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Laktabai J, Kimachas E, Kipkoech J, Menya D, Arthur D, Zhou Y, Chepkwony T, Abel L, Robie E, Amunga M, Ambani G, Woldeghebriel M, Garber E, Eze N, Mudabai P, Gallis JA, Fashanu C, Saran I, Woolsey A, Visser T, Turner EL, Prudhomme O’Meara W. 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 2024; 4:e0002451. [PMID: 38324584 PMCID: PMC10849268 DOI: 10.1371/journal.pgph.0002451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
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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Affiliation(s)
- Jeremiah Laktabai
- Moi University School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Emmah Kimachas
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Joseph Kipkoech
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Diana Menya
- Moi University School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Arthur
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Yunji Zhou
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
| | | | - Lucy Abel
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Emily Robie
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Mark Amunga
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - George Ambani
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | | | | | - Nwamaka Eze
- Clinton Health Access Initiative (CHAI), Lagos, Nigeria
| | | | - John A. Gallis
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | - Indrani Saran
- School of Social Work, Boston College, Newton, Massachusetts, United States of America
| | - Aaron Woolsey
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Theodoor Visser
- Clinton Health Access Initiative (CHAI), Boston, Massachusetts, United States of America
| | - Elizabeth L. Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Wendy Prudhomme O’Meara
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
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Rotimi K, Fagbemi B, Itiola AJ, Ibinaiye T, Aidenagbon A, Dabes C, Biambo AA, Iwegbu A, Onabajo S, Oguoma C, Oresanya O. Private sector availability and affordability of under 5 malaria health commodities in selected states in Nigeria and the Federal Capital Territory. J Pharm Policy Pract 2023; 17:2294024. [PMID: 38223355 PMCID: PMC10783550 DOI: 10.1080/20523211.2023.2294024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background To guarantee uninterrupted service delivery, quality-assured products must be affordable and continuously available across all sectors, including the private sector, which provides more than 60% of healthcare services in Nigeria. We investigated the private sector availability and affordability of under 5 malaria commodities to establish the level of access in this sector. Methods We surveyed patent medicine and pharmacy stores across seven states in Nigeria and the Federal Capital Territory to establish the availability and affordability of selected malaria commodities for children under 5 years. Availability was measured as the percentage of visited outlets with the product of interest on the day of visit, while affordability was assessed by establishing if it cost more than a day's wage for the least-paid government worker to purchase a full course of malaria diagnostic test and/or medication. Results Artemisinin-based antimalarials for uncomplicated and severe malaria were the most available commodities. SPAQ1 and SPAQ2 used for seasonal malaria chemoprevention campaign were surprisingly also available in some outlets. However, only about half (48.3% and 53.3%) of the surveyed outlets had stock of artemether/lumefantrine (AL1) and artesunate injection, respectively. The median price of surveyed products ranged from USD (United States Dollars) 0.38 to USD 2.17 per treatment/test. Except for amodiaquine tablet and artemether injection, which cost less, all other originator brands cost the same or more than the lowest-priced generic. Antimalarial products were affordable as their median prices were not more than a day's wage for the least-paid government worker. However, when the cost of testing and treatment with artemisinin-based combination therapies (ACTs) was assessed, testing and treatment with dihydroartemisinin/piperaquine were unaffordable as the they cost more than 1.5 times the daily wage of the least-paid government worker. Conclusion The overall private sector availability of under-five malaria commodities in surveyed locations was suboptimal. Also, testing and treatment with recommended ACTs were not affordable for all surveyed products. These findings suggest the need for interventions to improve access to affordable under-five malaria commodities.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sarah Onabajo
- National Agency for Food and Drug Administration and Control, Lagos, Nigeria
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Coveney L, Musoke D, Russo G. Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries. Health Policy Plan 2023; 38:1050-1063. [PMID: 37632759 PMCID: PMC10566321 DOI: 10.1093/heapol/czad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 08/07/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023] Open
Abstract
Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.
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Affiliation(s)
- Laura Coveney
- The Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, United Kingdom
| | - David Musoke
- School of Public Health, Makerere University, New Mulago Hill Road, Mulango, Kampala, Uganda
| | - Giuliano Russo
- The Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, United Kingdom
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Laktabai J, Kimachas E, Kipkoech J, Menya D, Arthur D, Zhou Y, Chepkwony T, Abel L, Robie E, Amunga M, Ambani G, Woldeghebriel M, Garber E, Eze N, Mudabai P, Gallis JA, Fashanu C, Saran I, Woolsey A, Visser T, Turner EL, O'Meara WP. 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. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.14.23295586. [PMID: 37745516 PMCID: PMC10516073 DOI: 10.1101/2023.09.14.23295586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years. These reductions would not have been possible without publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to their overconsumption. We test an innovative, scalable, and sustainable strategy to target ACT subsidies to clients with a confirmatory diagnosis. We supported point-of-care malaria testing (mRDTs) in 39 retail medicine outlets in western Kenya and randomized them to three study arms; control arm offering subsidized RDT testing for 0.4USD, client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully subsidized) first-line 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 and resulted 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. 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.
