Understanding the impact of subsidizing artemisinin-based combination therapies (ACTs) in the retail sector--results from focus group discussions in rural Kenya.
BACKGROUND
There 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.


RESULTS
Eighteen 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
This 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.
Malaria Public Health Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya. skedenge@nairobi.kemri-wellcome.org
Sarah V
SV
Kedenge
Beth P
BP
Kangwana
Evelyn W
EW
Waweru
Andrew J
AJ
Nyandigisi
Jayesh
J
Pandit
Simon J
SJ
Brooker
Robert W
RW
Snow
Catherine A
CA
Goodman
D000962:Antimalarials / Q000191:economics* / Q000600:supply & distribution; D037621:Artemisinins / Q000191:economics* / Q000600:supply & distribution; D005260:Female; D017144:Focus Groups; D006801:Humans; D007630:Kenya; D008288:Malaria / Q000188:drug therapy; D008297:Male; D055118:Medication Adherence
D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin