Training shopkeepers to improve malaria home management in rural Kenya

In rural Kenya, where qualified pharmacists are rare, many people buy medicines from general shops to treat themselves at home. Often they receive incorrect medication or doses. Would the training of shopkeepers, who help treat the majority of children with fevers, be cost-effective in improving malaria treatment in young children?

At a summit inAbuja in 2000, African leaders agreed that by 2005 at least 60 percent of peopleill with malaria in sub-Saharan Africa should be able to access affordabletreatment within 24 hours of developing the symptoms. Yet research in 28African countries showed that on average, only 42 percent of children under five years old were given anti-malarial treatment fora fever, and many of them received incorrect doses. As up to 60 percent ofchildhood fevers are treated with medicine bought from general retailers, shopkeeperscould play a significant role in improving the treatment of malaria in young children.

Research by theKenya Medical Research Institute (KEMRI)-WellcomeTrust Collaborative Research Programme and Kenya’s Ministry of Health assessedthe cost and cost-effectiveness of a recent programme that involved trainingshopkeepers and community mobilisation for treating childhood fevers in therural Kilifi District in Kenya. The programme offeredworkshops for shopkeepers on appropriate treatment for malaria in youngchildren and also ran community information activities, with impact maintainedthrough refresher training and monitoring.

The evaluationassessed the programme’s cost-effectiveness during the early phase ofimplementation at sub-division level, and estimated the cost-effectiveness forgovernment run district level implementation. A simple model was used topredict the cost per death and per disability adjusted life year (DALY)averted.

The study found thefollowing:

• The proportion of young childrenreceiving a sufficient dose of the recommended multidose anti-malarial fromshopkeepers rose from two percent to 15 percent in the earlyimplementation phase, at a cost of US$ 4 per additional case treatedcorrectly.
• It was estimated that if the sameimpact was achieved at district level, the cost would be cheaper US$ 0.84per additional case treated correctly.
• The programme’s estimated economiccost per death averted was US$ 505.42 for the early phase and US$ 105.92at the district level, with a cost per DALY averted of US$ 18.38 and US$3.85 respectively.
• The initial financial expense fordevelopment of the programme at district level was estimated at US$11,477. The first year of running the programme at district level wasestimated to cost US$ 81,450, with an annual running cost thereafter ofUS$ 18,129.

The studyindicated that the shopkeeper training programme is likely to be highlycost-effective if an effective anti-malarial is used, when compared withstandards for similar interventions in low-income countries. It suggested fourkey policy lessons:

• Efforts to ensure this intervention wassustainable were successful. Surveys in the second and third year of theprogramme showed that the intervention had become consistently moreeffective.
• The intervention showed thatshopkeeper training could be used for over-the-counter sales of otheranti-malarial drugs, and possibly for introducing combinationanti-malarial therapies.
• The programme’s relatively expensivestart-up costs suggest a need for donor organisation funding and possiblycontributions from the pharmaceutical industry. The smaller annual runningcost could be covered by district budgets.
• The cost per DALY averted for both phasesof the programme was well below the “highly attractive” cost per DALYaverted of US$ 30 for interventions in low-income countries.