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Affiliation(s)
- J Laktabai
- Moi University School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - E Kimachas
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - J Kipkoech
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - D Menya
- Moi University School of Public Health, College of Health Sciences, Moi University
| | - D Arthur
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | - Y Zhou
- Department of Biostatistics, University of Washington, Seattle WA
| | - T Chepkwony
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - L Abel
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - E Robie
- Duke Global Health Institute
| | - M Amunga
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - G Ambani
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | | | - E Garber
- Clinton Health Access Initiative (CHAI) Nigeria
| | - Nwamaka Eze
- Clinton Health Access Initiative (CHAI) Nigeria
| | | | - J A Gallis
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | | | - I Saran
- School of Social Work, Boston College
| | - A Woolsey
- Clinton Health Access Initiative (CHAI) Boston, Massachusetts
| | - T Visser
- Clinton Health Access Initiative (CHAI) Boston, Massachusetts
| | - E L Turner
- Department of Biostatistics & Bioinformatics and Duke Global Health Institute, Duke University, Durham, NC
| | - W Prudhomme O'Meara
- Duke Global Health Institute and Moi University School of Public Health, College of Health Science
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Soniran OT, Mensah BA, Cheng NI, Abuaku B, Ahorlu CS. Improved adherence to test, treat, and track (T3) malaria strategy among Over-the-Counter Medicine Sellers (OTCMS) through interventions implemented in selected rural communities of Fanteakwa North district, Ghana. Malar J 2022; 21:317. [PMID: 36335323 PMCID: PMC9636763 DOI: 10.1186/s12936-022-04338-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
Abstract
Background Prompt diagnosis and treatment of malaria prevents a mild case from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector where many patients with malaria-like symptoms first seek treatment. This study was aimed at improving implementation of the T3 policy among OTCMS using some interventions that could be scaled-up easily at the national level. Methods Interventions were evaluated using a two-arm, cluster randomized trial across 8 rural communities (4 clusters per arm), in two adjacent districts of Ghana. A total of 7 OTCMS in the intervention arm and 5 OTCMS in the control arm in the selected communities participated in the study. Five interventions were implemented in the intervention arm only. These were acquisition of subsidized malaria rapid diagnostic test (RDT) kits, training of OTCMS, supportive visits to OTCMS, community sensitization on malaria, and introduction of malaria surveillance tool. The primary outcome was the proportion of children under 10 years with fever or suspected to have malaria visiting OTCMS and getting tested (using RDT) before treatment. Secondary outcomes included OTCMS adherence to national malaria treatment guidelines and the recommended RDT retail price. Outcomes were measured using mystery client (an adult who pretends to be a real patient) surveys supplemented by a household survey. Proportions were compared using chi-square test or Fisher exact test. Results Following deployment of interventions, mystery client survey showed that OTCMS’ adherence to malaria protocol in the intervention arm increased significantly (p < 0.05) compared to the control arm. Household surveys in the intervention arm showed that caregivers self-treating their children or visiting drug vendors significantly decreased in favour of visits to OTCMS shops for treatment (p < 0.001). End-line malaria testing rate was higher compared with the baseline rate, though not statistically significant (30.8% vs 10.5%; p = 0.1238). OTCMS in the intervention arm also adhered to the subsidized RDT retail price of GHc2.40. Conclusion Interventions targeting OTCMS in rural communities have the potential of improving adherence to the T3 malaria policy and subsequently improving management of uncomplicated malaria in Ghana. Trial registration: ISRCTN registry ISRCTN77836926. Registered on 4 November 2019.
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Deletions of the Plasmodium falciparum histidine-rich protein 2/3 genes are common in field isolates from north-eastern Tanzania. Sci Rep 2022; 12:5802. [PMID: 35388127 PMCID: PMC8987040 DOI: 10.1038/s41598-022-09878-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/30/2022] [Indexed: 11/26/2022] Open
Abstract
Plasmodium falciparum parasites lacking histidine-rich protein 2 and 3 (pfhrp2/3) genes have been reported in several parts of the world. These deletions are known to compromise the effectiveness of HRP2-based malaria rapid diagnostic tests (HRP2-RDT). The National Malaria Control Programme (NMCP) in Tanzania adopted HRP2-RDTs as a routine tool for malaria diagnosis in 2009 replacing microscopy in many Health facilities. We investigated pfhrp2/3 deletions in 122 samples from two areas with diverse malaria transmission intensities in Northeastern Tanzania. Pfhrp2 deletion was confirmed in 1.6% of samples while pfhrp3 deletion was confirmed in 50% of samples. We did not find parasites with both pfhrp2 and pfhrp3 deletions among our samples. Results from this study highlight the need for systematic surveillance of pfhrp2/3 deletions in Tanzania to understand their prevalence and determine their impact on the performance of mRDT.
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Tougher S, Hanson K, Goodman CA. Does subsidizing the private for-profit sector benefit the poor? Evidence from national antimalarial subsidies in Nigeria and Uganda. HEALTH ECONOMICS 2021; 30:2510-2530. [PMID: 34291524 DOI: 10.1002/hec.4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 06/13/2023]
Abstract
Subsidising quality-assured artemisinin combination therapies (QAACTs) for distribution in the for-profit sector is a controversial strategy for improving access. The Affordable Medicines Facility-malaria (AMFm) was the largest initiative of this kind. We assessed the equity of AMFm in two ways using nationally representative household survey data on care seeking for children from Nigeria and Uganda. First, the delivery of subsidized drugs through the for-profit sector via AMFm was compared with two alternative mechanisms: subsidized delivery in public health facilities and unsubsidized delivery in the for-profit sector. Second, we developed a novel extension of benefit incidence analysis (BIA) methods based on the concept of pass-through, and applied them to Uganda. In Nigeria, the use of subsidized QAACTs from both public health facilities and for-profit outlets was concentrated among the rich, while in Uganda, the use of QAACTs from both sources was concentrated among the poor. Similarly, the BIA of AMFm found that the intervention was pro-poor in Uganda. Unsubsidized antimalarials from for-profit outlets were distributed equally across wealth quintiles in both countries. Private sector subsidies may have a role in bolstering access to effective malaria treatments, including among the poor, but the equity impact of subsidies may depend on context.
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Affiliation(s)
- Sarah Tougher
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Kara Hanson
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Catherine A Goodman
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
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Ashigbie PG, Shepherd S, Steiner KL, Amadi B, Aziz N, Manjunatha UH, Spector JM, Diagana TT, Kelly P. Use-case scenarios for an anti-Cryptosporidium therapeutic. PLoS Negl Trop Dis 2021; 15:e0009057. [PMID: 33705395 PMCID: PMC7951839 DOI: 10.1371/journal.pntd.0009057] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptosporidium is a widely distributed enteric parasite that has an increasingly appreciated pathogenic role, particularly in pediatric diarrhea. While cryptosporidiosis has likely affected humanity for millennia, its recent "emergence" is largely the result of discoveries made through major epidemiologic studies in the past decade. There is no vaccine, and the only approved medicine, nitazoxanide, has been shown to have efficacy limitations in several patient groups known to be at elevated risk of disease. In order to help frontline health workers, policymakers, and other stakeholders translate our current understanding of cryptosporidiosis into actionable guidance to address the disease, we sought to assess salient issues relating to clinical management of cryptosporidiosis drawing from a review of the literature and our own field-based practice. This exercise is meant to help inform health system strategies for improving access to current treatments, to highlight recent achievements and outstanding knowledge and clinical practice gaps, and to help guide research activities for new anti-Cryptosporidium therapies.
