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Table 1 Key lessons and implications for the implementation and evaluation of nationwide programmes of subsidised ACT and RDTs in the private sector.

From: Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia

Programme evaluation
Lessons learnt Implications
• Difficult to assess the impact of programme due to the lack of routine monitoring with standardised indicators, especially at the household level • Need for routine monitoring and evaluation using standardised indicators to measure impact on specific programme objectives, particularly in more remote areas:
• Could not assess ACT uptake, appropriateness of ACT uptake, quality of ACT and RDTs and how these products are used    • At the household level (in addition to the standard indicator of access to prompt treatment of fevers)
  Access to affordable, good quality parasitological diagnosis prior to treatment with ACT
Adherence to ACT treatment regimen
Use of sub-standard drugs, in particular sub-standard artemisinin drugs and artemisinin monotherapies
Median price paid for recommended ACT (compared to the most popular anti-malarial)
     • At drug outlet level (in addition to indicators of awareness, availability and price)
  Quality of RDTs and ACT under field conditions
Correct use and interpretation of RDTs by providers
Correct treatment regimen dispensed by providers
• Difficult to assess why things worked or did not work • Consider a comprehensive evaluation of the implementation process using qualitative methods, in order to understand how implementation can and should be improved
Programme implementation
Lessons learnt Implications
• A high level of brand awareness was achieved through an effective behaviour change communication strategy about Malarine
• Awareness, availability and uptake of Malacheck was lower than for Malarine
• Availability of both ACT and RDTs took years to pick up and was particularly low in rural areas and with mobile providers. In part this is explained by supply bottlenecks.
• Despite Malarine being available, actual uptake remained low compared to other anti-malarial drugs. Problems with uptake likely to be associated with community perceptions and expectations.
• Depending on the setting, significant additional resources may be required to raise awareness and knowledge through IEC activities
• In order to ensure improved targeting of ACT to patients with malaria, attention needs to be paid to biological testing in behaviour change communications, and in the training and support of private providers. This is particularly important in low transmission settings where the majority of fevers are not due to malaria
• Need to monitor availability of products in remote areas and consider interventions to improve reach
• Need to ensure reliable supply of products
• Need to consider different strategies for different types of providers i.e. mobile providers in rural areas versus trained formal providers in market towns
• Need to monitor actual use; if it remains limited, seek to understand why and address the underlying problem(s) - which may require consideration of changing the price, the product (eg switching from co-blistered mefloquine and artesunate) or/and modifying the communications strategy.