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

The economic burden of malaria: a systematic review

Background

Quantifying disease costs is critical for policymakers to set priorities, allocate resources, select control and prevention strategies, and evaluate the cost-effectiveness of interventions. Although malaria carries a very large disease burden, the availability of comprehensive and comparable estimates of malaria costs across endemic countries is scarce.

Methods

A literature review to summarize methodologies utilized to estimate malaria treatment costs was conducted to identify gaps in knowledge.

Results

Only 45 publications met the inclusion criteria. They utilize different methods, include distinct cost components, have varied geographical coverage (a country vs a city), include different periods in the analysis, and focus on specific parasite types or population groups (e.g., pregnant women).

Conclusions

Cost estimates currently available are not comparable, hindering broad statements on the costs of malaria, and constraining advocacy efforts towards investment in malaria control and elimination, particularly with the finance and development sectors of the government.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04303-6.

Household economic burden of childhood severe pneumonia in Bangladesh: a cost-of-illness study

OBJECTIVE

To estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh.

DESIGN

An incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters.

SETTING

Four urban and rural study sites from two districts in Bangladesh.

PATIENTS

Children aged 2-59 months with severe pneumonia.

RESULTS

1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss.

CONCLUSIONS

Severe pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden.

Health shocks, medical insurance and household vulnerability: Evidence from South Africa

Background

South Africa has a dual system of healthcare model differentiated across socio-economic lines. While on the one hand there exists high quality private facilities that is expensive and accessible to the minority, on the other is the free but stretched and over-crowded public healthcare that the rest of the population relies on. Accessing private facilities requires private medical insurance or requires coping strategies that can lead to household vulnerability.

Objective

The objective of this study is to analyse the relationship between health shocks and household vulnerability in the South African context of high poverty and low medical insurance penetration rate.

Data

The study employs data from waves three to five of South Africa’s nationally representative National Income Dynamics Study (NIDS) conducted between the period 2012–2017 in approximately two-year intervals.

Methods

Using food expenditure shock as an indicator for vulnerability, the study utilises a range of econometric techniques from panel logit regression to quasi-experimental design based difference in difference regressions to assess the association between health shocks, medical insurance and household vulnerability.

Findings

The main finding of the study is that a significant proportion of households in the upper income quintile utilise private healthcare even when not covered by private medical insurance. This preference for private over public health facilities make them vulnerable to health shocks as they cope by sacrificing food consumption to incur additional health expenditure. In contrast, lower income households that are unable to access the high-cost private healthcare tend to rely on the strained public healthcare system. They are not able to use their constrained food expenditure as a coping strategy for private or out-of-pocket medical expenses because their food consumption is already at a bare minimum.

Conclusion

The results confirm that access to quality healthcare is a privilege in South Africa, available only to the minority of the population. The study paints a grim picture of household vulnerability in South Africa and underlines the need for a National Health Insurance that would enable universal access to quality healthcare in the country.

The Investment Case for Malaria Elimination in Thailand: A Cost-Benefit Analysis

After a dramatic decline in the annual malaria incidence in Thailand since 2000, the Thai government developed a National Malaria Elimination Strategy (NMES) to end local malaria transmission by 2024. This study examines the expected costs and benefits of funding the NMES (elimination scenario) versus not funding malaria elimination programming (resurgence scenario) from 2017 to 2036. Two case projection approaches were used to measure the number of malaria cases over the study period, combined with a set of Thailand-specific economic assumptions, to evaluate the cost of a malaria case and to quantify the cost-benefit ratio of elimination. Model A projects cases based on national historical case data using a log-normal regression and change-point analysis model. Model B projects cases based on periodic Yala Province-level outbreak cycles and incorporating NMES political and programmatic goals. In the base case, both models predict that elimination would prevent 1.86-3.11 million malaria cases from 2017 to 2036, with full NMES implementation proving to be cost-saving in all models, perspectives, and scenarios, except for the health system-only perspective in the Model A base case and all perspectives in the Model A worst case. From the societal perspective, every 1 US dollars (US$) spent on the NMES would-depending on case projections used-potentially result in a considerable return on investment, ranging from US$ 2 to US$ 15. Although the two case projection approaches resulted in different cost-benefit ratios, both models showed cost savings and suggest that ending local malaria transmission in Thailand would yield a positive return on investment.

Eliminating malaria by 2040 among agricultural households in Africa: potential impact on health, labor productivity, education and gender equality

Background: Ambitious goals have been set to eradicate malaria by the year 2040. Given the high poverty levels and the intense levels of malaria transmission in sub-Saharan Africa, suppressing malaria in rural agricultural communities in these regions will be one of the greatest challenges to achieving malaria eradication. This study has two objectives. The first is to estimate how eradicating malaria by 2040 would affect agricultural households in sub-Saharan Africa. The second is to identify where additional research is needed to develop better estimates of how eradicating malaria by 2040 would affect those households. Methods: Using agricultural census data and malaria morbidity data, we developed estimates of the number of malaria cases in 2018 among agricultural households with fewer than 10 hectares of land for 35 countries in sub-Saharan Africa. By combining these estimates with additional evidence from the literature, we analyzed how achieving malaria eradication by 2040 would affect indicators related to four Sustainable Development Goals: health, poverty, education and gender equality. Results: Our analysis found that achieving malaria eradication by 2040 would prevent approximately 841 million cases of malaria and thereby decrease the number of lost workdays among agricultural households by approximately 3.2 billion days. Eradicating malaria by 2040 would also increase the number of school days attended by children by 1.5 billion days while also reducing the number of caregiving days provided by women for malaria cases by approximately 1.1 billion days. Conclusions: This article analyzes the impact of eradicating malaria among agricultural households in sub-Saharan Africa using indicators related to four of the Sustainable Development Goals. Enhanced data collection efforts related to these four indicators would facilitate more rigorous estimates of how eradicating malaria would affect these indicators over the next two decades.

