Illness perception: social cost and coping-strategies of malaria cases

The Macroeconomic Impact of Increasing Investments in Malaria Control in 26 High Malaria Burden Countries: An Application of the Updated EPIC Model

BACKGROUND

Malaria remains a major public health problem. While globally malaria mortality affects predominantly young children, clinical malaria affects all age groups throughout life. Malaria not only threatens health but also child education and adult productivity while burdening government budgets and economic development. Increased investments in malaria control can contribute to reduce this burden but have an opportunity cost for the economy. Quantifying the net economic value of investing in malaria can encourage political and financial commitment.

METHODS

We adapted an existing macroeconomic model to simulate the effects of reducing malaria on the gross domestic product (GDP) of 26 high burden countries while accounting for the opportunity costs of increased investments in malaria. We compared two scenarios differing in their level of malaria investment and associated burden reduction: sustaining malaria control at 2015 intervention coverage levels, time at which coverage levels reached their historic peak and scaling-up coverage to reach the 2030 global burden reduction targets. We incorporated the effects that reduced malaria in children and young adolescents may have on the productivity of working adults and on the future size of the labour force augmented by educational returns, skills, and experience. We calibrated the model using estimates from linked epidemiologic and costing models on these same scenarios and from published country-specific macroeconomic data.

RESULTS

Scaling-up malaria control could produce a dividend of US$ 152 billion in the modelled countries, equivalent to 0.17% of total GDP projected over the study period across the 26 countries. Assuming a larger share of malaria investments is paid out from domestic savings, the dividend would be smaller but still significant, ranging between 0.10% and 0.14% of total projected GDP. Annual GDP gains were estimated to increase over time. Lower income and higher burden countries would experience higher gains.

CONCLUSION

Intensified malaria control can produce a multiplied return despite the opportunity cost of greater investments.

Economic burden of malaria and predictors of cost variability to rural households in south-central Ethiopia

Background

While recognizing the recent remarkable achievement in the global malaria reduction, the disease remains a challenge to the malaria endemic countries in Africa. Beyond the huge health consequence of malaria, policymakers need to be informed about the economic burden of the disease to the households. However, evidence on the economic burden of malaria in Ethiopia is scanty. The aims of this study were to estimate the economic burden of malaria episode and to identify predictors of cost variability to the rural households.

Methods

A prospective costing approach from a household perspective was employed. A total of 190 malaria patients were enrolled to the study from three health centers and nine health posts in Adami Tullu district in south-central Ethiopia, in 2015. Primary data were collected on expenditures due to malaria, forgone working days because of illness, socioeconomic and demographic situation, and households’ assets. Quantile regression was applied to predict factors associated with the cost variation. Socioeconomic related inequality was measured using concentration index and concentration curve.

Results

The median cost of malaria per episode to the household was USD 5.06 (IQR: 2.98–8.10). The direct cost accounted for 39%, while the indirect counterpart accounted for 61%. The history of malaria in the last six months and the level of the facility visited in the health system predominantly influenced the direct cost. The indirect cost was mainly influenced by the availability of antimalarial drugs in the health facility. The concentration curve and the concentration index for direct cost indicate significant pro-rich inequality. Plasmodium falciparum is significantly more costly for households compared to Plasmodium vivax.

Conclusion

The economic burden of malaria to the rural households in Ethiopia was substantial—mainly to the poor—indicating that reducing malaria burden could contribute to the poverty reduction as well.

Economic cost analysis of malaria case management at the household level during the malaria elimination phase in The People's Republic of China

BACKGROUND

In China, malaria has been posing a significant economic burden on households. To evaluate malaria economic burden in terms of both direct and indirect costs has its meaning in improving the effectiveness of malaria elimination program in China.

