Researchjournalis Journal of Sociology

Vol. 2 | No. 2 February | 2014 ISSN 2347-8241

Cost Drivers Of Household Treatment Of Presumptive Malaria In Home-Based Management Of Malaria In EjisuJuaben Municipality
Benedicta O. Asante

ZoomLion Ghana LTD, Research and Development Department

Agyei-Baffour P

Kwame Nkrumah University of Science and Technology, College of Health Sciences, School of Medical Sciences, Kumasi, Ghana

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Abstract
Home-Based Management of Malaria (HBMM) is one of the key strategies to reduce the burden of malaria for vulnerable populations in endemic countries. The strategy seeks to allow caregivers to have immediate health care from some selected and trained community members. The study sought to identify the cost drivers of presumptive malaria treatment and cost of seeking care from the community medicine distributors (CMDs). A cross-sectional study was done in the Ejisu-Juaben Municipality in the Ashanti Region. The study involved randomly selected 400 caregivers, (10) health staff and (90) community-based medicine distributors (CMDs). Structured questionnaires were employed to collect these data and data was analyzed into descriptive statistics with SPSS version 17 software. Test for associations were done at 95% confidence interval. With the assumption that transport cost and food cost were zero (0) in HBMM. The results reveals that, the cost of treatment of malaria for children between 6-11 months ranged from GHP0.01-1.00 ( 0.19 STD), while children between the ages of 12-24 months ranged from GH1.00-1.50 (0.04 STD) and 36-59 months ranged from GH2.00-3.00 (0.30 STD). Generally cost was described as affordable and drivers of treatment cost were level of severity of the illness, distance to the homes, time spent in travelling and in the consumers homes as well as the number of population within the CMDs catchment area. Cost incurred in accessing HBMM treatment was affordable to caregivers Drivers of treatment cost in HBMM varies from the caregivers and care seekers.

Keyword: Malaria, Cost, Home-based management, Households, Treatment.

1. Introduction
Malaria, one of the world's most common and serious tropical diseases, cause at least one million deaths every year. Majority of which occur in the most resource-poor countries which also accommodate more than half of the world's population and are at risk of acquiring malaria. This proportion increases each year because of deteriorating health systems, growing drug and insecticide resistance, climate change, natural disasters and armed conflicts. Overall malaria accounts for 10% of Africas disease burden, and is estimated that malaria costs the continent more than $12 billion annually. The estimated cost to effectively control malaria in the 82 countries with the highest burden is about $3.2 billion annually. In Ghana however, statistics show that one in five childhood deaths result from malaria. The cost of treatment of malaria alone is crippling the health budget in that in 2007 alone the cost of treating malaria amounted to about US $772 million and this equalled the entire health budget for 2008, and represents 10% of the countrys GDP for 2006.

According to these researchers (Goodman et al., 2000; Akazili, 2002; Hanson et al., 2004) the economic burden of malaria was not high at the worldwide, but it was seen greatly in the various household and this was

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Vol. 2 | No. 2 February | 2014 ISSN 2347-8241

the barrier to accessing health care as stated earlier. Lots of studies on malaria management are throwing more light on the importance of wealth position on malaria burden as well as access to treatment and prevention actions. In other studies, they value and measured economic cost basis on output or income losses incurred in the household rather than using a general indicator such as average wage rate. Loss of output and wages accounted for the highest proportion of the economic 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. Comparing the methods used by other researchers for valuing economic cost, demonstrating the significant impact that methods of measurement and valuation could have on the estimation of economic cost, and justify the recommendation for methodological research in this area (Lipsey, 1994).

Issues influencing cost of home-based management of malaria vary from one point to the other. Factors can either increase or decrease the size of cost. According to Collette (1994), level of severity of the illness, distant to the homes, kind of the interventions received (intensive or standard case management), time spent in travelling and in the consumers homes as well as the size of each of population each CMDs handles could affect the cost of HBMM. From the article of Joel (2006), there was an ideal that, the length of illness before getting a treatment was the key factor that determines either a high or low cost of treatment: In that, the longer the length of illness the higher the cost of treatment hence vice versa. In 1994, Lipsey studies also showed that, the cost of illness for outpatients who received early diagnosis and prompt treatment was four to seven times cheaper than the cost of illness for those who were hospitalized. Therefore, people from malaria endemic sectors should be educated in seeking early treatment from health facilities.

