The impact of the private sector co-payment mechanism (PSCM) on the private market for ACT in Nigeria: results of the 2018 cross-sectional outlet and household market surveys

Abstract

Background The private sector plays a large role in malaria treatment provision in Nigeria. To improve access to, and affordability of, quality-assured artemisinin-based combination therapy (QA-ACT) within this sector, the Affordable Medicines Facility-Malaria began operations in 2010 and transitioned to a private sector co-payment mechanism (PSCM) until 2017. To assess the impact of the scheme on the ACT market, cross-sectional household and outlet surveys were conducted in 2018 to coincide with the final stockages of ACT medicines procured under the PSCM. Methods An outlet survey was conducted targeting private pharmacies and Proprietary and Patent Medicine Vendors (PPMVs) across different regions of Nigeria to assess supply-side market factors related to availability and cost of anti-malarials, including artemisinin-based combinations subsidised under the PSCM (called green leaf ACT on account of their green leaf logo) and those not subsidised (non-green leaf ACT). A concurrent household survey was conducted to determine demand-side factors related to treatment-seeking practices, ACT brand preference and purchase decision. Data were compared with previous ACTWatch surveys to consider change over time. Results Availability of artemisinin-based combinations increased significantly over the PSCM period and was almost universal by the time of the 2018 market survey. This increase was seen particularly among PPMVs. While the cost of green leaf ACT remained relatively stable over time, the cost of non-green leaf ACT reduced significantly so that by 2018 they had equivalent affordability. Unsubsidised brands were also available in different formulations and dosages, with double-strength artemisinin-based combination reported as the most frequently purchased dosage type, and child artemisinin-based combinations popular in suspension and dispersible forms (forms not subsidised by the PSCM). Conclusions The PSCM had a clear impact on increasing not only the reach of subsidized QA brands, but also of non-subsidised brands. Increased market competition led to innovation from unsubsidised brands and large reductions in costs to make them competitive with subsidised brands. Concerns are drawn from the large market share that non-QA brands have managed to gain as well as the continued market share of oral artemisinin monotherapies. Continued monitoring of the market is recommended, along with improved local capacity for QA-certification and monitoring.

The private sector market for mRDTs in Nigeria - results of the 2018 market survey.

“…One-third of HHs seeking diagnosis at PPMVs/pharmacies is lower than the proportion that said they would seek treatment at these locations (about 45%) [5] and lower than the proportion of the population that report using these channels as their primary healthcare option in national surveys [2,7]. The 2018 market survey shows only half of HHs had heard of mRDTs and just a third thought they were affordable.…”

“…It is not clear why outlets in urban and southern states should have lower availability than rural and northern areas. Both urban and southern areas generally have lower rates of poverty (compared to rural and northern areas) and higher consumer demand for treatment from the private sector [5,14]. However, demand for malaria diagnostics was not as clear-cut, with no difference in demand for urban and rural PPMVs, and high demand for PPMVs but low demand for pharmacies in the south.…”

“…In 2018, both an outlet survey and a household survey were conducted to assess the ACT and mRDT private sector markets in Nigeria. Full methods are presented in Edwards et al [5]. Brie y, 321 pharmacies and 374 PPMVs were selected from six different states in Nigeria, representing both rural and urban areas, northern and southern regions, and different malaria endemicities.…”

“…A market survey was conducted in 2018 at the termination of the PSCM to assess the state of both demand and supply side market factors related to malaria diagnostics and treatments among Proprietary and Patent Medicine Vendors (PPMVs) and pharmacies in the private sector. A recent study presented the results of this survey in relation to ACT and found that the AMFm-PSCM period increased both availability and affordability of ACT medicines in Nigeria, particularly among PPMVs [1,5]. Interestingly, these improvements were not limited to just the subsidised ACT brands; in response to increased market competition, non-subsidised ACT brands had reduced prices and increased their availability and market share [5].…”

“…A recent study presented the results of this survey in relation to ACT and found that the AMFm-PSCM period increased both availability and affordability of ACT medicines in Nigeria, particularly among PPMVs [1,5]. Interestingly, these improvements were not limited to just the subsidised ACT brands; in response to increased market competition, non-subsidised ACT brands had reduced prices and increased their availability and market share [5].…”