Drivers of Patient Costs in Accessing HIV/AIDS Services in Tanzania

BACKGROUND

Patient costs pose a challenge in accessing antiretroviral therapy for people living with HIV in sub-Saharan Africa. The study aimed at identifying drivers for out-of-pocket (OOP) costs in Tanzania.

METHODS

In 2009, 500 adult patients who attended 10 HIV clinics across 7 regions of Tanzania were asked about time and resources consumed to access HIV services. Bivariate and multivariate median regression models were used to determine the main drivers for OOP costs.

RESULTS

Male and female patients have a median OOP costs of $40.37 and $28.01 per year, respectively ( P = .01). Males spend significantly more on travel ($26.51) than females ($19.68; P = .02). Living in rural areas and poor social economic status (SES) are associated with greater OOP costs ( P = .001) for both sexes.

CONCLUSION

Poor SES and rural residence are main drivers of OOP costs. Patients are less likely to seek health care unless they are in dire need, leading to expensive services.

Household economic costs associated with mental, neurological and substance use disorders: a cross-sectional survey in six low- and middle-income countries

BACKGROUND

Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries.

AIMS

To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.

METHOD

We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982).

RESULTS

Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies.

CONCLUSIONS

Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission.

DECLARATION OF INTEREST

D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Estimating malaria disease burden in the Asia-Pacific

Background: The Asia-Pacific aims to eliminate malaria by 2030. Many of the 22 endemic countries have earlier targets. To track progress towards elimination and predict timelines and funding required it is essential to have an accurate picture of the true burden of malaria over time. Estimating this is a major challenge with most countries having incomplete data on numbers of cases and wide variation between health system access and performance. Regular estimates are published by the World Health Organization (WHO), but these are not split by species, can have a wide range of uncertainty, change over time and are not available for every year. Methods: For the Asia Pacific Leaders Malaria Alliance, the burden of malaria for the 22 malaria-endemic countries in the Asia-Pacific from 2000 to 2015 was estimated by combining data submitted by countries to WHO with a systematic review to estimate the proportion of cases recorded. Due to a lack of suitable data, it was only possible to apply this method to 2013-2015. A simplified method was then derived to estimate the annual burden of falciparum and vivax malaria as inputs to a mathematical model to predict the cost of elimination, which is described elsewhere. Results: The total number of estimated cases was around double the number of confirmed cases reported in the Asia Pacific with a broad range of uncertainty around these estimates due primarily to sparsity of data with which to estimate proportions of cases reported. The ranges of estimated burdens were mostly like those published for countries by WHO, with some exceptions. Conclusions: The accuracy and precision of malaria burden estimates could be greatly improved by having more regular large surveys on access to healthcare in malaria-endemic areas and making subnational data on malaria incidence and reporting completeness publicly available.

Eliminating malaria by 2040 among agricultural households in Africa: potential impact on health, labor productivity, education and gender equality

Background: Ambitious goals have been established to eradicate malaria by the year 2040. Suppressing malaria in rural agricultural communities in sub-Saharan Africa represents one of the greatest challenges to achieving malaria eradication given the poverty and high intensity of malaria transmission in these regions. The objective of this study is to examine how suppressing malaria among smallholder agricultural households in sub-Saharan Africa over the next two decades will affect progress towards achieving the Sustainable Development Goals.Methods: Using agricultural census data and malaria morbidity data, we developed estimates of the number of malaria cases among smallholder agricultural households for each country in sub-Saharan Africa. Using these estimates as well as additional data from the literature, we analyzed how achieving malaria eradication by 2040 would affect indicators related to four Sustainable Development Goals: health, poverty, education and gender equality.Results: Our analysis found that achieving malaria eradication would prevent approximately 1 billion malaria cases and thereby decrease the number of lost work-days among agricultural households due to malaria morbidity by approximately 3.8 billion days. Eradicating malaria by 2040 would also increase the number of school days attended by children by 4.5 billion days while also reducing the number of caregiving days by women for malaria cases by approximately 1.9 billion days.Conclusions: This article analyzed the impact of eradicating malaria among smallholder agricultural households in sub-Saharan Africa in terms of four of the Sustainable Development Goals. Greater recognition of the non-health benefits of achieving malaria eradication could catalyze the agricultural sector to intensify their contributions to eradicating malaria.

Malaria incidence trends and their association with climatic variables in rural Gwanda, Zimbabwe, 2005-2015

BACKGROUND

Malaria is a public health problem in Zimbabwe. Although many studies have indicated that climate change may influence the distribution of malaria, there is paucity of information on its trends and association with climatic variables in Zimbabwe. To address this shortfall, the trends of malaria incidence and its interaction with climatic variables in rural Gwanda, Zimbabwe for the period January 2005 to April 2015 was assessed.

METHODS

Retrospective data analysis of reported cases of malaria in three selected Gwanda district rural wards (Buvuma, Ntalale and Selonga) was carried out. Data on malaria cases was collected from the district health information system and ward clinics while data on precipitation and temperature were obtained from the climate hazards group infrared precipitation with station data (CHIRPS) database and the moderate resolution imaging spectro-radiometer (MODIS) satellite data, respectively. Distributed lag non-linear models (DLNLM) were used to determine the temporal lagged association between monthly malaria incidence and monthly climatic variables.

RESULTS

There were 246 confirmed malaria cases in the three wards with a mean incidence of 0.16/1000 population/month. The majority of malaria cases (95%) occurred in the > 5 years age category. The results showed no correlation between trends of clinical malaria (unconfirmed) and confirmed malaria cases in all the three study wards. There was a significant association between malaria incidence and the climatic variables in Buvuma and Selonga wards at specific lag periods. In Ntalale ward, only precipitation (1- and 3-month lag) and mean temperature (1- and 2-month lag) were significantly associated with incidence at specific lag periods (p < 0.05). DLNM results suggest a key risk period in current month, based on key climatic conditions in the 1-4 month period prior.

