Download Literature review 2012.

Review of the published literature on malaria
diagnostics, consumer demand, and public and private
sector providers in Uganda
Key Insights
October 5, 2012
JHU·CCP
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Stop Malaria Project
Contents
Summary ....................................................................................................................................................... 4
Background and Methods ............................................................................................................................. 6
Misdiagnosis in Uganda ................................................................................................................................ 7
Nankabirwa. Malaria misdiagnosis in Uganda – implications for policy change (2009)........................... 7
Isengoma. Accuracy of malaria rapid diagnostic tests in community studies and their impact on
treatment of malaria in an area with declining malaria burden in north-eastern Tanzania (2011)......... 7
Uganda Malaria Indicator Survey (2009) .................................................................................................. 7
Hume. Household cost of malaria overdiagnosis in rural Mozambique (2008) ....................................... 8
Yuckich. Cost Savings with Rapid Diagnostic Tests for Malaria in Low-Transmission Areas: Evidence
from Dar es Salaam, Tanzania (2010) ....................................................................................................... 8
Provider, community and private sector insights ......................................................................................... 9
Asiimwe. Early experiences on the feasibility, acceptability, and use of malaria rapid diagnostic tests at
peripheral health centres in Uganda-insights into some barriers and facilitators (2012)........................ 9
Chandler. Introducing malaria rapid diagnostic tests at registered drug shops in Uganda. (2012) ....... 10
Chandler. How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial
at health facilities in Ghana (2010) ......................................................................................................... 11
Cohen. Prices, Diagnostic Tests and the Demand for Malaria Treatment: Evidence from a Randomized
Trial (Kenya) (2010) ................................................................................................................................. 14
Cohen. Adoption of over-the- counter malaria diagnostics in Africa: T he role of subsidies, beliefs,
externalities, and competition. (2011) ................................................................................................... 14
Hansen. Willingness-to-pay (WTP) for a rapid malaria diagnostic test and artemisinin-based
combination therapy from private drug shops in Mukono district, Uganda (2012) .............................. 14
Harvey. Improving community health worker use of malaria rapid diagnostic tests in Zambia: package
instructions, job aid and job aid-plus-training (2008)............................................................................. 15
Kyabayinze. Use of RDTs to improve malaria diagnosis and fever case management at primary health
care facilities in Uganda (2010)............................................................................................................... 15
Masanja. Increased use of malaria rapid diagnostic tests improves targeting of anti-malarial treatment
in rural Tanzania: implications for nationwide rollout of malaria rapid diagnostic tests (2012) ........... 16
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Mukanga. Community acceptability of use of rapid diagnostic tests for malaria by community health
workers in Uganda(2010)........................................................................................................................ 17
Mukanga. Access, acceptability and utilization of community health workers using diagnostics for case
management of fever in Ugandan children: a cross-sectional study (2012) .......................................... 17
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Summary
Background
Malaria in Uganda is not as prevalent as once thought. In accordance with previous policies, caregivers
and providers both tended to assume that fevers were malaria and treated cases as such. This results in
much misdiagnosis. In 2009, over-diagnosis of malaria was as high as 79% and as much as 49% of
children under 5 were under-diagnosed. In the same year, only 17% of children under five with fever
received a test for malaria. To ensure appropriate care for patients, Uganda has instituted a new policy
in 2012 saying all patients should be tested first.
Data from other countries show that the benefits of testing prior to treatment for households, for now,
appear to be primarily non-monetary. Households who are wrongly diagnosed with malaria tend to have
more provider visits and are thus more likely to miss work. The poorest households are the most
disproportionately affected. While households can save money in drugs by taking a test, these savings
do not necessarily offset the cost of the test. Key benefits for households may include reduced loss of
productivity and reduced risk of complications. Key benefits for the health sector include reduced waste
of ACTs and reduced risk of developing ACT resistance.
Providers
Facilitators
 Perception that tests boost patient satisfaction and willingness to come to health
center/provider
 Perception that tests are easy and fast
 Perception that tests facilitate their diagnosis
Barriers
 Lack of ancillary supplies
 Lack of clear guidelines on how to manage negative test results
 Lack of support supervision
 Fear of missing a malaria case that could become severe, made harder by inability to follow-up
on patients except when they see them again in the community or through a follow-up visit
 Perceived by community members as rude and poorly stocked with drugs.
