Willingness to pay for antiretroviral therapy, viral load, and premium services; A contingent valuation survey of people living with HIV in southern Nigeria.

BACKGROUND: With stagnating funding for HIV and AIDS control programs in Nigeria, alternative funding models for antiretroviral therapy (ART) including out of pocket payment are being considered to sustain momentum epidemic control targets. We assessed willingness to pay for ART related services, and factors associated with willingness to pay. METHODS: Between July and August 2019, we conducted a survey among people living with HIV (PLHIV) on ART in 3 states in southern Nigeria. Randomly sampled respondents on ART for at least 6 months, aged ≥ 18 years, able to communicate in English or pidgin English, and consenting to the survey were enrolled. Respondents were asked if they were willing to pay for clinical consultation, antiretroviral drugs (ARVs), viral load testing services and premium ART services (including fast track services). Respondents indicating willingness to pay for any of these services were asked the maximum amount they were willing to pay using contingent valuation methodology. We assessed the weighted proportions of PLHIV on ART willing to pay for ART and used survey-featured logistic regression measures to assess sociodemographic and ART related factors associated with willingness to pay for ART services. RESULTS: Overall, 1,598 PLHIV with a mean age of 39.03 years (standard deviation [SD]: 11.23 years), were included in this analysis. Of these, 65.8% (1,079), 73.9% (1,192), 61.0% (995) and 33.6% (472) were willing to pay for ART consultation, ARVs, viral load testing services and premium ART services respectively. The median maximum amount PLHIV were willing to pay for clinical consultation and for ARVs was NGN1,000 (USD equivalent of $2.78; interquartile range [IQR]: 500-2,000) respectively, and NGN2,500 (USD equivalent of $6.94; IQR: NGN1,000-5,000) and NGN2,000 (USD equivalent of $5.56; IQR: NGN1,000-3,000) for viral load testing and premium ART services respectively. Receiving ART in Lagos state, being employed and having a monthly income of NGN100,000 or more was associated with willingness to pay for the various ART services. CONCLUSION: We found generally high-level of willingness to pay for ART consultation, ARVs and viral load testing services but low willingness to pay for premium ART services among PLHIV on ART. The maximum amount PLHIV were willing to pay for various ART services fell short of benchmarks for alternative funding but can potentially supplement ART by funding differentiated service delivery models that require nominal amounts to facilitate person-centered differentiated service delivery models.

The potential role of patent and proprietary medicine vendors' associations in improving the quality of services in Nigeria's drug shops.

BACKGROUND: Patent and Proprietary Medicine Vendors (PPMVs) play a major role in Nigeria's health care delivery but regulation and monitoring of their practice needs appreciable improvement to ensure they deliver quality services. Most PPMVs belong to associations which may be useful in improving their regulation. However, little is known about how the PPMV associations function and how they can partner with relevant regulatory agencies to ensure members' compliance and observance of good practice. This study sought to describe the PPMV associations' structure and operations and the regulatory environment in which PPMVs function. With this information we explore ways in which the associations could help improve the coverage of Nigeria's population with basic quality health care services. METHODS: A mixed methods study was conducted across four rural local government areas (LGAs) (districts) in two Nigerian states of Bayelsa and Oyo. The study comprises a quantitative data collection of 160 randomly selected PPMVs and their shops, eight PPMV focus group discussions, in-depth interviews with 26 PPMV association executives and eight regulatory agency representatives overseeing PPMVs' practice. RESULTS: The majority of the PPMVs in the four LGAs belonged to the local chapters of National Association of Patent and Proprietary Medicine Dealers (NAPPMED). The associations were led by executive members and had regular monthly meetings. NAPPMED monitored members' activities, provided professional and social support, and offered protection from regulatory agencies. More than 80% of PPMVs received at least one monitoring visit in the previous 6 months and local NAPPMED was the organization that monitored PPMVs the most, having visited 68.8% of respondents. The three major regulators, who reached 30.0-36.3% of PPMVs reported lack of human and financial resources as the main challenge they faced in regulation. CONCLUSIONS: Quality services at drug shops would benefit from stronger monitoring and regulation. The PPMV associations already play a role in monitoring their members. Regulatory agencies and other organizations could partner with the PPMV associations to strengthen the regulatory environment and expand access to basic quality health services at PPMV shops in Nigeria.

Malaria testing and treatment knowledge among selected rural patent and proprietary medicine vendors (PPMV) in Nigeria.

BACKGROUND: Malaria is a leading cause of illness and death in Nigeria, but access of poor people to quality anti-malarial services remains low especially in the rural areas. Patent and proprietary medicine vendors (PPMVs) provide the majority of malaria treatment in rural areas, but little is known about their knowledge of malaria testing and treatment of uncomplicated malaria as recommended in the 2011 National Malaria Control Programme policy. METHODS: A cross-sectional survey was conducted in two purposively selected states (Oyo and Bayelsa) in Nigeria with each state representing a different geographic and linguistic-ethnic region in the southern part of the country. Two rural LGAs were randomly selected from each state and data were collected from 160 randomly selected PPMVS (40 per LGA) using a structured questionnaire. Data were analysed using descriptive statistics. RESULTS: The 2011 National Policy on Malaria Diagnosis and Treatment is mostly unknown to PPMVs. Although most PPMVs (89%) knew that artemisinin-based combination therapy (ACT) is recommended in the national policy, 91% also thought non-ACT were endorsed. The proportion of PPMVs who stated they would treat a malaria case with an artemisinin-based combination at the correct dose was 33% for a child under five, 47% for an adult male and 14% for a pregnant woman in her second trimester. The proportion of PPMVs who reported they would diagnose a case of malaria prior to treatment using a malaria rapid diagnostic test (RDT) kit was 1.9% for children under five, 7.5% for adult males and 3.1% for pregnant women in their first trimester due to lack of knowledge. Almost two-thirds (65.6%) would correctly refer children with severe malaria to health facility. CONCLUSIONS: Substantial knowledge gaps on the use of RDTs and treatment with artemisinin-based combinations exist among rural PPMVs. Given existing evidence regarding the effectiveness of private retail outlets in malaria case management, PPMVs should be provided with competency-based training and supervision to improve the quality of care they provide.