METHODS

A number of study sites (eight counties in five provinces) were selected from the malaria endemic area in China, representing the different levels of malaria incidence, risk classification, economic development. A number of households with malaria cases (n = 923) were surveyed during the May to December in 2012 to collect information on malaria economic burden. Descriptive statistics were used to characterize the basic profiles of selected malaria cases in terms of their gender, age group, occupation and malaria type. The malaria economic costs were evaluated by direct and indirect costs. Comparisons were carried out by using the chi-square test (or Z-test) and the Mann-Whitney U test among malaria cases with reference to local/imported malaria patients, hospitalized/out patients, and treatment hospitals.

RESULTS

The average cost of malaria per case was 1 691.23 CNY (direct cost was 735.41 CNY and indirect cost was 955.82 CNY), which accounted for 11.1 % of a household's total income. The average costs per case for local and imported malaria were 1 087.58 CNY and 4271.93 CNY, respectively. The average cost of a malaria patient being diagnosed and treated in a hospital at the county level or above (3 975.43 CNY) was 4.23 times higher than that of malaria patient being diagnosed and treated at a village or township hospital (938.80 CNY).

CONCLUSION

This study found that malaria has been posing a significant economic burden on households in terms of direct and indirect costs. There is a need to improve the effectiveness of interventions in order to reduce the impact costs of malaria, especially of imported infections, in order to eliminate the disease in China.

Gender gap in parents' financing strategy for hospitalization of their children: evidence from India

The 'missing women' dilemma in India has sparked great interest in investigating gender discrimination in the provision of health care in the country. No studies, however, have directly examined discrimination in health-care financing strategies in the case of severe illness of sons versus daughters. In this paper, we hypothesize that households who face tight budget constraints are more likely to spend their meager resources on hospitalization of boys rather than girls. We use the 60th round of the Indian National Sample Survey (2004) and a multinomial logit model to test this hypothesis and to throw some light on this important but overlooked issue. The results reveal that boys are much more likely to be hospitalized than girls. When it comes to financing, the gap in the usage of household income and savings is relatively small, while the gender gap in the probability of hospitalization and usage of more onerous financing strategies is very high. Ceteris paribus, the probability of boys to be hospitalized by financing from borrowing, sale of assets, help from friends, etc. is much higher than that of girls. Moreover, in line with our theoretical framework, the results indicate that the gender gap intensifies as we move from the richest to poorest households.

Household burden of malaria in South Africa and Mozambique: is there a catastrophic impact?

OBJECTIVES

To evaluate treatment-seeking behaviour, financial impact and time lost due to malaria events, in southern Mozambique and eastern South Africa.

METHODS

In-depth household surveys (828 in Mozambique and 827 in South Africa) were analysed. An asset index was calculated using principal component analysis to allow comparison across socio-economic groups. Direct costs of seeking care and the time lost due to malaria were determined. The extent of catastrophic payments was assessed using as thresholds the traditional 10% of household income and 40% of non-food income, as recently recommended by WHO.

RESULTS

Poverty was highly prevalent: 70% of the South African and 95% of Mozambican households studied lived on less than $1 per capita per day. Around 97% of those with recent malaria sought healthcare, mainly in public facilities. Out-of-pocket household expenditure per malaria episode averaged $2.30 in South Africa and $6.50 in Mozambique. Analysis at the individual household level found that 32-34% of households in Mozambique, compared with 9-13% of households in South Africa, incurred catastrophic payments for malaria episodes. Results based on mean values underestimated the prevalence of catastrophic payments. Days off work/school were higher in Mozambique.

CONCLUSIONS

The high rate of health seeking in public health facilities seems unusual in the African context, which bodes well for high coverage with artemisinin-based combinations, even if only deployed within the public sector. However, despite no or modest charges for public sector primary healthcare, households frequently incur catastrophic expenditure on a single malaria episode.

Economic costs of epidemic malaria to households in rural Ethiopia

OBJECTIVE

To estimate the direct and indirect costs of malaria morbidity among communities in an epidemic area in rural Southcentral Ethiopia.

