Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya.
Abstract
BACKGROUND:More 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 FINDINGS:We 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]
= 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25
(95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased
from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention
arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects
increased between 12 and 18 months, we were not able to estimate longer-term impact
of the intervention and could not independently evaluate the effects of the free testing
and the voucher on uptake of testing. CONCLUSIONS:Diagnosis-dependent ACT subsidies
and community-based interventions that include the private sector can have an important
impact on diagnostic testing and population-wide rational use of ACTs. Targeting of
the ACT subsidy itself to those with a positive malaria diagnostic test may also improve
sustainability and reduce the cost of retail-sector ACT subsidies. TRIAL REGISTRATION:ClinicalTrials.gov
NCT02461628.
Type
Journal articleSubject
HumansMalaria
Artemisinins
Drug Combinations
Antimalarials
Treatment Outcome
Predictive Value of Tests
Time Factors
Private Sector
Adolescent
Adult
Child
Child, Preschool
Infant
Drug Costs
Kenya
Female
Male
Nonprescription Drugs
Medication Adherence
Public-Private Sector Partnerships
Community Health Workers
Healthcare Financing
Point-of-Care Testing
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https://hdl.handle.net/10161/18523Published Version (Please cite this version)
10.1371/journal.pmed.1002607Publication Info
Prudhomme O'Meara, Wendy; Menya, Diana; Laktabai, Jeremiah; Platt, Alyssa; Saran,
Indrani; Maffioli, Elisa; ... Turner, Elizabeth L (2018). Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from
a cluster-randomized controlled trial in western Kenya. PLoS medicine, 15(7). pp. e1002607. 10.1371/journal.pmed.1002607. Retrieved from https://hdl.handle.net/10161/18523.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Manoj Mohanan
Associate Professor in the Sanford School of Public Policy
Manoj Mohanan is an applied microeconomist, focusing on health and development economics,
with a background in medicine and public health. His research focuses on topics related
to health and health care in developing countries including: performance-based contracts,
measurement of provider quality and performance, social franchising, and social accountability
/ monitoring. He also studies the role of subjective expectations and beliefs in
health care behavior.Several of his
Alyssa Platt
Biostatistician III
Education: Masters Degree, Applied Economics. Duke University. 2007Bachelors Degree,
Economics and Mathematics. University of North Carolina at GreensboroOverview: Alyssa
has ongoing collaborations with faculty from Duke Global Health Institute. Her professional
experience involves analysis and evaluation of health policy in areas of obesity,
physical activity and nutrition, health care access, and infectious disease. She is
experienced in longitudinal and cros
Elizabeth Louise Turner
Associate Professor of Biostatistics and Bioinformatics
Dr. Turner is Associate Professor of Biostatistics and Global Health and serves as
Director of the Research Design and Analysis Core of the Duke Global Health Institute.
Her primary methodological focus is on the design and analysis of randomized controlled
trials, particularly those that involve clustering such as cluster randomized trials
(CRTs), stepped wedge CRTs and individually-randomized group treatment trials. She
is expert in the implementation of trials in low resource settings, with a
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