021 (95% CI [$0.28–$0.34]). In Uganda, the volume-weighted mean price of RDT remained the same: $0.75 in 2018 (95% CI [$0.72–$0.77]) and $0.79 in 2020 (Fig. 8) (Additional file 11). RDT price also varied by geography and was higher in urban areas compared to rural areas across all surveys where data were collected.

Fig. 8
figure 8

RDT Prices in Nigeria and Uganda 2016–2021

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