 Demand for malaria diagnosis and antimalarials or commodities by patiehts
 Fear of being perceived as less competent when patient “knows” he has malaria
Adaptive behaviors to challenges from parasite-negative patients or from self to adhere to results:
 Develop good rapport with patient
 Explain test result and tell patient there are other explanations for the symptoms
 Provide analgesics or vitamins instead of antimalarials
 Consultation with other providers
Recommendations (in addition to addressing the facilitators and barriers mentioned above):
 Address consumer concerns about parasite-negative results so that communities do not lose
trust in the provider when a child dies.
 Clinicians should be supported in continuing to respond to the complex social context of their
work including to the patient’s “psychological needs” as a whole.
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Raise consciousness amongst clinicians of the reasons for and consequences of certain practices,
such as providing ‘placebo’ tests or drugs
Equip clinicians with skills to communicate with patients in order to elicit their specific needs,
for example to understand the meaning of a negative malaria test result, and to respond to
these without reliance on the use of commodities.
Private sector
Facilitators
 Perception from community that they are more accessible or have a more equal footing to
negotiate care.
Barriers
 Perception from public sector that drug shops provide dangerously poor quality care.
 Low willingness to pay by consumers
 Perception from private sector that tests would decrease profits from sales of ACTs
Recommendations (in addition to addressing the facilitators and barriers mentioned above):
 Public health sector and officials participate in the training and quality assurance of drug shops.
 Public health sector support for roles of drug shops and health workers both.
 Provision of subsidies and/or bundling RDTs and ACTs.
 Increase competition among retailers
Consumers
Facilitators
 Willing to try test and wait for result.
 Among higher SES and younger individuals, slightly more willing to pay for test
 Preference for reliable stocks and good relationships found with drug shop vendors
 See tests as a way to get “proper treatment.” [except when they disagree with the presumed
diagnosis; it can be interpreted as “sees tests as a way to confirm presumed diagnosis.” ]
 No major fears or concerns about blood when community engagement and good interactions
with health workers occur.
 Appreciation for health workers when they use tests or counsel and examine them
Barriers
 Preference for malaria diagnosis
 Fear of missing a malaria diagnosis, just in case
 Practice of finding the right diagnosis through experimentation with treatments; the treatment
that worked indicates what kind of disease it was.
 Lack of knowledge about new policy and RDTs (thus lack of knowledge on the right way to
handle negative diagnoses)
 Feel justified in rejecting negative test results (perhaps since they made effort to come to clinic)
 A small proportion fear pain of finger prick
 Feel comfortable requesting, and getting, incomplete doses from private sector
 Wary of travel or financial costs associated with getting the test
Recommendations (in addition to addressing the facilitators and barriers mentioned above):
 Raise awareness on current state of misdiagnosis in Uganda.
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Background and Methods
This literature review was commissioned to support the development of Stop Malaria’s Test and Treat
Campaign. The behavior change communication campaign will seek to boost testing and treatment
within 24 hours of fever onset. Key audiences for the campaign include: formal health providers, drug
shop vendors, caregivers of children under 5, and general consumers.
A search of the published literature using Google Scholar was conducted. Search terms included rapid
diagnostic tests, malaria diagnosis, consumers, community, health workers, health providers, drug
shops, retail and private sector, among others.
Studies thought to have relevance in terms of formative research for the BCC campaign were
purposively selected. All publications are from Uganda, with several exceptions. A few studies from
other countries were included because they had potentially relevant insights.
This was not a systematic review (for example it would not pass Cochrane or PICOS standards). As a
result, it is intended to provide insights on key factors affecting uptake and adherence to rapid
diagnostic test results. It is not intended to be an exhaustive summary of the literature.
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Misdiagnosis in Uganda
Nankabirwa. Malaria misdiagnosis in Uganda – implications for policy
change (2009)
http://www.malariajournal.com/content/8/1/66
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The traditional view of Uganda as a very high malaria endemic area where most of fevers are due
to malaria is unlikely to be true. A large majority of outpatients, across all age groups and
transmission areas, with the exception of children below five years of age in very high transmission
areas, do not have malaria parasitaemia.
Only 17–25% of patients above five years of age were parasitaemic. The overall prevalence rate of
44% was higher in children below five; however, this rate did not exceed 54% even in the areas
historically described as having the highest EIRs in the world. Thus, in nearly all studied populations,
the majority of patients present to outpatient facilities without malaria parasitaemia.
