Willingness-to-pay for a rapid malaria diagnostic test and artemisinin-based combination therapy from private drug shops in Mukono District, Uganda

Factors influencing the acceptability of the test, treat and refer practice for malaria among caregivers of under 5 children at community pharmacies and drug shops in Nigeria

BACKGROUND

Malaria affects children under the age of five and pregnant women, leading to high morbidity and mortality rates. In sub-Saharan Africa, Patent and Proprietary Medicine Vendors (PPMVs) have been identified as key players in the provision of malaria treatment due to their accessibility and availability in communities, but PPMVs are not usually tested before fever cases are treated as malaria or refer clients. The aim of this study was to explore the factors influencing caregivers' acceptance of the test, treatment and referral practices for malaria management provided by CPs and PPMVs in Kaduna and Lagos states, Nigeria.

METHODS

A cross-sectional quantitative telephone survey was conducted among 150 caregivers of children under five years old who received malaria services from trained CPs and PPMVs between May and July 2022. Descriptive and bivariate analyses were performed to identify factors significantly associated with the acceptability of malaria management services. All statistically significant factors from the bivariate analysis were explored using logistic regression models, and odds ratios (ORs) with confidence intervals (CIs) were calculated to predict acceptability. The 95% level was used to define statistically significant associations (p ≤ 0.05).

RESULTS

All caregivers were asked questions that aided in obtaining a diagnosis of malaria. More than two-thirds of the caregivers (68%) reported that the child was tested by a CP/PPMV. Among those treated (148), 89% reported that the child was administered artemisinin combination therapy (ACT) irrespective of whether the child tested positive or negative for malaria. At the bivariate level, acceptability was greater among caregivers of children aged 13 months and older than among caregivers of children aged 0-12 months (93% vs. 76%, p = 0.004). Caregivers of children who prescribed ACT had greater acceptance than did those not prescribing ACT (92% vs. 69%, p = 0.010). Multivariate analysis revealed that these relationships held.

CONCLUSIONS

The adoption of the test, treat, and refer practice as a standard approach by CPs and PPMVs could replace the widespread practice of prescribing medications without conducting tests. This shift has the potential to improve the quality of malaria management services and enhance patient outcomes.

Understanding Acceptability and Willingness-to-pay for a C-reactive Protein Point-of-care Testing Service to Improve Antibiotic Dispensing for Respiratory Infections in Vietnamese Pharmacies: A Mixed-methods Study

Background

Pharmacies are popular first points of contact for mild infections in the community. Pharmacy services in many countries have expanded to include vaccines and point-of-care tests. In low- and middle-income countries such as Vietnam, poor enforcement of regulations results in substantial volumes of over-the-counter antibiotic sales. Point-of-care tests could provide an economically viable way to reduce antibiotic sales, while still satisfying customer demand for convenient healthcare. C-reactive protein point-of-care testing (CRP-POCT) can reduce antibiotic prescribing for respiratory illness in primary care. Here, we explore the acceptability and feasibility of implementing CRP-POCT in pharmacies in Vietnam.

Methods

We conducted a mixed-methods study between April and June 2021. A customer exit survey with 520 participants seeking acute respiratory infection treatment at 25 pharmacies evaluated acceptability and willingness-to-pay (WTP) for CRP-POCT and post-service satisfaction. Factors driving customers" acceptance and WTP were explored through mixed-effects multivariable regression. Three focus group discussions with customers (20 participants) and 12 in-depth interviews with pharmacists and other stakeholders were conducted and analyzed thematically.

Results

Antibiotics were sold to 81.4% of patients with CRP levels <10 mg/L (antibiotics not recommended). A total of 96.5% of customers who experienced CRP-POCT supported its future introduction at pharmacies. Patients with antibiotic transactions (adjusted odds ratio [aOR], 2.25; 95% confidence interval [CI], 1.13-4.48) and those suffering acute respiratory infection symptoms for more than 3 days (aOR, 2.10; 95% CI, 1.08-4.08) were more likely to accept CRP-POCT, whereas customers visiting for children (aOR, 0.20; 95% CI, .10-.54) and those with preference for antibiotic treatment (aOR, 0.45; 95% CI, 0.23-0.89) were less likely to accept CRP-POCT. A total of 78.3% (95% CI, 74.8-81.7) of customers were willing to pay for CRP-POCT, with a mean cost of US$2.4 (±1.1). Customer's income and cost of total drug treatment were associated with increased WTP. Enablers for implementing CRP-POCT included customers' and pharmacists' perceived benefits of CRP-POCT, and the impact of COVID-19 on perceptions of POCT. Perceived challenges for implementation included the additional burden of service provision, lack of an enabling policy environment, and potential risks for customers.

Conclusions

Implementing CRP-POCT at pharmacies is a feasible and well-accepted strategy to tackle the overuse of antibiotics in the community, with appeal for both supply and demand sides. Creating an enabling policy environment for its implementation, and transparent discussion of values and risks would be key for its successful implementation.

Determinants of willingness to pay for health services: a systematic review of contingent valuation studies

INTRODUCTION

Stated preference studies are a valuable tool to elicit respondents' willingness to pay (WTP) for goods or services, especially in situations where no market valuation exists. Contingent valuation (CV) is a widely used approach among stated-preference techniques for eliciting WTP if prices do not exist or do not reflect actual costs, for example, when services are covered by insurance. This review aimed to provide an overview of relevant factors determining WTP for health services to support variable selection.

METHODS

A comprehensive systematic literature search and review of CV studies assessing determinants of WTP for health services was conducted, including 11 electronic databases. Two of the authors made independent decisions on the eligibility of studies. We extracted all determinants used and related p values for the effect sizes (e.g. reported in regression models with WTP for a health service as outcome variable). Determinants were summarised in systematic evidence tables and structured by thematic domains.

RESULTS

We identified 2082 publications, of which 202 full texts were checked for eligibility. We included 62 publications on 61 studies in the review. Across all studies, we identified 22 WTP determinants and other factors from 5 thematic domains: sociodemographic characteristics, perceived threat, perceived benefit, perceived barriers, and other information.

CONCLUSION

Our review provides evidence on 22 relevant determinants of WTP for health services, which may be used for variable selection and as guidance for planning CV surveys. Endogeneity should be carefully considered before interpreting these determinants as causal factors and potential intervention targets.

