The challenges of changing national malaria drug policy to artemisinin-based combinations in Kenya

Backgound: Sulphadoxine/sulphalene-pyrimethamine (SP) was adopted in Kenya as first line therapeutic for uncomplicated malaria in 1998. By the second half of 2003, there was convincing evidence that SP was failing and had to be replaced. Despite several descriptive investigations of policy change and implementation when countries moved from chloroquine to SP, the different constraints of moving to artemisinin-based combination therapy (ACT) in Africa are less well documented. Methods: A narrative description of the process of anti-malarial drug policy change, financing and implementation in Kenya is assembled from discussions with stakeholders, reports, newspaper articles, minutes of meetings and email correspondence between actors in the policy change process. The narrative has been structured to capture the timing of events, the difficulties and hurdles faced and the resolutions reached to the final implementation of a new treatment policy. Results: Following a recognition that SP was failing there was a rapid technical appraisal of available data and replacement options resulting in a decision to adopt artemether-lumefantrine (AL) as the recommended first-line therapy in Kenya, announced in April 2004. Funding requirements were approved by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and over 60 million US$ were agreed in principle in July 2004 to procure AL and implement the policy change. AL arrived in Kenya in May 2006, distribution to health facilities began in July 2006 coincidental with cascade in-service training in the revised national guidelines. Both training and drug distribution were almost complete by the end of 2006. The article examines why it took over 32 months from announcing a drug policy change to completing early implementation. Reasons included: lack of clarity on sustainable financing of an expensive therapeutic for a common disease, a delay in release of funding, a lack of comparative efficacy data between AL and amodiaquine-based alternatives, a poor dialogue with pharmaceutical companies with a national interest in antimalarial drug supply versus the single sourcing of AL and complex drug ordering, tendering and procurement procedures. Conclusion: Decisions to abandon failing monotherapy in favour of ACT for the treatment of malaria can be achieved relatively quickly. Future policy changes in Africa should be carefully prepared for a myriad of financial, political and legislative issues that might limit the rapid translation of drug policy change into action

The Impact of Retail-Sector Delivery of Artemether–Lumefantrine on Malaria Treatment of Children under Five in Kenya: A Cluster Randomized Controlled Trial

In a cluster randomized trial, Beth Kangwana and colleagues find that provision of subsidized packs of the malaria therapy artemether-lumefantrine to shops more than doubled the proportion of children with fever who received drugs promptly

Malaria drug shortages in Kenya: a major failure to provide access to effective treatment.

A key bench mark of successful therapeutic policy implementation, and thus effectiveness, is that the recommended drugs are available at the point of care. Two years after artemether-lumefathrine (AL) was introduced for the management of uncomplicated malaria in Kenya, we carried out a cross-sectional survey to investigate AL availability in government facilities in seven malaria-endemic districts. One of four of the surveyed facilities had none of the four AL weight-specific treatment packs in stock; three of four facilities were out of stock of at least one weight-specific AL pack, leading health workers to prescribe a range of inappropriate alternatives. The shortage was in large part caused by a delayed procurement process. National ministries of health and the international community must address the current shortcomings facing antimalarial drug supply to the public sector

Understanding the impact of subsidizing artemisinin-based combination therapies (ACTs) in the retail sector--results from focus group discussions in rural Kenya.

