Malaria diagnostic testing and conditional subsidies to target ACTs in the retail sector: the TESTsmART trial

项目摘要-TESTsmART试验 2016年，世界卫生组织估计，全球发生了2.16亿疟疾病例，但超过4亿 使用一线抗疟疾药物(青蒿素联合疗法或ACT)的疗程。这 ACTS的大量过度使用在很大程度上是由私营零售部门推动的。亚洲区超过一半的家庭 撒哈拉非洲在零售药店寻求发烧疾病的治疗，那里有ACT- 反之，但疟疾诊断测试实际上是不存在的，而且假定治疗发烧就像疟疾是 诺曼。廉价、捐赠者资助的ACTs的提供和诊断检测的缺乏导致了非常 对有需要的人采取行动的针对性不强。没有疟疾的人消耗65%-90%的 通过零售渠道分发的行为。不必要的ACTs消费是对稀缺公共卫生的消耗 资源，并威胁到未来公共资助补贴的可持续性。此外，它还让在场的人 并通过加速耐药性的传播而使未来的患者处于危险之中。尽管准确的看护点 疟疾的诊断方法(称为快速诊断测试或RDT)是可用的，但在零售业中并不常见 在已经尝试过的地方，它们对适当使用ACT的影响往往很小。我们假设 供应商和客户关于检测和治疗的决定都受到价格(或 利润)。针对这一点，我们建议测试一种可扩展的策略相关策略，该策略将测试和 为客户提供治疗补贴，并激励提供者检测疟疾。ACT补贴将是 仅对疟疾检测呈阳性的客户提供(有条件的ACT补贴)。差异化ACT定价 客户基于诊断测试的结果，结合提供商对测试的奖励，将使两者保持一致 消费者和供应商通过测试和适当的ACT使用来激励(价格和利润)。在目标1中，我们将 在肯尼亚使用一个单独随机的实验来测试两个水平的RDT补贴和两个 有条件的ACT补贴水平，用于检测寻求治疗疟疾的零售直销客户的吸收率- 就像疾病一样。在目标2中，我们将扩大检测和治疗补贴的组合，使最大限度地 在目标1中测试比率，并测试其影响，以及对供应商的测试激励，以确定ACT目标 在肯尼亚和尼日利亚进行了一项整群随机对照试验。我们的做法将确保公共补贴 针对确诊的疟疾病例，从而加强这类方案的可持续性。通过分配 检测和有条件治疗的补贴金额(而不是普遍的、仅限治疗的补贴)， 我们可以减少补贴疟疾治疗的成本，并在不妥协的情况下提高对ACTs的针对性 进入。

Project Summary—TESTsmART Trial In 2016, the WHO estimated that 216 million cases of malaria occurred worldwide, yet more than 400 million treatment courses of first-line antimalarials (artemisinin combination therapy or ACT) were consumed. This substantial overuse of ACTs is driven in large part by the private retail sector. More than half of families in sub- Saharan Africa seek treatment for febrile illness in retail medicine outlets where ACT is available over-the- counter, but malaria diagnostic testing is virtually absent and presumptive treatment of fever as malaria is the norm. Availability of inexpensive, donor-subsidized ACTs and the absence of diagnostic testing lead to very poor targeting of ACTs to people who need them. Individuals without malaria consume between 65-90% of ACTs distributed through retail outlets. Unnecessary consumption of ACTs is a drain on scarce public health resources and threatens the future sustainability of publicly-funded subsidies. In addition, it puts both present and future patients at risk by accelerating the spread of drug resistance. Although accurate point of care diagnostics are available for malaria (called rapid diagnostic tests or RDTs), they are uncommon in the retail sector and, where they have been tried, their impact on appropriate ACT use is often poor. We hypothesize that both providers and clients’ decisions about testing and treatment are strongly influenced by price (or profit). In response to this, we propose to test a scalable, policy-relevant strategy that integrates testing and treatment subsidies for the client, with incentives to the provider to test for malaria. ACT subsidies will be available only to customers with a positive malaria test (conditional ACT subsidy). Differential ACT pricing for clients based on the results of the diagnostic test, combined with provider rewards for testing, will align both consumers and providers incentives (price and profit) with testing and appropriate ACT use. In Aim 1, we will use an individually-randomized experiment in Kenya to test the effect of two levels of RDT subsidies and two levels of conditional ACT subsidies on testing uptake among retail outlet clients seeking treatment for malaria- like illnesses. In Aim 2, we will scale-up the combination of testing and treatment subsidies that maximized testing rates in Aim 1 and test their impact, along with incentives to providers’ for testing, on ACT targeting using a cluster-randomized controlled trial in Kenya and Nigeria. Our approach will ensure that public subsidies are directed at confirmed malaria cases thereby enhancing the sustainability of such programs. By allocating subsidy dollars across both testing and conditional treatment (rather than universal, treatment-only subsidies), we can reduce the cost of subsidizing malaria treatment and improve targeting of ACTs without compromising access.