CONCLUSIONS

As the period of high malaria risk is associated with precipitation and temperature at 1-4 month prior in a seasonal cycle, intensifying malaria control activities over this period will likely contribute to lowering the seasonal malaria incidence.

Economic burden of malaria on rural households in Gwanda district, Zimbabwe

BACKGROUND

Malaria is a serious public health problem in sub-Saharan Africa and is a leading cause of morbidity and mortality.

AIM

To estimate the economic burden of malaria in rural households.

SETTING

The study was conducted in Gwanda district of Matabeleland South in Zimbabwe. A total of five malarious wards and all their households were selected for the study frame, out of which 80 households were chosen using clinic records.

METHODS

A retrospective analysis of secondary data and a cross-sectional household survey were conducted to estimate the household economic burden of malaria. Eighty households from five rural wards were identified from the health facility malaria registers and followed up. A household was eligible for inclusion if there had been at least one reported malaria case during the period of 2013-2015. Interviewer administered questionnaires were used to collect household data on economic costs of malaria.

RESULTS

Our findings showed that households spent an average of $3.22 and $56.60 for managing an uncomplicated and a complicated malaria episode respectively. A household lost an average of eight productive working days per each malaria episode resulting in an average loss of 24% of the monthly household income. An estimated 35%, mostly poorer households suffered catastrophic health expenditures.

CONCLUSION

Malaria imposes significant economic burdens particularly on the poorer and vulnerable households. Although there are no user fees at rural clinics, households incur other costs to manage a malaria patient. These costs are far worse for complicated cases.

An Investment Case to Prevent the Reintroduction of Malaria in Sri Lanka

Sri Lanka has made remarkable gains in reducing the burden of malaria, recording no locally transmitted malaria cases since November 2012 and zero deaths since 2007. The country was recently certified as malaria free by World Health Organization in September 2016. Sri Lanka, however, continues to face a risk of resurgence due to persistent receptivity and vulnerability to malaria transmission. Maintaining the gains will require continued financing to the malaria program to maintain the activities aimed at preventing reintroduction. This article presents an investment case for malaria in Sri Lanka by estimating the costs and benefits of sustaining investments to prevent the reintroduction of the disease. An ingredient-based approach was used to estimate the cost of the existing program. The cost of potential resurgence was estimated using a hypothetical scenario in which resurgence assumed to occur, if all prevention of reintroduction activities were halted. These estimates were used to compute a benefit–cost ratio and a return on investment. The total economic cost of the malaria program in 2014 was estimated at U.S. dollars (USD) 0.57 per capita per year with a financial cost of USD0.37 per capita. The cost of potential malaria resurgence was, however, much higher estimated at 13 times the cost of maintaining existing activities or 21 times based on financial costs alone. This evidence suggests a substantial return on investment providing a compelling argument for advocacy for continued prioritization of funding for the prevention of reintroduction of malaria in Sri Lanka.

Costs and Cost-Effectiveness of Plasmodium vivax Control

The continued success of efforts to reduce the global malaria burden will require sustained funding for interventions specifically targeting Plasmodium vivax The optimal use of limited financial resources necessitates cost and cost-effectiveness analyses of strategies for diagnosing and treating P. vivax and vector control tools. Herein, we review the existing published evidence on the costs and cost-effectiveness of interventions for controlling P. vivax, identifying nine studies focused on diagnosis and treatment and seven studies focused on vector control. Although many of the results from the much more extensive P. falciparum literature can be applied to P. vivax, it is not always possible to extrapolate results from P. falciparum-specific cost-effectiveness analyses. Notably, there is a need for additional studies to evaluate the potential cost-effectiveness of radical cure with primaquine for the prevention of P. vivax relapses with glucose-6-phosphate dehydrogenase testing.

Falling into the Medical Poverty Trap in Sri Lanka: What Can be Done?

Sri Lanka's public health care system is free at the point of use and maintains a focus on equity. However, noncommunicable diseases, such as diabetes, are rapidly increasing in prevalence and posing new challenges to the system and to patients and households. In-depth interviews and focus group discussions were conducted in four districts of Sri Lanka to investigate the care-seeking experiences of diabetes patients from households at different income levels. Although health care is free, other direct and indirect costs served as deterrents to care seeking before and after diagnosis, and placed a high burden on households. The need for frequent visits to clinics with appropriate facilities for diagnosis and management of diabetes, often far from rural communities, posed high costs, in particular due to income foregone. Households employed coping strategies, but the need for frequent clinic visits posed repeated costs, which made it difficult for households to recover their economic status. Many patients, especially those from low-income, rural households, could not maintain the management regimen, and their condition deteriorated. There is a need for specialist facilities for the diagnosis and management of diabetes at locations closer to rural areas.

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.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study

BACKGROUND

Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked.

METHODS

An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc).

RESULTS

The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179).

CONCLUSION

Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.

Household costs of leprosy reactions (ENL) in rural India

Background

Erythema nodosum leprosum (ENL) is a common immune-mediated complication of lepromatous (LL) and borderline lepromatous (BL) leprosy. Most patients experience chronic or multiple acute ENL over many years during an economically active period of their lives. Understanding the economic burden of ENL is essential to provide effective patient support, yet this area has not been investigated.

Methods

Ninety-one patients with LL or BL leprosy attending a leprosy hospital in Purulia district of West Bengal, India, were interviewed using a structured questionnaire. Cases (n = 53) were identified as those who had one or more episodes of ENL within the last 3 years. Controls (n = 38) had LL or BL leprosy but no history of ENL. Data were collected on household income, direct and indirect costs, and coping strategies.

Findings

The total household cost was Rs 1543 per month or 27.9% (IQR 13.2-52.6) of monthly household income for cases, and Rs 237 per month or 4.9% (IQR 1.7-13.4) of monthly household income for controls. Indirect costs accounted for 65% of total household costs for cases. Direct costs accounted for the remaining 35% of household costs, and resulted almost entirely from treatment-seeking in the private sector. Total household costs exceeded 40% of household income for 37.7% of cases (n = 20) and 2.6% of controls (n = 1) [1 USD = 59 INR].

Interpretation

Households affected by ENL face significant economic burden and are at risk of being pushed further into poverty. Health policy should acknowledge the importance of private sector provision and the significant contribution to total household costs of lost productivity (indirect cost). Further work is needed to explore this area and identify solutions.

Erythema nodosum leprosum (ENL) is a common complication of leprosy and an important cause of nerve damage and disability. In most cases, ENL causes chronic or recurrent episodes of ill-health over many years. In this study, we show that having a family member affected by ENL places considerable financial burden on households in rural India. Household costs resulted predominantly from the impact of ENL on the productivity (ability to earn money) of household members. Out of pocket expenditure on treatment-seeking in the private sector accounted for the remaining costs. Leprosy affects poor and marginalised communities in low- and middle-income countries across the world; households affected by ENL are at risk of being pushed further into poverty. The findings of this study support the need to better understand ENL and develop improved strategies for the prevention and management of ENL.

The economic impact of the insured patients with severe chronic and acute illnesses: a qualitative approach

Background

Little research has focused on the economic hardship among the insured with severe illnesses and high treatment costs, in particular, the consequence of poorer insurance coverage for high-cost illnesses. Therefore, we presented the case for identifying the experiences of insured patients with severe chronic and acute illnesses. This study identified a qualitative understanding of the economic impact of severe chronic and acute illnesses and household strategies to deal with high treatment costs.

Design

Interviews were conducted with 19 insured households of three different health insurance programs with a family member that had been hospitalized for severe chronic or acute illnesses in either Banyumas or Margono Sukarjo hospitals in Banyumas, Central Java, Indonesia. A thematic analysis was applied to guide the interpretation of the data.

Results

Insured households with a family member that had been hospitalized for severe chronic and acute illnesses were greatly affected by the high treatment costs. Four major issues emerged from this qualitative study: insured patients are still burdened with high out-of-pocket payments, households adopt various strategies to cope with the high cost of treatments, households experience financial hardships, and positive and negative perceptions of the insured regarding their health insurance coverage for acute and chronic illnesses.

Conclusions

Askes and Jamsostek patients faced financial burdens from high cost sharing for hospital amenities, non-covered drugs, and treatments and other indirect costs. Meanwhile, Jamkesmas beneficiaries faced no financial burden for related medical services but were rather burdened with indirect costs for the carers. Households relied on internal resources to cover hospital bills as the first strategy, which included the mobilization of savings, sale of assets, and borrowing of money. External support was tapped secondarily and included financial support from extended family members, donations from neighbors and the community, and additional benefits from employers. However, insured households overall had positive perceptions of insurance.

The burden of rabies in Tanzania and its impact on local communities

BACKGROUND

Rabies remains a major public health threat in many parts of the world and is responsible for an estimated 55,000 human deaths annually. The burden of rabies is estimated to be around US$20 million in Africa, with the highest financial expenditure being the cost of post-exposure prophylaxis (PEP). However, these calculations may be substantial underestimates because the costs to households of coping with endemic rabies have not been investigated. We therefore aimed to estimate the household costs, health-seeking behaviour, coping strategies, and outcomes of exposure to rabies in rural and urban communities in Tanzania.

METHODS AND FINDINGS

Extensive investigative interviews were used to estimate the incidence of human deaths and bite exposures. Questionnaires with bite victims and their families were used to investigate health-seeking behaviour and costs (medical and non-medical costs) associated with exposure to rabies. We calculated that an average patient in rural Tanzania, where most people live on less than US$1 per day, would need to spend over US$100 to complete WHO recommended PEP schedules. High costs and frequent shortages of PEP led to poor compliance with PEP regimens, delays in presentation to health facilities, and increased risk of death.

CONCLUSION

The true costs of obtaining PEP were twice as high as those previously reported from Africa and should be considered in re-evaluations of the burden of rabies.

Determinants of household direct and indirect costs: an insight for health-seeking behaviour in Burkina Faso

The objective of the study is to identify the determinants of household direct and indirect costs in the Nouna District, Burkina Faso. The data used were from a household survey conducted during 2000-2001. The multinominal logit models were applied to investigate the determinants of direct and indirect costs. The respondents who were sick in the rainy season and severity of illness significantly increased the probability of having high direct and indirect household costs. Acute illness occured in an adult was positively associated with magnitude of household indirect costs. Household economic status and utilization of western medical care played an important role in magnitude of direct cost. The information on determinants of household direct and indirect costs is necessary in order to get a complete picture of household costs for seeking health care and identification of vulnerable social groups and households.

Social implications of malaria and their relationships with poverty

In poor countries, tragically, people die unnecessarily. Having changed our understanding about issues related to poverty, even in the fight against malaria we must keep in mind a number of issues other than simple lack of economic resources. In this article we tried to discuss the various aspects that make malaria a disease closely related to poverty and the effects of malaria on the same poverty of patients who are affected. If you want the program to "Rool Back Malaria" to succeed, you must program interventions that improve the living conditions of populations in endemic area, individually and as communities. As has become clear that the discovery of an effective vaccine will not eradicate the disease, remains a fundamental understanding of mechanisms related to poverty that cause Malaria remains one of the major killers in the world, to help communities affected and individuals to prevent, cure properly and not being afraid of this ancient disease.

Plasmodium vivax treatments: what are we looking for?

PURPOSE OF REVIEW

For over 50 years, the treatment of Plasmodium vivax has relied on a combination of chloroquine and primaquine, but this strategy is under threat. Chloroquine efficacy is now compromised across much of the vivax endemic world and there are significant operational difficulties in deploying primaquine. We review the recent advances in P. vivax chemotherapy that may influence the future management of this neglected pathogen.

RECENT FINDINGS

New-generation artemisinin combination therapies (ACTs) have shown potent efficacy against the erythrocytic stages of both drug-resistant P. vivax and Plasmodium falciparum. Antimalarial regimens containing slowly eliminated drugs provide a measure of protection against the first, and possibly second, relapse of tropical strains of P. vivax, but reliable radical cure is needed to prevent future relapses. Primaquine is currently the only licensed hypnozoitocidal treatment, but requires long treatment courses and its effectiveness in different endemic settings remains largely unknown.