METHODS

Community-based cross-sectional study of 2195 households in Adami Tulu district from October to November 2003. Treatment-seeking behaviour, expenditure on treatment and transportation, interruption of normal activities, time lost from working and household expenditure on preventive methods were ascertained through interview.

RESULTS

Of 12,225 surveyed individuals, 1748 (14.3%) reported perceived malaria during the preceding 2 weeks. 77.1% sought any form of care and 70% had recovered at the time of interview. The average treatment cost per patient at private clinics was Birr 24.00 ($2.76) and Birr 12.50 ($1.44) at public facilities. The average estimated direct cost of malaria per patient was Birr 14.00 ($1.60); the average indirect cost, Birr 35.26 ($4.08). Only 5% of all households reported any preventive expenditure in the preceding month, with a mean of Birr 0.76 ($0.09).

CONCLUSION

Malaria poses a significant economic burden on rural households and individuals both through out-of-pocket payment and person-days lost. The promotion and implementation of insecticide-treated nets would alleviate the economic consequences of the disease.

Rethinking the economic costs of malaria at the household level: evidence from applying a new analytical framework in rural Kenya

Background

Malaria imposes significant costs on households and the poor are disproportionately affected. However, cost data are often from quantitative surveys with a fixed recall period. They do not capture costs that unfold slowly over time, or seasonal variations. Few studies investigate the different pathways through which malaria contributes towards poverty. In this paper, a framework indicating the complex links between malaria, poverty and vulnerability at the household level is developed and applied using data from rural Kenya.

Methods

Cross-sectional surveys in a wet and dry season provide data on treatment-seeking, cost-burdens and coping strategies (n = 294 and n = 285 households respectively). 15 case study households purposively selected from the survey and followed for one year provide in-depth qualitative information on the links between malaria, vulnerability and poverty.

Results

Mean direct cost burdens were 7.1% and 5.9% of total household expenditure in the wet and dry seasons respectively. Case study data revealed no clear relationship between cost burdens and vulnerability status at the end of the year. Most important was household vulnerability status at the outset. Households reporting major malaria episodes and other shocks prior to the study descended further into poverty over the year. Wealthier households were better able to cope.

Conclusion

The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

Sri Lanka malaria maps

BACKGROUND

Despite a relatively good national case reporting system in Sri Lanka, detailed maps of malaria distribution have not been publicly available.

METHODS

In this study, monthly records over the period 1995 - 2000 of microscopically confirmed malaria parasite positive blood film readings, at sub-district spatial resolution, were used to produce maps of malaria distribution across the island. Also, annual malaria trends at district resolution were displayed for the period 1995 - 2002.

RESULTS

The maps show that Plasmodium vivax malaria incidence has a marked variation in distribution over the island. The incidence of Plasmodium falciparum malaria follows a similar spatial pattern but is generally much lower than that of P. vivax. In the north, malaria shows one seasonal peak in the beginning of the year, whereas towards the south a second peak around June is more pronounced.

CONCLUSION

This paper provides the first publicly available maps of both P. vivax and P. falciparum malaria incidence distribution on the island of Sri Lanka at sub-district resolution, which may be useful to health professionals, travellers and travel medicine professionals in their assessment of malaria risk in Sri Lanka. As incidence of malaria changes over time, regular updates of these maps are necessary.

Sri Lanka malaria maps

BACKGROUND

Despite a relatively good national case reporting system in Sri Lanka, detailed maps of malaria distribution have not been publicly available.

METHODS

In this study, monthly records over the period 1995 - 2000 of microscopically confirmed malaria parasite positive blood film readings, at sub-district spatial resolution, were used to produce maps of malaria distribution across the island. Also, annual malaria trends at district resolution were displayed for the period 1995 - 2002.

RESULTS

The maps show that Plasmodium vivax malaria incidence has a marked variation in distribution over the island. The incidence of Plasmodium falciparum malaria follows a similar spatial pattern but is generally much lower than that of P. vivax. In the north, malaria shows one seasonal peak in the beginning of the year, whereas towards the south a second peak around June is more pronounced.

