The Impact of Retail Sector Delivery of Artemether-Lumefantrine on Effective Malaria Treatment of Children Under Five in Kenya

Sarah V. Kedenge Beth Kangwana; Abdisalan M. Noor; Victor A. Alegana ; Andrew J Nyandigisi ; Jayesh Pandit ; Greg W Fegan ; Simon Brooker; Robert W Snow; Catherine A. Goodman

KEMRI-Wellcome Trust Research Programme

General Study Design • Design: pre-post randomized cluster controlled

trial to compare intervention and control areas

Teso

Butere Mumias

Busia

Survey ActivitiesHousehold and retail censuses, household, provider and

mystery shopper surveys and FGDs

Description of Under 5 Population Surveyed

• 86% of fevers experienced within 2 weeks of the interview had some action taken by caregiver

• Majority of actions were visits made to government facilities (31%) and specialized drug stores (33%)

• Also frequently used were general stores (18%)

Fever treatment actions taken by caregivers

• 3,288 households surveyed at baseline and 3,182 at follow up

• Total Under 5 population surveyed was 2,749 and 2,662 at baseline and follow up respectively

•Fever prevalence in children 3-59 months (in past 2 weeks) averaged at 28% at baseline and 30% at follow up

Anti-malarials Received

ControlMean (SD )

InterventionMean (SD )

P valueUnadjustedAdjusted

Baseline 39% (7.8) 46% (9.4)

Follow up 50%(11.8) 64%(10.5) 0.01920.0074

ControlMean (SD )

InterventionMean (SD )

P valueUnadjustedAdjusted

Baseline 30% (11.1) 39% (7.7)

Follow up 23% (7.8) 12% (4.8) 0.00360.0518

RECEIVED AN ANTI MALARIAL

RECEIVED AN ANTI- MALARIAL MONOTHERAPY

Children 3-59 months who received AL on the same day or following day of fever developing

CONTROL INTERVENTION0%

10%

20%

30%

40%

50%

60%

70%

80%

5% 5%

20%

45%

BASELINE

FOLLOW UP

P-value= 0.0001

Adherence

ControlMean (SD )

InterventionMean (SD )

P valueUnadjustedAdjusted

Baseline 40% (23.3) 53% (40.2)

Follow up 49% (24.8) 67% (8.5) 0.06060.1095

ADHERED TO THE RIGHT DOSE

ADHERED TO THE RIGHT PRICE

• 95% of those purchasing Tibamal reported paying the recommended retail price of 20KSH ($0.25)

Study Limitations

• Distribution of AL

• Study limited to children 3-59 months

• Studies limited to one province which is malaria endemic and at the Kenyan-Ugandan border

• Difficult to determine future changes in treatment seeking behavior

Policy Implications & Lessons learnt• Subsidizing ACTs in the retail sector can lead to a

substantial increase in coverage in prompt and effective treatment

• Although the design of the intervention differs with that of AMF-m, the findings can be cautiously interpreted to demonstrate how crowding out anti-malarial monotherapies and increasing access to AL by increasing its distribution at decreased costs could work

• Further research required to:- assess feasibility of introducing diagnosis at retail outlets to improve targeting of ACT.- come up with innovative and practical strategies to improve drug adherence both in the public and private sector.

Acknowledgements

• Division of Malaria Control: Dr Juma, Dr Akhwale, Dr Memusi, Dr Nyandigisi and the team

• Pharmacy and Poisons Board: Dr Pandit• Population Services International : Manya

Andrews and Mbogo Bunyi and the rest of the team

• DFID, USAID and the Wellcome Trust• DHMTs and DOs in Teso, Butere Mumias and

Busia• Field workers, shopkeepers and care givers