SUMMARY

In regions coendemic for P. vivax and P. falciparum, a unified treatment policy for malaria of any parasitological cause is likely to confer the greatest individual and public health benefit. Optimizing the safety and effectiveness of primaquine through the development of rapid diagnostic tests for glucose-6-phosphate dehydrogenase deficiency and improving drug adherence will be crucial endeavors in the fight against vivax malaria.

Seasonal and geographic differences in treatment-seeking and household cost of febrile illness among children in Malawi

Background

Households in malaria endemic countries experience considerable costs in accessing formal health facilities because of childhood malaria. The Ministry of Health in Malawi has defined certain villages as hard-to-reach on the basis of either their distance from health facilities or inaccessibility. Some of these villages have been assigned a community health worker, responsible for referring febrile children to a health facility. Health facility utilization and household costs of attending a health facility were compared between individuals living near the district hospital and those in hard-to-reach villages.

Methods

Two cross-sectional household surveys were conducted in the Chikhwawa district of Malawi; one during each of the wet and dry seasons. Half the participating villages were located near the hospital, the others were in areas defined as hard-to-reach. Data were collected on attendance to formal health facilities and economic costs incurred due to recent childhood febrile illness.

Results

Those living in hard-to-reach villages were less likely to attend a formal health facility compared to those living near the hospital (Dry season: OR 0.35, 95%CI0.18-0.67; Wet season: OR 0.46, 95%CI0.27-0.80). Analyses including community health workers (CHW) as a source of formal health-care decreased the strength of this relationship, and suggested that consulting a CHW may reduce attendance at health facilities, even if indicated. Although those in hard-to-reach villages were still less likely to attend in both the dry (OR 0.53, 95%CI 0.25-1.11) and wet (OR 0.60, 95%CI 0.37-0.98) seasons. Household costs for those who attended a health facility were greater for those in HTR villages (Dry: USD5.24; Wet: USD5.60) than for those living near the district hospital (Dry: USD3.45; Wet: USD4.46).

Conclusion

Those living in hard-to-reach areas were less likely to attend a health facility for a childhood febrile event and experienced greater associated household costs. Consulting CHWs was infrequent, but appeared to reduce attendance at a health facility, even when indicated. Health service planners must consider geographic and financial barriers to accessing public health facilities in designing appropriate interventions.

The economic costs of malaria in four Kenyan districts: do household costs differ by disease endemicity?

BACKGROUND

Malaria inflicts significant costs on households and on the economy of malaria endemic countries. There is also evidence that the economic burden is higher among the poorest in a population, and that cost burdens differ significantly between wet and dry seasons. What is not clear is whether, and how, the economic burden of malaria differs by disease endemicity. The need to account for geographical and epidemiological differences in the estimation of the social and economic burden of malaria is well recognized, but there is limited data, if any, to support this argument. This study sought to contribute towards filling this gap by comparing malaria cost burdens in four Kenyan districts of different endemicity.

METHODS

A cross-sectional household survey was conducted during the peak malaria transmission season in the poorest areas in four Kenyan districts with differing malaria transmission patterns (n = 179 households in Bondo; 205 Gucha; 184 Kwale; 141 Makueni).

FINDINGS

There were significant differences in duration of fever, perception of fever severity and cost burdens. Fever episodes among adults and children over five years in Gucha and Makueni districts (highland endemic and low acute transmission districts respectively) lasted significantly longer than episodes reported in Bondo and Kwale districts (high perennial transmission and seasonal, intense transmission, respectively). Perceptions of illness severity also differed between districts: fevers reported among older children and adults in Gucha and Makueni districts were reported as severe compared to those reported in the other districts. Indirect and total costs differed significantly between districts but differences in direct costs were not significant. Total household costs were highest in Makueni (US$ 19.6 per month) and lowest in Bondo (US$ 9.2 per month).

CONCLUSIONS

Cost burdens are the product of complex relationships between social, economic and epidemiological factors. The cost data presented in this study reflect transmission patterns in the four districts, suggesting that a relationship between costs burdens and the nature of transmission might exist, and that the same warrants more attention from researchers and policy makers.

Artemisinin combination therapy for vivax malaria

Early parasitological diagnosis and treatment with artemisinin-based combination therapies (ACTs) are key components of worldwide malaria elimination programmes. In general, use of ACTs has been limited to patients with falciparum malaria whereas blood-stage infections with Plasmodium vivax are mostly still treated with chloroquine. We review the evidence for the relative benefits and disadvantages of the existing separate treatment approach versus a unified ACT-based strategy for treating Plasmodium falciparum and P vivax infections in regions where both species are endemic (co-endemic). The separate treatment scenario is justifiable if P vivax remains sensitive to chloroquine and diagnostic tests reliably distinguish P vivax from P falciparum. However, with the high number of misdiagnoses in routine practice and the rise and spread of chloroquine-resistant P vivax, there might be a compelling rationale for a unified ACT-based strategy for vivax and falciparum malaria in all co-endemic regions. Analyses of the cost-effectiveness of ACTs for both Plasmodium species are needed to assess the role of these drugs in the control and elimination of vivax malaria.

The economic benefits resulting from the first 8 years of the Global Programme to Eliminate Lymphatic Filariasis (2000-2007)

BACKGROUND

Between 2000-2007, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) delivered more than 1.9 billion treatments to nearly 600 million individuals via annual mass drug administration (MDA) of anti-filarial drugs (albendazole, ivermectin, diethylcarbamazine) to all at-risk for 4-6 years. Quantifying the resulting economic benefits of this significant achievement is important not only to justify the resources invested in the GPELF but also to more fully understand the Programme's overall impact on some of the poorest endemic populations.