Given the low prevalence of malaria, high frequency of fever among outpatients (79%), and
current practice of presumptive diagnosis, the current rates of outpatient malaria over-diagnosis
in Uganda are massive, reaching as high as 79% for patients five years and older and remaining
high even in the children below five years of age in areas of highest malaria transmission (47%).
BUT there is also a large proportion (49%) of children below five years of age who are not
diagnosed although parasitaemic and subsequently not treated for malaria.
Thus, there is a need for the change of policy from presumptive to parasitological-based diagnosis.
Note: Uganda updated its national malaria policy in 2012. The new policy now states that all cases
suspected of malaria (which includes all fevers) should receive a test for malaria and receive the
appropriate treatment. This is in line with the updated WHO guidelines for malaria case
management from 2010 and WHO’s new initiative Test, Treat and Track which launched in 2012.
Isengoma. Accuracy of malaria rapid diagnostic tests in community
studies and their impact on treatment of malaria in an area with declining
malaria burden in north-eastern Tanzania (2011)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3145609/
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The risk of false positive RDT was significantly higher in cases with fever compared to afebrile cases
(OR≥2.40, p < 0.001)
Thus, with declining malaria prevalence, RDTs will identify majority of febrile cases with parasites
and lead to improved management of malaria and non-malaria fevers.
Uganda Malaria Indicator Survey (2009)
http://www.measuredhs.com/pubs/pdf/MIS6/MIS6.pdf
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52% of children under 5 have malaria. It is higher in rural areas, and highest in Mid-Northern region.
Both sexes are equally likely to have malaria. In this age group, older children are more likely to have
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malaria. Other socioeconomic factors include: living in a rural area, having a mother with no
education or primary education, and having lower income (particularly bottom 20%). All regions are
significantly affected except for Southwestern region and Kampala.
76% and 98% respectively, of those living in rural and urban areas live within 5 km of a health
facility. Similarly high proportions live within 5 km of a market (where other health services and drug
sellers can be found).
Only 66% of mothers aged 15-49 know that a child should seek treatment within 24 hours. Mothers
in rural areas and those with no or only a primary education and lower income are less likely to state
this.
Only 50% of children with fever received advice or treatment within 24 hours. Children in rural areas
are less likely to be brought to a health facility within 24 hours.
44% of children with fever went to a public health facility; 56% went to a private health facility.
Children of less wealthy mothers are more likely to be brought to public health facilities because
they are free.
Only 17% of children with fever had a diagnostic test.
Only 60% of the children who took an ACT started the treatment within 24 hours.
The most commonly cited sources of information about malaria are the radio (77%) and health
providers (17%).
Hume. Household cost of malaria overdiagnosis in rural Mozambique
(2008)
http://www.malariajournal.com/content/7/1/33
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Adults overdiagnosed with malaria had more repeat visits (67% v 46%, p = 0.01–0.06) compared to
those with true malaria.
A surprisingly high number of patients (53%) sought further health advice after their initial
consultation and 25% of these interactions took place with traditional medicine outlets or shops
rather than the clinic they had originally attended.
There was no difference in costs between patients correctly or incorrectly diagnosed with malaria.
Median costs over three weeks were $0.28 for those who had one visit and $0.76 for ≥3 visits and
were proportionally highest among the poorest (p < 0.001). It is imperative that the treatment the
poorest receive is correct in order to prevent wastage of limited economic resources.
Accurate malaria diagnosis and appropriate management at primary level is critical for improving
health outcomes and reducing poverty.
Several studies in developing countries [about the household cost of malaria, not misdiagnosis] have
shown that indirect costs (time missed from work) are around three times higher than direct costs
(medications and consultations)
Yuckich. Cost Savings with Rapid Diagnostic Tests for Malaria in LowTransmission Areas: Evidence from Dar es Salaam, Tanzania (2010)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912577/
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RDTs decreased patient expenditure on drugs (savings = U.S. $0.36; P = 0.002) and provider drug
costs (savings = U.S. $0.43; P = 0.034) compared with control facilities.
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However, RDT introduction did not significantly reduce patients' overall expenditures.
The RDTs reduced drug costs in this setting but did not offset the cost of the tests, although they
also resulted in non-monetary benefits, including improved management of patients and increased
compliance with test results.