Willingness-to-pay for COVID-19 vaccine in ten low-middle-income countries in Asia, Africa and South America: A cross-sectional study

Vaccine hesitancy is considered as one of the greatest challenges to control the ongoing coronavirus disease 2019 (COVID-19) pandemic. A related challenge is the unwillingness of the general public to pay for vaccination. The objective of this study was to determine willingness-to-pay (WTP) for COVID-19 vaccine among individuals from ten low- middle-income countries (LMICs) in Asia, Africa, and South America. Data were collected using an online questionnaire distributed during February - May 2021 in ten LMICs (Bangladesh, Brazil, Chile, Egypt, India, Iran, Nigeria, Pakistan, Sudan, and Tunisia). The major response variable of in this study was WTP for a COVID-19 vaccine. The assessment of COVID-19 vaccine hesitancy was based on items adopted from the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) vaccine hesitancy scale constructs. In this study, 1337 respondents included in the final analysis where the highest number of respondents was from India, while the lowest number was from Egypt. A total of 88.9% (1188/1337) respondents were willing to pay for the COVID-19 vaccination, and 11.1% (149/1337) were not. The average WTP for COVID-19 vaccination was 87.9 US dollars ($), (range: $5-$200). The multivariate model analysis showed that the country, monthly household income, having a history of respiratory disease, the agreement that routine vaccines recommended by health workers are beneficial and having received the flu vaccination within the previous 12 months were strongly associated with the WTP. Based on the country of origin, the highest mean WTP for COVID-19 vaccine was reported in Chile, while the lowest mean WTP for the vaccine was seen among the respondents from Sudan. The availability of free COVID-19 vaccination services appears as a top priority in the LMICs for successful control of the ongoing pandemic. This is particularly important for individuals of a lower socio- economic status. The effects of complacency regarding COVID-19 extends beyond vaccine hesitancy to involve less willingness to pay for COVID-19 vaccine and a lower value of WTP for the vaccine.

Factors influencing patients' willingness-to-pay for disease-modifying therapies for multiple sclerosis

BACKGROUND

High and ever-increasing costs of Multiple Sclerosis (MS) disease-modifying therapies (DMTs) have impaired patient access to DMTs in the US. Patients' willingness-to-pay (WTPs) for DMTs were recently examined, but their influencers were not determined. Thus, the objective of this study was to examine factors influencing patients' WTPs for DMTs for multiple sclerosis (MS).

METHODS

Data were obtained from a previous survey of 1,200 US patients with MS on their preferences and WTPs for DMTs. Patients' characteristics (i.e., age, gender, race, marital status, education, employment status, comorbidity, health status, and health insurance) and their MS experiences (i.e., number of years with MS, MS type, number of relapses, fatigue, mood-change, MS symptom, and DMTs experience) were investigated as influencing factors. Patient's WTP for a DMT was obtained from a direct question in the survey. A two-part model was estimated using logistic regression and generalized linear regression.

RESULTS

Responses from 480 patients were analyzed. Their average age was 53 years old. Most of them were female (79%), white (97%), and married (71%). Approximately 61% of them had a four-year college degree or lower, 54% were either unemployed, retired, or students, 59% were enrolled in private insurance, 81% had at least one comorbid condition, and 73% considered themselves having good or better health status. Approximately 44% had at least one relapse in two years, 89% experienced fatigue, 37% experienced mood-change, and on average had MS for more than 13 years. The majority of them had relapsing-remitting MS (66%), considered themselves to have some levels of disability for MS (78%), and had used or were currently using DMTs (97%). The average WTP for a DMT was $579 per month. Patients with professional degrees, or with one or more comorbid conditions were more likely willing to pay for a DMT. Patients who were white, had a professional degree, or were in fair or better health status were willing to pay a significantly higher amount for a DMT. Patients, who were female, were employed, did not have private insurance, had a higher number of MS experience years, or who experienced mood change were willing to pay significantly less amount for a DMT.

CONCLUSION

Various patients' characteristics and MS experiences, including gender, race, education, employment, health insurance, comorbidity, health status, DMT experience, and mood change influenced patients' WTPs for a DMT.

Management of Childhood Infections in Poorly Planned Urban Settlements in Kampala and Wakiso Districts of Uganda

The main objective of this study was to assess the management of childhood infections in high-density poorly planned urban areas of Kampala and Wakiso districts in Uganda, to develop a strategy to deliver integrated community case management (iCCM) of childhood illness services. A total of 72 private healthcare facilities were surveyed (36 drug shops, eight pharmacies, 27 private clinics, and one herbal clinic); supplemented by focus group discussions with village health teams (VHTs), drug shops, and private clinic providers. The majority of drug shops (96.4%, 27/28), pharmacies (100%, 8/8), and (68%, private clinics 17/27) were registered; however, supervision was poor. The majority of patients (> 77%) who visited private health facilities were children aged < 5 years. Furthermore, over 80% (29/64) of the children with uncomplicated malaria were reported to have been given artemether–lumefantrine, and 42% with difficulty breathing were given an antibiotic. Although > 72% providers said they referred children with severe illnesses, taking up referral was complicated by poverty, long distances, and the perception that there were inadequate drugs at referral facilities. Less than 38% of all the facilities had malaria treatment guidelines; < 15% had iCCM guidelines; 6% of the drug shops had iCCM guidelines; and < 13% of the facilities had pneumonia and diarrhea treatment guidelines. Village health teams existed in the study areas, although they had little knowledge on causes and prevention of pneumonia. In conclusion, this study found that quality of care was poor and introduction of iCCM delivered through VHTs, drug shops, and private clinics may, with proper training and support, be a feasible intervention to improve care.

Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia

How countries, particularly low- and middle-income economies, should pay the coronavirus disease 2019 (COVID-19) vaccine is an important and understudied issue. We undertook an online survey to measure the willingness-to-pay (WTP) for a COVID-19 vaccine and its determinants in Indonesia. The WTP was assessed using a simple dichotomous contingent valuation approach and a linear regression model was used to assess its associated determinants. There were 1,359 respondents who completed the survey. In total, 78.3% (1,065) were willing to pay for the COVID-19 vaccine with a mean and median WTP of US$ 57.20 (95%CI: US$ 54.56, US$ 59.85) and US$ 30.94 (95%CI: US$ 30.94, US$ 30.94), respectively. Being a health-care worker, having a high income, and having high perceived risk were associated with higher WTP. These findings suggest that the WTP for a COVID-19 vaccine is relatively high in Indonesia. This WTP information can be used to construct a payment model for a COVID-19 vaccine in the country. Nevertheless, to attain higher vaccine coverage, it may be necessary to partially subsidize the vaccine for those who are less wealthy and to design health promotion materials to increase the perceived risk for COVID-19 in the country.

Enhancing livestock vaccination decision-making through rapid diagnostic testing

•Compared to vaccination, the collective approach to diagnostic testing presents a low-fixed cost.•Existing household livestock-health behaviors increase the likelihood for uptake of preventative health practices.•Initial evidence to support household investments in livestock preventative health over therapeutic treatments.

Effect of Prices, Distribution Strategies, and Marketing on Demand for HIV Self-testing in Zimbabwe: A Randomized Clinical Trial

IMPORTANCE

HIV self-testing is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, particularly in Zimbabwe, where HIV prevalence is 13%. Evidence is lacking, however, on the optimal pricing policies and delivery strategies for maximizing the effect of HIV self-testing.