BACKGROUND: There is considerable interest in the potential of private sector subsidies to increase availability and affordability of artemisinin-based combination therapies (ACTs) for malaria treatment. A cluster randomized trial of such subsidies was conducted in 3 districts in Kenya, comprising provision of subsidized packs of paediatric ACT to retail outlets, training of retail staff, and community awareness activities. The results demonstrated a substantial increase in ACT availability and coverage, though patient counselling and adherence were suboptimal. We conducted a qualitative study in order to understand why these successes and limitations occurred. METHODOLOGY/PRINCIPAL FINDINGS: Eighteen focus group discussions were conducted, 9 with retailers and 9 with caregivers, to document experiences with the intervention. Respondents were positive about intervention components, praising the focused retailer training, affordable pricing, strong promotional activities, dispensing job aids, and consumer friendly packaging, which are likely to have contributed to the positive access and coverage outcomes observed. However, many retailers still did not stock ACT, due to insufficient supplies, lack of capital and staff turnover. Advice to caregivers was poor due to insufficient time, and poor recall of instructions. Adherence by caregivers to dosing guidelines was sub-optimal, because of a wish to save tablets for other episodes, doses being required at night, stopping treatment when the child felt better, and the number and bitter taste of the tablets. Caregivers used a number of strategies to obtain paediatric ACT for older age groups. CONCLUSIONS/SIGNIFICANCE: This study has highlighted that important components of a successful ACT subsidy intervention are regular retailer training, affordable pricing, a reliable supply chain and community mobilization emphasizing patient adherence and when to seek further care

The effect of an anti-malarial subsidy programme on the quality of service provision of artemisinin-based combination therapy in Kenya: a cluster-randomized, controlled trial.

BACKGROUND: Many patients with suspected malaria in sub-Saharan Africa seek treatment from private providers, but this sector suffers from sub-standard medicine dispensing practices. To improve the quality of care received for presumptive malaria from the highly accessed private retail sector in western Kenya, subsidized pre-packaged artemether-lumefantrine (AL) was provided to private retailers, together with a one day training for retail staff on malaria diagnosis and treatment, job aids and community engagement activities. METHODS: The intervention was assessed using a cluster-randomized, controlled design. Provider and mystery-shopper cross-sectional surveys were conducted at baseline and eight months post-intervention to assess provider practices. Data were analysed based on cluster-level summaries, comparing control and intervention arms. RESULTS: On average, 564 retail outlets were interviewed per year. At follow-up, 43% of respondents reported that at least one staff member had attended the training in the intervention arm. The intervention significantly increased the percentage of providers knowing the first line treatment for uncomplicated malaria by 24.2% points (confidence interval (CI): 14.8%, 33.6%; adjusted p=0.0001); the percentage of outlets stocking AL by 31.7% points (CI: 22.0%, 41.3%; adjusted p=0.0001); and the percentage of providers prescribing AL for presumptive malaria by 23.6% points (CI: 18.7%, 28.6%; adjusted p=0.0001). Generally outlets that received training and job aids performed better than those receiving one or none of these intervention components. CONCLUSION: Overall, subsidizing ACT and retailer training can significantly increase the percentage of outlets stocking and selling AL for the presumptive treatment of malaria, but further research is needed on strategies to improve the provision of counselling advice to retail customers

Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: Evidence from a prospective cohort survey in Nairobi informal settlements

Objectives: COVID-19 may spread rapidly in densely populated urban informal settlements. Kenya swiftly implemented mitigation policies; we assess the economic, social and health-related harm disproportionately impacting women. Design: A prospective longitudinal cohort study with repeated mobile phone surveys in April, May and June 2020. Participants and setting: 2009 households across five informal settlements in Nairobi, sampled from two previously interviewed cohorts. Primary and secondary outcome measures: Outcomes include food insecurity, risk of household violence and forgoing necessary health services due to the pandemic. Gender-stratified linear probability regression models were constructed to determine the factors associated with these outcomes. Results: By May, more women than men reported adverse effects of COVID-19 mitigation policies on their lives. Women were 6 percentage points more likely to skip a meal versus men (coefficient: 0.055; 95% CI 0.016 to 0.094), and those who had completely lost their income were 15 percentage points more likely versus those employed (coefficient: 0.154; 95% CI 0.125 to 0.184) to skip a meal. Compared with men, women were 8 percentage points more likely to report increased risk of household violence (coefficient: 0.079; 95% CI 0.028 to 0.130) and 6 percentage points more likely to forgo necessary healthcare (coefficient: 0.056; 95% CI 0.037 to 0.076). Conclusions: The pandemic rapidly and disproportionately impacted the lives of women. As Kenya reopens, policymakers must deploy assistance to ensure women in urban informal settlements are able to return to work, and get healthcare and services they need to not lose progress on gender equity made to date

