A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya.

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, scalable 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-subsidized) 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 performed. 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 outlet 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 appropriate 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. Trial registration: ClinicalTrials.gov NCT04428307.

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Published Version (Please cite this version)

10.1371/journal.pgph.0002451

Publication Info

Laktabai, Jeremiah, Emmah Kimachas, Joseph Kipkoech, Diana Menya, David Arthur, Yunji Zhou, Tabitha Chepkwony, Lucy Abel, et al. (2024). A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya. PLOS global public health, 4(2). p. e0002451. 10.1371/journal.pgph.0002451 Retrieved from https://hdl.handle.net/10161/30758.

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Scholars@Duke

Gallis

John Gallis

Biostatistician, Senior

Overview
John currently collaborates with researchers and methodologists at the Duke Global Health Institute and the Duke Department of Biostatistics & Bioinformatics.  His varied research experience includes design and analysis of weight loss-related randomized controlled trials (RCTs), design and analysis of cluster randomized trials (CRTs), and implementation of the multiphase optimization strategy (MOST).  Recently, he has primarily worked with researchers examining the effects of interventions on maternal mental health and child health and development.  His research interests include the design of CRTs and analysis methods for clustered data, among many other interests.

Education
Master of Science (Sc.M.) in Biostatistics. Johns Hopkins Bloomberg School of Public Health               
Bachelor of Science (B.S.) in Mathematics: Southern Utah University

Links:
LinkedIn Profile: https://www.linkedin.com/in/john-gallis-2258b843/
Duke website: https://sites.duke.edu/johngallis/


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