OBJECTIVE

To assess demand for HIV self-testing among adults and priority-population subgroups under alternative pricing and distribution strategies.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial recruited study participants between February 15, 2018, and April 25, 2018, in urban and rural communities in Zimbabwe. A factorial design was used to randomize participants to a combination of self-test price, distribution site, and promotional message. Individuals and their household members had to be at least 16 years old to be eligible for participation. This intention-to-treat population comprised 3996 participants.

INTERVENTIONS

Participants were given a voucher that could be redeemed for an HIV self-test within 1 month at varying prices (US $0-$3) and distribution sites (clinics or pharmacies in urban areas, and retail stores or community health workers in rural areas). Vouchers included randomly assigned promotional messages that emphasized the benefits of HIV testing.

MAIN OUTCOMES AND MEASURES

Proportion of participants who obtained self-tests in each trial arm, measured by distributor records.

RESULTS

Among the 4000 individuals enrolled, 3996 participants were included. In total, the mean (SD) age was 35 (14.7) years, and most participants (2841 [71.1%]) were female. Self-testing demand was highly price sensitive; 260 participants (32.5%) who were offered free self-tests redeemed their vouchers, compared with 55 participants (6.9%) who were offered self-tests for US $0.50 (odds ratio [OR], 0.14; 95% CI, 0.10-0.19), a reduction in demand of more than 25 percentage points. Demand was below 3% in the $1, $2, and $3 groups, which was statistically significantly lower than the demand in the free distribution group: in pooled analyses, demand was considerably lower among participants in higher-than-$0 price groups compared with the free distribution group (2.8% vs 32.5%; OR, 0.05; 95% CI, 0.04-0.07). In urban areas, demand was statistically significantly higher with pharmacy-based distribution compared with clinic-based distribution (6.8% vs 2.9%; adjusted OR, 2.78; 95% CI, 1.74-4.45). Price sensitivity was statistically significantly higher among rural residents, men, and those who had never received testing before. Promotional messages did not influence demand.

CONCLUSIONS AND RELEVANCE

This study found that demand for HIV self-testing in Zimbabwe was highly price sensitive, suggesting that free distribution may be essential for promoting testing among high-priority population groups; additionally, pharmacy-based distribution was preferable to clinic-based distribution in urban areas.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03559959.

The Accuracy and Perception of Test-Based Management of Malaria at Private Licensed Chemical Shops in the Middle Belt of Ghana

The sale of artemisinin-based combination therapy (ACT) by private licensed chemical shops (LCS) without testing is contrary to current policy recommendations. This study assessed the accuracy and perception of test-based management of malaria using malaria rapid diagnostic test (mRDT) kits at private LCS in two predominantly rural areas in the middle part of Ghana. Clients presenting at LCS with fever or other signs and symptoms suspected to be malaria in the absence of signs of severe malaria were tested with mRDT by trained attendants and treated based on the national malaria treatment guidelines. Using structured questionnaires, exit interviews were conducted within 48 hours and a follow-up interview on day 7 (±3 days). Focus group discussions and in-depth interviews were also conducted to assess stakeholders' perception on the use of mRDT at LCS. About 79.0% (N = 1,797) of clients reported with a fever. Sixty-six percent (947/1,426) of febrile clients had a positive mRDT result. Eighty-six percent (815/947) of clients with uncomplicated malaria were treated with the recommended ACT. About 97.8% (790/808) of clients with uncomplicated malaria treated with ACT were reported to be well by day 7. However, referral for those with negative mRDT results was very low (4.1%, 27/662). A high proportion of clients with a positive mRDT result received the recommended malaria treatment. Test-based management of malaria by LCS attendants was found to be feasible and acceptable by the community members and other stakeholders. Successful implementation will however require effective referral, supervision and quality control systems.

A scoping review on the field validation and implementation of rapid diagnostic tests for vector-borne and other infectious diseases of poverty in urban areas

BACKGROUND

Health personnel face challenges in diagnosing vector-borne and other diseases of poverty in urban settings. There is a need to know what rapid diagnostic technologies are available, have been properly assessed, and are being implemented to improve control of these diseases in the urban context. This paper characterizes evidence on the field validation and implementation in urban areas of rapid diagnostics for vector-borne diseases and other diseases of poverty.

MAIN BODY

A scoping review was conducted. Peer-reviewed and grey literature were searched using terms describing the targeted infectious diseases, diagnostics evaluations, rapid tests, and urban setting. The review was limited to studies published between 2000 and 2016 in English, Spanish, French, and Portuguese. Inclusion and exclusion criteria were refined post hoc to identify relevant literature regardless of study design and geography. A total of 179 documents of the 7806 initially screened were included in the analysis. Malaria (n = 100) and tuberculosis (n = 47) accounted for the majority of studies that reported diagnostics performance, impact, and implementation outcomes. Fewer studies, assessing mainly performance, were identified for visceral leishmaniasis (n = 9), filariasis and leptospirosis (each n = 5), enteric fever and schistosomiasis (each n = 3), dengue and leprosy (each n = 2), and Chagas disease, human African trypanosomiasis, and cholera (each n = 1). Reported sensitivity of rapid tests was variable depending on several factors. Overall, specificities were high (> 80%), except for schistosomiasis and cholera. Impact and implementation outcomes, mainly acceptability and cost, followed by adoption, feasibility, and sustainability of rapid tests are being evaluated in the field. Challenges to implementing rapid tests range from cultural to technical and administrative issues.

CONCLUSIONS

Rapid diagnostic tests for vector-borne and other diseases of poverty are being used in the urban context with demonstrated impact on case detection. However, most evidence comes from malaria rapid diagnostics, with variable results. While rapid tests for tuberculosis and visceral leishmaniasis require further implementation studies, more evidence on performance of current tests or development of new alternatives is needed for dengue, Chagas disease, filariasis, leptospirosis, enteric fever, human African trypanosomiasis, schistosomiasis and cholera.

Protocol of economic evaluation and equity impact analysis of mHealth and community groups for prevention and control of diabetes in rural Bangladesh in a three-arm cluster randomised controlled trial

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is one of the leading causes of death and disability worldwide, generating substantial economic burden for people with diabetes and their families, and to health systems and national economies. Bangladesh has one of the largest numbers of adults with diabetes in the South Asian region. This paper describes the planned economic evaluation of a three-arm cluster randomised control trial of mHealth and community mobilisation interventions to prevent and control T2DM and non-communicable diseases' risk factors in rural Bangladesh (D-Magic trial).

METHODS AND ANALYSIS

The economic evaluation will be conducted as a within-trial analysis to evaluate the incremental costs and health outcomes of mHealth and community mobilisation interventions compared with the status quo. The analyses will be conducted from a societal perspective, assessing the economic impact for all parties affected by the interventions, including implementing agencies (programme costs), healthcare providers, and participants and their households. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of intermediate hyperglycaemia and T2DM prevented and cost per case of diabetes prevented among individuals with intermediate hyperglycaemia at baseline and cost per mm Hg reduction in systolic blood pressure. In addition to ICERs, the economic evaluation will be presented as a cost-consequence analysis where the incremental costs and all statistically significant outcomes will be listed separately. Robustness of the results will be assessed through sensitivity analyses. In addition, an analysis of equity impact of the interventions will be conducted.