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Affiliation(s)
- Paul G. Ashigbie
- Novartis Institute for Tropical Diseases, Emeryville, California, United States of America
| | - Susan Shepherd
- Alliance for International Medical Action (ALIMA), Dakar, Senegal
| | - Kevin L. Steiner
- The Ohio State University, Columbus, Ohio, United States of America
| | - Beatrice Amadi
- Children’s Hospital, University Teaching Hospitals, Lusaka, Zambia
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Natasha Aziz
- Novartis Institute for Tropical Diseases, Emeryville, California, United States of America
| | - Ujjini H. Manjunatha
- Novartis Institute for Tropical Diseases, Emeryville, California, United States of America
| | - Jonathan M. Spector
- Novartis Institute for Tropical Diseases, Emeryville, California, United States of America
| | - Thierry T. Diagana
- Novartis Institute for Tropical Diseases, Emeryville, California, United States of America
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition Group, University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
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Bath D, Goodman C, Yeung S. Modelling the cost-effectiveness of introducing subsidised malaria rapid diagnostic tests in the private retail sector in sub-Saharan Africa. BMJ Glob Health 2020; 5:bmjgh-2019-002138. [PMID: 32439690 PMCID: PMC7247415 DOI: 10.1136/bmjgh-2019-002138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 11/18/2022] Open
Abstract
Background Over the last 10 years, there has been a huge shift in malaria diagnosis in public health facilities, due to widespread deployment of rapid diagnostic tests (RDTs), which are accurate, quick and easy to use and inexpensive. There are calls for RDTs to be made available at-scale in the private retail sector where many people with suspected malaria seek care. Retail sector RDT use in sub-Saharan Africa (SSA) is limited to small-scale studies, and robust evidence on value-for-money is not yet available. We modelled the cost-effectiveness of introducing subsidised RDTs and supporting interventions in the SSA retail sector, in a context of a subsidy programme for first-line antimalarials. Methods We developed a decision tree following febrile patients through presentation, diagnosis, treatment, disease progression and further care, to final health outcomes. We modelled results for three ‘treatment scenarios’, based on parameters from three small-scale studies in Nigeria (TS-N), Tanzania (TS-T) and Uganda (TS-U), under low and medium/high transmission (5% and 50% Plasmodium falciparum (parasite) positivity rates (PfPR), respectively). Results Cost-effectiveness varied considerably between treatment scenarios. Cost per disability-adjusted life year averted at 5% PfPR was US$482 (TS-N) and US$115 (TS-T) and at 50% PfPR US$44 (TS-N) and US$45 (TS-T), from a health service perspective. TS-U was dominated in both transmission settings. Conclusion The cost-effectiveness of subsidised RDTs is strongly influenced by treatment practices, for which further evidence is required from larger-scale operational settings. However, subsidised RDTs could promote increased use of first-line antimalarials in patients with malaria. RDTs may, therefore, be more cost-effective in higher transmission settings, where a greater proportion of patients have malaria and benefit from increased antimalarial use. This is contrary to previous public sector models, where RDTs were most cost-effective in lower transmission settings as they reduced unnecessary antimalarial use in patients without malaria.
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Affiliation(s)
- David Bath
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Shunmay Yeung
- Department of Clinical Research, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Taylor C, Linn A, Wang W, Florey L, Moussa H. Examination of malaria service utilization and service provision: an analysis of DHS and SPA data from Malawi, Senegal, and Tanzania. Malar J 2019; 18:258. [PMID: 31358005 PMCID: PMC6664566 DOI: 10.1186/s12936-019-2892-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background Ensuring universal access to malaria diagnosis and treatment is a key component of Pillar 1 of the World Health Organization Global Technical Strategy for Malaria 2016–2030. To achieve this goal it is essential to know the types of facilities where the population seeks care as well as the malaria service readiness of these facilities in endemic countries. Methods To investigate the utilization and provision of malaria services, data on the sources of advice or treatment in children under 5 years with fever from the household-based Demographic and Health Surveys (DHS) and on the components of malaria service readiness from the facility-based Service Provision Assessment (SPA) surveys were examined in Malawi, Senegal and Tanzania. Facilities categorized as malaria-service ready were those with: (1) personnel trained in either malaria rapid diagnostic testing (RDT), microscopy or case management/treatment of malaria in children; (2) national guidelines for the diagnosis and treatment of malaria; (3) diagnostic capacity (available RDT tests or microscopy equipment as well as staff trained in its use); and, (4) unexpired artemisinin-based combination therapy (ACT) available on the day of the survey. Results In all three countries primary-level facilities (health centre/health post/health clinic) were the type of facility most used for care of febrile children. However, only 69% of these facilities in Senegal, 32% in Malawi and 19% in Tanzania were classified as malaria-service ready. Of the four components of malaria-service readiness in the facilities most frequented by febrile children, diagnostic capacity was the weakest area in all three countries, followed by trained personnel. All three countries performed well in the availability of ACT. Conclusions This analysis highlights the need to improve the malaria-service readiness of facilities in all three countries. More effort should be focused on facilities that are commonly used for care of fever, especially in the areas of malaria diagnostic capacity and provider training. It is essential for policymakers to consider the malaria-service readiness of primary healthcare facilities when allocating resources. This is particularly important in limited-resource settings to ensure that the facilities most visited for care are properly equipped to provide diagnosis and treatment for malaria.
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Affiliation(s)
- Cameron Taylor
- The Demographic and Health Surveys (DHS) Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA.
| | - Annē Linn
- U.S. President's Malaria Initiative, USAID, Washington, DC, USA
| | - Wenjuan Wang
- The Demographic and Health Surveys (DHS) Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA
| | - Lia Florey
- U.S. President's Malaria Initiative, USAID, Washington, DC, USA
| | - Hamdy Moussa
- The Demographic and Health Surveys (DHS) Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD, 20850, USA
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Mpimbaza A, Nayiga S, Ndeezi G, Rosenthal PJ, Karamagi C, Katahoire A. Understanding the context of delays in seeking appropriate care for children with symptoms of severe malaria in Uganda. PLoS One 2019; 14:e0217262. [PMID: 31166968 PMCID: PMC6550380 DOI: 10.1371/journal.pone.0217262] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/08/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction A large proportion of children with uncomplicated malaria receive appropriate treatment late, contributing to progression of illness to severe disease. We explored contexts of caregiver delays in seeking appropriate care for children with severe malaria. Methods This qualitative study was conducted at the Children’s Ward of Jinja Hospital, where children with severe malaria were hospitalized. A total of 22in-depth interviews were conducted with caregivers of children hospitalized with severe malaria. Issues explored were formulated based on the Partners for Applied Social Sciences (PASS) model, focusing on facilitators and barriersto caregivers’promptseeking and accessing ofappropriate care. The data were coded deductively using ATLAS.ti (version 7.5). Codes were then grouped into families based on emerging themes. Results Caregivers’ rating of initial symptoms as mild illness lead to delays in response. Use of home initiated interventions with presumably ineffective herbs or medicines was common, leading to further delay. When care was sought outside the home, drug shops were preferred over public health facilities for reasons of convenience. Drug shops often provided sub-optimal care, and thus contributed to delays in access to appropriate care. Public facilities were often a last resort when illness was perceived to be progressing to severe disease. Further delays occurred at health facilities due to inadequate referral systems. Conclusion Communities living in endemic areas need to be sensitized about the significance of fever, even if mild, as an indicator of malaria. Additionally, amidst ongoing efforts at bringing antimalarial treatment services closer to communities, the value of drug shops as providers ofrationalantimalarialtreatment needs to be reviewed.
