Abstract:
Objectives:
There is an urgent need to understand
how to improve targeting of artemisinin combination
therapy (ACT) to patients with confirmed malaria
infection, including subsidised ACTs sold over-the-
counter. We hypothesised that offering an antimalarial
subsidy conditional on a positive malaria rapid
diagnostic test (RDT) would increase uptake of testing
and improve rational use of ACTs.
Methods:
We designed a 2×2 factorial randomised
experiment evaluating 2 levels of subsidy for RDTs and
ACTs. Between July 2014 and June 2015, 444
individuals with a malaria-like illness who had not
sought treatment were recruited from their homes. We
used scratch cards to allocate participants into 4 groups
in a ratio of 1:1:1:1. Participants were eligible for an
unsubsidised or fully subsidised RDT and 1 of 2 levels
of ACT subsidy (current retail price or an additional
subsidy conditional on a positive RDT). Treatment
decisions were documented 1 week later. Our primary
outcome was uptake of malaria testing. Secondary
outcomes evaluated ACT consumption among those
with a negative test, a positive test or no test.
Results:
Offering a free RDT increased the probability
of testing by 18.6 percentage points (adjusted
probability difference (APD), 95% CI 5.9 to 31.3). An
offer of a conditional ACT subsidy did not have an
additional effect on the probability of malaria testing
when the RDT was free (APD=2.7; 95% CI
−
8.6 to
14.1). However, receiving the conditional ACT subsidy
increased the probability of taking an ACT following a
positive RDT by 19.5 percentage points (APD, 95% CI
2.2 to 36.8). Overall, the proportion who took ACT
following a negative test was lower than those who took
ACT without being tested, indicated improved targeting
among those who were tested.
Conclusions:
Both subsidies improved appropriate
fever management, demonstrating the impact of these costs on decision making. However, the conditional ACT
subsidy did not increase testing. We conclude that each
of the subsidies primarily impacts the most immediate
decision.