ETHICS AND DISSEMINATION

The approval to conduct the study was obtained by the University College London Research Ethics Committee (4766/002) and by the Ethical Review Committee of the Diabetic Association of Bangladesh (BADAS-ERC/EC/t5100246). The findings of this study will be disseminated through different means within academia and the wider policy sphere.

TRIAL REGISTRATION NUMBER

ISRCTN41083256; Pre-results.

Improving the first-line treatment of febrile illnesses in Ghana: willingness to pay for malaria rapid diagnostic tests at licensed chemical shops in the Kintampo area

Background

Use of malaria rapid diagnostic test (mRDT) enhances patient management and reduces costs associated with the inappropriate use of antimalarials. Despite its proven clinical effectiveness, mRDT is not readily available at licensed chemical shops in Ghana. Therefore, in order to improve the use of mRDT, there is the need to understand the willingness to pay for and sell mRDT. This study assessed patients’ willingness to pay and licensed chemical operators’ (LCS) willingness to sell mRDTs.

Methods

The study was a cross-sectional survey conducted in Kintampo North Municipality and Kintampo South District of Ghana. Contingent valuation method using the dichotomous approach was applied to explore patient’s willingness to pay. In-depth interviews (IDIs) were used to obtain information from licensed chemical operators’ willingness to sell.

Results

Majority 161 (97%) of the customers were willing to pay for mRDT while 100% of licensed chemical operators were also willing to sell mRDT. The average lowest amount respondents were willing to pay was Ghana cedis (GH¢) 1.1 (US$ 0.26) and an average highest amount of GH¢ 2.1 (US$ 0.49). LCS operators were willing to sell the test kit at an average lowest price of GH¢1 (US$ 0.23) and average highest price of GH¢2 (US$ 0.47).

Conclusion

Community members were willing to pay for mRDT and LCS operators are willing to sell mRDTs. However, the high cost of the mRDT is likely to prevent the widespread use of mRDT. There is a clear need to find system-compatible ways to subsidize the use of mRDT via National Health Insurance scheme.

Towards lab-on-a-chip diagnostics for malaria elimination

Malaria continues to be one of the most devastating diseases impacting global health. Although there have been significant reductions in global malaria incidence and mortality rates over the past 17 years, the disease remains endemic throughout the world, especially in low- and middle-income countries. The World Health Organization has put forth ambitious milestones moving toward a world free of malaria as part of the United Nations Millennium Goals. Mass screening and treatment of symptomatic and asymptomatic malaria infections in endemic regions is integral to these goals and requires diagnostics that are both sensitive and affordable. Lab-on-a-chip technologies provide a path toward sensitive, portable, and affordable diagnostic platforms. Here, we review and compare currently-available and emerging lab-on-a-chip diagnostic approaches in three categories: (1) protein-based tests, (2) nucleic acid tests, and (3) cell-based detection. For each category, we highlight the opportunities and challenges in diagnostics development for malaria elimination, and comment on their applicability to different phases of elimination strategies.

Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda

BACKGROUND

Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops.

METHODS

Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers.

FINDINGS

The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results.

CONCLUSION

mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.

Market for Artemether-Lumefantrine to treat childhood malaria in a district of southern Mozambique

Malaria is one of the leading causes of death in sub-Saharan Africa. Artemisinin-based combination therapies are used as first-line treatment drugs, but their market is far from competitive. Market failures include limited availability, low quality, lack of information, and high costs of access. We estimated the theoretical demand for one of the most common artemisinin-based combination therapies, artemether-lumefantrine (AL), and its determinants among caregivers of children with malaria seeking care at public health facilities, thus, entitled to receive drugs for free, in southern Mozambique (year 2012). The predicted theoretical demand was contrasted with international and local private market AL prices. Respondents stated high willingness to pay but lower ability to pay (ATP), which was defined as the theoretical demand. The ATP was on average of 0.94 USD for the treatment of a malaria episode. This implied an average gap of 1.04 USD between average local private prices and theoretical demand. Predicted ATP decreased by 14% for every additional malaria episode that the child had suffered during the malaria season. The market price was unaffordable for a large share of our sample, highlighting an unequal welfare distribution between suppliers and potential consumers, as well as issues of inequity in the private delivery of AL.

Private sector role, readiness and performance for malaria case management in Uganda, 2015

Background

Several interventions have been put in place to promote access to quality malaria case management services in Uganda’s private sector, where most people seek treatment. This paper describes evidence using a mixed-method approach to examine the role, readiness and performance of private providers at a national level in Uganda. These data will be useful to inform strategies and policies for improving malaria case management in the private sector.

Methods

The ACTwatch national anti-malarial outlet survey was conducted concurrently with a fever case management study. The ACTwatch nationally representative anti-malarial outlet survey was conducted in Uganda between May 18th 2015 and July 2nd 2015. A representative sample of sub-counties was selected in 14 urban and 13 rural clusters with probability proportional to size and a census approach was used to identify outlets. Outlets eligible for the survey met at least one of three criteria: (1) one or more anti-malarials were in stock on the day of the survey; (2) one or more anti-malarials were in stock in the 3 months preceding the survey; and/or (3) malaria blood testing (microscopy or RDT) was available. The fever case management study included observations of provider-patient interactions and patient exit interviews. Data were collected between May 20th and August 3rd, 2015. The fever case management study was implemented in the private sector. Potential outlets were identified during the main outlet survey and included in this sub-sample if they had both artemisinin-based combination therapy (ACT) [artemether–lumefantrine (AL)], in stock on the day of survey as well as diagnostic testing available.

Results

A total of 9438 outlets were screened for eligibility in the ACTwatch outlet survey and 4328 outlets were found to be stocking anti-malarials and were interviewed. A total of 9330 patients were screened for the fever case management study and 1273 had a complete patient observation and exit interview. Results from the outlet survey illustrate that the majority of anti-malarials were distributed through the private sector (54.3%), with 31.4% of all anti-malarials distributed through drug stores and 14.4% through private for-profit health facilities. Availability of different anti-malarials and diagnostic testing in the private sector was: ACT (80.7%), quality-assured (QA) ACT (72.0%), sulfadoxine–pyrimethamine (SP) (47.1%), quinine (73.2%) and any malaria blood testing (32.9%). Adult QAACT ($1.62) was three times more expensive than SP ($0.48). The results from the fever case management study found 44.4% of respondents received a malaria test, and among those who tested positive for malaria, 60.0% received an ACT, 48.5% received QAACT; 14.4% a non-artemisinin therapy; 14.9% artemether injection, and 42.5% received an antibiotic.

Conclusion

The private sector plays an important role in malaria case management in Uganda. While several private sector initiatives have improved availability of QAACT, there are gaps in malaria diagnosis and distribution of non-artemisinin monotherapies persists. Further private sector strategies, including those focusing on drug stores, are needed to increase coverage of parasitological testing and removal of non-artemisinin therapies from the marketplace.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1824-x) contains supplementary material, which is available to authorized users.