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Affiliation(s)
- Arthur Mpimbaza
- Child Health & Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
- * E-mail:
| | - Susan Nayiga
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Grace Ndeezi
- Department of Pediatrics & Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Philip J. Rosenthal
- Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Charles Karamagi
- Department of Pediatrics & Child Health, Makerere University, College of Health Sciences, Kampala, Uganda
- Clinical Epidemiology Unit, Department of Medicine, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Anne Katahoire
- Child Health & Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
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REASSURED diagnostics to inform disease control strategies, strengthen health systems and improve patient outcomes. Nat Microbiol 2018; 4:46-54. [PMID: 30546093 PMCID: PMC7097043 DOI: 10.1038/s41564-018-0295-3] [Citation(s) in RCA: 377] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 10/18/2018] [Indexed: 01/27/2023]
Abstract
Lack of access to quality diagnostics remains a major contributor to health burden in resource-limited settings. It has been more than 10 years since ASSURED (affordable, sensitive, specific, user-friendly, rapid, equipment-free, delivered) was coined to describe the ideal test to meet the needs of the developing world. Since its initial publication, technological innovations have led to the development of diagnostics that address the ASSURED criteria, but challenges remain. From this perspective, we assess factors contributing to the success and failure of ASSURED diagnostics, lessons learnt in the implementation of ASSURED tests over the past decade, and highlight additional conditions that should be considered in addressing point-of-care needs. With rapid advances in digital technology and mobile health (m-health), future diagnostics should incorporate these elements to give us REASSURED diagnostic systems that can inform disease control strategies in real-time, strengthen the efficiency of health care systems and improve patient outcomes.
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Cohen J, Saran I. The impact of packaging and messaging on adherence to malaria treatment: Evidence from a randomized controlled trial in Uganda. JOURNAL OF DEVELOPMENT ECONOMICS 2018; 134:68-95. [PMID: 30177864 PMCID: PMC6088513 DOI: 10.1016/j.jdeveco.2018.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/19/2018] [Accepted: 04/25/2018] [Indexed: 05/07/2023]
Abstract
Despite substantial public and private costs of non-adherence to infectious disease treatments, patients often do not finish their medication. We explore adherence to medication for malaria, a major cause of morbidity and health system costs in Africa. We conducted a randomized trial in Uganda testing specialized packaging and messaging, designed to increase antimalarial adherence. We find that stickers with short, targeted messages on the packaging increase adherence by 9% and reduce untaken pills by 29%. However, the currently used method of boosting adherence through costly, specialized packaging with pictorial instructions had no significant impacts relative to the standard control package. We develop a theoretical framework of the adherence decision, highlighting the role of symptoms, beliefs about being cured, and beliefs about drug effectiveness to help interpret our results. Patients whose symptoms resolve sooner are substantially less likely to adhere, and the sticker interventions have the strongest impact among these patients.
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Affiliation(s)
- Jessica Cohen
- Harvard T.H. Chan School of Public Health and J-PAL, Building 1, Room 1209, 665 Huntington Avenue, Boston, MA 02115, USA
| | - Indrani Saran
- Harvard T.H. Chan School of Public Health, Building 1, 665 Huntington Avenue, Boston, MA 02115, USA
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Ladner J, Davis B, Audureau E, Saba J. Treatment-seeking patterns for malaria in pharmacies in five sub-Saharan African countries. Malar J 2017; 16:353. [PMID: 28851358 PMCID: PMC5574241 DOI: 10.1186/s12936-017-1997-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 08/18/2017] [Indexed: 12/01/2022] Open
Abstract
Background Artemisinin-based combination therapy (ACT) is recommended as the first-line anti-malarial treatment strategy in sub-Saharan African countries. WHO policy recommends parasitological confirmation by microscopy or rapid diagnostic test (RDT) in all cases of suspected malaria prior to treatment. Gaps remain in understanding the factors that influence patient treatment-seeking behaviour and anti-malarial drug purchase decisions in the private sector. The objective of this study was to identify patient treatment-seeking behaviour in Ghana, Kenya, Nigeria, Tanzania, and Uganda. Methods Face-to-face patient interviews were conducted at a total of 208 randomly selected retail outlets in five countries. At each outlet, exit interviews were conducted with five patients who indicated they had come seeking anti-malarial treatment. The questionnaire was anonymous and standardized in the five countries and collected data on different factors, including socio-demographic characteristics, history of illness, diagnostic practices (i.e. microscopy or RDT), prescription practices and treatment purchase. The price paid for the treatment was also collected from the outlet vendor. Results A total of 994 patients were included from the five countries. Location of malaria diagnosis was significantly different in the five countries. A total of 484 blood diagnostic tests were performed, (72.3% with microscopy and 27.7% with RDT). ACTs were purchased by 72.5% of patients who had undergone blood testing and 86.5% of patients without a blood test, regardless of whether the test result was positive or negative (p < 10−4). A total of 531 patients (53.4%) had an anti-malarial drug prescription, of which 82.9% were prescriptions for an ACT. There were significant differences in prescriptions by country. A total of 923 patients (92.9%) purchased anti-malarial drugs in an outlet, including 79.1% of patients purchasing an ACT drug: 98.0% in Ghana, 90.5% in Kenya, 80.4% in Nigeria, 69.2% in Tanzania, and 57.7% in Uganda (p < 10−4). Having a drug prescription was not a significant predictive factor associated with an ACT drug purchase (except in Kenya). The number of ACT drugs purchased with a prescription was greater than the number purchased without a prescription in Kenya, Nigeria and Tanzania. Conclusions This study highlights differences in drug prescription and purchase patterns in five sub-Saharan African countries. The private sector is playing an increasingly important role in fever case management in sub-Saharan Africa. Understanding the characteristics of private retail outlets and the role they play in providing anti-malaria drugs may support the design of effective malaria interventions.
