2345-6(7!869%1!:&)&+&'(&!;*(9

!

!!!"#$%!&'()"*+,-.................................$-/01*2)'.3.4-/56&'*-+.7819*(8:.;+'81+&'*-+&6.

www.ACTwatch.info.............................Page.1.

Released'March'23,'2017'!Suggested!citation!ACTwatch'Group'and'Population'Services'Kenya'(PSK)..(2017)..ACTwatch'Study'Reference'Document:'Kenya'Outlet'Survey'2016..Washington.DC:.PSI.... .Contact!Dr..Megan.Littrell.ACTwatch.Principal.Investigator..PSI.|[email protected]!

Country.contact.Julius.Ngigi.Population.Services.International,.ACTwatch.Whitefield.place,.School.Lane,.Westlands.P.O..Box.14355V00800,.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).... PS.Kenya.Dr..Anne.Musuva..Kenya.Malaria.Control.Unit.Dr..Rebecca.Kiptui.Dr..Dorothy.Memusi. Kenya.Pharmacy.and.Poisons.Board.Dr..Edward.Abwao..ACTwatch.Team..Andrew.Andrada.Erick.Auko.Dr..Katie.Bates.Dr..Paul.Bouanchaud.Dr..Desmond.Chavasse.Robyn.Cyr.Kevin.Duff.Keith.Esch.Anna.Fulton.Tarryn.Haslam.Catharine.Hurley.Whitney.Isenhower.Beth.Kangwana.Gloria.Kigo.Aliza.Lailari.Dr..Megan.Littrell..Julius.Ngigi.Dr..Kate.O’Connell.Ricki.Orford..Stephen.Poyer.Dr..Justin.Rahariniaina.Christina.Riley.Dr..Andria.Rusk.Julianna.Smith.Rachel.Thompson.Cynthia.Whitman.Sharon.Juma.Marlon.Githua...

Data.Collection.Management..Ipsos:.Hulda.Kibera.Hilda.Kiritu.James.Macharia.Samuel.Muthoka.Hamida.Omar.James.Ombasa.Aggrey.Oriwo.Anne.Wanyingi. Regional.Coordinators.Risper.Akinyi.Johnston.Musyoka.Dickens.Nyamogo.Bernard.Obeda..Supervisors.Amina.Day.Vincent.Depaul.Jonh.Maingi.Harmony.Momanyi.Antony.Njeru.Erick.Odhiambo.Kevin.Onchana.Stephen.Ouma. Quality.Controllers.Patrick.Atandi.Malach.Ayega.Joan.Chebet.Sophie.June.Joan.Mwaka.Richard.Njoroge.Linda.Norah.Peter.Olande.

Enumerators Fredric.Aika.Titus.Akendo.Premmy.Anjina.Susan.Chebet.William.Chepkwony.Monica.Ireri.Jane.Irungu.Meshack.Isaboke.Agnes.Karimi.Kevin.Kiget.James.Kinyua.Patrick.Kithinji.Peter.Maiko.Paul.Mboya.Brian.Meya.Jared.Muga.Stephen.Musyoka.Osbon.Mwema.Nyabare.Irene.Mweni.Mutisya.Ben.Nduati.Margaret.Ndungu.Sophia.Ngaire.Anne.Njeri.Mugai.Anne.Njeri.Mureithi.Francis.Nyakundi.Daisy.Nyambura.Edwin.Nyarango.James.Nzioki.Roselida.Obiero.Antony.Omare.Geofrey.Omogi.Malachi.Ontachi.Collins.Ouko.Ignisius.Rateng.Philemon.Rono.Diana.Seleina.Natasha.Silvia.David.Thuo.Jane.Wanza.Benard.Washington


.Table!of!Contents!.

LIST.OF.TABLES...................................................................................................................................................3.

LIST.OF.FIGURES.................................................................................................................................................5.

DEFINITIONS.......................................................................................................................................................9.

INTRODUCTION................................................................................................................................................11.

SUMMARY.OF.METHODS.AND.DATA.COLLECTION..........................................................................................12.

SUMMARY.OF.KEY.FINDINGS...........................................................................................................................15.

RESULTS.SECTION.A:.CORE.INDICATORS..........................................................................................................39.

RESULTS.SECTION.B:.CORE.INDICATORS.ACROSS.NATIONAL.MALARIA.BURDEN.STRATIFICATION.................56.

RESULTS.SECTION.C:.CORE.INDICATORS.ACROSS.SURVEY.ROUND:.2010,.2011,.2014,.2016..........................92.

ANNEX.1:.ACTWATCH.BACKGROUND............................................................................................................116.

ANNEX.2:.COUNTRY.BACKGROUND...............................................................................................................119.

ANNEX.3:.OUTLET.SURVEY.METHODS............................................................................................................125.

ANNEX.4:.SAMPLED.LOCATIONS....................................................................................................................131.

ANNEX.5:.DETAILED.SAMPLE.DESCRIPTION...................................................................................................142.

ANNEX.6:.QUESTIONNAIRE............................................................................................................................146.

ANNEX.7:.ANTIMALARIAL.REFERENCE...........................................................................................................169.

ANNEX.8:.RDT.REFERENCE.............................................................................................................................173.

ANNEX.9..SAMPLING.WEIGHTS......................................................................................................................175.

ANNEX.10:.INDICATOR.DEFINITIONS..............................................................................................................177.

ANNEX.11..ADULT.EQUIVALENT.TREATMENT.DOSE.(AETD)..........................................................................185.

ANNEX.12:.ANTIMALARIAL.VOLUMES............................................................................................................187.. .

!


List!of!Tables!

Table.S1:.Key.results,.by.outlet.type,.2016......................................................................................................................15.

Results.Section.A:.Core.Indicators...Table.A1:.Availability.of.antimalarials,.among.all.screened.outlets,.by.outlet.type........................................................39.Table.A2:.Availability.of.antimalarials,.among.outlets.stocking.at.least.one.antimalarial,.by.outlet.type.......................41.Table.A3:.Types.of.qualityVassured.and.nonVquality.assured.ACTs.audited.in.the.public.and.private.sectors................43.Table.A4:.Antimalarial.market.composition.....................................................................................................................44.Table.A5a:.Price.of.tablet.formulation.antimalarials,.by.outlet.type...............................................................................45.Table.A5b:.Price.of.preVpackaged.antimalarials,.by.outlet.type......................................................................................46.Table.A6:.Availability.of.malaria.blood.testing.among.antimalarialVstocking.outlets*,.by.outlet.type............................47.Table.A7:.Malaria.blood.testing.market.composition......................................................................................................48.Table.A8:.Price.of.malaria.blood.testing.for.adults,.by.outlet.type..................................................................................49.Table.A9:.Antimalarial.market.share................................................................................................................................50.Table.A11:.Malaria.blood.testing.market.share...............................................................................................................52.Table.A13:.Provider.case.management.knowledge.and.practices,.by.outlet.type..........................................................54.Table.A14:.Provider.antimalarial.treatment.knowledge.and.practices,.by.outlet.type...................................................55.

Results.Section.B:.Core.Indicators.across.national.malaria.burden.stratification...Table.B1:.Availability.of.antimalarials,.among.all.screened.outlets,.by.outlet.type,.across.strata..................................56.Table.B2:.Availability.of.antimalarials,.among.all.outlets.stocking.at.least.one.antimalarial,.by.outlet.type,.across.

strata........................................................................................................................................................................62.Table.B4:.Antimalarial.market.composition,.across.strata...............................................................................................68.Table.B5a:.Price.of.tablet.formulation.antimalarials,.by.outlet.type,.across.strata.........................................................69.Table.B5b:.Price.of.preVpackaged.antimalarials,.by.outlet.type,.across.strata................................................................73.Table.B6:.Availability.of.malaria.blood.testing.among.antimalarialVstocking.outlets*,.by.outlet.type,.across.strata.....74.Table.B8:.Price.of.malaria.blood.testing,.by.outlet.type,.across.strata............................................................................76.Table.B9.1:.Antimalarial.market.share,.endemic.............................................................................................................78.Table.B9.2:.Antimalarial.market.share,.highland.............................................................................................................79.Table.B9.3:.Antimalarial.market.share,.low.risk...............................................................................................................80.Table.B9.4:.Antimalarial.market.share,.seasonal.low......................................................................................................81.Table.B10.1:.Antimalarial.market.share.across.outlets,.endemic....................................................................................82.Table.B10.2:.Antimalarial.market.share.across.outlets,.highland....................................................................................83.Table.B10.3:.Antimalarial.market.share.across.outlets,.low.risk.....................................................................................84.Table.B10.4:.Antimalarial.market.share.across.outlets,.seasonal.low.............................................................................85.Table.B13:.Provider.case.management.knowledge.and.practices,.by.outlet.type,.across.strata....................................86.Table.B14:.Provider.antimalarial.treatment.knowledge.and.practices,.by.outlet.type,.across.strata.............................89.

Results.Section.C:.Core.Indicators.across.Survey.Round:.2010,.2011,.2014,.2016.Table.C1:.Availability.of.antimalarials,.among.all.screened.outlets,.by.outlet.type,.across.survey.round......................92.Table.C2:.Availability.of.antimalarials,.among.outlets.stocking.at.least.one.antimalarial,.by.outlet.type,.across.survey.

round.......................................................................................................................................................................97.


Table.C4:.Antimalarial.market.composition,.across.survey.round.................................................................................102.Table.C6:.Availability.of.malaria.blood.testing.among.antimalarialVstocking.outlets*,.by.outlet.type,.across.survey.

round.....................................................................................................................................................................106.Table.C9:.Antimalarial.market.share,.across.survey.round............................................................................................110.Table.C10:.Antimalarial.market.share,.across.outlet.type,.across.survey.round...........................................................112.Table.C14:.Provider.antimalarial.treatment.knowledge.and.practices,.by.outlet.type,.across.survey.round...............114.Table.X2:.Detailed.sample.description...........................................................................................................................142.Table.X3:.Number.of.antimalarials.audited...................................................................................................................169.Table.X4:.QualityVassured.(QA.ACT).and.NonVquality.assured.ACTs..............................................................................170.Table.X5:.Severe.Malaria.Treatment..............................................................................................................................172.Table.X6:.Number.of.RDTs.audited................................................................................................................................173.Table.X7:.RDT.Brand.Names.and.Manufacturers*.........................................................................................................174.Table.X8:.Adult.Equivalent.Treatment.Dose.Definitions................................................................................................186.Table.X9:.Antimalarial.volumes,.by.outlet.type.............................................................................................................187..

. .


