Malaria treatment and policy in three regions in Nigeria: The role of patent medicine vendors.
Malaria is a major cause of illness and death in Nigeria, and a significant drain on its economy and the poor. Yet most Nigerians do not obtain appropriate treatment for malaria, and depend on informal private providers for anti-malarial drugs (AMDs), largely through patent medicine vendors (PMVs). This study seeks to better understand the role played by PMVs in the provision of AMDs in Nigeria, and to explore ways to improve the regulation and delivery of AMDs. This scoping study involves cross-sectional surveys of 110 PMVs and 113 households using a multi-stage random selection of respondents from 6 urban and 6 rural local government areas in three states (Oyo, Kaduna, and Enugu States), each representing a different geographic and linguistic-ethnic region of the country. These were supplemented by key informant interviews with 54 community leaders, 55 PMV Association officers, 31 government and health officials, and observations of 106 drug shop inventories from the same communities. In addition to describing characteristics about PMVs and PMV associations, this study focused on the role they play in malaria treatment. Although PMV demographic characteristics, knowledge, attitudes, and sources of drugs varied considerably across study sites, in each of the states examined, PMVs were the major source of malaria treatment (39% overall), followed by self-treatment (25%), which in many cases also utilize the PMVs. Less than one quarter of all PMVs interviewed knew about the change in recommended malaria treatment from chloroquine and to ACTs. PMVs still recommended and provided drugs whose efficacy is highly questionable: 92% of shops had sulfadoxine-pyrimethamine in stock, 72% had chloroquine (both not recommended), whereas only 9% had ACTs. More shops (32%) had monotherapy artesunates than ACTs, even though monotherapy is not recommended due to the risk of promoting drug resistance to artemisinins. Another common finding among all types of informants was the high level of concern about the quality of the drugs. Although more government regulation was suggested by all parties, PMV Associations were also identified as potentially playing important roles in providing information, influencing PMV behaviour, and procuring drugs. Community involvement in drug regulation was also viewed as highly desirable by PMVs (92%). Further research topics are discussed in the paper, along with areas where action is needed to address the problems of inappropriate treatment and poor quality drugs. Interventions need to reduce the opportunities for PMVs to knowingly supply sub-standard drugs, which is likely to involve a combination of more effective government regulation and self-regulation by PMV associations. An active role for communities and introduction of new technologies to facilitate monitoring and communications are also worth investigating.
Working Paper 1, Nigeria Series, 29 pp.