Written by Deborah Ayando and Tolulope Oginni
Malaria is a catastrophic disease that mostly occurs in tropical and subtropical environments around the globe. It is the leading killer of children in underdeveloped countries and is often responsible for the high mortality rates of children under the age of five. Children under five are more susceptible to malaria infection and death in high transmission areas with more than 70% of all malaria deaths attributed to this group. Favourable climatic conditions support the rapid transmission of malaria to places where people have no or low immunity to the disease, high malaria transmission could also be attributed to the movement of people with low or no immunity to an endemic area.
In 2020, four African countries accounted for just over half of all malaria deaths worldwide: Nigeria (31.9%), the Democratic Republic of the Congo (13.2%), the United Republic of Tanzania (4.1%), and Mozambique (3.8%). Sub-Saharan Africa continues to carry the heaviest malaria burden, accounting for about 95% of all malaria cases and 96% of all deaths in 2020. Malaria is endemic in Nigeria, an estimated 76 per cent of Nigeria’s population is at risk of malaria by living in high transmission areas.
Once the diagnosis of malaria has been made, appropriate antimalarial treatment must be initiated immediately. However, only 25% of women aged 15-49 who have had malaria think it is treatable and think Artemisinin Combination Therapies (ACT) are a good option, less than 20% think paracetamol, and quinine are good treatment options and some use traditional medicine which is less likely to be effective.
In the quest to understand why the take-up of high-quality antimalarial, especially ACTs is low in Nigeria, EHA Clinics in collaboration with two PhD students at the University of Michigan in the United States conducted a pilot study on “Information frictions, demand for quality, and welfare in the market for antimalarial”. The focus of the study is on the price difference between higher and lower quality medicine, and whether people think vendors around them sell proper medicine.
The first stage of the study involved qualitative interviews with doctors, individuals, and pharmacists in the Kano metropolis, carried out by 4 trained field officers. A semi-structured interviewer-administered questionnaire was used to assess their knowledge of the availability of substandard antimalarials in the market and price as a limiting factor to purchasing antimalarials. They projected that 40-60% of antimalarials sold in the market are likely to be substandard.
Afterwards, a vendor census was conducted in sixteen residential areas where pharmacies, chemist shops, and traditional remedy homes were cited. Questionnaires were administered to the vendor owners and/or managers on the quality of antimalarial available and their perception of substandard ones. To further improve the understanding of antimalarial choices and quality uncertainty, 20 field enumerators were trained. The training was sectioned into two parts; 4 of the field officers were trained for 2 days on “mystery shopping” and antimalarial drug testing while the other part included 16 of them trained on household survey.
Mystery shopping was carried out for two days in identified sixteen markets (residential areas) where vendor census was initially carried out. The idea was to randomly buy ACTs and get them tested using the RxAll device, a scanning device designed to identify a drug sample and its quality level returning results to a mobile app in 20 seconds.
The baseline household survey was done for 8 days using a semi-structured interviewer-administered questionnaire. The survey was carried out specifically on individuals who make health care decisions in 24 houses that were systematically selected from each market. An end-line interview in the same households recruited during baseline followed immediately, this is to compare responses and ascertain quality data collection. This activity went hand in hand with the drug testing at the sixteen locations.
Out of the 50 ACTs purchased during the mystery shopping, only 1 was found to contain in its tablet a substandard pill as indicated unmatched on the testing device.
WHO. World malaria report 2018. Geneva: World Health Organisation, 2018.
WHO. Malaria key facts. World Health Organisation, 2018.
Nigeria Malaria Indicator Survey (MIS) 2015 [MIS20].