METHODOLOGY

To calculate the economic benefits, the number of clinical manifestations averted was first quantified and the savings associated with this disease prevention then analyzed in the context of direct treatment costs, indirect costs of lost-labor, and costs to the health system to care for affected individuals. Multiple data sources were reviewed, including published literature and databases from the World Health Organization, International Monetary Fund, and International Labour Organization

PRINCIPAL FINDINGS

An estimated US$21.8 billion of direct economic benefits will be gained over the lifetime of 31.4 million individuals treated during the first 8 years of the GPELF. Of this total, over US$2.3 billion is realized by the protection of nearly 3 million newborns and other individuals from acquiring lymphatic filariasis as a result of their being born into areas freed of LF transmission. Similarly, more than 28 million individuals already infected with LF benefit from GPELF's halting the progression of their disease, which results in an associated lifetime economic benefit of approximately US$19.5 billion. In addition to these economic benefits to at-risk individuals, decreased patient services associated with reduced LF morbidity saves the health systems of endemic countries approximately US$2.2 billion.

CONCLUSIONS/SIGNIFICANCE

MDA for LF offers significant economic benefits. Moreover, with favorable program implementation costs (largely a result of the sustained commitments of donated drugs from the pharmaceutical industry) it is clear that the economic rate of return of the GPELF is extremely high and that this Programme continues to prove itself an excellent investment in global health.

Reviewing the literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets

Background

Effective case management is central to reducing malaria mortality and morbidity worldwide, but only a minority of those affected by malaria, have access to prompt effective treatment.

In Kenya, the Division of Malaria Control is committed to ensuring that 80 percent of childhood fevers are treated with effective anti-malarial medicines within 24 hours of fever onset, but this target is largely unmet. This review aimed to document evidence on access to effective malaria treatment in Kenya, identify factors that influence access, and make recommendations on how to improve prompt access to effective malaria treatment. Since treatment-seeking patterns for malaria are similar in many settings in sub-Saharan Africa, the findings presented in this review have important lessons for other malaria endemic countries.

Methods

Internet searches were conducted in PUBMED (MEDLINE) and HINARI databases using specific search terms and strategies. Grey literature was obtained by soliciting reports from individual researchers working in the treatment-seeking field, from websites of major organizations involved in malaria control and from international reports.

Results

The review indicated that malaria treatment-seeking occurs mostly in the informal sector; that most fevers are treated, but treatment is often ineffective. Irrational drug use was identified as a problem in most studies, but determinants of this behaviour were not documented. Availability of non-recommended medicines over-the-counter and the presence of substandard anti-malarials in the market are well documented. Demand side determinants of access include perception of illness causes, severity and timing of treatment, perceptions of treatment efficacy, simplicity of regimens and ability to pay. Supply side determinants include distance to health facilities, availability of medicines, prescribing and dispensing practices and quality of medicines. Policy level factors are around the complexity and unclear messages regarding drug policy changes.

Conclusion

Kenya, like many other African countries, is still far from achieving the Abuja targets. The government, with support from donors, should invest adequately in mechanisms that promote access to effective treatment. Such approaches should focus on factors influencing multiple dimensions of access and will require the cooperation of all stakeholders working in malaria control.

Paying for hospital-based care of Kala-azar in Nepal: assessing catastrophic, impoverishment and economic consequences

Households obtaining health care services in developing countries incur substantial costs, despite services generally being provided free of charge by public health institutions. This constitutes an economic burden on low-income households, and contributes to deepening their level of poverty. In addition to the economic burden of obtaining health care, the method of financing these payments has implications for the distribution of household assets. This effect on resource-poor households is amplified since they have decreased access to health insurance. Recent literature, however, ignores the importance of the method of financing health care payments. This paper looks at the case of Nepal and highlights the impact on households of paying for hospital-based care of Kala-azar (KA) by analysing the catastrophic, impoverishment and economic consequences of their coping strategies. The paper utilizes micro-data on a random selection of 50% of the KA-affected households of Siraha and Saptari districts of Nepal. The empirical results suggest that direct costs of hospital-based treatment of KA are catastrophic since they consume 17% of annual household income. This expenditure causes more than 20% of KA-affected households to fall below the poverty line, with the remaining households being pushed into the category of marginal poor; the poverty gap ratio is more than 90%. Further, KA incidence can have prolonged and severe economic consequences for the household economy due to the mechanisms of informal sector financing to which households resort. A heavy burden of loan repayments can lead households on a downward spiral that eventually becomes a poverty trap. In other words, the method of financing health care payments is an important ingredient in understanding the economic burden of disease.

Effect of removing direct payment for health care on utilisation and health outcomes in Ghanaian children: a randomised controlled trial

BACKGROUND

Delays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly.

METHODS AND FINDINGS

2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66-1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.

CONCLUSIONS

In the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured.

The economic burden of malaria on the household in south-central Vietnam

Background

Each year, several thousand cases of malaria occur in south-central Vietnam. Evidence from elsewhere suggests that malaria can have an economic impact on the household as the illness prevents households from completing their normal, physically demanding, productive duties such as tending crops and animals. The economic impact of malaria on households was explored within the Raglay ethnic minority living in the montainous and forested area of south-central Vietnam (Ninh Thuan Province).

Methods

Two-hundred fifty-one malaria patients were identified and interviewed in an exit survey at Community Health Centres. The same patient sample was then re-interviewed in a household survey two to four weeks later. Survey data were complemented by approximately 40 informal discussions with health workers, vendors, patients, and community leaders.

Results

Each episode of malaria was estimated to cost the patient's household an average of 11.79 USD (2005 prices), direct costs for travel and treatment representing 6% of the total while the remainder was loss in annual income.

Conclusion

Whilst government provision of malaria treatment keeps the direct costs relatively low, the overall loss in income due to illness can still be significant given the poverty amongst this population, especially when multiple cases of malaria occur annually within the same household.