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Affiliation(s)
- Joël Ladner
- Rouen University Hospital, Epidemiology and Health Promotion Department, Hôpital Charles Nicolle, 1 Rue de Germont, 76 031, Rouen Cedex, France.
| | | | - Etienne Audureau
- Paris Est University Hôpital, Henri Mondor Hospital, Public Health, Assistance Publique Hôpitaux de Paris, Créteil, France
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Saran I, Maffioli EM, Menya D, O'Meara WP. Household beliefs about malaria testing and treatment in Western Kenya: the role of health worker adherence to malaria test results. Malar J 2017; 16:349. [PMID: 28830439 PMCID: PMC5568326 DOI: 10.1186/s12936-017-1993-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/10/2017] [Indexed: 12/02/2022] Open
Abstract
Background Although use of malaria diagnostic tests has increased in recent years, health workers often prescribe anti-malarial drugs to individuals who test negative for malaria. This study investigates how health worker adherence to malaria case management guidelines influences individuals’ beliefs about whether their illness was malaria, and their confidence in the effectiveness of artemisinin-based combination therapy (ACT). Methods A survey was conducted with 2065 households in Western Kenya about a household member’s treatment actions for a recent febrile illness. The survey also elicited the individual’s (or their caregiver’s) beliefs about the illness and about malaria testing and treatment. Logistic regressions were used to test the association between these beliefs and whether the health worker adhered to malaria testing and treatment guidelines. Results Of the 1070 individuals who visited a formal health facility during their illness, 82% were tested for malaria. ACT rates for malaria-positive and negative individuals were 89 and 49%, respectively. Overall, 65% of individuals/caregivers believed that the illness was “very likely” malaria. Individuals/caregivers had higher odds of saying that the illness was “very likely” malaria when the individual was treated with ACT, and this was the case both among individuals not tested for malaria [adjusted odds ratio (AOR) 3.42, 95% confidence interval (CI) [1.65 7.10], P = 0.001] and among individuals tested for malaria, regardless of their test result. In addition, 72% of ACT-takers said the drug was “very likely” effective in treating malaria. However, malaria-negative individuals who were treated with ACT had lower odds of saying that the drugs were “very likely” effective than ACT-takers who were not tested or who tested positive for malaria (AOR 0.29, 95% CI [0.13 0.63], P = 0.002). Conclusion Individuals/caregivers were more likely to believe that the illness was malaria when the patient was treated with ACT, regardless of their test result. Moreover, malaria-negative individuals treated with ACT had lower confidence in the drug than other individuals who took ACT. These results suggest that ensuring health worker adherence to malaria case management guidelines will not only improve ACT targeting, but may also increase patient/caregivers’ confidence in malaria testing and treatment. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1993-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Indrani Saran
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.
| | | | - Diana Menya
- School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Wendy Prudhomme O'Meara
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, 27701, USA.,School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya.,Duke University Medical Center, Duke University, Durham, USA
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Bennett A, Avanceña ALV, Wegbreit J, Cotter C, Roberts K, Gosling R. Engaging the private sector in malaria surveillance: a review of strategies and recommendations for elimination settings. Malar J 2017; 16:252. [PMID: 28615026 PMCID: PMC5471855 DOI: 10.1186/s12936-017-1901-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 06/07/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In malaria elimination settings, all malaria cases must be identified, documented and investigated. To facilitate complete and timely reporting of all malaria cases and effective case management and follow-up, engagement with private providers is essential, particularly in settings where the private sector is a major source of healthcare. However, research on the role and performance of the private sector in malaria diagnosis, case management and reporting in malaria elimination settings is limited. Moreover, the most effective strategies for private sector engagement in malaria elimination settings remain unclear. METHODS Twenty-five experts in malaria elimination, disease surveillance and private sector engagement were purposively sampled and interviewed. An extensive review of grey and peer-reviewed literature on private sector testing, treatment, and reporting for malaria was performed. Additional in-depth literature review was conducted for six case studies on eliminating and neighbouring countries in Southeast Asia and Southern Africa. RESULTS The private health sector can be categorized based on their commercial orientation or business model (for-profit versus nonprofit) and their regulation status within a country (formal vs informal). A number of potentially effective strategies exist for engaging the private sector. Conducting a baseline assessment of the private sector is critical to understanding its composition, size, geographical distribution and quality of services provided. Facilitating reporting, referral and training linkages between the public and private sectors and making malaria a notifiable disease are important strategies to improve private sector involvement in malaria surveillance. Financial incentives for uptake of rapid diagnostic tests and artemisinin-based combination therapy should be combined with training and community awareness campaigns for improving uptake. Private sector providers can also be organized and better engaged through social franchising, effective regulation, professional organizations and government outreach. CONCLUSION This review highlights the importance of engaging private sector stakeholders early and often in the development of malaria elimination strategies.
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Affiliation(s)
- Adam Bennett
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA 94158 USA
| | - Anton L. V. Avanceña
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Jennifer Wegbreit
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Chris Cotter
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Kathryn Roberts
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
| | - Roly Gosling
- Malaria Elimination Initiative, UCSF Global Health Group, 550 16th Street, 3rd Floor, San Francisco, CA 94158 USA
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA 94158 USA
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Hanson K, Goodman C. Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015. Malar J 2017; 16:205. [PMID: 28526075 PMCID: PMC5438573 DOI: 10.1186/s12936-017-1829-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background The World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors. Results Repeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores—which are the most common source of anti-malarial medicines—was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5–2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs. Conclusions Significant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1829-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Incardona S, Serra-Casas E, Champouillon N, Nsanzabana C, Cunningham J, González IJ. Global survey of malaria rapid diagnostic test (RDT) sales, procurement and lot verification practices: assessing the use of the WHO-FIND Malaria RDT Evaluation Programme (2011-2014). Malar J 2017; 16:196. [PMID: 28506275 PMCID: PMC5433078 DOI: 10.1186/s12936-017-1850-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 05/09/2017] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Malaria rapid diagnostic tests (RDTs) play a critical role in malaria case management, and assurance of quality is a key factor to promote good adherence to test results. Since 2007, the World Health Organization (WHO) and the Foundation for Innovative New Diagnostics (FIND) have coordinated a Malaria RDT Evaluation Programme, comprising a pre-purchase performance evaluation (product testing, PT) and a pre-distribution quality control of lots (lot testing, LT), the former being the basis of WHO recommendations for RDT procurement. Comprehensive information on malaria RDTs sold worldwide based on manufacturers' data and linked to independent performance data is currently not available, and detailed knowledge of procurement practices remains limited. METHODS The use of the PT/LT Programme results as well as procurement and lot verification practices were assessed through a large-scale survey, gathering product-specific RDT sales and procurement data (2011-14 period) from a total of 32 manufacturers, 12 procurers and 68 National Malaria Control Programmes (NMCPs). RESULTS Manufacturers' reports showed that RDT sales had more than doubled over the four years, and confirmed a trend towards increased compliance with the WHO procurement criteria (from 83% in 2011 to 93% in 2014). Country-level reports indicated that 74% of NMCPs procured only 'WHO-compliant' RDT products, although procurers' transactions datasets revealed a surprisingly frequent overlap of different products and even product types (e.g., Plasmodium falciparum-only and Plasmodium-pan) in the same year and country (60 and 46% of countries, respectively). Importantly, the proportion of 'non-complying' (i.e., PT low scored or not evaluated) products was found to be higher in the private health care sector than in the public sector (32% vs 5%), and increasing over time (from 22% of private sector sales in 2011 to 39% in 2014). An estimated 70% of the RDT market was covered by the LT programme. The opinion about the PT/LT Programmes was positive overall, and quality of RDTs as per the PT Programme was rated as the number one procurement criteria. CONCLUSIONS This survey provided in-depth information on RDT sales and procurement dynamics, including the largely unstudied private sector, and demonstrated how the WHO-FIND Programme has positively influenced procurement practices in the public sector.