Provider, community and private sector insights
Asiimwe. Early experiences on the feasibility, acceptability, and use of
malaria rapid diagnostic tests at peripheral health centres in Ugandainsights into some barriers and facilitators (2012)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398266/
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(92%) reported a belief that a positive mRDT result was true.
Of the same health workers, only 49% believed that a negative mRDT result was truly negative.
57% (36/63) reported failure to regularly perform the test due to programmatic constraints, such
as lack of ancillary supplies , heavy workload , inadequate staffing, and unclear national guidelines
o Without adequate clean tap water at the HCs, health workers were expected to perform
mRDTs on patients with soiled fingers without the means to clean them properly.
o We provided cotton wool to supplement the small and thin alcohol swabs supplied with
the mRDT. One swab was not sufficient to clean patients’ soiled hands, which can be
common in rural agricultural settings
o It was common for health workers not to have a wristwatch or wall clock to time the
testing process, and yet they were trained to use a timer for the process.
o 74% (47/63) of all health workers thought it wasteful to change gloves from one patient
to the next.
Health workers reported enthusiasm to use mRDTs on a daily basis and felt that mRDTs were
relevant tools for fever case management. “With blood tests, we can now confidently tell that the
patient is not suffering from malaria.’
Health workers felt that health centre attendees had more confidence and respect in them because
of their capacity to perform the test. “The community now has confidence in us and the services we
offer because of the RDTs.”
The proportion of health workers that did not prescribe ACT or non-ACT anti-malarials to patients
testing negative or ‘slightly’ positive, gave folic acid, multivitamins, or analgesics. This category of
health workers reasoned that they were saving ACT for those who were mRDT positive and still
meeting the expectations of patients who insisted on getting a treatment for their complaints.
mRDTs were found to be acceptable to and used by the target users, provided clear policy guide
lines exist, ancillary tools are easy to use and health supplies beyond the diagnostic tools are met.
Based on our results, health workers ’ needs for comprehensive case management should be met,
and speci fic guidance for managing febrile patients with negative test out comes should be
provided alongside the new health technology.
94% (977/1035) of HC attendees who completed the interviews were willing to have a mRDT
performed on them or their children.
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(59%) who were willing to take a blood test believed that they were justified to challenge or reject
a negative mRDT result if it was not associated with a drug prescription. “‘I like the idea of taking
a blood test, but I still need to get treated even if the test says I have no malaria. Would I have
come to the clinic if I was healthy?”
99% (of those willing to take the blood test) said they were willing to wait for the mRDT result if they
had to.
Lack of confidence in the mRDT result, dissatisfaction with the decision of the health worker not
to give malaria treatment, or fear of the pain of the finger prick were the main reasons for
reluctance to have a test done. Some patients considered testing as a waste of time, or perceived
the test results as false, preferring to believe that malaria was the cause of the febrile illness.
Conceptual framework for health worker and patient acceptance of RDTs
1. Learnability: ability of the health worker to understand how to correctly perform the mRDT,
a new health technology, and accurately read the test results.
2. Willingness: health worker intention to carry out a blood test each time it is necessary, wait
for the results, and prescribe medication (or not) in line with national guidance and test
results. Regarding the HC attendee, willingness was defined as HC attendees’ intention to
have the test performed on themselves or their child, wait for test results, and take
medication (or not) in line with the test results.
3. Suitability: health workers’ belief that the test is relevant for his/her work and that test
results are a true indication of the presence or absence of malaria parasites. Regarding HC
attendees, suitability was defined as HC attendees’ belief that the test is relevant in
determining whether or not they or their child has malaria.
4. Satisfaction: a health worker’s feeling that the test is convenient to perform and that it is a
process he/she likes doing. Regarding the HC attendee, suitability was described as feeling
that a test is convenient to take and that it is a process they would like to carry out again. It
also refers to the ease-of-use of the mRDT, which is affected by the design of the mRDT, its
labelling, and instructions.
5. Efficacy: that the health worker is able to make the effort and time to perform a test, read,
interpret, and record test results, as well as prescribe medication in line with the test
results, as part of their daily routine work.
6. Effectiveness: that the enabling organisational and supporting systems, such as training,
supervision, job aids, supplies, medicines, space, lighting, timers, storage, and disposal are
present or carried out and are integrated into existing routine systems.
Chandler. Introducing malaria rapid diagnostic tests at registered drug
shops in Uganda. (2012)
(not publicly accessible, see attachment)
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In Uganda, around two-thirds of medicines are procured from the private sector, mostly drug shops.
