Abstract:
Background: Inappropriate treatment of non-malaria fevers with artemisinin-based combination therapies (ACTs) is
a growing concern, particularly in light of emerging artemisinin resistance, but it is a behavior that has proven
difficult to change. Pay for performance (P4P) programs have generated interest as a mechanism to improve health
service delivery and accountability in resource-constrained health systems. However, there has been little experimental
evidence to establish the effectiveness of P4P in developing countries. We tested a P4P strategy that emphasized
parasitological diagnosis and appropriate treatment of suspected malaria, in particular reduction of unnecessary
consumption of ACTs.
Methods: A random sample of 18 health centers was selected and received a refresher workshop on malaria case
management. Pre-intervention baseline data was collected from August to September 2012. Facilities were
subsequently randomized to either the comparison (n = 9) or intervention arm (n = 9). Between October 2012 and
November 2013, facilities in the intervention arm received quarterly incentive payments based on seven performance
indicators. Incentives were for use by facilities rather than as payments to individual providers. All non-pregnant
patients older than 1 year of age who presented to a participating facility and received either a malaria test or
artemether-lumefantrine (AL) were eligible to be included in the analysis. Our primary outcome was prescription
of AL to patients with a negative malaria diagnostic test (n = 11,953). Our secondary outcomes were prescription
of AL to patients with laboratory-confirmed malaria (n = 2,993) and prescription of AL to patients without a malaria
diagnostic test (analyzed at the cluster level, n = 178 facility-months).
Results: In the final quarter of the intervention period, the proportion of malaria-negative patients in the
intervention arm who received AL was lower than in the comparison arm (7.3 % versus 10.9 %). The improvement
from baseline to quarter 4 in the intervention arm was nearly three times that of the comparison arm (ratio of
adjusted odds ratios for baseline to quarter 4 = 0.36, 95 % CI: 0.24–0.57). The rate of prescription of AL to patients
without a test was five times lower in the intervention arm (adjusted incidence rate ratio = 0.18, 95 % CI: 0.07–0.48).
Prescription of AL to patients with confirmed infection was not significantly different between the groups over the
study period.