List!of!Figures!.Figure.X1:.Map.of.the.four.malaria.epidemiology.zones.in.Kenya...................................................................................12.Figure.X2:.Map.of.sampled.areas.....................................................................................................................................13.Figure.1:.Survey.flow.diagram,.Kenya,.2016....................................................................................................................14.Figure.2.'Market.composition:.outlet.type.distribution,.2010V2016................................................................................17.Figure.3..Market.composition:.outlet.type.distribution,.2016,.by.strata.........................................................................17.Figure.4..Percentage.of.outlets.with.at.least.one.antimalarial.in.stock.on.the.day.of.the.survey,.2010V2016................18.Figure.5..Percentage.of.outlets.with.at.least.one.antimalarial.in.stock.on.the.day.of.the.survey,.across.strata,.2016...18.Figure.6..Percentage.of.antimalarialVstocking.outlets.with.ACT.in.stock.on.the.day.of.the.survey,.2010V2016..............19.Figure.7..Percentage.of.antimalarialVstocking.outlets.with.ACT.in.stock.on.the.day.of.the.survey,.across.strata,.2016

.................................................................................................................................................................................19.Figure.8..Percentage.of.antimalarialVstocking.outlets.with.qualityVassured.ACT.in.stock.on.the.day.of.the.survey,.

2010V2016................................................................................................................................................................20.Figure.9..Percentage.of.antimalarialVstocking.outlets.with.qualityVassured.ACT.in.stock.on.the.day.of.the.survey,.

across.strata,.2016...................................................................................................................................................20.Figure.10..Percentage.of.antimalarialVstocking.outlets.with.qualityVassured.ACT.marked.with.the.‘green.leaf’.logo........

in.stock.on.the.day.of.the.survey,.2010V2016..........................................................................................................21.Figure.11..Percentage.of.antimalarialVstocking.outlets.with.qualityVassured.ACT.marked.with.the.‘green.leaf’.logo........

in.stock.on.the.day.of.the.survey,.across.strata,.2016............................................................................................21.Figure.12..Percentage.of.antimalarialVstocking.outlets.with.nonVquality.assured.ACT.in.stock.on.the.day.of.the.survey,.

2010V2016................................................................................................................................................................22.Figure.13..Percentage.of.antimalarialVstocking.outlets.with.nonVquality.assured.ACT.in.stock.on.the.day.of.the.survey,.

across.strata,.2016...................................................................................................................................................22.Figure.14..Types.of.qualityVassured.ACT.and.nonVquality.assured.ACT.audited.among.publicV.and.privateVsector.

outlets,.Kenya,.2016................................................................................................................................................23.Figure.15..Percentage.of.antimalarialVstocking.outlets.with.nonVartemisinin.therapy.in.stock.on.the.day.of.the.survey,.

2010V2016................................................................................................................................................................24.Figure.16..Percentage.of.antimalarialVstocking.outlets.with.nonVartemisinin.therapy.in.stock.on.the.day.of.the.survey,.

across.strata,.2016...................................................................................................................................................24.Figure.17..Percentage.of.antimalarialVstocking.outlets.with.SP.in.stock.on.the.day.of.the.survey,.2010V2016..............25.Figure.18..Percentage.of.antimalarialVstocking.outlets.with.SP.in.stock.on.the.day.of.the.survey,.across.strata,.2016.25.Figure.19..Percentage.of.antimalarialVstocking.outlets.with.oral.quinine.in.stock.on.the.day.of.the.survey,.2010V2016

.................................................................................................................................................................................26.Figure.20..Percentage.of.antimalarialVstocking.outlets.with.oral.quinine.in.stock.on.the.day.of.the.survey,.across.

strata,.2016..............................................................................................................................................................26.Figure.21..Percentage.of.antimalarialVstocking.outlets.with.severe.malaria.treatment.in.stock.on.the.day.of.the.

survey,.2010V2016...................................................................................................................................................27.Figure.22..Percentage.of.antimalarialVstocking.outlets.with.any.severe.malaria.treatment.in.stock.on.the.day.of.the.

survey,.across.strata,.2016......................................................................................................................................27.Figure.23..Antimalarial.market.share,.2010V2016............................................................................................................28.Figure.24..Antimalarial.market.share.within.sector,.2010V2016......................................................................................28.Figure.25..Antimalarial.market.share,.2016.....................................................................................................................29.Figure.26..Antimalarial.market.share,.across.strata,.2016...............................................................................................29.Figure.27..Percentage.of.antimalarialVstocking.outlets.with.malaria.blood.testing.available,.2010V2016......................30.


Figure.28..Percentage.of.antimalarialVstocking.outlets.with.malaria.blood.testing.available,.across.strata,.2016.........30.Figure.29..Percentage.of.antimalarialVstocking.outlets.with.malaria.microscopy.available,.2010V2016.........................31.Figure.30..Percentage.of.antimalarialVstocking.outlets.with.malaria.microscopy.available,.across.strata,.2016............31.Figure.31..Percentage.of.antimalarialVstocking.outlets.with.malaria.RDTs,.2010V2016..................................................32.Figure.32..Percentage.of.antimalarialVstocking.outlets.with.malaria.RDTs,.across.strata,.2016.....................................32.Figure.33..Malaria.blood.testing.market.share,.2016......................................................................................................33.Figure.34..Malaria.RDT.market.share.by.manufacturer,.across.sector,.2016..................................................................33.Figure.35..PrivateVsector.median.price.of.antimalarial.adult.equivalent.treatment.dosages.(AETD),.2010V2016...........34.Figure.36..PrivateVsector.median.price.of.SP.and.qualityVassured.ACT.adult.equivalent.treatment.dosages.(AETD).and.

preVpackaged.pediatric.qualityVassured.AL,.2016....................................................................................................34.Figure.37..PrivateVsector.median.price.of.SP.and.qualityVassured.ACT.adult.equivalent.treatment.dosages.(AETD).and.

preVpackaged.pediatric.qualityVassured.AL,.across.strata,.2016.............................................................................35.Figure.38..Median.privateVsector.consumer.price.of.QA.ACT.adult.equivalent.treatment.dosages.(AETD).with.and.

without.the.‘green.leaf’.logo,.2010V2016................................................................................................................35.Figure.39..Median.privateVsector.consumer.prices.for.malaria.RDT.testing.and.preVpackaged.AL.treatment.for.adults.

and.children,.2016...................................................................................................................................................36.Figure.40..Percentage.of.providers.who.correctly.stated.the.firstVline.treatment.for.uncomplicated.malaria,.2010V

2016.........................................................................................................................................................................36.Figure.41..Percentage.of.providers.who.correctly.stated.the.firstVline.treatment.for.uncomplicated.malaria,.across.

strata,.2016..............................................................................................................................................................37.Figure.42..Percentage.of.providers.who.correctly.stated.the.firstVline.dosing.regimen.for.uncomplicated.malaria.for.a.

twoVyearVold.child,.2010V2016................................................................................................................................37.Figure.43..Percentage.of.providers.who.correctly.stated.the.firstVline.dosing.regimen.for.uncomplicated.malaria.for.a.

twoVyearVold.child,.across.strata,.2016...................................................................................................................38.Figure.X3..Organization.of.Health.Service.Delivery.System...........................................................................................120.Figure.X4..Malaria.Epidemiological.Zones......................................................................................................................122.Figure.X1:.Map.of.the.four.malaria.epidemiology.zones.in.Kenya.................................................................................126.Figure.X2:.Map.of.sampled.areas...................................................................................................................................141.. .


Acronyms!!! ACT. Artemisinin.combination.therapy..

AETD. Adult.equivalent.treatment.dose.

AL. Artemether.lumefantrine.

AM. Antimalarial.

AMFm. Affordable.Medicines.Facility.–.malaria.

AMREF. African.Medical.and.Research.Foundation.

AMT. Artemisinin.monotherapy.

API. Active.Pharmaceutical.Ingredient.

AQ. Amodiaquine.

ASAQ. Artesunate.amodiaquine..

BMGF. The.Bill.and.Melinda.Gates.Foundation.

CHAI. Clinton.Health.Access.Initiative..

CHEW. Community.Extension.Health.Worker.

CHV. Community.Health.Volunteer.

CHW. Community.Health.Worker.

CI. Confidence.Interval.

CIA. Central.Intelligence.Agency.

DFID. Department.for.International.Development.

DHA.PPQ.. Dihydroartemisinin.piperaquine..

DHS. The.Demographic.and.Health.Survey..

DOMC. Division.of.Malaria.Control.

DRC. Democratic.Republic.of.Congo.

EMA.

GFATM.

European.Medicines.Agency..

Global.Fund.to.Fight.AIDS,.TB.and.Malaria.

GPS. Global.Positioning.System.

HDI. Human.Development.Index.

IM. Intramuscular.injection.

IPTp. Intermittent.Preventive.Treatment.in.Pregnancy.

IQR. Interquartile.Range.

IRS. Indoor.Residual.Spraying.

ITN. Insecticide.Treated.Net.

IV. Intravenous.injection..

KEMSA. Kenya.Medical.Supplies.Authority.

Kg. Kilogram.


KII. Key.Informant.Interview.

KNBS.. Kenya.National.Bureau.of.Statistics.

KNH. Kenya.National.Hospital.

KNMS. Kenya.National.Malaria.Strategy..

KSH. Kenya.Shilling.

LLIN. Long.Lasting.Insecticidal.Net.

LSHTM. London.School.of.Hygiene.and.Tropical.Medicine.

MCH. Maternal.and.Child.Health.

Mg. Milligrams.

MMV. Medicines.for.Malaria.Venture.

MOH. Ministry.of.Health..

nAT. NonVArtemisinin.Therapy.

NGO. NonVGovernmental.Organization.

NMCP. National.Malaria.Control.Program.

Oral.AMT. Oral.Artemisinin.Monotherapy...

ORS. Oral.Rehydration.Salts.

OS. Outlet.Survey.

Pf. Plasmodium'falciparum.

PHF. Public.Health.Facility.

PMI. President’s.Malaria.Initiative.

PPB. Pharmacy.and.Poisons.Board.

PPS. Probability.Proportional.to.Size.

PSI. Population.Services.International.

PSK. Population.Services.Kenya.

QA.. QualityVAssured..

RDT. Rapid.diagnostic.test..

SP. Sulfadoxine/.Sulfamethoxypyrazine.pyrimethamine.

UK. United.Kingdom.

UON.ERC. University.of.Nairobi.Ethics.and.Research.Committee.

US(A). United.States.(of.America).

USAID. United.States.Agency.for.International.Development.

USD. United.States.Dollar.

WHO.. World.Health.Organization.

WHO/AFRO. World.Health.Organization/Africa.region.


.

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).provided.malaria.blood. testing. (microscopy. or. rapid. diagnostic. tests). but. did. 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.Kenya,.they.were.defined.as.locations...

Census!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.. The. administrative. unit. for. the. census. of.public.health.facilities.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. World. Health. Organization. (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.60Vkg.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..

ArtemisininNbased!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..

NonNartemisinin!therapy!

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

FirstNline!treatment!!

The. governmentVrecommended. treatment. for. uncomplicated. malaria.. Kenya's. firstVline.treatment.for.uncomplicated.malaria.for.adults.is.artemether.lumefantrine..

SecondNline!treatment!

The.governmentVrecommended,.secondVline.treatment.for.uncomplicated.malaria..Kenya’s.secondVline.treatment.for.uncomplicated.malaria.is.dihydroartemisininVpiperaqiuine..

