Improved adherence to test, treat, and track (T3) malaria strategy among Over-the- Counter Medicine Sellers (OTCMS) through interventions implemented in selected rural communities of Fanteakwa North district, Ghana

Background: Prompt diagnosis and treatment of malaria prevents a mild case from developing into severe disease and death. Unfortunately, parasitological testing of febrile children is greater in the public and formal private sector than in the informal private sector where many patients with malaria-like symptoms first seek treatment. This study was aimed at improving implementation of the T3 policy among OTCMS using some interventions that could be scaled-up easily at the national level. Methods: Interventions were evaluated using a two-arm, cluster randomized trial across 8 rural communities (4 clusters per arm), in two adjacent districts of Ghana. A total of 7 OTCMS in the intervention arm and 5 OTCMS in the control arm in the selected communities participated in the study. Five (5) interventions were implemented in the intervention arm only. These were acquisition of subsidized malaria rapid diagnostic test (mRDT) kits, training of OTCMS, supportive visits to OTCMS, community sensitization on malaria, and introduction of malaria surveillance tool. The primary outcome was the proportion of children under 10 years with fever or suspected to have malaria visiting OTCMS and getting tested (using mRDT) before treatment. Secondary outcomes included OTCMS adherence to national malaria treatment guidelines and the recommended mRDT retail price. Outcomes were measured using mystery client (an adult who pretends to be a real patient) surveys supplemented by a household survey. Proportions were compared using chi-square test or fisher exact test. Results: Following deployment of interventions, mystery client survey showed that OTCMS’ adherence to malaria protocol in the intervention arm increased significantly (p<0.05) compared to the control arm. Household surveys in the intervention arm showed that Caregivers self-treating their children or visiting drug vendors significantly decreased in favor of visits to OTCMS shops for treatment (p<0.001). End-line malaria testing rate was higher compared with the baseline rate, though not statistically significant (30.8% vs 10.5%; p=0.1238). OTCMS in the intervention arm also adhered to the subsidized mRDT retail price of GHc2.40. Conclusion: Interventions targeting OTCMS in rural communities have the potential of improving adherence to the T3 malaria policy and subsequently improving management of uncomplicated malaria in Ghana. Trial registration ISRCTN registry ISRCTN77836926. Registered on 4 November 2019.