dc.description.abstract |
ACTs are responsible for a substantial proportion of the global reduction in malaria mortality
over the last ten years, made possible by publicly-funded subsidies making these drugs
accessible and affordable in the private sector. However, inexpensive ACTs available in
retail outlets have contributed substantially to overconsumption. We test an innovative, scal-
able strategy to target ACT-subsidies to clients with a confirmatory diagnosis. We supported
malaria testing(mRDTs) in 39 medicine outlets in western Kenya, randomized to three study
arms; control arm offering subsidized mRDT testing (0.4USD), client-directed intervention
where all clients who received a positive RDT at the outlet were eligible for a free (fully-sub-
sidized) ACT, and a combined client and provider directed intervention where clients with a
positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT per-
formed. Our primary outcome was the proportion of ACT dispensed to individuals with a
positive diagnostic test. Secondary outcomes included proportion of clients tested at the out-
let and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test
results informed treatment decisions, resulting in targeting of ACTs to confirmed malaria
cases– 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further
improvements, compared to the control arm, in testing rates(RD = 0.09, 95%CI:-0.08,0.26)
or dispensing of ACTs to test-positive clients(RD = 0.01,95% CI:-0.14, 0.16). Clients were
often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT
subsidy was passed on to the client. This uncertainty undermines our ability to definitively
conclude that client-directed subsidies are not effective for improving testing and appropri-
ate treatment. We conclude that mRDTs could reduce ACT overconsumption in the private
retail sector, but incentive structures are difficult to scale and their value to private providers
is uncertain. |
en_US |