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. intravenous. or. intramuscular. artesunate. as. firstVline. treatment. in. the.management. of. severe. falciparum. malaria.. If. artesunate. is. not. available,. artemether. in.preference.to.quinine.should.be.used.for.treating.severe.malaria.cases..Rectal.artesunate.is.suitable.for.preVreferral.treatment.in.children.under.six.years.of.age.1.

QualityNassured!ArtemisininNBased!Combination!Therapies!(QA!ACTs)!

QA.ACTs.are.ACTs.that.comply.with.the.Global.Fund.to.Fight.AIDS,.Tuberculosis.and.Malaria’s.(GFATM). Quality. Assurance. Policy.. A. QA. ACT. is. any. ACT. that. appeared. on. the. GFATM’s.indicative. list. of. antimalarials.meeting. the.GFATM’s. quality. assurance. policy. prior. to. data.collection.(see.http://www.theglobalfund.org/en/healthproducts/qualityassurance/).or.that.previously.had.CVstatus. in.an.earlier.GFATM.quality.assurance.policy..QA.ACTs.also.include.ACTs.that.have.been.granted.regulatory.approval.by.the.European.Medicines.Agency.(EMA).–.specifically.Eurartesim®.and.Pyramax®..

QualityNassured!ACT!with!the!“green!leaf”!logo,!or!“coNpaid!ACTs”!

The.“green.leaf”.logo.indicates.that.a.qualityVassured.ACT.was.acquired.through.a.coVpayment.mechanism.administered.by. the.GFATM.(Affordable.Medicines.Facility,.malaria.–.or.AMFm)..These.subsidized. (coVpaid).qualityVassured.ACTs.were.available.to.firstVline.buyers.in.Kenya.in.the.public.sector.between.2010V2011.and.in.the.private.sector.from.2010V2016... .

QualityNassured!RDT!

QA.RDTs.are.RDTs.that.comply.with.the.GFATM’s.Quality.Assurance.Policy..A.QA.RDT.is.any.RDT. that. appeared. on. the. GFATM’s. indicative. list. of. RDTs. meeting. the. GFATM’s. quality.assurance. policy. prior. to. data. collection. (see.http://www.theglobalfund.org/en/healthproducts/qualityassurance/)...

!

1.World.Health.Organization..(2015)..Guidelines'for'the'treatment'of'malaria,'3rd'edition..Geneva:.WHO..


Introduction!! This. country. reference. document. is. a. detailed. presentation. of. the. 2016. national. ACTwatch. outlet. survey. (OS).conducted.in.Kenya..The.2016.OS.follows.previous.survey.rounds.conducted.by.ACTwatch.in.Kenya.in.2010,.2011,.and.2014...ACTwatch.is.a.multiVcountry.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.highVquality.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.....ACTwatch.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.qualityVassured.ACTs.in.the.public.and.private.sectors.through.mechanisms,.including.the.GFATM.coVpayment.mechanism.piloted.under.the.AMFm..The.initial.AMFm.pilot.period.was.2010V2011.and.coVpaid.ACTs.were.delivered.to.firstVline.buyers.in.Kenya.through.2016.under.the.GFATM.privateVsector.copayment.mechanism...

•! National.efforts.to.improve.availability.of.malaria.blood.testing.and.confirmatory.testing.prior.to.antimalarial.treatment. in.both. the.public. and.private. sectors.. Treatment.guidelines. released. in.2014.now. recommend.confirmatory.testing.prior.to.treatment.in.all.cases...

•! Extension.of.malaria.testing.and.treatment.to.the.community.level.through.scale.up.of.service.provision.by.community.health.workers...

•! Change.in.treatment.policy.in.2012.to.injectable.artesunate.as.the.firstVline.treatment.for.severe.malaria,.and.efforts.to.ensure.availability.of.artesunate.IV/IM.at.public.health.facilities....

The.2016.OS.was.the.fourth.round.of.ACTwatch.outlet.surveys.conducted.in.Kenya..This.report.presents.trend.lines.with.four.data.points:.1).the.2010.outlet.survey,.2).the.2011.outlet.survey,.3).the.2014.outlet.survey,.and.4).the.most.recent.2016.survey..These.surveys.are.designed.to.monitor.key.antimalarial.market.indicators.at.the.national.level...The.2010,.2011,.and.2014.outlet.surveys.provided.estimates.by.urban/rural.domains,.while.the.2016.outlet.survey.provided.estimates.for.domains.defined.by.the.National.Malaria.Control.Program.based.on.malaria.risk.and.burden..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.2016.outlet.survey..Please.see.annexes.for.information.about.the.

study.context,.design,.implementation,.and.data.analysis....•! Table.numbers.are.consistent.across.all.sections.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...

!!!"#$%!&'()"*+,-.............................4&28.?@.

89.&'.')8.+&'*-+&6.68986.*+.\8+0&.X8'!88+.O5+8.K').&+>.#525:'.?I')P.@A?K".#.,566.>8:(1*/'*-+.-,.')8.18:8&1().>8:*2+.&+>.M8')->:.*:./1-9*>8>.*+.#++8S.L".R1*8,60P.')*:.:'5>0.!&:.:'1&'*,*8>.'-./1-9*>8.8:'*M&'8:.!*')*+.8&().-,.,-51.M&6&1*&.8/*>8M*-6-20.a-+8:E.^+>8M*(..(-&:'&6=P.`*2)6&+>P.G-!.]*:_P.&+>.78&:-+&6.G-!..(65:'81:P.&.(8+:5:.-,.&66.-5'68':.!*').')8./-'8+'*&6.'-.:866.-1.>*:'1*X5'8.&+'*M&6&1*&6:.&+>m-1./1-9*>8.M&6&1*&.X6-->.'8:'*+2.!&:.(-M/68'8>".%)8.28-21&/)*(.&18&. ,-1. :&M/6*+2.-5'68':.!&:.8S'8+>8>. '-. ')8.>*9*:*-+. 68986. '-.&()*898.&. :5,,*(*8+'. :&M/68.:*a8. ,-1.8:'*M&'*+2._80.*+>*(&'-1:.,-1.*M/-1'&+'.-5'68'.'0/8:".%)*:.X--:'81.:&M/6*+2.:'1&'820.!&:.5:8>.'-.-X'&*+.&.:5,,*(*8+'.:&M/68.:*a8.,-1.*+>*(&'-1.8:'*M&'8:.!*')*+./5X6*(.)8&6').,&(*6*'*8:"..Q5'68':.!818.:(188+8>.'-.>8'81M*+8.86*2*X*6*'0".Q5'68':.86*2*X68.,-1.')8.:51980.M8'.&'.68&:'.-+8.-,.')188.(1*'81*&E.?=.-+8.-1.M-18.&+'*M&6&1*&6:.!818.*+.:'-(_.-+.')8.>&0.-,.')8.:51980P.@=.-+8.-1.M-18.&+'*M&6&1*&6:.!818.*+.:'-(_.*+.')8.')188.M-+'):./18(8>*+2.')8.:51980P.&+>m-1.L=.M&6&1*&.X6-->.'8:'*+2..*+.Z*2518.?".#.>8'&*68>.:&M/68.:5MM&10.*:./1-9*>8>.*+.#++8S.U"...#.:'15('518>.h58:'*-++&*18.!&:.5:8>.'-.(-M/68'8.&+.&5>*'.-,.&66.&+'*M&6&1*&6:.&+>.]D%:.&:.!866.&:.&./1-9*>81.*+'819*8!.&'&.8+'10.!&:.(-M/68'8>.5:*+2.F*(1-:-,'.#((8::".#66.>&'&.(68&+*+2.&+>.&+&60:*:.!818./81,-1M8>.5:*+2.7'&'&.?L"?..&((-1>*+2.'-.>8,*+*'*-+:.&//6*8>.&(1-::.#$%!&'()./1-d8('.(-5+'1*8:.

!!!"#$%!&'()"*+,-.............................4&28.?L.

G$D9+&!U@V!,-=!*)!/-

!!!"#$%!&'()"*+,-.............................4&28.?T.

!G$D9+&!BV!89+#&1!).*5!%$-D+-i.

r?IP?AWs..

I!Q5'68':.:(188+8>ii.

r?BPWU@s..

;!Q5'68':.*+'819*8!8>iii.. . r@P@B?s.! B!t r?PI?Bs.! @t. r@ILs.! Xt. rK?s.

.

Q5'68':.+-'..:(188+8>.r?P@UKs.

.

Q5'68':.')&'.>*>.+-'.M88'.:(188+*+2.

(1*'81*&.r?UPUK?s.

.

Q5'68':.+-'.*+'819*8!8>.

r@As..

!]8:/-+>8+'.+-'.&9&*6&X68. . rLBs..Q5'68'.(6-:8>.&'.'*M8.-,.9*:*'....... r@?Is..Q5'68'.(6-:8>./81M&+8+'60.......... rI@?s..Q')81. ........... r?As..]8,5:8>. .......... rKIss.

!..]8:/-+>8+'.+-'.&9&*6&[email protected]'68'.(6-:8>.&'.'*M8.-,.9*:*'.......r?s..]8,5:8>...........................................r?Bs.

?E. #+'*M&6&1*&6:.*+.:'-(_.-+.>&0.-,.9*:*'.@E.. #+'*M&6&1*&6:.18/-1'8>60.*+.:'-(_.>51*+2.')8./189*-5:.L.M-+'):.X5'.+-'.-+.')8.>&0.-,.')8.9*:*'.LE.. F&6&1*&.X6-->.'8:'*+2.&9&*6&X68.X5'.+-.&+'*M&6&1*&6:.*+.:'-(_...i. ;>8+'*,*8>.&:.-5'68':.!*')./-'8+'*&6.'-.:866.-1.>*:'1*X5'8.&+'*M&6&1*&6:.&+>m-1./1-9*>8.M&6&1*&.X6-->.'8:'*+2.>51*+2.

')8.(8+:5:.-1.X--:'81.:&M/6*+2..ii. #>M*+*:'818>.h58:'*-+:.'-.&::8::.(5118+'.-1.18(8+'..!*').&+.-5'68'.18/18:8+'&'*98..

3!Q5'68':.')&'.M8'..:(188+*+2.(1*'81*&.

. r@P@I?s.! B!t r?PILBs.! @!t r@ILs.! X!t rK?s.

.

www.ACTwatch.info....................Page.15.

Summary'of'Key'Findings' Table'S1:'Key'results,'by'outlet'type,'2016.

'.

Public.Health.Facility.

Community.Health.Workers.

ALL'Public'/'NotC'ForC

Profit1'

[email protected].

Registered.Pharmacy.

Unregistered.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).Readiness'for'malaria'case'management''Proportion(of(all(screened((outlets*(with:.

N=796. N=1815. N=2,650. N=360. N=145. N=493. N=14,204. N=15,202. N=17,852.

Availability.of.malaria.blood.testing.

86.4. 4.3. 12.4. 62.3. 21.4. 11.6. 0.0. 1.8. 3.3.(82.4,.89.6). (2.2,.8.2). (9.5,.16.1). (54.5,.69.5). (15.6,.28.8). (8.7,.15.3). @. (1.4,.2.3). (2.8,.3.8).

