Abstract
BackgroundPrivate sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops.MethodsDrug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever ‘appropriately treated of malaria with ACT’ was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers.FindingsThe introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results.ConclusionmRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.
Highlights
The private health sector in Africa is an important supplier of treatment for malaria distributing more than half of all antimalarial drugs in many malaria-endemic countries [1,2]
The incremental cost-effectiveness ratio (ICER) from a health sector perspective was US$0.55 meaning that introducing subsidised mRDT diagnosis in drug shops currently offering presumptive treatment with subsidised Artemisinin-based combination therapies (ACTs) would cost the health sector US$0.55 per additional patient appropriately treated of malaria
The absolute health sector costs were similar in the two arms, at US$3.13 per drug shop customer with suspected malaria seen in the mRDT arm and US$2.89 in the presumptive arm (Table 2)–a difference of US$0.24 per customer
Summary
The private health sector in Africa is an important supplier of treatment for malaria distributing more than half of all antimalarial drugs in many malaria-endemic countries [1,2]. Despite the WHO recommendation in 2010 for parasitological confirmation prior to malaria treatment [3], the vast majority of private suppliers do not as yet routinely offer malaria diagnostic testing before selling drugs. Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops
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