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Affiliation(s)
| | | | | | | | - Jane Cunningham
- Global Malaria Programme, World Health Organization (WHO-GMP), Geneva, Switzerland
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Phok S, Phanalasy S, Thein ST, Likhitsup A. Private sector opportunities and threats to achieving malaria elimination in the Greater Mekong Subregion: results from malaria outlet surveys in Cambodia, the Lao PDR, Myanmar, and Thailand. Malar J 2017; 16:180. [PMID: 28464945 PMCID: PMC5414126 DOI: 10.1186/s12936-017-1800-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 04/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this paper is to review multi-country evidence of private sector adherence to national regulations, guidelines, and quality-assurance standards for malaria case management and to document current coverage of private sector engagement and support through ACTwatch outlet surveys implemented in 2015 and 2016. Results Over 76,168 outlets were screened, and approximately 6500 interviews were conducted (Cambodia, N = 1303; the Lao People’s Democratic Republic (PDR), N = 724; Myanmar, N = 4395; and Thailand, N = 74). There was diversity in the types of private sector outlets providing malaria treatment across countries, and the extent to which they were authorized to test and treat for malaria differed. Among outlets stocking at least one anti-malarial, public sector availability of the first-line treatment for uncomplicated Plasmodium falciparum or Plasmodium vivax malaria was >75%. In the anti-malarial stocking private sector, first-line treatment availability was variable (Cambodia, 70.9%; the Lao PDR, 40.8%; Myanmar P. falciparum = 42.7%, P. vivax = 19.6%; Thailand P. falciparum = 19.6%, P. vivax = 73.3%), as was availability of second-line treatment (the Lao PDR, 74.9%; Thailand, 39.1%; Myanmar, 19.8%; and Cambodia, 0.7%). Treatment not in the National Treatment Guidelines (NTGs) was most common in Myanmar (35.8%) and Cambodia (34.0%), and was typically stocked by the informal sector. The majority of anti-malarials distributed in Cambodia and Myanmar were first-line P. falciparum or P. vivax treatments (90.3% and 77.1%, respectively), however, 8.8% of the market share in Cambodia was treatment not in the NTGs (namely chloroquine) and 17.6% in Myanmar (namely oral artemisinin monotherapy). In the Lao PDR, approximately 9 in 10 anti-malarials distributed in the private sector were second-line treatments—typically locally manufactured chloroquine. In Cambodia, 90% of anti-malarials were distributed through outlets that had confirmatory testing available. Over half of all anti-malarial distribution was by outlets that did not have confirmatory testing available in the Lao PDR (54%) and Myanmar (59%). Availability of quality-assured rapid diagnostic tests (RDT) amongst the RDT-stocking public sector ranged from 99.3% in the Lao PDR to 80.1% in Cambodia. In Cambodia, the Lao PDR, and Myanmar, less than 50% of the private sector reportedly received engagement (access to subsidized commodities, supervision, training or caseload reporting), which was most common among private health facilities and pharmacies. Conclusions Findings from this multi-country study suggest that Cambodia, the Lao PDR, Myanmar, and Thailand are generally in alignment with national regulations, treatment guidelines, and quality-assurance standards. However, important gaps persist in the private sector which pose a threat to national malaria control and elimination goals. Several options are discussed to help align the private sector anti-malarial market with national elimination strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-1800-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Sochea Phok
- Population Services Khmer, 29 334 St, Boeung Keng Kang, P. O. Box 258, Phnom Penh, Cambodia
| | - Saysana Phanalasy
- Population Services International Lao PDR, T4 Road Unit 16, Donkai Village, P. O. Box 8723, Vientiane, Lao People's Democratic Republic
| | - Si Thu Thein
- Population Services International Myanmar, 16 West Shwe Gone Dine 4th St, Bahan Township, Yangon, Myanmar
| | - Asawin Likhitsup
- , 108/210 Siphraya River View Condo, Yotha Rd, Sampanthawong, Bangkok, 10100, Thailand
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Bennett A, Bisanzio D, Yukich JO, Mappin B, Fergus CA, Lynch M, Cibulskis RE, Bhatt S, Weiss DJ, Cameron E, Gething PW, Eisele TP. Population coverage of artemisinin-based combination treatment in children younger than 5 years with fever and Plasmodium falciparum infection in Africa, 2003-2015: a modelling study using data from national surveys. Lancet Glob Health 2017; 5:e418-e427. [PMID: 28288746 PMCID: PMC5450656 DOI: 10.1016/s2214-109x(17)30076-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 01/12/2017] [Accepted: 01/13/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Artemisinin-based combination therapies (ACTs) are the most effective treatment for uncomplicated Plasmodium falciparum malaria infection. A commonly used indicator for monitoring and assessing progress in coverage of malaria treatment is the proportion of children younger than 5 years with reported fever in the previous 14 days who have received an ACT. We propose an improved indicator that incorporates parasite infection status (as assessed by a rapid diagnostic test [RDT]), which is available in recent household surveys. In this study we estimated the annual proportion of children younger than 5 years with fever and a positive RDT in Africa who received an ACT in 2003-15. METHODS Our modelling study used cross-sectional data on treatment for fever and RDT status for children younger than 5 years compiled from all nationally available representative household surveys (the Malaria Indicator Surveys, Demographic and Health Surveys, and Multiple Indicator Cluster Surveys) across sub-Saharan Africa between 2003 and 2015. Estimates for the proportion of children younger than 5 years with a fever within the previous 14 days and P falciparum infection assessed by RDT who received an ACT were incorporated in a generalised additive mixed model, including data on ACT distributions, to estimate coverage across all countries and time periods. We did random effects meta-analyses to examine individual, household, and community effects associated with ACT coverage. FINDINGS We obtained data on 201 704 children younger than 5 years from 103 surveys (22 MIS, 61 DHS, and 20 MICS) across 33 countries. RDT results were available for 40 of these surveys including 40 261 (20%) children, and we predicted RDT status for the remaining 161 443 (80%) children. Our results showed that ACT coverage in children younger than 5 years with a fever and P falciparum infection increased across sub-Saharan Africa in 2003-15, but even in 2015, only 19·7% (95% CI 15·6-24·8) of children younger than 5 years with a fever and P falciparum infection received an ACT. In meta-analyses, children younger than 5 years were more likely to receive an ACT for fever and P falciparum infection if they lived in an urban area (vs rural area; odds ratio [OR] 1·18, 95% CI 1·06-1·31), had household wealth above the national median (vs wealth below the median; OR 1·26, 1·16-1·39), had a caregiver with any education (vs no education; OR 1·31, 1·22-1·41), had a household insecticide-treated net (ITN; vs no ITN; OR 1·21, 1·13-1·29), were older than 2 years (vs ≤2 years; OR 1·09, 1·01-1·17), or lived in an area with a higher mean P falciparum prevalence in children aged 2-10 years (OR 1·12, 1·02-1·23). In the subgroup of children for whom treatment was sought, those who sought treatment in the public sector were more likely to receive an ACT (vs the private sector; OR 3·18, 2·67-3·78). INTERPRETATION Despite progress during the 2003-15 malaria programme, ACT treatment for children with malaria remains unacceptably low. More work is needed at the country level to understand how health-care access, service delivery, and ACT supply might be improved to ensure appropriate treatment for all children with malaria. FUNDING US President's Malaria Initiative and Medicines for Malaria Venture.
