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

项目总结-TESTsmART试验 2016年，世界卫生组织估计，全球发生了2.16亿例疟疾病例，但超过4亿例。 一线抗疟药物（青蒿素综合疗法）疗程的消耗量。这 青蒿素综合疗法的大量过度使用在很大程度上是由私营零售部门造成的。超过一半的家庭在亚 撒哈拉非洲在有青蒿素综合疗法的零售药店寻求发热性疾病的治疗， 但疟疾诊断检测几乎不存在， norm.廉价的、由捐助者补贴的青蒿素综合疗法的可用性和诊断检测的缺乏导致 青蒿素综合疗法没有很好地针对需要者。没有疟疾的人消耗65-90%的 青蒿素综合疗法通过零售点销售。青蒿素综合疗法的不必要消费消耗了稀缺的公共卫生资源 这将增加公共资源，并威胁到公共资助补贴的未来可持续性。此外，它还将两个 和未来的病人处于危险之中，因为它加速了耐药性的传播。虽然精确的床旁监护 疟疾的诊断方法（称为快速诊断测试或RDTs），它们在零售中并不常见。 然而，在某些国家，这些措施对青蒿素综合疗法的适当使用的影响往往不大。我们假设 提供者和客户关于检测和治疗的决定都受到价格的强烈影响（或 利润）。针对这一点，我们建议测试一个可扩展的，与政策相关的战略，将测试和 为客户提供治疗补贴，并鼓励提供者进行疟疾检测。补贴将是 仅提供给疟疾检测呈阳性的客户（有条件的ACT补贴）。差异化ACT定价， 基于诊断测试结果的客户端，结合提供商对测试的奖励，将使两者保持一致。 消费者和供应商的激励措施（价格和利润）与测试和适当的ACT使用。在目标1中，我们 在肯尼亚进行了一项单独随机实验，以测试两种RDT补贴水平和两种 对寻求疟疾治疗的零售店客户进行测试的有条件青蒿素综合疗法补贴水平- 比如疾病在目标2中，我们将扩大检测和治疗补贴的组合， 目标1中的检测率，并测试其对ACT目标的影响，沿着对提供者检测的激励措施 在肯尼亚和尼日利亚进行了一项随机分组对照试验。我们的做法将确保公共补贴 针对确诊的疟疾病例，从而加强这些方案的可持续性。通过分配 对检测和有条件治疗的补贴资金（而不是普遍的、仅用于治疗的补贴）， 我们可以降低疟疾治疗的补贴成本，提高青蒿素综合疗法的针对性， access.

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.