CONCLUSION

This paper provides the first publicly available maps of both P. vivax and P. falciparum malaria incidence distribution on the island of Sri Lanka at sub-district resolution, which may be useful to health professionals, travellers and travel medicine professionals in their assessment of malaria risk in Sri Lanka. As incidence of malaria changes over time, regular updates of these maps are necessary.

Malaria Treatment Seeking Practices among Mothers in Rural Refugee Villages in Belize, Central America: A Qualitative Study

Since early and appropriate treatment is an important determinant in the outcome of malaria infection in children, a study using qualitative data collection methods was conducted to investigate child malaria treatment-seeking practices among mothers in rural refugee villages in Belize, Central America. Qualitative methods, which included in-depth key informant interviews, focus group discussions, and rapid assessment interviews, were used to produce in-depth details on how mothers identified and defined fever and malaria and their behaviors relating to treatment practices. The use of multi-method qualitative data collection techniques provided important contributions that were used in designing a series of health education messages to impact child malaria treatment.

Rapid assessment procedures of malaria in low endemic countries: community perceptions in Jepara district, Indonesia

Most studies on community perceptions toward malaria have been undertaken in high-endemic countries, and studies from low-endemic countries have only recently been published. Similar information is also needed for hypoendemic countries such as Indonesia, to cope with the persistence of foci-endemic malaria in these regions. An applied qualitative method, Rapid Assessment Procedures, was employed during a 3-month intensive data collection period in Jepara district, Central Java province. Data were retrieved from 38 free-listings, 28 in-depth interviews, seven focus group discussions and unstructured observation. Qualitative thematic content analysis was applied. In this community, malaria (known as katisen or panas tis) was considered a common but minor illness. Insufficient understanding of malaria signs and symptoms in the subvillages likely leads to delay in illness recognition and treatment; not surprisingly self-treatment is common and the dosage most likely below the recommended dose. The health center was used but when it did not work, most people would shift back to traditional services due to cost considerations. Low understanding and acceptance of the causal link between the mosquito and malaria, likely leading to poor comprehension of preventive activities, as well as confusion of malaria with dengue fever, were identified. In conclusion, this study highlights a consistent gap between the common understanding and the biomedical description of malaria. If case management continues to be the main strategy in malaria control program, the emic perspective of the people must be well-integrated into the program. Likewise, interventions to improve home-treatment should also be developed.

The economic impact of malaria in Africa: a critical review of the evidence

Information on the economic burden of malaria in Africa is needed to target interventions efficiently and equitably, and to justify investment in research and control. A standard method of estimation has been to sum the direct costs of expenditure on prevention and treatment, and the indirect costs of productive labour time lost. This paper discusses the many problems in using such data to reflect the burden to society or the potential benefits from control. Studies have generally focussed on febrile illness, overestimating the burden of uncomplicated malaria, but underestimating the costs of severe illness, other debilitating manifestations, and mortality. Many use weak data to calculate indirect costs, which fail to account for seasonal variations, the difference between the average and marginal product of labour, and the ways households and firms 'cope' in response to illness episodes. Perhaps most importantly, the costs of coping mechanisms in response to the risk of disease are excluded, although they may significantly affect productive strategies and economic growth. Future work should be rooted in a sound understanding of the health burden of malaria and the organisation of economic activities, and address the impact on the productive environment, and epidemiological and socio-economic geographical variation.