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Affiliation(s)
- Adam Bennett
- Malaria Elimination Initiative, Global Health Group, University of San Francisco, San Francisco, CA, USA.
| | - Donal Bisanzio
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Joshua O Yukich
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Bonnie Mappin
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Michael Lynch
- World Health Organization, Geneva, Switzerland; US Centers for Disease Control, Atlanta, GA, USA
| | | | - Samir Bhatt
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Daniel J Weiss
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ewan Cameron
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Peter W Gething
- Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas P Eisele
- Center for Applied Malaria Research and Evaluation, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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21
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Visser T, Bruxvoort K, Maloney K, Leslie T, Barat LM, Allan R, Ansah EK, Anyanti J, Boulton I, Clarke SE, Cohen JL, Cohen JM, Cutherell A, Dolkart C, Eves K, Fink G, Goodman C, Hutchinson E, Lal S, Mbonye A, Onwujekwe O, Petty N, Pontarollo J, Poyer S, Schellenberg D, Streat E, Ward A, Wiseman V, Whitty CJM, Yeung S, Cunningham J, Chandler CIR. Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review. PLoS One 2017; 12:e0173093. [PMID: 28253315 PMCID: PMC5333947 DOI: 10.1371/journal.pone.0173093] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. Methods Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. Results Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. Conclusions Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.
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Affiliation(s)
- Theodoor Visser
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail:
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kathleen Maloney
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Toby Leslie
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lawrence M. Barat
- US President’s Malaria Initiative, United States Agency for International Development, Washington DC, United States of America
| | | | - Evelyn K. Ansah
- Research & Development Division, Ghana Health Service, Accra, Ghana
| | | | - Ian Boulton
- TropMed Pharma Consulting, Lower Shiplake, Oxfordshire, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jessica L. Cohen
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Justin M. Cohen
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | - Caitlin Dolkart
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Katie Eves
- Mentor Initiative, West Sussex, United Kingdom
| | - Günther Fink
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sham Lal
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Nora Petty
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | | | - David Schellenberg
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Abigail Ward
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health and Community Medicine, University of New South Wales, UNSW, Sydney, Australia
| | - Christopher J. M. Whitty
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jane Cunningham
- Global Malaria Program, World Health Organization, Geneva, Switzerland
| | - Clare I. R. Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Ezennia IJ, Nduka SO, Ekwunife OI. Cost benefit analysis of malaria rapid diagnostic test: the perspective of Nigerian community pharmacists. Malar J 2017; 16:7. [PMID: 28049466 PMCID: PMC5210296 DOI: 10.1186/s12936-016-1648-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 12/15/2016] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Sunday Odunke Nduka
- Department of Clinical Pharmacy and Pharmacy Management, Nnamdi Azikiwe University, Awka, Nigeria
| | - Obinna Ikechukwu Ekwunife
- Department of Clinical Pharmacy and Pharmacy Management, Nnamdi Azikiwe University, Awka, Nigeria. .,Collaborative Research Group for Evidence-Based Public Health, Department of Prevention and Evaluation, Leibniz Institute for Prevention Research and Epidemiology - BIPS / University of Bremen, Bremen, Germany.
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23
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Ducrotoy MJ, Bardosh KL. How do you get the Rose Bengal Test at the point-of-care to diagnose brucellosis in Africa? The importance of a systems approach. Acta Trop 2017; 165:33-39. [PMID: 27725154 DOI: 10.1016/j.actatropica.2016.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 12/23/2022]
Abstract
Brucellosis is a major neglected zoonotic disease, whose burden both in animals and humans is severely under-reported. Diagnosis in humans identifies cases in order to treat the disease at the individual level. In animals diagnosis is implemented at the population level in the context of appropriate control or eradication strategies. Molecular and bacteriological diagnosis are rarely undertaken in sub-Saharan Africa, at least outside research projects, due to cost, skills and laboratory infrastructure issues. The brucellosis toolbox contains a wide range of serological tests, but the perfect test for use in animals and humans respectively does not exist. Drug and diagnostic discovery for the neglected zoonoses are notoriously poor, and there is limited investment interest in developing new tools for brucellosis diagnosis. But are current tools being used to their full capacity? The rose Bengal test (RBT) stands out as an efficient, practical and very cheap test adapted for use in the resource-poor context. In this paper, we argue that a social science or system's approach to explore the practicality of improving diagnostic capacity at the point-of care in high-risk brucellosis areas of rural Africa may be a step towards solving the issue of under-diagnosis, but this must go hand-in-hand with implementation of control measures at source in the animal reservoir and capacity to treat human cases.
