Relative costs and effectiveness of treating uncomplicated malaria in two rural districts in Zambia: implications for nationwide scale-up of home-based management

Malaria case management is one of the key strategies to control malaria [1]. The adoption of new effective artemisinin-based combination therapy (ACT) in Africa has began to show positive health impacts in terms of malaria morbidity and mortality reduction [1, 2] with some countries contemplating malaria elimination [1]. Additionally, the introduction of rapid diagnostic tests (RDTs) for malaria has changed the approach to malaria diagnosis. Presumptive treatment of fevers as malaria is no longer encouraged because it leads to misdiagnosis of the disease and irrational drug use [3]. With the adoption of RDTs in routine health services, malaria confirmation is no longer a preserve of areas with laboratory services. RDTs are increasingly gaining attention for their practical use given the limitations of scaling up microscopy services [4]. RDT diagnosis of malaria has been said to be rapid and requiring less inputs than microscopy and no specialized personnel is required to perform the tests [5, 6]. This has potentially improved patient access to diagnosis services, especially in peripheral health centres [6].

In spite of all these achievements, access to prompt and effective case management still remains a challenge. It is for this reason that WHO recommended the adoption of the home management of malaria (HMM). HMM has been shown to be feasible and acceptable [7]. Additionally various approaches for scaling up HMM include pharmacists, villages volunteers or shopkeepers [8]. The choice of strategy depends on the health system context.

Malaria in Zambia is a major cause of visitation and hospitalization. In 2009, approximately three million cases and 2,000 deaths were recorded from health facilities countrywide [9]. ACT and RDTs in Zambia are provided free of charge in the public sector both in rural and urban areas up to health facility level. In urban areas, some private health facilities do provide malaria and other health services to a less extent. However, in rural areas, the people mostly depend solely on the available public health facilities. Sometimes, the facilities are in distant locations, which create geographical access barriers. In areas where the health facilities exist, the lack of adequate human resources sometimes leads to delays and long queues.

Community health workers (CHWs) form part of the health system in the rural areas. Their main mandate, until recently, was in health education. However, due to the growing demand for patient care, plans are underway to scale up HMM with ACT and RDTs using CHWs. CHWs are able to interpret instructions correctly on how to use RDTs [10] and they can safely prescribe ACT.

A study was carried to evaluate the cost and effectiveness of managing uncomplicated malaria with ACT and RDTs using CHWs in comparison with the health facility model.

The average utilization of CHWs by the target population in the two districts was estimated at 29% (35% in Chongwe and 23% in Kalomo district). The utilization rate was estimated using the catchment population of the CHWs in each district as the denominator and the number of visits to the CHW as the numerator. The catchment population under consideration was 16,079 in Chongwe and 18,279 in Kalomo. The crude parasite prevalence was 24% and 26% among CHW and health facility visits respectively. These figures are within the national estimates of 27% from the national population based parasitological surveys [13].

At community level no microscopy testing was done, all the cases were diagnosed using RDT while at health facility level either microscopy or RDT was used. This is in line with national policy of introducing only RDTs at community level but health facilities can use whichever test is available at the time of a patient visit. The proportion of patients in whom a confirmatory test was performed was higher at community (97%) than at health facility level (56%) as shown in Table 2.

The average cost per case appropriately tested was higher at health facility than at community level. This is because personnel and capital costs are higher at health facility level. The current HMM strategy uses CHWs who have been working on voluntary basis and thus are not salaried. However, the costs of RDTs and ACT are the same at HF and HMM level because they use the same national procurement and distribution system.

The community approach could provide an effective and cost-effective way of increasing access to prompt and effective case management. HMM with RDTs and ACTs can be scaled up even in resource constraint settings, such as Zambia where there is also a looming human resource crisis. It also provides more evidence on the economical and health benefits of introducing ACT and RDTs in the HMM strategy.

It is important to point out that better practices were reported in the HMM model than at health facility level. CHWs adhered to case management guidelines and this consequently resulted in more cases appropriately diagnosed and treated than at facility level. The findings also bring out an improtant aspect that the availability of commodities for malaria control should not be the only bottleneck to be improved upon in an effort to deliver effective case management. Traning and mentoring is key to ensure that heath workers adhere to good case management so that they utilize the available tools correctly. Otherwise the cost-effectiveness of ACT and RDTs are negated by the poor practice of health workers [14]. Non adherence to malaria diagnostic test result has already been documented to be a problem among health workers in Zambia [15, 16]. The training model for CHWs used in this study can also be scaled up to large scale health facility level so as to introduce good practices at health facility level. This has the potential to improve not only malaria case management but overall patient management as well. This model of training was used in a health facility study in one district and similar good case management practices were attained [2]. This is because not prescribing anti-malarials to non-malaria fevers, provides an opportunity for patients to be invstiagated for another cause of illness. HMM with ACT and RDTs is thus not only economical but it can potentially lead to better health outcomes. In Kenya, a study demonstrated that shopkeeper trainings improved the proportion of cases taking appropriate anti-malarial doses [8].

The cost per case appropriately diagnosed and treated through HMM is lower than cost which have been reported by other studies for scaling up HMM using various strategies. In Ghana, IPTc via community based voulunteers found the least cost effective method to be about USD 8.19. HMM without diagnosis has been demonstrated not to have better outcomes than the facility level [17]. This seems to emphasize the need to adopt the strategy of including the diagnosis component in HMM as has been recommended by other researchers [8]. RDTs are attractive and easy to scale up at community level than microscopy because less capital invetsments are required [5, 6]. Furthermore, in Zambia, it has been demonstarted that RDTs are cost effective in the management of malaria at facility level [11]. The negative effects of false negatives are minimized by use of HRP-II based RDTs which have been shown to overestimate the burden of malaria by 10% [18].

The scale-up costs found in this study are substantial at the beginning of the programme, but the maintenance costs are feasible and can be managed by district level management. This is because in the case of Zambia, both ACT and RDTs are centrally procured and thus the HMM strategy does not require its own logistics and management system. The CHWs are also already part of the health care system and do receive baseline training in health programmes. This level of community involvement provides a vehicle for the delivery of HMM by adding effective tools such as RDTs and ACT instead of treating malaria patients with SP based on fever. Thus other malaria programmes contemplating HMM should consider the health system context and review existing channels which can be used to have an effective HMM strategy.

The cost per patient appropriately diagnosed could change upwards if CHWs were to be salaried, however, the level of increase would be determined by the volume of non-malaria services that CHWs may be allowed to offer if salaried. Additionally, capital investments such as screening rooms or booths for CHWs to work in may also positively change the unit costs found in the HMM strategy. However, none of these would render the HMM strategy to be less effective.

Further areas for research include the impact of HMM strategy on the outcomes of non-malaria fevers and the effectiveness of the training model proposed in this study in a multicentre study.

HMM was more cost-effective for management of uncomplicated malaria in rural areas than the standard of care at health facility level (USD4.22 versus USD6.61). Utilization and adherence to both diagnostic and treatment guidelines was higher in HMM strategy than at health facility level. Scale-up costs for HMM would depend on the expected utilisation and the desired patient to provider ratio.