The Impact of Retail-Sector Delivery of Artemether-Lumefantrine on Malaria Treatment of Children under Five in Kenya: A Cluster Randomized Controlled Trial
Abstract
Background It has been proposed that artemisinin-based combination therapy (ACT) be subsidised in the private sector in order to improve affordability and access. This study in western Kenya aimed to evaluate the impact of providing subsidized artemether-lumefantrine (AL) through retail providers on the coverage of prompt, effective antimalarial treatment for febrile children aged 3-59 months.
Methods and Findings
We used a cluster-randomized, controlled design with nine control and
nine intervention sublocations, equally distributed across three
districts in western Kenya. Cross-sectional household surveys were
conducted before and after the delivery of the intervention. The
intervention comprised provision of subsidized packs of paediatric ACT
to retail outlets, training of retail outlet staff, and community
awareness activities. The primary outcome was defined as the proportion
of children aged 3–59 months reporting fever in the past 2 weeks who
started treatment with AL on the same day or following day of fever
onset. Data were collected using structured questionnaires and analyzed
based on cluster-level summaries, comparing control to intervention
arms, while adjusting for other covariates. Data were collected on 2,749
children in the target age group at baseline and 2,662 at follow-up. 29%
of children experienced fever within 2 weeks before the interview. At
follow-up, the percentage of children receiving AL on the day of fever
or the following day had risen by 14.6% points in the control arm (from
5.3% [standard deviation (SD): 3.2%] to 19.9% [SD: 10.0%]) and 40.2%
points in the intervention arm (from 4.7% [SD: 3.4%] to 44.9% [SD:
11.7%]). The percentage of children receiving AL was significantly
greater in the intervention arm at follow-up, with a difference between
the arms of 25.0% points (95% confidence interval [CI]: 14.1%, 35.9%;
unadjusted p = 0.0002, adjusted p = 0.0001). No significant differences
were observed between arms in the proportion of caregivers who sought
treatment for their child's fever by source, or in the child's
adherence to AL.
Conclusions
Subsidizing ACT in the retail sector can significantly increase ACT
coverage for reported fevers in rural areas. Further research is needed
on the impact and cost-effectiveness of such subsidy programmes at a
national scale.
Citation
PLoS Med (2011) 8 (5): e1000437 [doi:10.1371/journal.pmed.1000437]