The TESTsmART project aims to improve antimalarial stewardship in the retail sector, which distributes the majority of antimalarials in sub-Saharan Africa. Through a combination of diagnosis and treatment subsidies and provider-directed incentives, the project aligns provider and customer incentives with appropriate case management to improve health outcomes.

Each year, approximately half of the more than 200 million cases of malaria seek care in the informal or retail health sector. Since 2010, approximately $670 million has been invested in subsidies for artemisinin-combination therapy (ACT). Declining prices of ACTs create a trade-off between access and targeting; lower prices improve uptake of effective therapies by those with malaria but also increase inappropriate use by those without malaria. It is estimated that at least two thirds of ACTs purchased over-the-counter are consumed by individuals without malaria.

Targeting subsidized ACTs to individuals with parasitologically-confirmed malaria would significantly contribute to the sustainability and cost-effectiveness of retail subsidies as well as safeguard the future efficacy of these key drugs. We propose an innovative approach that links the ACT subsidy to the results of a diagnostic test (a conditional subsidy), allowing the subsidy to be targeted only to parasitologically-confirmed malaria cases. Untested and test-negative clients would pay a higher, unsubsidized price while test-positive clients would have access to a discounted ACT.