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Affiliation(s)
- Marie J Ducrotoy
- Division of Infection and Pathway Medicine, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
| | - Kevin L Bardosh
- Division of Infection and Pathway Medicine, School of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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24
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Novotny J, Singh A, Dysoley L, Sovannaroth S, Rekol H. Evidence of successful malaria case management policy implementation in Cambodia: results from national ACTwatch outlet surveys. Malar J 2016; 15:194. [PMID: 27059952 PMCID: PMC4826540 DOI: 10.1186/s12936-016-1200-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 03/01/2016] [Indexed: 01/11/2023] Open
Abstract
Background For over a decade, Cambodia has implemented a number of policies and innovative strategies to increase access to quality malaria case management services and address the drivers of multi-drug resistance. This paper utilizes outlet survey trend data collected by the ACTwatch project to demonstrate how changes in Cambodian policy and strategies have led to shifts in anti-malarial markets. Methods Anti-malarial ACTwatch outlet surveys were conducted in Cambodia in 2009 (June–July), 2011 (June–August) and 2013 (September–October). A census of all outlets with the potential to sell or distribute anti-malarials was conducted within a nationally representative sample of communes. Drug information, sales/distribution in the previous week, and retail price were collected for each anti-malarial in stock. Information on availability of malaria blood testing was also collected. Results A total of 7833 outlets were enumerated in 2009, 18,584 in 2011, and 16,153 in 2013. The percentage of public health facilities with at least one anti-malarial in stock on the day of the survey increased between 2009 (65.8 %) and 2011 (90.0 %) and remained high in 2013 (82.0 %). Similar trends were found for village malaria workers (VMW). Overall, private sector availability of anti-malarials declined over time and varied by outlet type. By 2013 most anti-malarial stocking public health facilities (81.5 %), VMW (95.4 %), private for-profit health facilities (64.8 %), and pharmacies (71.9 %) had the countries first-line artemisinin-based combination therapy (ACT) treatment in stock. In 2013, 60 % of anti-malarials were delivered through the private sector, 40 % through the public sector, and the most common anti-malarial to be sold or distributed was the first-line ACT, comprising 62.8 % of the national market share. Oral artemisinin monotherapy, which had accounted for 6 % of total anti-malarial market share in 2009, was no longer reportedly sold/distributed in 2013. Malaria blood testing availability remained high over time among public facilities and VMW, with availability over 90 % in 2011 and 2013. Moderate availability was observed in the private sector. Conclusions Continued implementation of successful public and private sector strategies in support of evolving malaria drug treatment policies will be important to protect the efficacy of anti-malarial medicines and ultimately facilitate malaria elimination in Cambodia by 2025. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1200-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Joe Novotny
- Clinton Health Access Initiative, #7B, Str. 81 and corner Str. 109, Sangkat Boeung Raing, Khan Don Penh, Phnom Penh, Cambodia
| | - Amandeep Singh
- Clinton Health Access Initiative, #7B, Str. 81 and corner Str. 109, Sangkat Boeung Raing, Khan Don Penh, Phnom Penh, Cambodia
| | - Lek Dysoley
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia.,School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Siv Sovannaroth
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia
| | - Huy Rekol
- Cambodia National Centre of Entomology, Parasitological and Malaria control, House 372, St Monivong Vong, Boeung Keng Kang I, Chamcar Mon, Phnom Penh, Cambodia
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Boadu NY, Amuasi J, Ansong D, Einsiedel E, Menon D, Yanow SK. Challenges with implementing malaria rapid diagnostic tests at primary care facilities in a Ghanaian district: a qualitative study. Malar J 2016; 15:126. [PMID: 26921263 PMCID: PMC4769585 DOI: 10.1186/s12936-016-1174-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 02/17/2016] [Indexed: 12/19/2022] Open
Abstract
Background Rapid diagnostic Tests (RDTs) for malaria enable diagnostic testing at primary care facilities in resource-limited settings, where weak infrastructure limits the use of microscopy. In 2010, Ghana adopted a test-before-treat guideline for malaria, with RDT use promoted to facilitate diagnosis. Yet healthcare practitioners still treat febrile patients without testing, or despite negative malaria test results. Few studies have explored RDT implementation beyond the notions of provider or patient acceptability. The aim of this study was to identify the factors directly influencing malaria RDT implementation at primary care facilities in a Ghanaian district. Methods Qualitative interviews, focus groups and direct observations were conducted with 50 providers at six purposively selected primary care facilities in the Atwima–Nwabiagya district. Data were analysed thematically. Results RDT implementation was hampered by: (1) healthcare delivery constraints (weak supply chain, limited quality assurance and control, inadequate guideline emphasis, staffing limitations); (2) provider perceptions (entrenched case-management paradigms, limited preparedness for change); (3) social dynamics of care delivery (expected norms of provider-patient interaction, test affordability); and (4) limited provider engagement in policy processes leading to fragmented implementation of health sector reform. Conclusion Limited health system capacity, socio-economic, political, and historical factors hampered malaria RDT implementation at primary care facilities in the study district. For effective RDT implementation providers must be: (1) adequately enabled through efficient allocation and management of essential healthcare commodities; (2) appropriately empowered with the requisite knowledge and skill through ongoing, effective professional development; and (3) actively engaged in policy dialogue to demystify socio-political misconceptions that hinder health sector reform policies from improving care delivery. Clear, consistent guideline emphasis, with complementary action to address deep-rooted provider concerns will build their confidence in, and promote uptake of recommended policies, practices, and technology for diagnosing malaria.
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Affiliation(s)
- Nana Yaa Boadu
- School of Public Health, University of Alberta, Edmonton, Canada. .,Nursing Best Practices Research Center, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
| | - John Amuasi
- Kumasi Collaborative Center for Research in Tropical Medicine, (EOD Group) KNUST, Kumasi, Ghana.
| | - Daniel Ansong
- Research and Development Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Edna Einsiedel
- Department of Communication and Culture, University of Calgary, Calgary, AB, Canada.
| | - Devidas Menon
- Health Technology and Policy Unit, School of Public Health, University of Alberta, Edmonton, Canada.
| | - Stephanie K Yanow
- School of Public Health, University of Alberta, Edmonton, Canada. .,Alberta Provincial Laboratory for Public Health, Edmonton, Canada.
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26
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Visser T, Daily J, Hotte N, Dolkart C, Cunningham J, Yadav P. Rapid diagnostic tests for malaria. Bull World Health Organ 2015; 93:862-6. [PMID: 26668438 PMCID: PMC4669726 DOI: 10.2471/blt.14.151167] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 08/20/2015] [Accepted: 08/25/2015] [Indexed: 11/27/2022] Open
Abstract
Maintaining quality, competitiveness and innovation in global health technology is a constant challenge for manufacturers, while affordability, access and equity are challenges for governments and international agencies. In this paper we discuss these issues with reference to rapid diagnostic tests for malaria. Strategies to control and eliminate malaria depend on early and accurate diagnosis. Rapid diagnostic tests for malaria require little training and equipment and can be performed by non-specialists in remote settings. Use of these tests has expanded significantly over the last few years, following recommendations to test all suspected malaria cases before treatment and the implementation of an evaluation programme to assess the performance of the malaria rapid diagnostic tests. Despite these gains, challenges exist that, if not addressed, could jeopardize the progress made to date. We discuss recent developments in rapid diagnostic tests for malaria, highlight some of the challenges and provide suggestions to address them.
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Affiliation(s)
- Theodoor Visser
- Clinton Health Access Initiative, Inc., 383 Dorchester Avenue, Suite 400, Boston, MA 02127, United States of America (USA)
| | | | - Nora Hotte
- William Davidson Institute, University of Michigan, Ann Arbor, USA
| | - Caitlin Dolkart
- Clinton Health Access Initiative, Inc., 383 Dorchester Avenue, Suite 400, Boston, MA 02127, United States of America (USA)
| | - Jane Cunningham
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Prashant Yadav
- William Davidson Institute, University of Michigan, Ann Arbor, USA
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