Willingness to pay for a dengue vaccine and its associated determinants in Indonesia: A community-based, cross-sectional survey in Aceh

Vaccination strategies are being considered as a part of dengue prevention programs in endemic countries. To accelerate the introduction of dengue vaccine into the public sector program and private markets, understanding the private economic benefits of a dengue vaccine is therefore essential. The aim of this study was to assess the willingness to pay (WTP) for a dengue vaccine among community members in Indonesia and its associated explanatory variables. A community-based, cross-sectional survey was conducted in nine regencies of Aceh province, Indonesia, from November 2014 to March 2015. A pre-tested validated questionnaire was used to facilitate the interviews. To assess the explanatory variables influencing participants' WTP for a dengue vaccine, a linear regression analysis was employed. We interviewed 677 healthy community members; 476 participants (87.5% of the total) were included in the final analysis. An average individual was willing to pay around US-$ 4 (mean: US-$ 4.04; median: US-$ 3.97) for a dengue vaccine. Our final multivariate model revealed that working as a civil servant, living in the city, and having good knowledge on dengue viruses, a good attitude towards dengue, and good preventive practice against dengue virus infection were associated with a higher WTP (P<0.05). Our model suggests that marketing efforts should be directed to community members who are working in the suburbs especially as farmers. In addition, the results of our study underscore the need for low-cost quality vaccines, public sector subsidies for vaccinations, and intensifying efforts to further educate and encourage households regarding other dengue preventive measures, using trusted individuals as facilitators.

Cost benefit analysis of malaria rapid diagnostic test: the perspective of Nigerian community pharmacists

Background

In 2010, the World Health Organization issued a guideline that calls for a shift from presumptive to test-based treatment. However, test-based treatment is still unpopular in community pharmacies. This could be due to unwillingness of customers to spend extra finance on rapid diagnostic test (RDT). It could also result from lack of interest from community pharmacists since they may perceive no financial gain attached to this service. This study assessed the cost-benefit of test-based malaria treatment to community pharmacists.

Methods

The study was a community pharmacy-based cross sectional survey. Potential benefit of RDT was determined using customers’ willingness-to-pay (WTP) for service. Average WTP was estimated using contingent valuation. Binary logistic regression was used to assess correlates of WTP acceptance while multiple linear regression was used to model the relationship between the independent variables and WTP amount. Cost associated with provision of RDT was estimated from provider’s perspective. Probabilistic sensitivity analysis was used to capture parameter uncertainty. Benefit-cost ratio (BCR) was calculated to determine study objective.

Results

A total of 135 out of 235 participants (57.4%) responded to the WTP question. Of this subset, 111 participants (82.2%) preferred RDT before malaria treatment. Average WTP [minimum–maximum] was US$1.23 [US$0.0–US$5.03]. Educated participants had 1.8 times higher odds of WTP for RDT. Participants that understood RDT as described in the questionnaire had 18.3 times higher odds of WTP for RDT compared to participants that did not understand RDT as described in the questionnaire. Additionally, a unit increase in level of education (e.g. from primary to secondary school) led to US$0.298 increase in WTP amount for RDT. Also, a unit increase in malaria frequency (e.g. from ‘never’ to ‘rarely’) led to US$0.293 decrease in WTP amount for RDT. Average cost [minimum–maximum] of RDT test kit and pharmacist time spent in administering the test were US$0.15 [US$0.13–US$0.17] and US$0.41 [US$0.18–US$0.52], respectively. BCR of test-based malaria treatment was 6.7 (95% CI 6.4–7.0).

Conclusion

Test-based malaria treatment is cost-beneficial for pharmacy practitioners. This finding could be used as an advocacy tool to increase community pharmacists’ interest and uptake of test-based malaria treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1648-0) contains supplementary material, which is available to authorized users.

Optimal price subsidies for appropriate malaria testing and treatment behaviour

Background

Malaria continues to be a serious public health problem particularly in Africa. Many people infected with malaria do not access effective treatment due to high price. At the same time many individuals receiving malaria drugs do not suffer from malaria because of the common practice of presumptive diagnosis. A global subsidy on artemisinin-based combination therapy (ACT) has recently been suggested to increase access to the most effective malaria treatment.

Methods

Following the recommendation by World Health Organization that parasitological testing should be performed before treatment and ACT prescribed to confirmed cases only, it is investigated in this paper if a subsidy on malaria rapid diagnostic tests (RDTs) should be incorporated. A model is developed consisting of a representative individual with fever suspected to be malaria, seeking care at a specialized drug shop where RDTs, ACT medicines, and cheap, less effective anti-malarials are sold. Assuming that the individual has certain beliefs of the accuracy of the RDT and the probability that the fever is malaria, the model predicts the diagnosis-treatment behaviour of the individual. Subsidies on RDTs and ACT are introduced to incentivize appropriate behaviour: choose an RDT before treatment and purchase ACT only if the test is positive.

Results

Solving the model numerically suggests that a combined subsidy on both RDT and ACT is cost minimizing and improves diagnosis-treatment behaviour of individuals. For certain beliefs, such as low trust in RDT accuracy and strong belief that a fever is malaria, subsidization is not sufficient to incentivize appropriate behaviour.

Conclusions

A combined subsidy on both RDT and ACT rather than a single subsidy is likely required to improve diagnosis-treatment behaviour among individuals seeking care for malaria in the private sector.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1582-1) contains supplementary material, which is available to authorized users.

Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies

Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.

Improving Access to Malaria Rapid Diagnostic Test in Niger State, Nigeria: An Assessment of Implementation up to 2013

Nigeria's 2009-2013 malaria strategic plan adopted WHO diagnosis and treatment guidelines, which include the use of rapid diagnostic tests (RDTs) prior to prescribing treatment with artemisinin combination therapies (ACTs). The current study explores accessibility barriers to the use of RDTs in Niger State and makes recommendations for improving the uptake of RDTs. The study employs literature review, review of data from the Niger State Health Management Information System for January-October 2013, and application of Peters' conceptual framework for assessing access to health services. Data showed that 27 percent of public health facilities (HFs) implemented RDTs, with the aid of donor funds. In these facilities, 77 percent of fever cases presented during the study period were tested with RDTs; 53 percent of fever cases were confirmed cases of malaria, while 60 percent of fever cases were treated. Stockouts of RDTs were a major constraint, and severe fever tended to trigger presumptive treatment. We conclude that although implementation of RDTs led to a reduction in the use of ACTs at HFs, more substantial reduction could be achieved if the state government directed more resources towards the acquisition of RDTs as well as raising the level of awareness of potential users.

