The Impact of Retail Sector Delivery of Artemether-Lumefantrine on Effective Malaria Treatment of Children Under Five in Kenya Sarah V. Kedenge Beth Kangwana; Abdisalan M. Noor; Victor A. Alegana ; Andrew J Nyandigisi ; Jayesh Pandit ; Greg W Fegan ; Simon Brooker; Robert W Snow; Catherine A. Goodman KEMRI-Wellcome Trust Research Programme

General Study Design Design: pre-post randomized cluster controlled trial to compare intervention and control areas Teso Butere Mumias Busia

Survey Activities Household and retail censuses, household, provider and mystery shopper surveys and FGDs

Description of Under 5 Population Surveyed 86% of fevers experienced within 2 weeks of the interview had some action taken by caregiver Majority of actions were visits made to government facilities (31%) and specialized drug stores (33%) Also frequently used were general stores (18%) Fever treatment actions taken by caregivers 3,288 households surveyed at baseline and 3,182 at follow up Total Under 5 population surveyed was 2,749 and 2,662 at baseline and follow up respectively Fever prevalence in children 3-59 months (in past 2 weeks) averaged at 28% at baseline and 30% at follow up

Anti-malarials Received Control Mean (SD ) Intervention Mean (SD ) P value Unadjusted Adjusted Baseline39% (7.8)46% (9.4) Follow up 50%(11.8)64%(10.5) Control Mean (SD ) Intervention Mean (SD ) P value Unadjusted Adjusted Baseline30% (11.1)39% (7.7) Follow up23% (7.8)12% (4.8) RECEIVED AN ANTI MALARIAL RECEIVED AN ANTI- MALARIAL MONOTHERAPY

Children 3-59 months who received AL on the same day or following day of fever developing

Adherence Control Mean (SD ) Intervention Mean (SD ) P value Unadjusted Adjusted Baseline 40% (23.3)53% (40.2) Follow up 49% (24.8)67% (8.5) ADHERED TO THE RIGHT DOSE ADHERED TO THE RIGHT PRICE 95% of those purchasing Tibamal reported paying the recommended retail price of 20KSH ($0.25)

Study Limitations Distribution of AL Study limited to children 3-59 months Studies limited to one province which is malaria endemic and at the Kenyan-Ugandan border Difficult to determine future changes in treatment seeking behavior

Policy Implications & Lessons learnt Subsidizing ACTs in the retail sector can lead to a substantial increase in coverage in prompt and effective treatment Although the design of the intervention differs with that of AMF-m, the findings can be cautiously interpreted to demonstrate how crowding out anti-malarial monotherapies and increasing access to AL by increasing its distribution at decreased costs could work Further research required to: - assess feasibility of introducing diagnosis at retail outlets to improve targeting of ACT. - come up with innovative and practical strategies to improve drug adherence both in the public and private sector.

Acknowledgements Division of Malaria Control: Dr Juma, Dr Akhwale, Dr Memusi, Dr Nyandigisi and the team Pharmacy and Poisons Board: Dr Pandit Population Services International : Manya Andrews and Mbogo Bunyi and the rest of the team DFID, USAID and the Wellcome Trust DHMTs and DOs in Teso, Butere Mumias and Busia Field workers, shopkeepers and care givers