Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya

Abstract

BackgroundMore than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy.Methods and findingsWe conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys—at baseline, 6 months, 12 months, and 18 months—of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2–15 pp; p = 0.015; adjusted risk ratio [RR] ...

Can individuals’ beliefs help us understand nonadherence to malaria test results? Evidence from rural Kenya

“…Of those who tested positive, 75% reported taking an ACT compared to 19% of those who tested negative and 26% of those who were not tested. The number of inappropriate users, that is, individuals who buy ACT when tested negative, is less than what other studies report (Cohen et al, 2015; Prudhomme O’Meara et al, 2018). Still, about one in five patients did not adhere to negative test results and purchased ACT when it was not necessary.…”

“…In our setting, rural western Kenya, malaria testing is relatively uncommon, with 43% of individuals reporting being tested for malaria for their recent febrile illness. More than 70% of individuals with a recent fever reported taking ACTs, nearly two‐thirds of which were sourced from the retail sector: 84% of those tested positive reported taking ACTs; 60% of those untested and 34% of those tested negative also took ACTs (Prudhomme O’Meara et al, 2018).…”

Incentivizing appropriate malaria case management in the private sector: a study protocol for two linked cluster randomized controlled trials to evaluate provider- and client-focused interventions in western Kenya and Lagos, Nigeria

“…In Kenya, the private sector, where 60% of fever cases seek care, is an important source for malaria treatments [ 8 ]. Although private retail outlets and chemists are not routinely permitted to conduct mRDTs in Kenya, nationwide surveys show that nearly 71% of ACTs are distributed through the private sector [ 11 ].…”

“…To truly transform global malaria case management, new solution-focusing interventions targeting the private sector are required to drive testing uptake, encourage the use of ACTs for positive cases, improve routine data reporting, and better leverage donor resources. Our previous work demonstrated a substantial reduction in the misuse of antimalarials through a successful collaboration between community health workers (CHWs) who offered free community-based diagnostic testing and retail outlets that provided subsidized ACTs to customers with a positive test at the CHW [ 8 ].…”

Incentivizing appropriate malaria case management in the private sector: a study protocol for two linked cluster randomized controlled trials to evaluate provider- and client-focused interventions in western Kenya and Lagos, Nigeria

“…In Kenya, the private sector, where 60% of fever cases seek care, is an important source for malaria treatments [11]. Although private retail outlets and chemists are not routinely permitted to conduct mRDTs in Kenya, nationwide surveys show that nearly 71% of ACTs are distributed through the private sector [12].…”