Intermittent preventive treatment of malaria in pregnancy: the incremental cost-effectiveness of a new delivery system in Uganda

The main objective of this study was to assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilisers could administer intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) to pregnant women. The study was implemented in 21 community clusters (intervention) and four clusters where health centres provided routine IPTp (control). The primary outcome measures were the proportion of women who completed two doses of SP; the effect on anaemia, parasitaemia and low birth weight; and the incremental cost-effectiveness of the intervention. The study enrolled 2785 pregnant women. The majority, 1404/2081 (67.5%) receiving community-based care, received SP early and adhered to the two recommended doses compared with 281/704 (39.9%) at health centres (P<0.001). In addition, women receiving community-based care had fewer episodes of anaemia or severe anaemia and fewer low birth weight babies. The cost per woman receiving the full course of IPTp was, however, higher when delivered via community care at US$2.60 compared with US$2.30 at health centres, due to the additional training costs. The incremental cost-effectiveness ratio of the community delivery system was Uganda shillings 1869 (US$1.10) per lost disability-adjusted life-year (DALY) averted. In conclusion, community-based delivery increased access and adherence to IPTp and was cost-effective.

Effect of a community-based delivery of intermittent preventive treatment of malaria in pregnancy on treatment seeking for malaria at health units in Uganda

BACKGROUND

The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention.

OBJECTIVE

To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp.

STUDY DESIGN

An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs.

RESULTS

More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community.

CONCLUSION

The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.

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.

Computational modeling tools for the design of potent antimalarial bisbenzamidines: Overcoming the antimalarial potential of pentamidine

Malaria is nowadays a worldwide and serious problem with a significant social, economic, and human cost, mainly in developing countries. In addition, the emergence and spread of resistance to existing antimalarial therapies deteriorate the global malaria situation, and lead thus to an urgent need toward the design and discovery of new antimalarial drugs. In this work, a QSAR predictive model based on GETAWAY descriptors was developed which is able to explain with, only three variables, more than 77% of the variance in antimalarial potency and displays a good internal predictive ability (of 73.3% and 72.9% from leave-one-out cross-validation and bootstrapping analyses, respectively). The performance of the proposed model was judged against other five methodologies providing evidence of the superiority of GETAWAY descriptors in predicting the antimalarial potency of the bisbenzamidine family. Moreover, a desirability analysis based on the final QSAR model showed that to be a useful way of selecting the predictive variable level necessary to obtain potent bisbenzamidines. From the proposed model it is also possible to infer that elevated high atomic masses/polarizabilities/van der Waals volumes could play a negative/positive/positive role in the molecular interactions responsible for the desired drug conformation, which is required for the optimal binding to the macromolecular target. The results obtained point out that our final QSAR model is statistically significant and robust as well as possessing a high predictive effectiveness. Thus, the model provides a feasible and practical tool for looking for new and potent antimalarial bisbenzamidines.

Assessment of indirect cost-of-illness in a subsistence farming society by using different valuation methods

Indirect costs or productive labour time lost are the largest share of household economic burden of illness. However, the estimate of household indirect cost can vary depending on the valuation methods used. We therefore estimated household indirect cost in a subsistence farming society in Burkina Faso based on daily production value. These results were validated by using willingness-to-pay method and current wage rate. Among the three methods, the value of a day lost for adults assessed by willingness-to-pay method was considerably higher than other methods. There were no significant differences in indirect costs estimated by daily production value and wage rate. There were significantly higher indirect costs for households which were of higher economic status when daily production value was used. It might raise a question of equity. The willingness-to-pay method can capture the various aspects of indirect cost such as differences among age groups and gender, important individual characteristics and seasons. Thus, it is an appropriate approach for rural subsistence farmer communities. Estimation of indirect cost by wage rate can also be used as a rapid estimation of indirect cost in a rural area in developing countries as an alternative for daily production value.

Breaking the poor health-poverty link in the 21st Century: do health systems help or hinder?

It is depressing but true that, at the beginning of the 21st Century, poverty and ill-health are still closely interrelated. This review traces the current pathways from poor health to poverty in low- and middle-income countries, first at the national level, then at the household level. Ill health can have a substantial impact on gross domestic product, holding countries back from economic development, the fruits of which could be used to improve population health. At the household level, people may be pushed into poverty as a result of paying for health care. Households are forced to pay for the direct and indirect costs of health care at precisely the time when their incomes may be lowered by ill health. For this reason, many forego care, or rely on self-care or informal care, which may hasten the decline in their health and reduce their productivity. Sick people face a double jeopardy: their ill-health puts them at greater risk of poverty, and their poverty is likely to damage their health still further. The review goes on to discuss the role of health systems in the generation of poverty, before concluding with pointers as to how health systems can become part of the solution, rather than part of the problem.

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.

Cost-of-illness studies : a review of current methods

The number of cost-of-illness (COI) studies has expanded considerably over time. One outcome of this growth is that the reported COI estimates are inconsistent across studies, thereby raising concerns over the validity of the estimates and methods. Several factors have been identified in the literature as reasons for the observed variation in COI estimates. To date, the variation in the methods used to calculate costs has not been examined in great detail even though the variations in methods are a major driver of variation in COI estimates. The objective of this review was to document the variation in the methodologies employed in COI studies and to highlight the benefits and limitations of these methods. The review of COI studies was implemented following a four-step procedure: (i) a structured literature search of MEDLINE, JSTOR and EconLit; (ii) a review of abstracts using pre-defined inclusion and exclusion criteria; (iii) a full-text review using pre-defined inclusion and exclusion criteria; and (iv) classification of articles according to the methods used to calculate costs. This review identified four COI estimation methods (Sum_All Medical, Sum_Diagnosis Specific, Matched Control and Regression) that were used in categorising articles. Also, six components of direct medical costs and five components of indirect/non-medical costs were identified and used in categorising articles.365 full-length articles were reflected in the current review following the structured literature search. The top five cost components were emergency room/inpatient hospital costs, outpatient physician costs, drug costs, productivity losses and laboratory costs. The dominant method, Sum_Diagnosis Specific, was a total costing approach that restricted the summation of medical expenditures to those related to a diagnosis of the disease of interest. There was considerable variation in the methods used within disease subcategories. In several disease subcategories (e.g. asthma, dementia, diabetes mellitus), all four estimation methods were represented, and in other cases (e.g. HIV/AIDS, obesity, stroke, urinary incontinence, schizophrenia), three of the four estimation methods were represented. There was also evidence to suggest that the strengths and weaknesses of each method were considered when applying a method to a specific illness. Comparisons and assessments of COI estimates should consider the method used to estimate costs both as an important source of variation in the reported COI estimates and as a marker of the reliability of the COI estimate.