Narrative review of current context of malaria and management strategies in Uganda (Part I)

In accordance with international targets, the Uganda National Malaria Control Strategic Plan established specific targets to be achieved by 2010. For children under five, this included increasing the number of children sleeping under mosquito nets and those receiving a first-line antimalarial to 85%, and decreasing case fatality to 2%. This narrative review offers contextual information relevant to malaria management in Uganda since the advent of artemisinin combination therapy (ACT) as first-line antimalarial treatment in 2004. A comprehensive search using key words and phrases was conducted using the web search engines Google and Google Scholar, as well as the databases of PubMed, ERIC, EMBASE, CINAHL, OvidSP (MEDLINE), PSYC Info, Springer Link, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews were searched. A total of 147 relevant international and Ugandan literature sources meeting the inclusion criteria were included. This review provides an insightful understanding on six topic areas: global and local priorities, malarial pathology, disease burden, malaria control, treatment guidelines for uncomplicated malaria, and role of the health system in accessing antimalarial medicines. Plasmodium falciparum remains the most common cause of malaria in Uganda, with children under five being most vulnerable due to their underdeveloped immunity. While international efforts to scale up malaria control measures have resulted in considerable decline in malaria incidence and mortality in several regions of sub-Saharan Africa, this benefit has yet to be substantiated for Uganda. At the local level, key initiatives have included implementation of a new antimalarial drug policy in 2004 and strengthening of government health systems and programs. Examples of such programs include removal of user fees, training of frontline health workers, providing free ACT from government systems and subsidized ACT from licensed private outlets, and introduction of the integrated community case management program to bring diagnostics and treatment for malaria, pneumonia and diarrhea closer to the community. However despite notable efforts, Uganda is far from achieving its 2010 targets. Several challenges in the delivery of care and treatment remain, with those most vulnerable and living in rural settings remaining at greatest risk from malaria morbidity and mortality.

Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications

Background

Malaria is a major public health problem in Uganda and the current policy recommends introduction of rapid diagnostic tests for malaria (RDTs) to facilitate effective case management. However, provision of RDTs in drug shops potentially raises a new set of issues, such as adherence to RDTs results, management of severe illnesses, referral of patients, and relationship with caretakers. The main objective of the study was to examine the impact of introducing RDTs in registered drug shops in Uganda and document lessons and policy implications for future scale-up of malaria control in the private health sector.

Methods

A cluster-randomized trial introducing RDTs into registered drug shops was implemented in central Uganda from October 2010 to July 2012. An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops, the lessons learned and policy implications.

Results

Introducing RDTs into drug shops was feasible. To scale-up this intervention however, drug shop practices need to be regulated since the registration process was not clear, supervision was inadequate and record keeping was poor. Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome, but at evaluation this was not found to be a constraint. This presents an important lesson for introducing health management information system into drug shops. Involving stakeholders, especially the district health team, in the design was important for ownership and sustainability. The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions.

Conclusion

Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy. It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector.

Estimating the cost of referral and willingness to pay for referral to higher-level health facilities: a case series study from an integrated community case management programme in Uganda

Background

Integrated community case management (iCCM) relies on community health workers (CHWs) managing children with malaria, pneumonia, diarrhoea, and referring children when management is not possible. This study sought to establish the cost per sick child referred to seek care from a higher-level health facility by a CHW and to estimate caregivers’ willingness to pay (WTP) for referral.

Methods

Caregivers of 203 randomly selected children referred to higher-level health facilities by CHWs were interviewed in four Midwestern Uganda districts. Questionnaires and document reviews were used to capture direct, indirect and opportunity costs incurred by caregivers, CHWs and health facilities managing referred children. WTP for referral was assessed through the ‘bidding game’ approach followed by an open-ended question on maximum WTP. Descriptive analysis was conducted for factors associated with referral completion and WTP using logistic and linear regression methods, respectively. The cost per case referred to higher-level health facilities was computed from a societal perspective.

Results

Reasons for referral included having fever with a negative malaria test (46.8 %), danger signs (29.6 %) and drug shortage (37.4 %). Among the referred, less than half completed referral (45.8 %). Referral completion was 2.8 times higher among children with danger signs (p = 0.004) relative to those without danger signs, and 0.27 times lower among children who received pre-referral treatment (p < 0.001). The average cost per case referred was US$ 4.89 and US$7.35 per case completing referral. For each unit cost per case referred, caregiver out of pocket expenditure contributed 33.7 %, caregivers’ and CHWs’ opportunity costs contributed 29.2 % and 5.1 % respectively and health facility costs contributed 39.6 %.

The mean (SD) out of pocket expenditure was US$1.65 (3.25). The mean WTP for referral was US$8.25 (14.70) and was positively associated with having received pre-referral treatment, completing referral and increasing caregiver education level.

Conclusion

The mean WTP for referral was higher than the average out of pocket expenditure. This, along with suboptimal referral completion, points to barriers in access to higher-level facilities as the primary cause of low referral. Community mobilisation for uptake of referral is necessary if the policy of referring children to the nearest health facility is to be effective.

A Cluster Randomised Trial Introducing Rapid Diagnostic Tests into Registered Drug Shops in Uganda: Impact on Appropriate Treatment of Malaria

BACKGROUND

Inappropriate treatment of malaria is widely reported particularly in areas where there is poor access to health facilities and self-treatment of fevers with anti-malarial drugs bought in shops is the most common form of care-seeking. The main objective of the study was to examine the impact of introducing rapid diagnostic tests for malaria (mRDTs) in registered drug shops in Uganda, with the aim to increase appropriate treatment of malaria with artemisinin-based combination therapy (ACT) in patients seeking treatment for fever in drug shops.

METHODS

A cluster-randomized trial of introducing mRDTs in registered drug shops was implemented in 20 geographical clusters of drug shops in Mukono district, central Uganda. Ten clusters were randomly allocated to the intervention (diagnostic confirmation of malaria by mRDT followed by ACT) and ten clusters to the control arm (presumptive treatment of fevers with ACT). Treatment decisions by providers were validated by microscopy on a reference blood slide collected at the time of consultation. The primary outcome was the proportion of febrile patients receiving appropriate treatment with ACT defined as: malaria patients with microscopically-confirmed presence of parasites in a peripheral blood smear receiving ACT or rectal artesunate, and patients with no malaria parasites not given ACT.

FINDINGS

A total of 15,517 eligible patients (8672 intervention and 6845 control) received treatment for fever between January-December 2011. The proportion of febrile patients who received appropriate ACT treatment was 72·9% versus 33·7% in the control arm; a difference of 36·1% (95% CI: 21·3 - 50·9), p<0·001. The majority of patients with fever in the intervention arm accepted to purchase an mRDT (97·8%), of whom 58·5% tested mRDT-positive. Drug shop vendors adhered to the mRDT results, reducing over-treatment of malaria by 72·6% (95% CI: 46·7- 98·4), p<0·001) compared to drug shop vendors using presumptive diagnosis (control arm).

CONCLUSION

Diagnostic testing with mRDTs compared to presumptive treatment of fevers implemented in registered drug shops substantially improved appropriate treatment of malaria with ACT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01194557.