Availability.of.QA.ACT.87.1. 2.4. 10.7. 45.3. 68.3. 56.1. 0.2. 3.3. 4.4.

(83.0,.90.4). (0.9,.6.3). (8.3,.13.8). (38.7,.52.1). (60.8,.75.1). (50.5,.61.4). (0.1,.0.5). (2.8,.4.0). (3.8,.5.0).Availability.of.QA.ACT.and.malaria.blood.testing.

78.3. 1.9. 9.4. 31.6. 16.2. 9.3. 0.0. 1.1. 2.2.(73.6,.82.4). (0.7,.4.9). (7.3,.12.1). (25.0,.39.1). (11.9,.21.6). (6.6,.12.9). @. (0.8,.1.4). (1.9,.2.6).

Availability.of.QA.ACT,.blood.testing.not.available..

8.8. 0.5. 1.3. 13.7. 52.2. 46.8. 0.2. 2.3. 2.1.(6.2,.12.3). (0.2,.1.7). (0.8,.2.1). (10.4,.17.8). (44.3,.59.9). (42.0,.51.6). (0.1,.0.5). (1.9,.2.7). (1.8,.2.5).

[email protected].(artesunate.IV/IM)..

46.0. 0.0. 4.6. 7.7. 1.6. 1.0. 0.0. 0.2. 0.8.

(39.7,.52.4). @. (3.6,.5.9). (4.5,.13.0). (0.5,.5.2). (0.5,.2.2). @. (0.1,.0.3). (0.7,.1.0).Readiness'for'malaria'case'management'Proportion(of(antimalarial4stocking(outlets(!(with:("

N=734. N=65. N=.831. N=280. N=134. N=428. N=244. N=1,086. N=1,917.

Availability.of.malaria.blood.testing.

89.2. 78.2. 86.5. 68.9. 23.0. 13.1. 0.2. 22.7. 35.6.(85.3,.92.2). (65.5,.87.2). (82.5,.89.7). (60.8,.76.0). (16.8,.30.6). (9.8,.17.3). (0.0,.1.8). (18.3,.27.7). (31.4,.40.0).

Availability.of.QA.ACT' 94.9. 100.0. 94.7. 59.3. 73.2. 64.3. 9.9. 46.7. 56.4.(91.0,.97.2). @. (91.3,.96.8). (51.2,.67.0). (65.6,.79.7). (58.6,.69.7). (5.1,.18.4). (39.4,.54.1). (50.1,.62.6).

Availability.of.QA.ACT.and.malaria.blood.testing'

85.3. 78.2. 83.0. 41.4. 17.3. 10.7. 0.2. 15.0. 28.8.(80.4,.89.1). (65.5,.87.2). (79.0,.86.4). (33.3,.50.1). (12.8,.23.0). (7.7,.14.7). (0.0,.1.8). (11.6,.19.1). (25.2,.32.8).

Availability.of.QA.ACT,.blood.testing.not.available.'

9.6. 21.8. 11.7. 17.9. 55.9. 53.6. 9.7. 31.7. 27.6.(6.8,.13.4). (12.8,.34.5). (8.5,.15.9). (13.4,.23.5). (47.6,.63.9). (48.5,.58.7). (4.9,.18.2). (27.0,.36.8). (23.7,.31.9).

[email protected].(artesunate.IV/IM)..

50.1. 0.0. 40.8. 10.1. 1.7. 1.2. 0.0. 2.9. 10.6.

(43.6,.56.5). @. (31.7,.50.6). (5.9,.16.8). (0.5,.5.6). (0.5,.2.6). @. (1.7,.4.7). (8.6,.13.0).Readiness'for'IPTp'Proportion(of(outlets(with:(' . . . . . . . . .

17.6. 0.0. 1.7. 19.6. 46.6. 48.1. 2.1. 4.1. 3.8.


Table'S1:'Key'results,'by'outlet'type,'2016.

'.


Community.Health.Workers.

ALL'Public'/'NotC'ForC

Profit1'

[email protected].


Unregistered.Pharmacy. General.Retailer.

ALL'Private.

ALL'Outlets'

Availability.of.SP,.among.all.screened.outlets*. (13.7,.22.3). @. (1.2,.2.4). (14.6,.25.7). (36.6,.56.9). (41.3,.55.0). (1.4,.3.1). (3.4,.4.9). (3.2,.4.5).

Availability.of.SP,.among.all.screened.outlets.in.endemic.areas*.

70.0. 0.0. 4.3. 25.8. 52.7. 47.9. 1.1. 4.4. 4.3.

(56.4,.80.8). @. (3.0,.6.2). (16.3,.38.3). (30.5,.73.8). (38.4,.57.6). (0.5,.2.4). (3.6,.5.2). (3.7,.5.1).

Availability.of.SP,[email protected].!.

19.1. 0.0. 14.7. 25.6. 49.9. 55.2. 85.2. 57.6. 48.9.(15.0,.24.1). @. (10.5,.20.1). (19.5,.32.9). (38.9,.61.0). (47.1,.63.0). (75.1,.91.6). (50.8,.64.0). (43.1,.54.7).

Availability.of.SP,[email protected].!.

70.7. 0.0. 42.8. 29.3. 58.5. 52.3. 47.0. 47.3. 46.2.

(57.6,.81.1). @. (20.1,.69.0). (17.6,.44.5). (32.5,.80.6). (42.3,.62.1). (21.8,.73.8). (38.9,.55.8). (36.9,.55.8).

'Antimalarial'market'share'within'outlet/sector'type''

%. . %. %. %. %. %. %. %.

%.QA.ACT"market.share.^. 23.3. 0.5. 25.6. 7.4. 4.5. 20.0. 0.6. 32.5. 58.2.

PrivateCsector'price' . . . Median.[IQR].(N).

Median.[IQR].(N).

Median.[IQR].(N).

Median.[IQR].(N).

Median.[IQR].(N).

Median.[IQR].(N).

Median.price.for.one.QA.ACT.AETD.(tablets).

n/a. n/a. n/a. $1.51. $1.51. $1.21. $1.00. $1.31. n/a.. . . [[email protected]].(220). [[email protected]].(133). [[email protected]].(358). [[email protected]].(30). [[email protected]].(741). .

Median.price.for.one.SP.AETD.(tablets).

n/a. n/a. n/a. $0.50. $0.50. $0.50. $0.35. $.0.45. n/a.. . . [[email protected]]90. [[email protected]]91. [[email protected]]370. [[email protected]]217. [[email protected]]768. .

[email protected].#.

n/a. n/a. n/a. $0.50. $1.00. $0.50. $0.50. $0.50. n/a.. . . [[email protected]].(15). [[email protected]].(5). [[email protected]].(25). [[email protected]].(2). [[email protected]].(47). .

Median.price.for.an.RDT.##.n/a. n/a. n/a. $1.00. $1.00. $1.00. $0.00. $1.00. n/a.. . . [[email protected]].(117). [[email protected]].(17). [[email protected]].(42). [[email protected]].(2). [[email protected]].(178). .

1.Inclusive.of.N=.39.screened/[email protected]@[email protected].*. 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)....!. Outlets.with.at.least.one.antimalarial.in.stock.on.the.day.of.the.survey.or.reportedly.in.stock.within.the.past.3.months..^....Percent.market.volume.(adult.equivalent.treatment.dosages.sold/distributed.in.the.previous.week).accounted.for.by.QA.ACT.sale/distribution.within.distribution.by.the.outlet/sector..#[email protected]@kg.child.##.Price.inclusive.of.consultation./.service.fees.for.a.child.under.age.5..Source:.ACTwatch.Outlet.Survey,.Kenya,.2016..


Figure'2.(Market'composition:'outlet'type'distribution,'2010C2016'Among"all"outlets"with"at"least"one"antimalarial"in"stock,"across"survey"round.

.

.

.

.

The.private.sector.accounted.for.the.majority.of.antimalarial@stocking.outlets.across.all.survey.rounds..Unregistered.pharmacies.and.general.retailers.comprised.over.50%.of.the.antimalarial.market.composition.in.every.survey.round.'

Figure'3.'Market'composition:'outlet'type'distribution,'2016,'by'strata'' 'Among"all"outlets"with"at"least"one"antimalarial"in"stock"

The.private.sector.accounted.for.the.majority.of.antimalarial@stocking.outlets.across.all. four.strata..Community.health.workers.(CHWs).stocking.antimalarials.were.found.in.endemic.and.highland.areas,. but.were.not. common.antimalarial. service.delivery.points. in. low. risk. and. seasonal. low.areas.. In. endemic. areas,. 38%.of. antimalarial@stocking.outlets.were.unregistered.pharmacies.compared.to.only.about.one.in.four.outlets.in.highland.(24%).and.low.risk.areas.(27%),.and.16%.in.seasonal.low.areas..General.retailers.accounted.for.41%.of.antimalarial@stocking.outlets.in.seasonal.low.areas.compared.to.24%.in.low.risk,.18%.in.endemic.areas,.and.14%.in.highland.areas...

11% 3%3%

12%

3%31%

37%

2010N=1,471

Public.Health.Facility

Community.Health.Worker

[email protected]

[email protected]

Registered.Pharmacy

Unregistered.Pharmacy

General.Retailer

13% 3%

19%

3%30%

31%

2011N=1,348

14%

9%1%

14%

6%38%

18%

EndemicN=338

Public.Health.Facility

Community.Health.Worker

[email protected]

[email protected]

Registered.Pharmacy

Unregistered.Pharmacy

General.Retailer

24%

6%4%

21%7%

24%

14%

HighlandN=250

21%

1%4%

14%

3%16%

41%

Seasonal.lowN=323

9%2%

22%

16%27%

24%

Low.risk.N=451

10%1%

3…

21%

12%

33%

20%

0%

2014N=1,501

15% 4%3%

18%

9%

27%

25%

2016N=1,362

!!!"#$%!&'()"*+,-..................../&01.23.

!"#$%&'()'*&%+&,-.#&'/0'/$-1&-2'3"-4'.-'1&.2-'/,&'.,-"5.1.%".1'",'2-/+6'/,'-4&'7.8'/0'-4&'2$%9&8:';. ;)&98&(*1:=. &+>. .&91&:.?@3BC.(-8;&91>.'-.5-!19.&4&*5&6*5*'7.*+.5-!.9*:H.?32BC.&+>.:1&:-+&5.5-!.&91&:.?@2BC".#+'*8&5&9*&5:.!191.01+19&557.+-'.&4&*5&651.&8-+0.$FG:.&+>.01+19&5.91'&*519:.&(9-::.>-8&*+:"...

A

2A

IA

EA

MA

NA

JA

OA

3A

@A

2AA

/./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.- V-!.R*:H W1&:-+&5.V-!

!!!"#$%!&'()"*+,-..................../&01.2@.