What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts?

This paper presents the findings of a critical review of studies carried out in low- and middle-income countries (LMICs) focusing on the economic consequences for households of illness and health care use. These include household level impacts of direct costs (medical treatment and related financial costs), indirect costs (productive time losses resulting from illness) and subsequent household responses. It highlights that health care financing strategies that place considerable emphasis on out-of-pocket payments can impoverish households. There is growing evidence of households being pushed into poverty or forced into deeper poverty when faced with substantial medical expenses, particularly when combined with a loss of household income due to ill-health. Health sector reforms in LMICs since the late 1980s have particularly focused on promoting user fees for public sector health services and increasing the role of the private for-profit sector in health care provision. This has increasingly placed the burden of paying for health care on individuals experiencing poor health. This trend seems to continue even though some countries and international organisations are considering a shift away from their previous pro-user fee agenda. Research into alternative health care financing strategies and related mechanisms for coping with the direct and indirect costs of illness is urgently required to inform the development of appropriate social policies to improve access to essential health services and break the vicious cycle between illness and poverty.

Opportunities and limiting factors of intensive vegetable farming in malaria endemic Côte d'Ivoire

Poverty reduction policies guide development strategies. In economies that depend heavily on agriculture, in the face of rapid population growth, innovative approaches are required to satisfy food needs, increase household welfare and alleviate poverty. Irrigated agriculture is an important strategy to enhance crop production, but it must be well tailored to specific socio-ecological settings, as otherwise, it might increase the burden of water-related parasitic diseases and delay economic advance. The purpose of this study is to assess and quantify the effect of ill health, particularly malaria, on the performance of farm activity, with an emphasis on drip-irrigated vegetable farming in rural Côte d'Ivoire. Vegetable yields and revenues were monitored among 12 farmers and linked with longitudinal medical and entomological surveys. Over the course of 10 months, farmers were classified as sick, on average, for 14-15 days, with malaria accounting for 8-9 days (58%), confirming that malaria is the most important disease in this setting. There was a large heterogeneity among farmers, with malaria-related work losses ranging between 0 and 26 days. Work absenteeism correlated with overall yields and revenues. During a single cabbage production cycle, those farmers who were prescribed sick because of malaria for more than 2 days (mean: 4.2 days) had 47% lower yields and 53% lower revenues than farmers who missed a maximum of 2 days (mean: 0.3 days). This is consequential in an intensive cropping system, where substitutes for qualified workers are not readily available. We conclude that mitigating the burden of malaria is an important step towards reducing the vulnerability of people engaged in intensive agricultural production. This calls for targeted interventions to facilitate agriculture-based rural development that might spur social and economic development and reduce inequities in sub-Saharan Africa.

The cost and cost-effectiveness of malaria vector control by residual insecticide house-spraying in southern Mozambique: a rural and urban analysis

OBJECTIVES

To compare two separately funded, but operationally similar, residual household-spraying (RHS) initiatives; one rural and one peri-urban in southern Mozambique.

METHODS

The rural programme is a regional project involving the participation and co-ordination of organizations across three countries in southern Africa and is focussed on control in an area in Mozambique of 7552 km2. The second programme focuses on spraying a peri-urban community within a 10-km radius around MOZAL, an aluminium smelter plant of area 410 km2. An ingredients approach was used to derive unit costs for both the rural and peri-urban spraying programmes using detail retrospective cost data and effectiveness indicators.

RESULTS

The economic cost per person covered per year using Carbamates for indoor residual spraying (IRS) in the rural area, excluding the costs of project management and monitoring and surveillance was $3.48 and in the peri-urban area, $2.16. The financial costs per person covered in the rural area and peri-urban area per year were $3.86 and $2.41, respectively. The economic costs per person covered were respectively increased by 39% and 31% when project management and monitoring and surveillance were included. The main driving forces behind the costs of delivering RHS are twofold: the population covered and insecticide used. Computed economic and financial costs are presented for all four insecticide families available for use in RHS.

CONCLUSIONS

The results from both these initiatives, especially the rural area, should be interpreted as conservative cost estimates as they exclude the additional health gains that the newly introduced programmes have had on malaria rates in the neighbouring areas of South Africa and Swaziland. Both these initiatives show that introducing an IRS programme can deliver a reduction in malaria-related suffering providing financial support, political will, collaborative management and training and community involvement are in place.

Malaria and property accumulation in rice production systems in the savannah zone of Côte d'Ivoire

Irrigation stabilizes agricultural production and hence improves farmers' living standards and conditions. The permanent presence of water may, however, increase the burden of water-related parasitic diseases and counter the economic benefits of irrigation by reducing farmers' health. The purpose of this study was to assess the impact of malaria on farm household property, beyond the health risk (studied elsewhere). The research question was: by weakening individuals, does malaria reduce productive capacities and income workers, and consequently limit their property accumulation? To test this hypothesis, we use data on property (farming equipment, livestock and durable consumer goods) and Plasmodium falciparum indicators generated by a study carried out in 1998 in the Ivorian savannah zone characterized by inland valley rice cultivation, with a sample of nearly 750 farming households. Property is influenced by many factors related to the size of the family, the area under cultivation and high parasite density infection rate of P. falciparum. A significant negative correlation between high-density infection rate and the property values confirms that by reducing the living standards of households, malaria is a limiting factor for property accumulation.

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.