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Community perceptions of health providers:
o Health workers treated them rudely, even shouting at them, and did not have time or
inclination to care for each patient
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Community perceptions of drug shops:
o A source of health care that is more accessible in terms of convenience, cost, time spent,
social proximity and better quality in terms of services and reliability of stocks than public
health care facilities. A way of obtaining services without enduring indignity.
o Community members are aware of the power they hold over drug shop workers in providing
their income. This contributes to a sense of agency [compared to health facility], including
asking for advice and purchasing or rejecting treatment, including incomplete dose. Clients
are also empowered by the social proximity with a health worker in a drug shop Drug shop
workers are more integrated in the local community.
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Community perceptions of testing
o Diagnostic testing was deemed useful in theory. Some community members saw testing
as a means to fulfill curiosity about the ‘type of malaria’, saying that this should lead to
‘proper’ treatment.
o However, whether testing would be sought as a routine step is uncertain, since the appeal
of the tests waned in light of their travel and monetary costs and potential to conflict with
a presumptive diagnosis.
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Health worker and officials’ perceptions of drug shops:
o Concern over the quality of care provided, which was described as potentially dangerous.
Specifically: the use of expired drugs, the misdiagnosis and consequent mistreatment of
illnesses; and the prescription of underdoses and overdoses .
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Public backing of the Ministry of Health, recognizing and respecting the different roles drug shop
workers and health centre workers have, will be essential.
We recommend that health centre workers and district liaisons participate in RDT training of drug
shop workers as well as in ongoing support to maintain links and sustain changes prompted by
initial training
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Chandler. ‘As a clinician, you are not managing lab results, you are
managing the patient’: How the enactment of malaria at health facilities
in Cameroon compares with new WHO guidelines for the use of malaria
tests (2012)
(not publicly available; see attachment)
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Health workers described tests as important and desirable, but their results were overshadowed by
the role of clinical judgment.
They strongly felt that malaria is well known, common and serious and therefore must be treated
presumptively.
What health workers saw and heard from patients (‘signs and symptoms’) dictated treatment
regardless of test results
They emphasized the importance of ‘psychological treatment’ for patients as central to their healing
and satisfaction. it was the welcome they gave to patients (at 15 FGDs) and the good interpersonal
skills of the staff (at 13 FGDs) that satisfied patients. In only four FGDs did health workers discuss the
availability of testing services as important to patients.
Medicines were sometimes given to patients as a ‘placebo,’ including antimalarials, other medicines
and the mode of delivery. For example, drips were often symbols of care for patients
However, health workers also described diagnostic tests as psychological, or ‘placebo’ treatment.
Respondents made it clear that a key reason tests were done was for the psychological rather
than diagnostic benefits
Health workers identified differences amongst their patients in expectations for malaria treatment
and laboratory investigations. Broadly, those considered better educated and more able to pay
would ask more questions and expect laboratory tests in order to know what their disease was.
For others, who were described as ‘not knowing’ the lab, or who could not afford it, health
workers reported that they would usually not test but move straight to treatment.
Health workers identified that patients were generally relieved to receive malaria treatment or
diagnoses because it is a disease that is common and well known, possible to cure, with simple
treatment, and a less distressing diagnosis overall than others such as diabetes, hypertension, TB or
HIV, which health workers found far harder to deliver to patients.
Clinical judgment of the health worker was most important, especially as the quality of laboratory
staff and resources was sometimes questioned. In the case of negative results, some health
workers reported the need to emphasize their knowledge of malaria over that of the patient in
order to persuade them of another diagnosis. However, this was not always easy, particularly with
those who have been to school and believe that they know all in all the domains’ who would not
accept a negative malaria diagnosis. For fear of their competence being undermined, participants,
particularly the medical doctors, said they often made the malaria diagnosis anyway.
The ‘juggling’ that clinicians conveyed, between patients’ desires, clinical guidelines and protecting
medical reputations, was most commonly described by medical doctors, who perhaps feel in a
stronger position to blame tests or‘quantity of blood’ than lower cadre colleagues. This diversion of
blame away from individuals and institutions may reflect difficulties with dealing with not knowing,
and the primacy of the ‘art’ of medicine.
Recommendations:
 Clinicians should be supported in continuing to respond to the complex social context of
their work including to the patient as a whole.
