Author(s): Jessica Cohen 1 , 3 , * , Günther Fink 1 , Katrina Berg 4 , Flavia Aber 5 , Matthew Jordan 3 , Kathleen Maloney 5 , William Dickens 2 , 3
The importance of scaling up parasitological confirmation of malaria for effective and efficient malaria control programs is widely recognized , . Efforts to increase access to malaria diagnosis have been fueled by a growing awareness of high levels of inappropriate malaria treatment and of the negative consequences of treating non-malarial illnesses with antimalarials. Reyburn et al.  find that, among Tanzanian inpatients admitted to the hospital for severe malaria, the case fatality rate was higher for those who were actually malaria-negative than for those who were malaria-positive based on blood film microscopy. In general, there is substantial symptom overlap between malaria and other common illnesses caused by viral and bacterial infections , . High rates of presumptive treatment with antimalarials can also result in a substantial waste of public and private resources - particularly in the presence of subsidies for expensive treatments such as ACT , , , , , , . Presumptive treatment can also accelerate the emergence of parasite resistance , , . Finally, the absence of widespread parasitological confirmation of malaria has been likened to "working with a blindfold" in that it is difficult to know where to target resources and how to track progress in malaria control programs , , , . For all these reasons, the WHO now recommends parasitological confirmation of malaria whenever possible in its malaria treatment guidelines .
The development and refinement of rapid diagnostic tests for malaria (RDTs) have substantially increased the ability to make diagnostic confirmation available at all levels of the health system, including the formal and informal private sector and community-based care , , , , . RDTs have been shown to be highly sensitive and specific and to outperform microscopy in field conditions , , , . Universal access to malaria diagnosis, however, is unlikely to be achievable through scale up of RDTs in the formal public health system alone. This is because many patients suspecting malaria seek treatment outside of the public sector, where facilities are often distant, suffer frequent stock outs and have limited operating hours , , , .
There has been considerable discussion around whether and how increasing the availability of RDTs in the retail sector should be pursued in connection to (or perhaps instead of) a subsidy on ACTs, such as the one implemented through the pilot Affordable Medicines Facility for Malaria , , , . In the context of ACT programs, scaling up RDTs offers the opportunity to significantly improve the targeting of public funds. While RDTs have been distributed in Cambodia's retail sector since 2002 , little is known regarding the quality of implementation, including how well the RDTs are being stored by shops, how successfully shops are performing them, and the extent to which the tests are being used to guide treatment behavior. If...