'!"#$%&'?)'*&%+&,-.#&'/0'.,-"5.1.%".1>2-/+6",#'/$-1&-2'3"-4'ABC'",'2-/+6'/,'-4&'7.8'/0'-4&'2$%9&8:';.'-.@JB.*+.IA2J.,9-8.3MB.*+.IA2M".X+.')1.;9*4&'1.:1('-9=.#$%.&4&*5&6*5*'7.>1(91&:1>.,9-8.OOB.*+.IA2M.'-.JIB.*+.IA2J".Y1(91&:1:.!191.-6:1941>.&8-+0.&55.;9*4&'1Q:1('-9.-.;)&98&(*1:.?3NBC".#8-+0.01+19&5.91'&*519:.:'-(H*+0.&+'*8&5&9*&5:=.-+57.2EB.!191.:'-(H*+0.#$%.*+.IA2J=.&.>1(91&:1.,9-8.IOB.*+.IA2M"..

'

A2AIAEAMANAJAOA3A@A2AA

/./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-18*(. &91&:. ?O3BC=.8->19&'1.*+.)*0)5&+>.?JJBC.&+>.5-!.9*:H.&91&:.?JMBC=.&+>.5-!.*+.:1&:-+&5.5-!.&91&:.?MIBC".Y*,,191+(1:.*+.;9*4&'1Q:1('-9.#$%.&4&*5&6*5*'7.!191.8-:'.+-'&651.&8-+0.01+19&5.91'&*519:.:'-(H*+0.&+'*8&5&9*&5:".#8-+0.')1:1.;9-4*>19:=.8-91.')&+.)&5,.!191.:'-(H*+0.#$%.*+.1+>18*(.&91&:.?NEBC.(-8;&91>.'-.2IB.*+.)*0)5&+>.&91&:.&+>.,1!19.')&+.NB.*+.5-!.9*:H.&+>.:1&:-+&5.5-!.&91&:"...

A

2A

IA

EA

MA

NA

JA

OA

3A

@A

2AA

/./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519 #55./9*4&'1

*&%+

&,-.

#&'/

0'/$-

1&-2

U+>18*( F*0)5&+> V-!.R*:H W1&:-+&5.V-!

!!!"#$%!&'()"*+,-..................../&01.IA.

!"#$%&'E)'*&%+&,-.#&'/0'.,-"5.1.%".1>2-/+6",#'/$-1&-2'3"-4'F$.1"-8>.22$%&7'ABC'",'2-/+6'/,'-4&'7.8'/0'

-4&'2$%9&8:';.&8-+0.&55.;9*4&'1Q:1('-9.-. ;)&98&(*1:. ?OEBC=. &+>. .22$%&7'ABC'",'2-/+6'/,'-4&'7.8'/0'

-4&'2$%9&8:'.+%/22'2-%.-.:';.:1&:-+&5.5-!.&91&:.?EMBC".Y*,,191+(1:.*+.;9*4&'1Q:1('-9.[#.#$%.&4&*5&6*5*'7.!191.8-:'.+-'&651.&8-+0.01+19&5.91'&*519:.:'-(H*+0.&+'*8&5&9*&5:".#8-+0.')1:1.;9-4*>19:=.8-91.')&+.MAB.!191.:'-(H*+0.[#.#$%.*+.1+>18*(.&91&:.?MIBC.(-8;&91>.'-.,1!19.')&+.2AB.*+.&55.-')19.>-8&*+:"...


/./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-18*( F*0)5&+> V-!.R*:H W1&:-+&5.V-!

!!!"#$%!&'()"*+,-..................../&01.I2.

!"#$%&'=1(5*+1>.,9-8.JEB.*+.IA2M.'-.MAB.*+.IA2J".Y1(5*+1:.!191.-6:1941>.,-9.1&().-.;)&98&(*1:.?NJBC".D+57.JB.-,.01+19&5.91'&*519:.!191.:'-(H*+0.[#.#$%.!*').')1.^0911+.51&,_.5-0-=.&.>1(91&:1.,9-8.I2B.*+.IA2M".

!"#$%&'==)'*&%+&,-.#&'/0'.,-"5.1.%".1>2-/+6",#'/$-1&-2'3"-4'F$.1"-8>.22$%&7'ABC'5.%6&7'3"-4'-4&'

H#%&&,'1&.0I'1/#/''''''''",'2-/+6'/,'-4&'7.8'/0'-4&'2$%9&8:'.+%/22'2-%.-.:';.:1&:-+&5.5-!.&91&:.?EABC".Y*,,191+(1:.*+.')1.&4&*5&6*5*'7.-,.;9*4&'1Q:1('-9.[#.#$%.!*').')1.5-0-.!191.8-:'.+-'&651.&8-+0.01+19&5.91'&*519:.:'-(H*+0.&+'*8&5&9*&5:".#8-+0.')1:1.;9-4*>19:=.IMB.!191.:'-(H*+0.[#.#$%.*+.1+>18*(.&91&:.(-8;&91>.'-.NB.-9.,1!19.*+.&55.-')19.>-8&*+:"...


/./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-18*( F*0)5&+> V-!.R*:H W1&:-+&5.V-!

!!!"#$%!&'()"*+,-..................../&01.II.

!"#$%&'=;)'*&%+&,-.#&'/0'.,-"5.1.%".1>2-/+6",#'/$-1&-2'3"-4',/,>F$.1"-8'.22$%&7'ABC'",'2-/+6'/,'-4&'7.8'

/0'-4&'2$%9&8:';.01+19&5.91'&*519:.?EBC".

!"#$%&'=J)'*&%+&,-.#&'/0'.,-"5.1.%".1>2-/+6",#'/$-1&-2'3"-4',/,>F$.1"-8'.22$%&7'ABC'",'2-/+6'/,'-4&'7.8'

/0'-4&'2$%9&8:'.+%/22'2-%.-.:';./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-./)&98&(7

S+910*:'191>./)&98&(7

T1+19&5.R1'&*519

#55./9*4&'1

/19(1+'&01.-,.-18*( F*0)5&+> V-!.R*:H W1&:-+&5.V-!


Figure'14.'Types'of'quality5assured'ACT'and'non5quality'assured'ACT'audited'among'public5'and'private5sector'outlets,'Kenya,'2016'

Among&all&ACT&medicines&audited&.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

Almost.all.QA.ACT.products.available.in.the.public.(100%).and.private.sectors.(98%).were.AL.tablets..The.majority.of.nonHQA.ACT.products.audited.in.the.public.sector.were.tablet.formulation.

nonHQA.AL.tablets.(75%)..In.the.private.sector,.nonHQA.AL.and.nonHQA.DHA.PPQ.tablets.each.comprised.oneHthird.of.nonHQA.ACTs.audited..

98%

2%

QualityHassured.Private.Sector

N=761

AL.tablet ASMQ.tablet ASAQ.tablet DHA.PPQ.tablet A.PPQ.tablet ASSP.tablet DHA.PPQ.Trim.tablet

Arterolane.PPQ.tablet A.NAP.tablet AL.nonHtablet ASMQ.nonHtablet DHA.PPQ.nonHtablet ASAQ.nonHtablet

100%

0%0%

QualityHassured.Public.Sector

N=2514

33%

1%

34%

8%

1%

2%

12%

9%

NonHquality.assured.Private.Sector

N=1125

75%

17%

6%2%

NonHquality.assured.Public.Sector

N=130

!!!"#$%!&'()"*+,-..................../&01.23.

!"#$%&'()*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'-0-4/%.&2"5"-"-'.8&%/9:'"-'5.0,6'0-'.8&';/:'01'.8&'5$%

!!!"#$%!&'()"*+,-..................../&01.2A.

!"#$%&'(A*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'B+'"-'5.0,6'0-'.8&';/:'01'.8&'5$%;1?.,-9.*+'19:*''1+'.?(@'!"#$%&'(()*(+*,&-.*/&'*&(+',*$+&'$*."'('0.'(&.$&,*#12& &

.

U/.!&;.1;;1+'*&557.-+57.&4&*5&651.*+.65*(.)1&5').,&(*5*'*1;.5-(&'1?.*+.1+?1:*(.&91&;H.&[email protected],.65*(.)1&5').,&(*5*'*1;.*+.1+?1:*(.

&91&;.)&?.U/.&4&*5&651".N-!1419H.U/.&4&*5&6*5*'7.*+.')1.

!!!"#$%!&'()"*+,-..................../&01.2F.

!"#$%&'(D*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'0%/3'E$"-"-&'"-'5.0,6'0-'.8&';/:'01'.8&'

5$%'51'.'7'51';.)&?.-9&5.Y>*+*+1.

&4&*5&651.*+.2CDF"..

!"#$%&'>?*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'0%/3'E$"-"-&'"-'5.0,6'0-'.8&';/:'01'.8&'

5$%

!!!"#$%!&'()"*+,-..................../&01.2@.

!"#$%&'>(*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'5&?1.&9'1;>+&'1. G[\G]H.Y>*+*+1. G[\G]H.&9'1:1')19. G[\G]H.&9'1:-'*5. G[\G]H.&+?.&9'1;>+&'1.

;>

!!!"#$%!&'()"*+,-..................../&01.2K.

!"#$%&'>F*'G-."2/3/%"/3'2/%6&.'58/%&='>?(?4>?(@'

7+('*.4+&"'02+*&4#()"+&8,'(+96.,*0.:)*.#$;?,3&:5&,+1*#0&'$6&'$*."'('0.'(&1(',,3&'10#,,&,)04+5&0#)$6&&

%)1.:&I-9*'7.-,.&+'*:&5&9*&5;.?*;'9*6>'1?.!191.?*;'9*6>'1?.')9->0).')1.'1?.+-+8&9'1:*;*+*+.')19&+'*+0.,-9.+1&957.

&55.+-+8&9'1:*;*+*+;.?*;'9*6>'1?.&(9-;;.;>9417.9->+?;.J2CDCH.ALBW.2CDDH.E3BW.2CD3H.2FBW.2CDFH.2ABM".X-+8^#.#$%.:&9=1'.;)&91.

)&;.*+(91&;1?.*+.91(1+'.71&9;.,9-:.KB.*+.2CDC.&+?.AB.*+.2CDD.'-.DKB.*+.2CD3.&+?.DFB.*+.2CDF"..

!"#$%&'>H*'G-."2/3/%"/3'2/%6&.'58/%&'7".8"-'5&,.0%='>?(?4>?(@'

7+('*.4+&"'02+*&4#()"+&8,'(+96.,*0.:)*.#$;?,3&-.*/.$&,+1*#03&:5&'$*."'('0.'(&*5@+3&'10#,,&,)04+5&0#)$6&

G+.')1.65*(.;1('-9H.')1.:&9=1'.;)&91.,-9.^#.#$%.*+(91&;1?.,9-:.AEB.*+.2CDC.&+?.3LB.*+.2CDD.'-.@@B.*+.2CD3.&+?.

K@B.*+.2CDF".G+.')1.65*(. /9*4&'1 />65*(. /9*4&'1 />65*( /9*4&'1 />65*( /9*4&'1

2CDC 2CDD 2CD3 2CDF

/1

9(1

+'&

01

.-,.