 Raise consciousness amongst clinicians of the reasons for and consequences of certain
practices, such as providing ‘placebo’ tests or drugs
 Encourage clinicians to experiment with their new tools in practice, including assessing the
responses of patients
 Equip clinicians with skills to communicate with patients in order to elicit their specific
needs, for example to understand the meaning of a negative malaria test result, and to
respond to these without reliance on the use of commodities
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Chandler. How can malaria rapid diagnostic tests achieve their potential?
A qualitative study of a trial at health facilities in Ghana (2010)
http://www.malariajournal.com/content/9/1/95
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Simply having and using RDTs improved patients’ perceptions of the health facility and increased
their willingness to attend the health centre.
However, the presence of the tests alone was insufficient to lead to satisfactory consultations.
Interviewees recognized that in negotiating the use of the new test, good relationships with
patients was of great importance. Discomfort associated with the RDT itself, such as waiting for the
result, could be reversed by the health worker’s interpersonal skills.
The greatest challenge: prescribing for patients with negative RDT results. Community members
were perceived as holding onto the idea that all fever is malaria and sometimes to mistrust health
workers who contradicted patients’ assertions of malaria, preferring a diagnosis of malaria.
Most health workers reported having been unaware that they were overdiagnosing malaria
Another key problem: lack of ability to trust RDTs, citing that ‘in a lot, at least one will fail’ and
‘nothing is 100%’. Their only method for assessing the quality of the tests was to follow up
patients after treatment.
Discussions with other health workers influenced health workers. For some, this led to greater
confidence in RDT results; for others, communication with peers led to reassurance of confidence in
clinical judgment over RDT results.
Strategies used by health workers for combating RDT negative patients’ expectations for antimalarials:
o Listen to the patients’ stories
o Communicate symptoms can be due to other causes
o Reassure patient can return for review
o Explain treatment according to symptoms
o Show the test results
o Give routine medication
o If you’re still under pressure…give antimalarials
Advantages of RDTs from health worker perspective:
o It works quicker…It’s time saving.
o It’s simple
o I do not need a microscope
o If he person has to go to the lab he won’t come back [so with RDTs he is more likely to come
back the same day]
o It can easily detect the malaria cases
o Not like microscopy…in case the person looking didn’t see well.
o It will help you diagnose
o It helps me to think more…after the test is negative to do a differential diagnosis.
o It takes a lot of the load off.
o It is a new thing [technology]
o It was putting the patients at ease…everyone wants to know what is going on in the blood.
o Patients prefer the right result so that you give the right treatment
To build confidence of health workers in the face of negative RDT results, a supporting package
should include:
o local preparation for the innovation
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o
o
o
o
o
o
o
o
unambiguous guidelines
training in alternative causes of disease
regular support for health workers to meet as communities of practice
interventions that address negotiation of health worker-patient relationships
Interventions that encourage self-reflection of practice
feedback systems for results of quality control of RDTs
feedback systems of the results of their practice with RDT
technical and/or clinical troubleshooting resource
Cohen. Prices, Diagnostic Tests and the Demand for Malaria Treatment:
Evidence from a Randomized Trial (Kenya) (2010)
http://www.cgdev.org/doc/events/6.29.10/Jessica_Cohen_Paper.pdf
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RDTs are not unpopular but they are not yet effective for reducing overtreatment with ACTs.
Over 80% of households who received an RDT voucher and visited a drug shop chose to be tested,
suggesting that there is no psychological barrier to testing.
Only 37% of people who bought ACTs were actually positive for malaria.
RDTs appear to improve targeting (to malaria positive patients) when subsidized and targeted to
older children and adults.
Any efforts to improve targeting should focus on both provider and consumer behavior since
patients apparently ignore test results in the absence of provider pressure.
Cohen. Adoption of over-the- counter malaria diagnostics in Africa: T he
role of subsidies, beliefs, externalities, and competition. (2011)
http://www.hsph.harvard.edu/faculty/jessica-cohen/files/cohen_dickens_rdts.pdf
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Shop owners do not have incentive to sell the test when consumers believe they are highly likely to
have malaria (they would reduce their profits from selling antimalarials)
Thus it is important to both educate customers about the prevalence of malaria and promote
competition among drug shops.
The latter would have the additional benefit of reducing the cost of tests and drugs , thus making
treatment accessible to more people
A full set of policies may require subsidies for the tests, education of consumers, and policies to
promote competition among drug shops.