Economic consequences of injury and resulting family coping strategies in Ghana

The toll of human suffering from illness and injury is usually measured by mortality and disability rates. Economic consequences, such as treatment costs and lost productivity, are often considered as well. Lately, increasing attention has been paid to the economic effects of illness on a household level. In this study, we sought to assess the economic consequences of injuries in Ghana by looking at the effects on households and the coping mechanisms these households employed. Using cluster sampling and household interviews, we surveyed 21,105 persons living in 431 urban and rural sites. We sought information on any injury that occurred to a household member during the prior year and that resulted in one or more days of disability time.A total of 1609 injuries were reported for the prior year. Treatment costs and disability days were higher in the urban area than in the rural. Coping strategies were different between the two areas. Rural households were more likely to utilize intra-family labor reallocation (90%) than were urban households (75%). Rural households were also more likely to borrow money (24%) than were urban (19%). Households in both areas were equally likely to sell belongings, although the nature of the belongings sold were different. Although injuries in the urban area had more severe primary effects (treatment cost and disability time), the ultimate effect on rural households appeared more severe. A greater percentage of rural households (28%) reported a decline in food consumption than did urban households (19%). These findings result in several policy implications, including measures that could be used to assist family coping strategies and measures directed toward injuries themselves.

Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities

We compared the financial and economic costs of malaria attack to that of a combination of other illness episodes on households in five malaria holo-endemic rural communities. The data was collected from household heads or their representatives using pre-tested interviewer-administered questionnaire. Information was collected on the amount of money household spent to treat both malaria and other illnesses respectively, together with the time lost due to both the groups of illnesses within 1 month prior to the interview. The findings showed that the cost of treating malaria illness accounted for 49.87% of curative health care costs incurred by the households. Average malaria expenditure was $1.84 per household per month, while it was $2.60 per month for the combination of other illness episodes. The average person-days lost due to malaria and the combination of other illnesses were almost equal. If the financial costs of treating malaria and other illnesses are combined, this cost will deplete 7.03% of the monthly average household income, with treatment of malaria illness alone depleting 2.91%. Thus, malaria is a big contributor to the economic burden of disease, in malaria holo-endemic communities. Community-effective malaria control programs are needed to reduce this burden on the households.

Patterns of care for childhood malaria in Zambia

Malaria is a major cause of death among children in many parts of the world, even though simple and effective treatments exist. This study examines care-seeking patterns and barriers to appropriate treatment for Zambian children with fever or convulsions, two key symptoms of malaria. The study focuses on community perceptions of and response to febrile illness, using illness narratives as the primary data collection vehicle. The 154 detailed narratives indicate that mothers recognize fever and treat promptly, and consider chloroquine in conjunction with anti-pyretics to be the appropriate treatment. Synchronic and diachronic analyses show that most treatment begins at home, although the majority of cases are also seen in the formal health system. However, whether treated at home or taken to the health center, most children do not receive appropriate care--in this case, a 3-day course of chloroquine--because of problems of access and lack of understanding of the importance of giving the full dose. Further, those children who continue to have fever despite receiving chloroquine seldom receive the recommended second-line treatment with sulfadoxine-pyrimethamine. Most children with symptoms of convulsions are taken to the health center, but are more likely than children with simple malaria to receive traditional treatments as well.

Household costs of 'malaria' morbidity: a study in Matale district, Sri Lanka

Short-run economic consequences of 'malaria' on households were examined in a household survey in Matale, a malaria-endemic district of Sri Lanka. On average a household incurred a total cost of Rs 318 (US$ 7) per patient who fully recovered from 'malaria'. 24% of this was direct cost, 44% indirect cost for the patient and 32% indirect cost for the household. Direct costs were greater for those seeking treatment in the private sector. Notably a large proportion of direct costs was spent on complementary goods such as vitamins and foods considered to be nutritional. Indirect cost was measured and valued on the basis of output/ income losses incurred at the household level rather than using a general indicator such as average wage rate. Loss of output and wages accounted for the highest proportion of the indirect cost of the patients as well as the households. Relative to children, more young adults and middle-aged people had 'malaria' which also caused greater economic loss in these age groups. Women tended to care for patients rather than substitute their labour to cover productive work lost due to illness. We compare the methods used by other researchers for valuing indirect cost, demonstrating the significant impact that methods of measurement and valuation can have on the estimation of indirect cost, and justify the recommendation for methodological research in this area.