'-'&

5.:

&9=

1'.

4-

5>:

1

^#.#$%.!*').0911+.51&, ^#.#$%.!*')->'.0911+.51&, X-+.^#.#$%

U/ Z')19.+-+8&9'1:*;*+*+.')19&65*(. /9*4&'1 />65*(. /9*4&'1

2CDC 2CDD 2CD3 2CDF

/1

9(1

+'&

01

.-,.

;1('

-9.

:&

9=1

'.4-

5>:

1

^#.#$%.!*').0911+.51&, ^#.#$%.!*')->'.0911+.51&, X-+.^#.#$%

U/ Z')19.+-+8&9'1:*;*+*+.')19&

!!!"#$%!&'()"*+,-..................../&01.2L.

!"#$%&'>)*'G-."2/3/%"/3'2/%6&.'58/%&='>?(@'7+('*.4+&"'02+*&4#()"+&8,'(+96.,*0.:)*.#$;?,3&:5)*(+*&*5@+&'$6&'$*."'('0.'(&*5@+& &

G+. 2CDFH. @CB. -,. &55. &+'*:&5&9*&5. ?*;'9*6>'*-+. !&;. ')9->0). ')1. '1?.U/.-+57"...

!"#$%&'>@*'G-."2/3/%"/3'2/%6&.'58/%&='/,%055'5.%/./='>?(@''7+('*.4+&"'02+*&4#()"+&8,'(+96.,*0.:)*.#$;?,3&:5&,+1*#0&'$6&'$*."'('0.'(&1(',,&

%)1.+'1?. ,-9. &6->'. -+18')*9?. -,. &+'*:&5&9*&5;. ?*;'9*6>'1?. *+.

)*0)5&+?.J2KBM.&+?.5-!.9*;=.&91&;.JE3BM.(-::

1

^#.#$%.!*').0911+.51&, ^#.#$%.!*')->'.0911+.51&, X-+.^#.#$%

U/ Z')19.+-+8&9'1:*;*+*+.')19&65*( /9*4&'1 />65*( /9*4&'1

S+?1:*( N*0)5&+? T-!.P*;= U1&;-+&5.T-!

/1

9(1

+'&

01

.-,.

;1('

-9.

:&

9=1

'.4-

5>:

1

^#.#$%.!*').0911+.51&, ^#.#$%.!*')->'.0911+.51&, X-+.^#.#$%

U/ Z')19.+-+8&9'1:*;*+*+.')19&

!!!"#$%!&'()"*+,-..................../&01.EC.

!"#$%&'>A*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'2/3/%"/'I300;'.&5."-#'/?*+0.65*(.)1&5').,&(*5*'*1;.J2CDCH.3FBW.2CDDH.AABW.2CD3H.L3BW.2CDFH.KLBM.&+?.65*(.N1&5').

O&(*5*'7

#55./>65*( /9*4&'1.O-98

/9-,*'.O&(*5*'7

P10*;'191?.

/)&9:&(7

Q+910*;'191?.

/)&9:&(7

R1+19&5.

P1'&*519

#55./9*4&'1

/1

9(1

+'&

01

.-,.

->

'51

';

2CDC 2CDD 2CD3 2CDF

C

DC

2C

EC

3C

AC

FC

@C

KC

LC

DCC

/>65*(.N1&5').

O&(*5*'7

#55./>65*( /9*4&'1.O-98

/9-,*'.O&(*5*'7

P10*;'191?.

/)&9:&(7

Q+910*;'191?.

/)&9:&(7

R1+19&5.

P1'&*519

#55./9*4&'1

/1

9(1

+'&

01

.-,.

->

'51

';

S+?1:*( N*0)5&+? T-!.P*;= U1&;-+&5.T-!

!!!"#$%!&'()"*+,-..................../&01.ED.

!"#$%&'>D*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'2/3/%"/'2",%05,09:'/0).?&'&. '91+?;. ;>001;'. 5-!19.

&4&*5&6*5*'7.*+.;1&;-+&5.5-!.&91&;.JEKBM.(-:

!!!"#$%!&'()"*+,-..................../&01.E2.

!"#$%&'F(*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'2/3/%"/'JKL5='>?(?4>?(@'!"#$%&'(()*(+*,&-.*/&'*&(+',*$+&'$*."'('0.'(&.$&,*#12$&*/+&6'5*'+&%,&-./#&'01'/-."2/3/%"/345.0,6"-#'0$.3&.5'7".8'2/3/%"/'JKL5='/,%055'5.%/./='>?(@' '!"#$%&'(()*(+*,&-.*/&'*&(+',*$+&'$*."'('0.'(&.$&,*#12$&*/+&6'5A*(.N1&5').

O&(*5*'7

#55./>65*( /9*4&'1.O-98

/9-,*'.O&(*5*'7

P10*;'191?.

/)&9:&(7

Q+910*;'191?.

/)&9:&(7

R1+19&5.

P1'&*519

#55./9*4&'1

/1

9(1

+'&

01

.-,.

->

'51

';

S+?1:*( N*0)5&+? T-!.P*;= U1&;-+&5.T-!


Figure'33.'Malaria'blood'testing'market'share,'2016'Relative&market&volume&(sale/distribution)&of&malaria&blood&testing&using&RDTs&and&microscopy,&by&outlet&type&and&type&of&test&& &

The.public. sector.delivered. the.majority.of. all.malaria. testing. in.2016. (67%),. and.most.malaria. testing.was.provided.using.

malaria.microscopy.(57%)..The.private.sector.accounted.for.33%.of.the.testing.market.share,.and.private8sector.testing.was.

delivered. primarily. by. private8for8profit. health. facilities. (29%. of. the. total. market. share).. Registered. pharmacies. and.

unregistered.pharmacies.each.provide.approximately.2%.of.the.market.share...

Figure'34.'Malaria'RDT'market'share'by'manufacturer,'across'sector,'2016'Relative&market&volume&(sale/distribution)&of&malaria&RDTs&by&manufacturer,&within&the&public&sector,&private&sector,&and&total&market& &

Access.Bio.Inc..was.the.most.common.manufacturer.of.RDTs.administered.in.both.the.public.and.private.sectors,.accounting.

for.76%.and.59%.of.market.share.in.those.sectors,.respectively..

0

10

20

30

40

50

60

70

80

90

100

Public Private Private.For8Profit.

Facility

Registered.

Pharmacy

Unregistered.

Pharmacy

General.Retailer

Percentage.of.total.market.volume

Microscopy RDT

0

10

20

30

40

50

60

70

80

90

100

Public Private

Percentage.of.within.outlet.market.volume.

Access.Bio Standard.Diagnostics,.Inc. CTK.Biotech,.Inc.

Other.RDT.manufacturer Manufacturer.not.specified

!!!"#$%!&'()"*+,-..................../&01.E3.

!"#$%&'F)*'+%"?(@'!"#$%&'((&AB3&$#$CD)'(.*5C',,)0+6&!E>&'$6&D)'(.*5C',,)0+6&!E>&8*':(+*&651?.61'!11+.2CDD.&+?.2CD3.&+?.*+.2CDFH.*'.!&;.'!-.

'*:1;.:-91.1`?(@'!"#$%&'((&AB3&J!&!E>3&'$6&@0+C@'12'%+6&@+6.'*0.1&8*0+'*"+$*&&5*'78&;;>91?.#$% ^>&5*'78&;;>91?.#$%. U/

2C

DC

.QU_

2CDC 2CDD 2CD3 2CDF

eC"AC

eD"AD

eC"AC

eC"AC

eD"ADeD"CC

eC"AC

eD"2D

eC"ACeC"EA

eD"CC

eC"AC

eC"CC

eC"AC

eD"CC

eD"AC

e2"CC

e2"AC

eE"CC

U/.#S%_ ^#.#$%.#S%_ /918

!!!"#$%!&'()"*+,-..................../&01.EA.

!"#$%&'FA*'+%"

!!!"#$%!&'()"*+,-..................../&01.EF.

!"#$%&'FD*'M&;"/-'9%"+?;H. :-91. ')&+. LCB. -,. 65*(.N1&5').

O&(*5*'7

#55./>65*( /9*4&'1.O-98

/9-,*'.O&(*5*'7

P10*;'191?.

/)&9:&(7

Q+910*;'191?.

/)&9:&(7

R1+19&5.

P1'&*519

#55./9*4&'1

/1

9(1

+'&

01

.-,.

->

'51

';

2CDC 2CDD 2CD3 2CDF

!!!"#$%!&'()"*+,-..................../&01.E@.

!"#$%&'H>*'+&%,&-./#&'01'9%0'51'.'7

!!!"#$%!&'()"*+,-..................../&01.EK.

!"#$%&'HF*'+&%,&-./#&'01'9%065*(.N1&5').

O&(*5*'7

#55./>65*( /9*4&'1.O-98/9-,*'.

O&(*5*'7

P10*;'191?.

/)&9:&(7

Q+910*;'191?.

/)&9:&(7

R1+19&5.P1'&*519 #55./9*4&'1

/1

9(1

+'&

01

.-,.

->

'51

';

S+?1:*( N*0)5&+? T-!.P*;= U1&;-+&5.T-!

www.ACTwatch.info....................Page.39

Results'Section'A:'Core'Indicators''

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

'Public.Health.Facility.

Community.Health.Worker.

[email protected]@Profit.Facility'

ALL'Public'/'NotB'ForBProfit'

[email protected].


Unregistered.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=796. N=1,815. N=39. N=2,650. N=360. N= 145. N=493. N=14,204. N=15,202. N=17,852.Any.antimalarial.at.the.time.of.survey.visit.

91.8. 2.4. 83.7. 11.3. 76.4. 93.3. 87.2. 2.4. 7.1. 7.7.(89.2,.93.8). (0.9,.6.3). (66.0,.93.2). (8.8,.14.5). (70.4,.81.4). (87.8,.96.5). (82.8,.90.6). (1.7,.3.5). (6.4,.7.9). (7.0,.8.5).

Any'ACT'88.1. 2.4. 79.9. 11.0. 65.3. 88.5. 73.8. 0.3. 4.5. 5.4.

(84.4,.91.1). (0.9,.6.3). (60.9,.91.1). (8.5,.14.1). (59.8,.70.3). (81.7,.93.0). (67.9,.79.0). (0.2,.0.6). (3.8,.5.2). (4.7,.6.1).Artemether.Lumefantrine.(AL)!.

88.1. 2.4. 79.9. 11.0. 63.0. 86.8. 71.2. 0.3. 4.3. 5.3.(84.4,.91.1). (0.9,.6.3). (60.9,.91.1). (8.5,.14.1). (57.4,.68.4). (80.1,.91.5). (65.5,.76.3). (0.2,.0.5). (3.7,.5.1). (4.6,.6.0).

Dihydroartemisinin.Piperaquine.(DHA.PPQ).

0.7. 0.0. 11.7. 0.3. 21.9. 56.9. 24.4. 0.0. 1.6. 1.5.(0.3,.2.1). @. (5.6,.22.8). (0.1,.0.5). (16.7,.28.2). (45.0,.68.0). (18.6,.31.3). (0.0,.0.1). (1.3,.2.1). (1.1,.1.9).

