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Assessing the independent and combined effects of subsidies for antimalarials and rapid diagnostic testing on fever management decisions in the retail sector: results from a factorial randomised trial in western Kenya
  1. Wendy Prudhomme O'Meara1,2,3,
  2. Manoj Mohanan2,4,5,
  3. Jeremiah Laktabai6,7,
  4. Adriane Lesser2,
  5. Alyssa Platt2,8,
  6. Elisa Maffioli2,5,
  7. Elizabeth L Turner2,8,
  8. Diana Menya3
  1. 1Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
  2. 2Duke Global Health Institute, Duke University, Durham, North Carolina, USA
  3. 3Moi University School of Public Health, College of Health Sciences, Eldoret, Kenya
  4. 4Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
  5. 5Department of Economics, Duke University, Durham, North Carolina, USA
  6. 6Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
  7. 7Moi University School of Medicine, College of Health Sciences, Eldoret, Kenya
  8. 8Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
  1. Correspondence to Professor Wendy Prudhomme O'Meara; wpo{at}


Objectives There is an urgent need to understand how to improve targeting of artemisinin combination therapy (ACT) to patients with confirmed malaria infection, including subsidised ACTs sold over-the-counter. We hypothesised that offering an antimalarial subsidy conditional on a positive malaria rapid diagnostic test (RDT) would increase uptake of testing and improve rational use of ACTs.

Methods We designed a 2×2 factorial randomised experiment evaluating 2 levels of subsidy for RDTs and ACTs. Between July 2014 and June 2015, 444 individuals with a malaria-like illness who had not sought treatment were recruited from their homes. We used scratch cards to allocate participants into 4 groups in a ratio of 1:1:1:1. Participants were eligible for an unsubsidised or fully subsidised RDT and 1 of 2 levels of ACT subsidy (current retail price or an additional subsidy conditional on a positive RDT). Treatment decisions were documented 1 week later. Our primary outcome was uptake of malaria testing. Secondary outcomes evaluated ACT consumption among those with a negative test, a positive test or no test.

Results Offering a free RDT increased the probability of testing by 18.6 percentage points (adjusted probability difference (APD), 95% CI 5.9 to 31.3). An offer of a conditional ACT subsidy did not have an additional effect on the probability of malaria testing when the RDT was free (APD=2.7; 95% CI −8.6 to 14.1). However, receiving the conditional ACT subsidy increased the probability of taking an ACT following a positive RDT by 19.5 percentage points (APD, 95% CI 2.2 to 36.8). Overall, the proportion who took ACT following a negative test was lower than those who took ACT without being tested, indicated improved targeting among those who were tested.

Conclusions Both subsidies improved appropriate fever management, demonstrating the impact of these costs on decision making. However, the conditional ACT subsidy did not increase testing. We conclude that each of the subsidies primarily impacts the most immediate decision.

Trial registration number NCT02199977.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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