Addressing Barriers to the Development and Adoption of Rapid Diagnostic Tests in Global Health

Immunochromatographic rapid diagnostic tests (RDTs) have demonstrated significant potential for use as point-of-care diagnostic tests in resource-limited settings. Most notably, RDTs for malaria have reached an unparalleled level of technological maturity and market penetration, and are now considered an important complement to standard microscopic methods of malaria diagnosis. However, the technical development of RDTs for other infectious diseases, and their uptake within the global health community as a core diagnostic modality, has been hindered by a number of extant challenges. These range from technical and biological issues, such as the need for better affinity agents and biomarkers of disease, to social, infrastructural, regulatory and economic barriers, which have all served to slow their adoption and diminish their impact. In order for the immunochromatographic RDT format to be successfully adapted to other disease targets, to see widespread distribution, and to improve clinical outcomes for patients on a global scale, these challenges must be identified and addressed, and the global health community must be engaged in championing the broader use of RDTs.

The impact of providing rapid diagnostic malaria tests on fever management in the private retail sector in Ghana: a cluster randomized trial

OBJECTIVE

To examine the impact of providing rapid diagnostic tests for malaria on fever management in private drug retail shops where most poor rural people with fever present, with the aim of reducing current massive overdiagnosis and overtreatment of malaria.

DESIGN

Cluster randomized trial of 24 clusters of shops.

SETTING

Dangme West, a poor rural district of Ghana.

PARTICIPANTS

Shops and their clients, both adults and children.

INTERVENTIONS

Providing rapid diagnostic tests with realistic training.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of clients testing negative for malaria by a double-read research blood slide who received an artemisinin combination therapy or other antimalarial. Secondary outcomes were use of antibiotics and antipyretics, and safety.

RESULTS

Of 4603 clients, 3424 (74.4%) tested negative by double-read research slides. The proportion of slide-negative clients who received any antimalarial was 590/1854 (32%) in the intervention arm and 1378/1570 (88%) in the control arm (adjusted risk ratio 0.41 (95% CI 0.29 to 0.58), P<0.0001). Treatment was in high agreement with rapid diagnostic test result. Of those who were slide-positive, 690/787 (87.8%) in the intervention arm and 347/392 (88.5%) in the control arm received an artemisinin combination therapy (adjusted risk ratio 0.96 (0.84 to 1.09)). There was no evidence of antibiotics being substituted for antimalarials. Overall, 1954/2641 (74%) clients in the intervention arm and 539/1962 (27%) in the control arm received appropriate treatment (adjusted risk ratio 2.39 (1.69 to 3.39), P<0.0001). No safety concerns were identified.

CONCLUSIONS

Most patients with fever in Africa present to the private sector. In this trial, providing rapid diagnostic tests for malaria in the private drug retail sector significantly reduced dispensing of antimalarials to patients without malaria, did not reduce prescribing of antimalarials to true malaria cases, and appeared safe. Rapid diagnostic tests should be considered for the informal private drug retail sector.Registration Clinicaltrials.gov NCT01907672.

Determinants of malaria diagnostic uptake in the retail sector: qualitative analysis from focus groups in Uganda

BACKGROUND

In Uganda, as in most other malaria-endemic countries, presumptive treatment for malaria based on symptoms without a diagnostic blood test is still very common. While diagnostic testing in public sector facilities is increasing, many people in Uganda who suspect malaria visit private sector outlets to purchase medications. Increasing the availability and uptake of rapid diagnostic tests (RDTs) for malaria in private outlets could help increase diagnostic testing for malaria but raises questions about the patient demand for and valuation of testing that are less critical for public sector introduction.

METHODS

In preparation for a behaviour change campaign to encourage and sustain the demand for RDTs in drug shops, eight focus group discussions with a total of 84 community members were conducted in six districts across Uganda's Eastern Region in November-December 2011. Focus groups explored incentives and barriers to seeking diagnosis for malaria, how people react to test results and why, and what can be done to increase the willingness to pay for RDTs.

RESULTS

Overall, participants were very familiar with malaria diagnostic testing and understood its importance, yet when faced with limited financial resources, patients preferred to spend their money on medication and sought testing only when presumptive treatment proved ineffective. While side effects did seem to be a concern, participants did not mention other potential costs of taking unnecessary or ineffective medications, such as money wasted on excess drugs or delays in resolution of symptoms. Very few individuals were familiar with RDTs.

CONCLUSION

In order to boost demand, these results suggest that private sector RDTs will have to be made convenient and affordable and that targeted behaviour change campaigns should strive to increase the perceived value of diagnosis.

How do risk preferences relate to malaria care-seeking behavior and the acceptability of a new health technology in Nigeria?

BACKGROUND

To reduce the burden of disease from malaria, innovative approaches are needed to engender behavior change. One unobservable, but fundamental trait-preferences for risk-may influence individuals' willingness to adopt new health technologies. We explore the association of risk preferences with malaria care-seeking behavior and the acceptability of malaria rapid diagnostic tests (RDTs) to inform RDT scale-up plans.

METHODS

In Oyo State, Nigeria, adult customers purchasing anti-malarial medications at selected drug shops took surveys and received an RDT as they exited. After an initial risk preference assessment via a simple lottery game choice, individuals were given their RDT result and treatment advice, and called four days later to assess treatment adherence. We used bivariable and multivariable regression analysis to assess the association of risk game choices with malaria care-seeking behaviors and RDT acceptability.

RESULTS

Of 448 respondents, 63.2% chose the lottery game with zero variance in expected payout, 27.9% chose the game with low variance, and 8.9% chose the game with high variance. Compared to participants who chose lower variance games, individuals choosing higher variance games were older, less educated, more likely to be male, and were more likely to patronize lower quality drug shops, seek care immediately, and report complete disability due to their illness. In contrast, individuals choosing lower variance games were more likely to follow the correct treatment directions and were more likely to report an increase in their willingness to pay for an RDT compared to other risk groups, our two measures of RDT acceptability. Differences in estimated associations between risk game choices and selected care-seeking behaviors remained after controlling sociodemographic confounders.

CONCLUSIONS

The uptake of health diagnostic information in terms of translating the RDT experience into willingness to pay for an RDT and treatment adherence to test results may vary according to risk preferences. Hence, health promotion communications may want to be crafted bearing in mind differences in uptake among people of different risk preferences to encourage wider RDT adoption and more rational malaria treatment. Estimates will serve as the basis for power calculations for an expanded study.

Introducing rapid diagnostic tests for malaria into drug shops in Uganda: design and implementation of a cluster randomized trial

Background

An intervention was designed to introduce rapid diagnostics tests for malaria (mRDTs) into registered drug shops in Uganda to encourage rational and appropriate treatment of malaria with artemisinin-based combination therapy (ACT). We conducted participatory training of drug shop vendors and implemented supporting interventions to orientate local communities (patients) and the public sector (health facility staff and district officials) to the behavioral changes in diagnosis, treatment and referral being introduced in drug shops. The intervention was designed to be evaluated through a cluster randomized trial. In this paper, we present detailed design, implementation and evaluation experiences in order to help inform future studies of a complex nature.