[email protected].........(QA.ACT).

87.1. 2.4. 71.9. 10.7. 45.3. 68.3. 56.1. 0.2. 3.3. 4.4.(83.0,.90.4). (0.9,.6.3). (53.7,.84.9). (8.3,.13.8). (38.7,.52.1). (60.8,.75.1). (50.5,.61.4). (0.1,.0.5). (2.8,.4.0). (3.8,.5.0).

QA.ACT.with.the.“green.leaf”.logo'

3.3. 0.1. 21.7. 0.7. 38.2. 61.8. 48.8. 0.1. 2.8. 2.5.(1.6,.6.9). (0.0,.0.4). (7.8,.47.6). (0.4,.1.5). (31.8,.45.1). (55.2,.68.1). (42.9,.54.8). (0.1,.0.3). (2.3,.3.4). (2.1,.3.1).

QA.ACT.without.the.“green.leaf”.logo.

86.3. 2.3. 59.2. 10.4. 10.4. 13.3. 9.5. 0.1. 0.7. 2.0.(82.2,.89.6). (0.8,.6.3). (36.7,.78.4). (7.9,.13.5). (7.3,.14.5). (6.6,.24.9). (6.6,.13.3). (0.0,.0.3). (0.5,.0.9). (1.7,.2.5).

QA.AL.!.87.1. 2.4. 71.9. 10.7. 45.1. 67.7. 55.4. 0.2. 3.3. 4.3.

(83.0,.90.4). (0.9,.6.3). (53.7,.84.9). (8.3,.13.8). (38.5,.51.8). (59.4,.74.9). (49.8,.60.8). (0.1,.0.5). (2.7,.4.0). (3.8,.5.0)[email protected]......([email protected])'

12.3. 0.1. 28.0. 1.6. 39.9. 71.7. 42.2. 0.1. 2.7. 2.5.(7.9,.18.7). (0.0,.0.3). (16.0,.44.4). (1.1,.2.3). (33.5,.46.7). (63.3,.78.8). (35.8,.48.9). (0.0,.0.2). (2.3,.3.2). (2.1,.3.0).

Any'nonBartemisinin'therapy.30.2. 0.0. 40.1. 3.2. 38.4. 53.3. 59.9. 2.2. 5.0. 4.7.

(25.1,.35.9). @. (21.6,.61.9). (2.4,.4.3). (31.5,.45.8). (42.9,.63.5). (53.2,.66.2). (1.5,.3.2). (4.3,.5.8). (4.1,.5.5).

Sulfadoxine.Pyrimethamine.17.6. 0.0. 10.5. 1.7. 19.6. 46.6. 48.1. 2.1. 4.1. 3.8.

(13.7,.22.3). @. (3.9,.25.0). (1.2,.2.4). (14.6,.25.7). (36.6,.56.9). (41.3,.55.0). (1.4,.3.1). (3.4,.4.9). (3.2,.4.5).

Oral.Quinine.5.1. 0.0. 5.3. 0.5. 8.6. 12.6. 22.1. 0.0. 0.9. 0.9.

(3.4,.7.7). @. (1.5,.16.6). (0.3,.0.8). (5.6,.12.9). (7.6,.20.0). (16.9,.28.3). (0.0,.0.1). (0.7,.1.2). (0.7,.1.1)[email protected].^.

0.0. 0.0. 0.0. 0.0. 2.9. 8.4. 4.7. 0.1. 0.3. 0.3.@. @. @. @. (1.3,.6.3). (3.9,.17.0). (2.8,.7.6). (0.0,.0.2). (0.2,.0.5). (0.2,.0.4).

Oral'artemisinin'monotherapy'

0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0.@. @. @. @. @. @. @. @. @. @.

NonBoral'artemisinin'monotherapy'

47.2. 0.0. 59.6. 5.0. 30.4. 15.1. 7.6. 0.0. 1.0. 1.5.(40.8,.53.7). @. (43.4,.73.9). (3.9,.6.4). (24.3,.37.2). (9.4,.23.5). (5.2,.10.9). @. (0.8,.1.3). (1.3,.1.8).


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





[email protected].



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=796. N=1,815. N=39. N=2,650. N=360. N= 145. N=493. N=14,204. N=15,202. N=17,852.Any'treatment'for'severe'malaria'

51.2. 0.0. 65.2. 5.4. 41.4. 20.0. 13.8. 0.0. 1.4. 2.0.(45.0,.57.3). @. (49.7,.78.1). (4.3,.6.9). (34.3,.48.9). (12.2,.30.8). (10.3,.18.2). @. (1.1,.1.8). (1.7,.2.3).

Artesunate.IV/IM.#.46.0. 0.0. 43.6. 4.6. 7.7. 1.6. 1.0. 0.0. 0.2. 0.8.

(39.7,.52.4). @. (25.5,.63.7). (3.6,.5.9). (4.5,.13.0). (0.5,.5.2). (0.5,.2.2). @. (0.1,.0.3). (0.7,.1.0).

Artemether.IV/IM.1.9. 0.0. 21.7. 0.5. 26.0. 12.8. 6.4. 0.0. 0.8. 0.8.

(0.7,.4.9). @. (11.4,.37.5). (0.3,.1.0). (20.4,.32.6). (7.6,.20.8). (4.2,.9.7). @. (0.6,.1.1). (0.6,.1.0).

Quinine.IV/IM.14.8. 0.0. 37.6. 1.9. 21.3. 9.1. 9.2. 0.0. 0.8. 0.9.

(11.0,.19.6). @. (20.0,.59.4). (1.3,.2.7). (16.4,.27.2). (4.2,.18.4). (6.5,.12.7). @. (0.6,.1.0). (0.8,.1.2).

*. The.denominator.includes.56.outlets.that.met.screening.criteria.for.a.full.interview.but.did.not.complete.the.interview.(were.not.interviewed.or.completed.a.partial.interview)....!. At.the.time.of.the.2016.Kenya.ACTwatch.outlet.survey,.artemether.lumefantrine.was.the.first@line.treatment.for.uncomplicated!malaria..^[email protected],.atovaquone@proguanil,.chloroquine,.and.mefloquine..#....At.the.time.of.the.2016.Kenya.ACTwatch.outlet.survey,.artesunate.IV/[email protected]..

Source:.ACTwatch.Outlet.Survey,.Kenya,.2016..


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





[email protected].



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=734. N=65. N=32. N=831. N=280. N=134. N=428. N=244. N=1,086. N=1,917.

Any'ACT'96.0. 100.0. 95.4. 96.7. 85.5. 94.8. 84.7. 12.6. 62.8. 69.7.

(92.1,.98.0). @. (81.1,.99.0). (93.7,.98.3). (80.2,.89.5). (90.4,.97.3). (79.7,.88.7). (6.8,.22.3). (53.5,.71.3). (61.8,.76.6).Artemether.Lumefantrine.(AL).!'

96.0. 100.0. 95.4. 96.7. 82.6. 93.0. 81.7. 12.4. 60.9. 68.1.(92.1,.98.0). @. (81.1,.99.0). (93.7,.98.3). (77.0,.87.0). (88.4,.95.9). (76.8,.85.7). (6.6,.22.1). (51.9,.69.1). (60.5,.74.9).

Dihydroartemisinin.Piperaquine.(DHA.PPQ).

0.8. 0.0. 14.0. 2.3. 28.7. 60.9. 28.0. 0.7. 23.0. 18.8.(0.3,.2.2). @. (6.7,.27.0). (1.2,.4.6). (22.1,.36.3). (48.2,.72.3). (21.3,.35.8). (0.2,.2.2). (18.0,.29.0). (14.6,.24.0).

[email protected].........(QA.ACT).

94.9. 100.0. 85.8. 94.7. 59.3. 73.2. 64.3. 9.9. 46.7. 56.4.(91.0,.97.2). @. (70.7,.93.8). (91.3,.96.8). (51.2,.67.0). (65.6,.79.7). (58.6,.69.7). (5.1,.18.4). (39.4,.54.1). (50.1,.62.6).

QA.ACT.with.the.“green.leaf”.logo.

3.6. 3.8. 25.9. 6.5. 50.1. 66.3. 56.0. 6.0. 39.7. 33.0.(1.7,.7.5). (0.7,.19.1). (9.5,.53.7). (3.3,.12.5). (42.4,.57.7). (60.1,.71.9). (49.4,.62.4). (3.0,.11.8). (33.3,.46.6). (27.2,.39.3).

QA.ACT.without.the.“green.leaf”.logo'

94.0. 97.7. 70.7. 91.7. 13.6. 14.3. 10.8. 4.3. 9.7. 26.4.(90.2,.96.4). (81.9,.99.7). (41.7,.89.0). (85.7,.95.3). (9.5,.19.0). (7.1,.26.7). (7.7,.15.1). (1.6,.10.8). (7.7,.12.3). (22.2,.31.0).

QA.AL.!'94.9. 100.0. 85.8. 94.7. 59.0. 72.5. 63.5. 9.9. 46.3. 56.1.

(91.0,.97.2). @. (70.7,.93.8). (91.3,.96.8). (50.9,.66.6). (64.5,.79.3). (57.8,.68.9). (5.1,.18.4). (39.0,.53.7). (49.8,.62.2)[email protected]......([email protected])'

13.4. 2.5. 33.5. 13.9. 52.3. 76.8. 48.5. 3.0. 37.9. 33.0.(8.5,.20.4). (1.2,.5.1). (19.3,.51.5). (9.6,.19.7). (44.6,.59.9). (68.7,.83.3). (41.4,.55.6). (1.3,.6.8). (31.5,.44.7). (27.5,.39.1).

Any'nonBartemisinin'therapy.32.9. 0.0. 47.8. 28.6. 50.3. 57.2. 68.7. 88.5. 69.6. 61.3.

(27.4,.38.9). @. (24.3,.72.4). (21.6,.36.7). (42.8,.57.8). (45.1,.68.4). (60.6,.75.8). (78.9,.94.1). (63.2,.75.4). (55.6,.66.7).

Sulfadoxine.Pyrimethamine.19.1. 0.0. 12.5. 14.7. 25.6. 49.9. 55.2. 85.2. 57.6. 48.9.

(15.0,.24.1). @. (4.6,.29.6). (10.5,.20.1). (19.5,.32.9). (38.9,.61.0). (47.1,.63.0). (75.1,.91.6). (50.8,.64.0). (43.1,.54.7).

Oral.Quinine.5.6. 0.0. 6.3. 4.6. 11.3. 13.4. 25.3. 0.8. 13.0. 11.3.

(3.7,.8.3). @. (1.8,.19.9). (3.0,.7.1). (7.5,.16.5). (8.0,.21.8). (19.4,.32.4). (0.3,.2.3). (10.2,.16.4). (9.0,.13.9)[email protected].^.