Hansen. Willingness-to-pay (WTP) for a rapid malaria diagnostic test and
artemisinin-based combination therapy from private drug shops in
Mukono district, Uganda (2012)
(not publicly available, see attachment)
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Patients
 The WTP for an RDT and a course of ACT among drug shop customers is considerably lower than
prevailing and estimated end-user prices for these commodities. The geometric mean WTP for an
RDT was US$0.53, US$1.82 for a course of ACT and US$2.05 for a course of ACT after a positive RDT.
 Factors associated with a higher WTP for RDT (multivariate and univariate, see Table 2 and 3):
o younger age
o female (univariate only)
o had a higher level of schooling (univariate only)
o occupations other than farming
o higher socio-economic status of the household
o no fever/malaria in the household in the previous 2 weeks and
o had a prior malaria diagnosis given by a health worker or a parasitological test before
coming to the drug shop
 Factors associated with a higher WTP for ACT are the same as RDT plus:
o travel time; customers who travelled longer to a drug shop were more willing to pay a
higher price for an ACT.
 RDTs were generally not well known (Mbonye et al . 2010 ; Chandler et al. 2011) and it may have
been more difficult for interviewees to place a value on a commodity that was unfamiliar.
 The findings of our study suggest that drug shop customers currently place a very low value on
seeking parasitological confirmation from an RDT before purchasing an antimalarial and
additional measures may be necessary to encourage use of RDTs.
 Recommendations:
o Need to develop novel mechanisms to promote diagnosis in drug shops, and to investigate
their feasibility and cost-effectiveness.
o Possible approaches include targeted subsidies and/or offering the RDT and ensuring
treatment as a single bundled commodity rather than two separate commodities
Harvey. Improving community health worker use of malaria rapid
diagnostic tests in Zambia: package instructions, job aid and job aid-plustraining (2008)
http://www.malariajournal.com/content/7/1/160
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Manufacturer's instructions like those provided with the RDTs used in this study are insufficient to
ensure safe and accurate use by CHWs. However, well-designed instructions plus training can ensure
high performance.
CHWs using the manufacturer's instructions performed 57% of test steps correctly. Those using the
job aid alone improved significantly to 80%. Job aid-plus-training scored 90%.
Sample of the job aids they developed: http://www2.wpro.who.int/sites/rdt/using_rdts/training/
Kyabayinze. Use of RDTs to improve malaria diagnosis and fever case
management at primary health care facilities in Uganda (2010)
http://www.malariajournal.com/content/9/1/200
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The authors trained health workers in lower level public health facilities, and one result was that
over 90% of all eligible OPD patients were offered a test.
Overall use of RDTs resulted in a 38% point reduction in antimalarial prescriptions
When children (compared to adults) receive negative test results, they are 2-3 times more likely to
get an anti-malarial drug. This shows that providers are much more conservative with children’s
treatment than with adults...However, a recent study in Uganda showed that it was safe to withhold
treatment for febrile smear negative patients for all age groups (the authors are citing a study by
Njama-Meya 2007)
63 HW total: Twenty-nine (46%) of all health workers interviewed were nursing assistants (three
months pre-service training in medical care), 22 (35%) nurses, 8 (13%) clinical officers and 4 (6%)
laboratory technologists.
o 40% mentioned that they would consider treating based on clinical suspicion despite a
negative RDT test result.
o Over 98% of the health workers said they were willing and committed to performing RDTs
on a daily basis in the management of out-patients who present with fever
o Majority (92%) of the respondents health care workers believed that positive RDT results
were always truly positive (sensitivity).
o But only half (51%) believed that negative RDT results were always truly negative,
reasoning that the RDTs can miss a true case of malaria.
o Almost all (98%) health care workers said they communicate RDTs results to patients.
Need clear recommendations to health workers to follow test results as well as guidance for treating
and referring negative patients
It is highly probable that the decreasing trend of presumptive treatment may have been as a result
of our regular visits to the health facilities to support and guide health workers in fever case
management with RDTs. If this is the case, the need for continued technical supportive super-vision
following comprehensive training on parasite-based malaria case management is important in order
to ensure sustained reduction in unnecessary anti-malarial drug use.
About a third of the patients that tested negative with RDTs still received AMD prescriptions. Health
workers mentioned that they treat RDT-negative patients because they are afraid of challenges of
severe malaria given the long distance to the referral hospitals and HC IV in case the need arises.
