Understanding the Impact of Subsidizing Artemisinin-Based Combination Therapies (ACTs) in the Retail Sector – Results from Focus Group Discussions in Rural Kenya

Abstract

BackgroundThere is considerable interest in the potential of private sector subsidies to increase availability and affordability of artemisinin-based combination therapies (ACTs) for malaria treatment. A cluster randomized trial of such subsidies was conducted in 3 districts in Kenya, comprising provision of subsidized packs of paediatric ACT to retail outlets, training of retail staff, and community awareness activities. The results demonstrated a substantial increase in ACT availability and coverage, though patient counselling and adherence were suboptimal. We conducted a qualitative study in order to understand why these successes and limitations occurred.Methodology/Principal FindingsEighteen focus group discussions were conducted, 9 with retailers and 9 with caregivers, to document experiences with the intervention. Respondents were positive about intervention components, praising the focused retailer training, affordable pricing, strong promotional activities, dispensing job aids, and consumer friendly packaging, which are likely to have contributed to the positive access and coverage outcomes observed. However, many retailers still did not stock ACT, due to insufficient supplies, lack of capital and staff turnover. Advice to caregivers was poor due to insufficient time, and poor recall of instructions. Adherence by caregivers to dosing guidelines was sub-optimal, because of a wish to save tablets for other episodes, doses being required at night, stopping treatment when the child felt better, and the number and bitter taste of the tablets. Caregivers used a number of strategies to obtain paediatric ACT for older age groups.Conclusions/SignificanceThis study has highlighted that important components of a successful ACT subsidy intervention are regular retailer training, affordable pricing, a reliable supply chain and community mobilization emphasizing patient adherence and when to seek further care.

Discovering the cost of care: consumer, provider, and retailer surveys shed light on the determinants of malaria health-seeking behaviours

“…The year 2010 was the first year that the Affordable Medicines Facility-malaria program to subsidize ACT at private retailers was implemented with the intention of reducing the cost of ACT to 40 KES (equivalent to $0.50 at the time) around the country [ 26 , 27 ]. However, the discrepancy between the cost of the drug and the full cost of a hospital visit for malaria care was large and posed a significant burden to the affected population.…”

Expanding Access to Malaria Diagnosis through Retail Shops in Western Kenya: What Do Shop Workers Think?

“…Our study found several shop workers who described scenarios in which they may not trust test results, potentially leading to an underutilization of the tests. A recent study by Kedenge and colleagues [31] evaluating the effectiveness of a subsidized antimalarial intervention in Kenyan retail shops found that shop workers did not consistently perform certain components of the intervention such as provision of advice, stating that they were too busy with other customers. This trend among for-profit shop workers may limit their ability to accurately and consistently administer rapid tests to their clients.…”

Towards subsidized malaria rapid diagnostic tests. Lessons learned from programmes to subsidise artemisinin-based combination therapies in the private sector: a review

“…Overall the private sector subsidy programmes of ACTs seem to have been successful in increasing availability of effective antimalarial treatment in private outlets, but in some contexts this availability was limited if implementation was not supported by complementary interventions like community awareness campaigns ( Yeung et al. 2011 ; Kedenge et al. 2013 ; O’Meara et al.…”

“…The private sector subsidy programmes of ACTs have started to open the road to subsidization of commodities through existing supply channels with the goal of reaching a target population ( Patouillard et al. 2010 ; Kedenge et al. 2013 ).…”