0.0. 0.0. 0.0. 0.0. 3.8. 9.0. 5.3. 3.4. 4.8. 3.8.@. @. @. @. (1.7,.8.1). (4.2,.18.2). (3.2,.8.7). (1.5,.7.5). (3.2,.7.0). (2.5,.5.6).

Oral'artemisinin'monotherapy.

0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0. 0.0.@. @. @. @. @. @. @. @. @. @.

NonBoral'artemisinin'monotherapy.

51.4. 0.0. 71.1. 44.2. 39.7. 16.2. 8.7. 0.0. 13.7. 19.9.(44.8,.58.0). @. (52.7,.84.5). (34.4,.54.4). (32.5,.47.4). (9.9,.25.5). (5.9,.12.6). @. (10.8,.17.3). (16.9,.23.3).

Any'treatment'for'severe'malaria.

55.8. 0.0. 77.9. 48.0. 54.2. 21.4. 15.8. 0.1. 20.1. 25.7.(49.5,.61.9). @. (61.0,.88.8). (37.5,.58.7). (46.4,.61.9). (12.8,.33.5). (11.9,.20.9). (0.0,.1.0). (16.1,.24.7). (22.1,.29.8).

Artesunate.IV/IM.#.50.1. 0.0. 52.1. 40.8. 10.1. 1.7. 1.2. 0.0. 2.9. 10.6.

(43.6,.56.5). @. (30.4,.73.1). (31.7,.50.6). (5.9,.16.8). (0.5,.5.6). (0.5,.2.6). @. (1.7,.4.7). (8.6,.13.0).Artemether.IV/IM' 2.1. 0.0. 25.9. 4.7. 34.1. 13.8. 7.4. 0.0. 11.7. 10.3.


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





[email protected].



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=734. N=65. N=32. N=831. N=280. N=134. N=428. N=244. N=1,086. N=1,917.

(0.8,.5.3). @. (13.6,.43.8). (2.5,.8.8). (27.4,.41.5). (8.1,.22.5). (4.9,.11.0). @. (9.1,.15.0). (7.9,.13.3).

Quinine.IV/IM'16.1. 0.0. 44.9. 16.7. 27.9. 9.7. 10.5. 0.1. 11.0. 12.2.

(12.0,.21.3). @. (22.6,.69.5). (11.8,.23.1). (21.7,.35.0). (4.5,.19.8). (7.5,.14.6). (0.0,.1.0). (8.5,.14.1). (9.9,.14.8).

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

!. At.the.time.of.the.2016.Kenya.ACTwatch.outlet.survey,.artemether.lumefantrine.was.the.first@line.treatment.for.uncomplicated.malaria..^[email protected],.atovaquone@proguanil,.chloroquine,.and.mefloquine..#....At.the.time.of.the.2016.Kenya.ACTwatch.outlet.survey,.artesunate.IV/[email protected]..



Table'A3:'Types'of'qualityBassured'and'nonBquality'assured'ACTs'audited'in'the'public'and'private'sectors'

ACT'generic'name'and'formulation''QualityBassured'ACT' NonBquality'assured'ACT'

Public.sector. Private.sector. Public.Sector. Private.Sector.

. %.(95%.CI). %.(95%.CI). %.(95%.CI). %.(95%.CI).

Proportion'of'all'audited'antimalarials:' N.audited=2514. N.audited=761. N.audited=130. N.audited=1125.

'Tablet'formulation:'

. . . .

Artemether.lumefantrine.99.8. 98.1. 75.0. 32.9.

(98.9,.100.0). (96.1,.99.0). (57.7,.86.9). (28.0,.38.1).

Artesunate.mefloquine.0.0. 0.0. 0.0. 0.7.@. @. @. (0.3,.1.7).

Artesunate.amodiaquine.0.2. 1.9. 0.0. 0.2.

(0.0,.1.1). (1.0,.3.9). @. (0.,.0.8).

Artesunate.SP.0.0. 0.0. 0.0. 1.2.@. @. @. (0.6,.2.4).

Dihydroartemisinin.piperaquine. 0.0. 0.0. 17.1. 34.2.@. @. (9.6,.28.7). (30.8,.37.7).

Artemisinin.piperaquine.0.0. 0.0. 0.0. 8.1.@. @. @. (6.1,.10.5).

Artemisinin.napthoquine.0.0. 0.0. 0.0. 1.9.@. @. @. (1.1,.3.4).

Aretrolane.Piperaquine. 0.0. 0.0. 0.0. 0.3.@. @. @. (0.1,.0.8).'NonBtablet'formulation*:'

. . . .

Artemether.lumefantrine.0.0. 0.0. 5.8. 11.4.@. @. (2.3,.13.6). (8.8,.14.7).

Dihydroartemisinin.piperaquine.0.0. 0.0. 2.1. 9.2.@. @. (0.5,.9.2). (7.2,.11.6).

*[email protected]..



Table'A4:'Antimalarial'market'composition'.'

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





[email protected].



General.Retailer.

ALL'Private.

ALL'Outlets'

%' %. %' %. %. %. %. %. %. %'

N= 1,362.outlets. 15.3. 3.8. 2.5. 21.6. 17.7. 8.7. 26.8. 25.2. 78.4. 78.4.(12.7,.18.2). (1.4,.9.8). (1.5,.4.4). (17.4,.26.5). (14.7,.21.1). (5.7,.13.1). (22.1,.32.1). (18.1,.33.9). (73.5,.82.6). (73.5,.82.6).

*. 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'A5a:'Price'of'tablet'formulation'antimalarials,'by'outlet'type'

'Private.

[email protected].

Registered.Pharmacy. Unregistered.Pharmacy. General.Retailer. ALL'Private.

Median'price'of'a'tablet'AETD*:'Median.[IQR].(N.of.Antimalarials).

Median.[IQR].(N.of.Antimalarials).




Any'ACT'$1.51. $3.01. $1.51. $1.00. $1.51.

[[email protected]].(401). [[email protected]].(399). [[email protected]].(748). [[email protected]].(38). [[email protected]].(1,586).

Artemether.lumefantrine.(AL) !' $1.51. $1.51. $1.21. $1.00. $1.51.[[email protected]].(305). [[email protected]].(213). [[email protected]].(513). [[email protected]].(35). [[email protected]].(1,066).

DHA.PPQ..$3.52. $3.92. $3.52. $5.02. $3.82.

[[email protected]].(72). [[email protected]].(120). [[email protected]].(172). [[email protected]].(3). [[email protected]].(367).

[email protected].(QA.ACT). $1.51. $1.51. $1.21. $1.00. $1.31.


QA.ACT.with.the.“green.leaf”.logo.$1.51. $1.51. $1.21. $1.21. $1.31.


QA.ACT.without.the.“green.leaf”.logo. $1.51. $1.51. $1.00. $1.00. $1.21.


QA.AL!.$1.51. $1.51. $1.21. $1.00. $1.31.


[email protected].([email protected]). $2.81. $3.82. $3.52. $1.51. $3.52.


....SP.$0.50. $0.50. $0.50. $0.35. $0.45.


....Quinine. $3.28. $4.22. $4.22. @. $4.22.

[[email protected]].(15). [[email protected]].(6). [[email protected]].(14). @. [[email protected]].(35).

*. [email protected][email protected]@kg.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.2016.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:.55.any.ACT.tablets,.39.AL.tablets,.11.DHAPPQ.tablets,.20.QA.ACT.tablets,.14.QA.ACT.with.the.'green.leaf'.logo.tablets,.6.QA.ACT.without.the.'green.leaf'.logo.tablets,.20.QA.AL.tablets,[email protected],.8.SP.tablets,.2.Quinine.tablets..

Source:.ACTwatch.Outlet.Survey,.Kenya,.2016...!

! !


!!

Table'A5b:'Price'of'preBpackaged'antimalarials,'by'outlet'type

'Private.

[email protected].

Registered.Pharmacy. Unregistered.Pharmacy. General.Retailer. ALL'Private.

Median'price'of'one'preBpackaged'therapy:'






.Adult.QA.AL.'$1.51. $1.51. $1.21. $1.00. $1.21.


Pediatric.QA.AL.*.$0.50. $1.00. $0.50. $0.50. $0.50.


*. [email protected]@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:.

15.adult.AL,.2.child.AL..

Source:.ACTwatch.Outlet.Survey,.Kenya,.2016...


Table'A6:'Availability'of'malaria'blood'testing'among'antimalarialBstocking'outlets*,'by'outlet'type



[email protected]@Profit.Facility.


[email protected].



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= 766. N= 187 N= 33 N= 986 N= 304 N= 136 N= 465 N= 310 N= 1,215 N= 2,201

Any.malaria.blood.testing.

88.6. 35.4. 83.6. 64.3. 66.9. 22.4. 12.1. 0.2. 20.8. 31.9.

(84.9,.91.6). (19.6,.55.3). (65.3,.93.2). (50.1,.76.4). (59.2,.73.8). (16.4,.29.8). (9.1,.16.0). (0.0,.1.4). (16.5,.25.8). (28.0,.36.0).. N= 766 N= 187 N= 33 N= 986 N= 304 N= 136 N= 465 N= 310 N= 1,215 N= 2,201 Microscopic.blood.tests.

45.5. 0.6. 71.3. 27.5. 48.5. 9.0. 3.3. 0.0. 12.5. 16.3.

(41.3,.49.9). (0.1,.4.9). (50.8,.85.7). (19.5,.37.2). (39.4,.57.7). (5.0,.15.5). (2.0,.5.3). @. (9.1,.16.8). (13.4,.19.7).. N= 766 N= 187 N=32 N= 985 N= 304 N= 136 N= 465 N= 310 N= 1,215 N= 2,200 Rapid.diagnostic.tests.(RDTs).

71.7. 35.4. 48.3. 53.4. 36.3. 16.3. 9.6. 0.2. 12.7. 23.0.

(64.6,.77.8). (19.6,.55.3). (26.9,.70.3). (41.2,.65.2). (30.4,.42.6). (11.2,.22.9). (7.0,.13.0). (0.0,.1.4). (10.0,.15.9). (19.7,.26.7).

[email protected].!.

14.2. 20.4. 10.0. 16.7. 24.2. 9.6. 5.4. 0.2. 8.0. 10.2.

(9.5,.20.6). (6.8,.47.5). (3.3,.26.6). (8.9,.29.2). (19.5,.29.7). (5.2,.17.3). (3.1,.9.1). (0.0,.1.4). (5.8,.11.1). (7.4,.13.9).

*. 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..Nine.antimalarial@stocking.outlets.were.missing.information.about.both.

availability.of.microscopy.and.availability.of.RDTs..Ten.antimalarial@stocking.outlets.had.partial.information.about.blood.testing.availability.and.are.included.in.the.denominator.of.the.indicator.“any.blood.testing.available.”.

!.The.denominator.includes.13.verifiable.RDTs.for.which.the.QA.status.could.not.be.determined.due.to.incomplete.product.information..


.

.

.

.

.

.

.

.

.

.


Table'A7:'Malaria'blood'testing'market'composition'..

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





2345-6(7!869%1!:&)&+&'(&!;*(9

Documents