Intervention (1): Doctor training
Half of all participating CSCOMs will be randomly selected to receive additional training on the sensitivity and specificity of RDTs. This training will be incorporated into the refresher training described above, and will include four key components:
1. First, we will organize a training on the accuracy of RDTs, with a focus on their ability to detect uncomplicated malaria. Facilitators will present data from field studies of RDT sensitivity and specificity. A Malian researcher will share information on his own research on the sensitivity and specificity of RDTs in a video testimonial.
2. We will show RDT accuracy data from the World Health Organization’s latest round of quality assurance testing for RDTs (WHO 2015). We will demonstrate in particular that the tests used in Bamako CSCOMs have only a 10% false negative rate for parasite concentrations of 200 per microliter and even lower rates for higher parasite counts.
3. We will report on studies that have tracked children who were not treated with antimalarials after a negative test and show no adverse effects (Baiden et al. 2012, d’Acremont 2010, Njama-Meya 2007).
4. A medical expert will lecture on the meaning of low parasitemia and the connection between parasite count and malarial illness.
The objective of this training is to help health care workers understand that RDT tests are reliable and very rarely miss simple malaria cases, and that patients who are not treated after a negative test are not adversely affected, especially in low-transmission regions.
The remaining interventions will be randomized “within-clinic”. More specifically, this means that clinics will be randomly assigned to receive interventions 2 and 3a or 3b for different randomly-selected days during the 6-week study period. These interventions will only be administered on days at which surveyors are present. To increase salience, avoid spillovers, and make sure doctors and clinic staff understand the intervention, we will administer the same intervention type to all patients that visit the clinic on the selected day(s). Before the intervention within the same clinic is changed, doctors and clinic staff are alerted to the difference, if any, and have the chance to ask questions about e.g. the information patients receive.
Intervention (2): Patient information
In collaboration with Malian doctors, we developed a short narrative video for patients that educates patients on what malaria is and what its symptoms are for both simple and severe cases, how a malaria test works and what it looks like to do one at the clinic, and what the Malian policy is: that malaria treatment should always occur with ACTs, but only after a negative malaria test, and how simple and severe malaria treatment differ (including in price).
Intervention (3): Patient vouchers
In collaboration with the CSCOM, intervention (3) offers a subsidy for artemisinin combination therapy (ACT) for simple malaria. This subsidy is administered in the form of a paper voucher that is valid for a free dose of ACTs on the day of receipt only. We will receive pre-authorization from the head doctor of each CSCOM for this treatment. Subsidized ACTs will only be given out with a valid prescription: the voucher requires a signature from a doctor or nurse as well as a confirmation of receipt from the client (either a signature from the client, or a signature from the person leading the intervention at the clinic). Pharmacies will be reimbursed for each signed voucher that they have received. In intervention version (a), the voucher is given to the patient, either handed out in the course of intervention (2), or accompanied by a very short informational dialogue on malaria treatment. This raises patient awareness for the type of treatment they are prescribed, and reinforces the message of intervention (2). In intervention version (b), the vouchers are instead given to doctors, to be handed out to patients they diagnose.
Each CSCOM will receive the following combinations of interventions 2, 3a, and 3b: no intervention (control), 2 only, 3a only, 3b only, 2 and 3a, 2 and 3b.