A village treatment center for malaria: community response in Sri Lanka

Early diagnosis and treatment of malaria cases is one of the basic elements of the current global malaria control strategy. In order to provide this service to people in rural areas there is a need for new cost-effective approaches. To ensure that such new approaches are acceptable to the target communities, it is important to know the rationale for people's malaria treatment-seeking behavior. The present study provides insights into the reasons for people's preferences for different types of healthcare facilities and describes variation of these preferences within a rural community in Sri Lanka. The study reports on the experiences with the establishment of a village health facility and its effect on the treatment-seeking behavior of the population. After the introduction of the village treatment center it quickly took over the role of main provider for diagnosis and treatment of malaria from the government facilities. The treatment center did not improve the response time in seeking treatment for young children, but the delay for adults was reduced by 1-2 days. Mothers with small children often preferred the government facilities since they wanted a more qualified opinion than available from the locally recruited staff of the village treatment center. The treatment center significantly reduced the stress and discomfort experienced by the elderly and handicapped segment of the community. The study indicated that the effective catchment area of a village treatment center will be influenced by the degree of initial support from key individuals in the communities, the selection procedure and training of assistants, and the history of the relationships between different villages to be served by the center. The government health services and communities across the dry zone of Sri Lanka could benefit substantially from the establishment of more village treatment centers. To ensure the long-term sustainability of these type of facilities it is necessary to assess the feasibility of charging a user fee and establishing multi-purpose clinics. Government policies and administrative procedures will need to be adjusted to make the successful operation of village treatment centers possible.

Local knowledge and treatment of malaria in Agusan del Sur, The Philippines

Information about local knowledge of malaria, its transmission, treatment and prevention were gathered at the outset of a Malaria Control Program in order to incorporate this information into community interventions. Data were collected using focus groups and indepth interviews with caretakers of children who had had a recent episode of malaria. These were supplemented as baseline data through a survey and the ongoing participation of researchers in the intervention. Local knowledge of malaria was influenced by clinical diagnosis and was based on the coexistence of signs of illness. People conventionally self-medicated or used herbs for symptomatic relief prior to seeking clinical diagnosis and treatment, with treatment delay influenced by the logistic difficulties within the region, direct and indirect costs associated with treatment seeking, and delays in the return of results once a blood film for diagnosis was made. People were familiar with mosquito control activities conducted by the Malaria Control Service and, as a result, most respondents associated malaria with mosquitos. However, the role of the mosquito as the sole vector, and the means by which malaria was transmitted, were not well appreciated.

Household responses to malaria and their costs: a study from rural Sri Lanka

A study of the cost of malaria at the household level, community perceptions, preventive measures and illness behaviour linked to the disease was undertaken in 5 villages in the dry zone of Sri Lanka. The surveyed community had a high knowledge of malaria, although side effects of antimalarial drugs were often confused with symptoms of the disease. The community sought prompt diagnosis and treatment at 'western-type' facilities, with 84% making use of government facilities as their first choice and 16% preferring private facilities. The preventive measures used were burning coils (54% of families) and special leaves (69% of families), and 93% of the families had their houses sprayed with insecticides. Average direct expenditure on a single malaria episode was $3 US, with some families spending more than 10% of the annual household net income per episode. The highest expenditure was on special diets for the sick person, to neutralize the perceived heating effect of the disease and its treatment.

The diagnosis and management of fever at household level in the Greater Accra Region, Ghana

> Qualitative research methods were used in rural and urban areas of the Greater Accra Region to generate data to describe the folk diagnosis, etiology and management of malaria. Respondents defined as fever a set of symptoms loosely concordant with clinical malaria. Primary cause of fever as heat and particularly in rural areas, an understanding of the role of mosquitos in transmitting fever was limited. First- and second-line treatments adopted by caretakers, when either they or their children were sick, involved considerable self-medication with chloroquine and paracetamol. Ethnographic data were supplemented and tested for generalizability through a cross-sectional survey, and the paper discusses this methodological approach.