Health workers should be equipped with skills to examine and investigate patients for alternative
causes of 'malaria-like' symptoms even with negative or positive RDT results and appropriate
referral systems should be in place to ensure appropriate management of non-malaria fevers that
present at LLHCFs.
Masanja. Increased use of malaria rapid diagnostic tests improves
targeting of anti-malarial treatment in rural Tanzania: implications for
nationwide rollout of malaria rapid diagnostic tests (2012)
http://www.malariajournal.com/content/11/1/221/abstract
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The rollout increased use of RDTs and reduced over-treatment with ACT during high malaria
transmission season
Additional measures (such as refresher trainings, closer supervisions, etc.) may be needed to
improve ACT targeting during low transmission seasons.
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Over-testing in post implementation area is also high. Over-testing may be associated with
wasted resources as patients who do not meet clinical criteria for malaria diagnostic testing are
tested. Although we did not assess reasons for over-testing, one may think that the problem may be
contributed by lower understanding of case selection for the test, probably resulting from lack
of experience in using the tests, unclear guideline, supportive supervision not focusing on the
topic or even patient pressure to get tested.
Adherence to RDT results is reasonably high with 83.2% of RDT-positive patients receiving ACT
and only 7.8% of RDT-negative patients receiving ACT. [However, the authors did not explain
what made adherence high.]
Mukanga. Community acceptability of use of rapid diagnostic tests for
malaria by community health workers in Uganda(2010)
http://www.malariajournal.com/content/9/1/203
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The spirit of volunteerism as demonstrated by CMDs not demanding to be paid for their services
was greatly appreciated by community members, and their trust and confidence in the CMD services
was often the main motivating factor for the CMDs to do voluntary work.
The recovery of sick children after treatment by CMDs enhanced the reputation of the CMDs
amongst their community. Programs need to address concerns about children with false negative
results. If the child is not followed closely and gets worse or even dies, this could potentially
undermine the credibility of the entire program.
Community members were concerned about the low education of CMDs, but had a high degree of
confidence that CMDs can perform the test once provided with adequate training.
Mukanga. Access, acceptability and utilization of community health
workers using diagnostics for case management of fever in Ugandan
children: a cross-sectional study (2012)
http://www.malariajournal.com/content/11/1/121
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57% of caregivers took their febrile children to a CHW at least once in the three month period
preceding the survey.
Perceived quality of service
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79% respondents thought CHWs services were better with RDTs, and 89% approved CHWs’
continued use of RDTs.
The main reasons for satisfaction were: availability of drugs (89.5%), use of RDT (73.4%), and use
of RRT (respiratory rate timers, to assess for pneumonia) (60.8%). Others were: the way the child
was examined (20.3%) and the way history was taken (9.3%). Multiple responses were allowed for
these questions on perceived quality.
A majority (99.1%) of respondents said they had no fears or concerns regarding drawing of blood
from children by CHWs. Among the four respondents who had fears, the reasons were: the agony of
pain suffered by the child, and concerns about CHWs’ safe use of RDTs without causing infections.
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Adherence to test results by CHWs
 88.9% of community members said CHWs administered drugs based on test results, 7.8% said “No”,
while 3.3% did not know.
 Respondents were asked if they trusted the test results, and 94.7% said they did, while 5.3% did not.
Among those who said “No”, the most commonly mentioned reasons were: CHW did not do the
test, CHW did not explain results; and, “my child did not improve.”
 Among those who received negative test results, 12.2% requested antimalarials. Reasons given: “I
saw my child was very sick”, and “I needed the medicine for protection” (pre-caution, just in case
the test was wrong)
 CHWs were the preferred choice for care for children with drug shops a close second at over 30%.
Drug shops remain very popular in spite of available free services for febrile children through
CHWs.
Other
 Caregivers preferred to go to a CHW when they lived 1-3 km from a health facility. If they live <1km,
they preferred to go to a health facility.
 An earlier qualitative study from this area (by the same authors) reported that some caregivers
expressed fear that the blood collected could be used for HIV testing, the procedure could infect
children with HIV, and the blood could be used for witchcraft. This study was conducted prior to
the introduction of RDTs in the community. It appears that the direct interaction of caregivers with
competent CHWs using the RDTs, and the community engagement that was undertaken prior to
the intervention may have changed some of the negative perceptions.
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