Methods

Three preparatory studies (formative, baseline and willingness-to-pay) were conducted to explore perceptions on diagnosis and treatment of malaria at drug shops, and affordable prices for mRDTs and ACTs in order to inform the design of the intervention and implementation modalities. The intervention required careful design with the intention to be acceptable, sustainable and effective. Critical components of intervention were: community sensitization and creating awareness, training of drug shop vendors to diagnose malaria with mRDTs, treat and refer customers to formal health facilities, giving pre-referral rectal artesunate and improved record-keeping. The primary outcome was the proportion of patients receiving appropriately-targeted treatment with ACT, evaluated against microscopy on a research blood slide.

Results

Introducing mRDTs in drug shops may seem simple, but our experience of intervention design, conduct and evaluation showed this to be a complex process requiring multiple interventions and evaluation components drawing from a combination of epidemiological, social science and health economics methodologies. The trial was conducted in phases sequenced such that each benefited from the other.

Conclusions

The main challenges in designing this trial were maintaining a balance between a robust intervention to support effective behaviour change and introducing practices that would be sustainable in a real-life situation in tropical Africa; as well as achieving a detailed evaluation without inadvertently influencing prescribing behaviour.

Trial registration

NCT01194557 registered with ClinicalTrials.gov 2 September 2010.

Prevalence of malaria parasitemia and purchase of artemisinin-based combination therapies (ACTs) among drug shop clients in two regions in Tanzania with ACT subsidies

Background

Throughout Africa, many people seek care for malaria in private-sector drug shops where diagnostic testing is often unavailable. Recently, subsidized artemisinin-based combination therapies (ACTs), a first-line medication for uncomplicated malaria, were made available in these drug shops in Tanzania. This study assessed the prevalence of malaria among and purchase of ACTs by drug shop clients in the setting of a national ACT subsidy program and sub-national drug shop accreditation program.

Method and Findings

A cross-sectional survey of drug shop clients was performed in two regions in Tanzania, one with a government drug shop accreditation program and one without, from March-May, 2012. Drug shops were randomly sampled from non-urban districts. Shop attendants were interviewed about their education, training, and accreditation status. Clients were interviewed about their symptoms and medication purchases, then underwent a limited physical examination and laboratory testing for malaria. Malaria prevalence and predictors of ACT purchase were assessed using univariate analysis and multiple logistic regression. Amongst 777 clients from 73 drug shops, the prevalence of laboratory-confirmed malaria was 12% (95% CI: 6–18%). Less than a third of clients with malaria had purchased ACTs, and less than a quarter of clients who purchased ACTs tested positive for malaria. Clients were more likely to have purchased ACTs if the participant was <5 years old (aOR: 6.6; 95% CI: 3.9–11.0) or the shop attendant had >5 years, experience (aOR: 2.8; 95% CI: 1.2–6.3). Having malaria was only a predictor of ACT purchase in the region with a drug shop accreditation program (aOR: 3.4; 95% CI: 1.5–7.4).

Conclusion

Malaria is common amongst persons presenting to drug shops with a complaint of fever. The low proportion of persons with malaria purchasing ACTs, and the high proportion of ACTs going to persons without malaria demonstrates a need to better target who receives ACTs in these drug shops.

Scale-up of malaria rapid diagnostic tests and artemisinin-based combination therapy: challenges and perspectives in sub-Saharan Africa

Guido Bastiaens and colleagues describe barriers to achieving scale-up and appropriate use of rapid diagnostic tests and artemisinin-based combination therapy for malaria in sub-Saharan Africa. Please see later in the article for the Editors' Summary

Expanding Access to Malaria Diagnosis through Retail Shops in Western Kenya: What Do Shop Workers Think?

Background. The common symptoms of malaria reduce the specificity of clinical diagnosis. Presumptive treatment is conventional but can lead to overdiagnosis of malaria, delay of appropriate treatment, overprescription of antimalarials, and drug resistance. Routine use of diagnostic tests can address many of these concerns. Though treatment is often procured from retailers, there is low availability of rapid diagnostic tests for malaria (MRDTs), a simple, inexpensive, and accurate diagnostic solution. We know little about the challenges to expanding access to diagnostics through these outlets. Methods. To understand the perceptions of the benefits and challenges to selling rapid diagnostic tests for malaria, we conducted focus group discussions with antimalarial retailers who serve the residents of the Webuye Health and Demographic Surveillance Site in western Kenya. Results. Medicine retailers perceived MRDTs to be beneficial to their customers and businesses but also included cost, fear of the tests, risks of self-treatment, and regulatory concerns among the challenges to using and selling MRDTs. Conclusion. MRDTs represent a viable approach to increase access to malaria diagnostic testing. Medicine retailers are eager for MRDTs to be made available to them. However, certain challenges remain to implementation in retail outlets and should be addressed in advance.

Feasibility of distributing rapid diagnostic tests for malaria in the retail sector: evidence from an implementation study in Uganda

BACKGROUND

Despite the benefits of malaria diagnosis, most presumed malaria episodes are never tested. A primary reason is the absence of diagnostic tests in retail establishments, where many patients seek care. Malaria rapid diagnostic tests (RDTs) in drug shops hold promise for guiding appropriate treatment. However, retail providers generally lack awareness of RDTs and training to administer them. Further, unsubsidized RDTs may be unaffordable to patients and unattractive to retailers. This paper reports results from an intervention study testing the feasibility of RDT distribution in Ugandan drug shops.

METHODS AND FINDINGS

92 drug shops in 58 villages were offered subsidized RDTs for sale after completing training. Data on RDT purchases, storage, administration and disposal were collected, and samples were sent for quality testing. Household surveys were conducted to capture treatment outcomes. Estimated daily RDT sales varied substantially across shops, from zero to 8.46 RDTs per days. Overall compliance with storage, treatment and disposal guidelines was excellent. All RDTs (100%) collected from shops passed quality testing. The median price charged for RDTs was 1000USH ($0.40), corresponding to a 100% markup, and the same price as blood slides in local health clinics. RDTs affected treatment decisions. RDT-positive patients were 23 percentage points more likely to buy Artemisinin Combination Therapies (ACTs) (p = .005) and 33.1 percentage points more likely to buy other antimalarials (p<.001) than RDT-negative patients, and were 5.6 percentage points more likely to buy ACTs (p = .05) and 31.4 percentage points more likely to buy other antimalarials (p<.001) than those not tested at all.

CONCLUSIONS

Despite some heterogeneity, shops demonstrated a desire to stock RDTs and use them to guide treatment recommendations. Most shops stored, administered and disposed of RDTs properly and charged mark-ups similar to those charged on common medicines. Results from this study suggest that distributing RDTs through the retail sector is feasible and can reduce inappropriate treatment for suspected malaria.