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The impact of retail sector delivery of artemether-lumefantrine on effective malaria treatment of children under five in Kenya

Background: With a low proportion of children receiving the first line treatment for suspected malaria, it has been proposed that artemisinin based combination therapy be subsidised in the private sector in order to improve affordability and access. This thesis presents an evaluation of a pilot subsidy mechanism in Western Kenya. Methods: The primary objective was to evaluate the impact of providing subsidized artemether-lumefantrine (AL) through trained retailers, on the coverage of prompt effective anti-malarial treatment for febrile children aged three to 59 months. I used a cluster-randomised, controlled design with nine control and nine intervention sublocations, equally distributed across three districts. Provider, mystery shopper and household cross-sectional surveys were conducted at baseline and one year later. Data were analysed based on cluster-level summaries, comparing control and intervention arms, while adjusting for covariates. On average details of 2,706 children and 564 retail outlets were captured per year. Results: Provider survey and mystery shopper data showed that at follow-up a significantly greater percentage of retailers stocked and dispensed AL, and knew that AL was the first line treatment for uncomplicated malaria in the intervention arm compared to the control. Significantly fewer retailers stocked antimalarial monotherapies. Household survey data showed that an average of 29% of children had experienced fever within the previous two weeks. Within this sample, the percentage receiving AL on the same day or following day of fever developing at follow-up was 25.0% points higher in the intervention arm than in the control arm, a statistically significant difference. However, adherence to dosing for AL purchased in the retail sector and advice given to caretakers by retailers remained unchanged post-intervention. Conclusion: Overall, subsidizing ACTs in the retail sector can significantly increase ACT coverage in rural areas. Further research is needed on ways to improve counselling and adherence as well as on the impact and cost-effectiveness of such an intervention at a national scale.