Patient vs. provider incentives for malaria care in Kenyan pharmacies: A cluster randomized controlled trial

Malaria afflicts 190 million people in sub-Saharan Africa each year, with children, pregnant women, and the poor bearing the brunt of the burden. Nearly all deaths and serious illness are preventable through available, effective, and inexpensive medication, and clinical guidelines clearly recommend testing prior to treatment. Despite this, most malaria cases are undiagnosed, resulting in a gap between treatment and need: missed diagnoses result in avoidable illness, and over-prescription of antimalarials can lead to drug resistance. Most malaria patients seek care at pharmacies, where I hypothesize that the mismatch between diagnosis and treatment reflects a misalignment of patient and provider incentives. In my dissertation, I investigate how realigning patient and provider incentives to diagnose suspected malaria cases prior to treatment can improve malaria case management. Building on prior work on the impact of subsidies for rapid diagnostic tests (RDTs) and malaria treatments, I test whether targeted incentives for RDTs and first-line antimalarials only to malaria-positive cases will improve treatment targeting through increasing test result adherence. Using a cluster randomized trial design in 140 pharmacies in malaria-endemic zones in Kenya, I randomize patient discounts and pharmacist performance incentives and compare their effectiveness and cost-effectiveness to the status quo standard of care. Pharmacies were randomized to a status quo control group or one of three treatment groups using a digital malaria case management tool: (1) patient discounts for RDTs and first-line antimalarials conditional on a positive test; (2) pharmacy incentives for selling RDTs to diagnose fevers and for selling first-line antimalarials conditional on a positive test; and (3) patient discounts and pharmacy incentives for RDT use and first-line antimalarial use for confirmed malaria-positive cases. This design allowed us to evaluate the impact of two part incentive structures as well as to examine the causal effect of targeting that incentive to the patient (demand-side) or the provider (supply-side). Preliminary findings from ~80 sites suggest that subsidies and incentives for diagnostic testing increase usage of testing and may nudge malaria positive individuals to purchase high quality antimalarials and improve treatment targeting. Data collection is ongoing until early 2022, and analysis is in progress. Collaborators on this work are Paul Gertler and Jonathan Kolstad, and this project has received funding from the Bill and Melinda Gates Foundation and USAID.

Trial pre-registration:
  • AEARegistry

  • Other current projects

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    Integrating early stimulation and play at scale: Mahay Mikolo cluster RCT in Madagascar

    Programs to promote nurturing and responsive caregiving, such as those in which community health workers (CHWs) conduct home visits to support optimal early child development (ECD), have been effective in small trials, but have not achieved similar success at scale. This study will explore two approaches to scale-up: converting a home-visiting model to a group-based model; and integrating the ECD curriculum into an existing government program. The objectives of the study are to: 1) Measure how the integration of ECD activities affects time and task allocation of CHWs and CHW psychosocial wellbeing; 2) Examine how the integration of ECD activities affects caregiver-child dyad participation in standard health and nutrition activities; and 3) Explore how the availability of age-appropriate play materials at home affects caregiver-child dyad participation rates in a group-based ECD program. Collaborators on this work are Lia C.H. Fernald, Emanuela Galasso, Ann Weber, Caitlin Barkume, and Lisy Ratsifandrihamanana.
    Study protocol (under review):
  • Protocol
  • Trial pre-registration:
  • AEARegistry

  • Publications

    Dieci, Maria, Juan J. Llibre-Rodriguez, Daisy Acosta, and William H. Dow. "Cuba’s cardiovascular risk factors: International comparison of levels and education gradients." Plos one 16, no. 3 (2021): e0247831.
  • Link
  • Dieci, Maria, Zachary Wagner, Willa Friedman, Sarah Burgess, Jessica Vandermark, Sandra I McCoy, Manisha Shah, and William H. Dow. "Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers." Studies in Family Planning, 52: 299-320 (2021).
  • Link to submitted article
  • Rosen, Daniel, Jessica Vernon, Rachel Silverman, Elizabeth Juma, Maria Dieci, and Prashant Yadav. "Malaria Case Management After the Affordable Medicines Facility for Malaria (AMFm): Availability, Quality, and Market Share for ACTs in Kenya’s Private Pharmacies." Center for Global Development Working Paper Series 561 (2020).
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