Mobility patterns during COVID-19 travel restrictions in Nairobi urban informal settlements: Who is leaving home and why

Nairobi’s urban slums are ill equipped to prevent spread of the novel coronavirus disease (COVID-19) due to high population density, multigenerational families in poorly ventilated informal housing, and poor sanitation. Physical distancing policies, curfews, and a citywide lockdown were implemented in March and April 2020 resulting in sharp decreases in movement across the city. However, most people cannot afford to stay home completely (e.g., leaving daily to fetch water). If still employed, they may need to travel longer distances for work, potentially exposing them COVID-19 or contributing to its spread. We conducted a household survey across five urban slums to describe factors associated with mobility in the previous 24 h. A total of 1695 adults were interviewed, 63% female. Of these, most reported neighborhood mobility within their informal settlement (54%), 19% stayed home completely, and 27% reported long-distance mobility outside their informal settlement, mainly for work. In adjusted multinomial regression models, women were 58% more likely than men to stay home (relative risk ratio (RRR): 1.58, 95% confidence interval (CI): 1.16, 2.14) and women were 60% less likely than men to report citywide mobility (RRR: 0.40; 95% CI 0.31, 0.52). Individuals in the wealthiest quintile, particularly younger women, were most likely to not leave home at all. Those who reported citywide travel were less likely to have lost employment (RRR: 0.49; 95% CI 0.38, 0.65) and were less likely to avoid public transportation (RRR: 0.30; 95% CI 0.23, 0.39). Employment and job hunting were the main reasons for traveling outside of the slum; less than 20% report other reasons. Our findings suggest that slum residents who retain their employment are traveling larger distances across Nairobi, using public transportation, and are more likely to be male; this travel may put them at higher risk of COVID-19 infection but is necessary to maintain income. Steps to protect workers from COVID-19 both in the workplace and while in transit (including masks, hand sanitizer stations, and reduced capacity on public transportation) are critical as economic insecurity in the city increases due to COVID-19 mitigation measures. Workers must be able to commute and maintain employment to not be driven further into poverty. Additionally, to protect the majority of individuals who are only travelling locally within their settlement, mitigation measures such as making masks and handwashing stations accessible within informal settlements must also be implemented, with special attention to the burden placed on women

Preprint—COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya

Objective: Urban slums are at high risk of COVID-19 transmission due to the lack of basic housing, water, and sanitation, and overcrowding. No systematic surveys of slum households’ experiences exist to date. Methods: A mobile phone knowledge, attitudes, and practices survey was conducted March 30-31, 2020. Participants were sampled from two study cohorts across five urban slums in Nairobi, Kenya. Findings: 2,009 individuals (63% female) participated. Knowledge of fever and cough as COVID-19 symptoms was high, but only 42% listed difficulty breathing. Most (83%) knew anyone could be infected; younger participants had lower perceived risk. High risk groups were correctly identified (the elderly - 64%; those with weak immune systems - 40%) however, 20% incorrectly stated children. Handwashing and using hand sanitizer were known prevention methods, though not having a personal water source (37%) and hand sanitizer being too expensive (53%) were barriers. Social distancing measures were challenging as 61% said this would risk income. A third worried about losing income, only 26% were concerned about infecting others if themselves sick. Government TV ads and short message service (SMS) were the most common sources of COVID-19 information and considered trustworthy (by \u3e 95%) but were less likely to reach less educated households. Conclusion: Knowledge of COVID-19 is high; significant challenges for behavior change campaigns to reach everyone with contextually appropriate guidance remain. Government communication channels should continue with additional efforts to reach less educated households. A strategy is necessary to facilitate social distancing, handwashing and targeted distributions of cash and food