According to some agencies, embedded in the cost involve in the various forms of activities within the HBMM were the factors which decrease or increase the cost of the programme. These activities included the administrative support, photo copies, stationery, telephone and supervision, meetings, training, as well as monitoring, and salaries for facilitators of CMDs. In addition is the cost of purchasing of bicycles, motor bikes, repairs and maintenance incurred on vehicles, motor bikes, and bicycles, boots, others are raincoats, torch lights and tool kits (made up of a box, cups and spoons, a torch light, napkins, stop watches, registers, treatment charts and blister packs of artesunate-amodiaquine, referral and tally cards) for distributors were also factors which pressurizes the cost of the programme. Again, at home, factors of late reporting of cases, adult wanting to take medicines when ill, mothers not completing medicines, and mothers refusing referral for lack of money as well as food and period of recovery, influence cost of home- based management. In

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budgetary, policy and theory formulation as well as service-planning decisions, the above could serve as the basis.

2. Methodology
2.1 Study Sites And Population
Ejisu-Juaben Municipality considered being one of the 26 political Municipalities of Ashanti Region. Its 2007 population was estimated at 162,256, with a growth rate of 3.4%. The population aged below one year was 4% and pre-school children for 20% of the population. Malaria was the leading cause of outpatient visits and accounts for 44.3% of OPD visits. Malaria was hyperendemic (Browne et al., 2000). It has 26 health facilities including 3 hospitals. It has 90 communities with 39 of them having functional village health committees. There were about 100 community-based medicine distributors (CMDs) who had been trained in home based management of malaria (HBMM) using pre-packed artesunate-amodiaquine (in the recent HBMM study), acute respiratory infections (ARI) and diarrhoea case management using ORS. The Municipality has doctorpatient ratio of 31344:1 and nurse-patient ratio of 4124:1.

The current malaria interventions were case management, home management of malaria, distribution of insecticides treated nets (ITNs), and intermittent preventive treatment in pregnancy (IPTp). The Municipality capital, Ejisu was 20 km from Kumasi, the regional capital. It was a predominantly rural Municipality, with the main of occupation of the people being subsistence farming. A few farmers engaged in commercial farming, mainly cocoa and oil palm (Source: Population Reference Bureau/ Data Finder - Ghana, 2004). The study was done within a total population of about 162,256. The study population consisted of caregivers of children less than five years, health providers and CMDs. They were consented to be part after reading the informed consent and or the study protocols was interpreted to them in a language best understood by them and in the presence of a witness (es).

2.2 Sampling Size

A cross-sectional study was done in the Ejisu-Juaben Municipality in the Ashanti Region. The study involved randomly selected 400 caregivers, (10) health staff and (90) community-based medicine distributors (CMDs). The main outcome of the study was the proportion of the caregivers whose children presented with fever and were taken to the community health workers otherwise known as community medicine distributors (CMDs) for uncomplicated malaria treatment. Based on an unknown parameter, a prevalence figure of 60% was used to calculate the sample size. With a power of 95% confidence level, 5% significance level, the required error of 0.002025, design effect of 1, non-respondents of 10%, the sample size was 455 rounded up to 500. This

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was estimated for the survey using the, n=Z2 p (1-p) d/e2, where Z= (1.96), p=proportion of event of interest, and e= required error, d=design effect.

2.3 Data Collection Method

Data on the cost of malaria and HBMM were collected as per objectives as follows: Information on identification of cost drivers were collected from caregivers and health providers including CMDs. These were done using structured questionnaires. For household cost, the cost of febrile episode receiving prompt treatment from CMDs, household cost of transport to and from source of care, household time costs of seeking care were collected. Structured questionnaires were employed to collect these data. Costing of HBMM was done in three main stages.

Identification stage: This stage involved grouping household costs into cost of care; drugs, food, transport and time. However, cost of food and transport were valued at zero cost since caregivers never incurred such costs.

Quantification stage: At this stage, monetary values were assigned to the various items using 2008 prevailing market prices to value.

Valuation stage: The opportunity costs were estimated by multiplying the time spent in hours by wage rate per hour. This was done as follows: first all caregivers and CMDs were assumed to be labourers receiving a minimum wage rate of 1.92 for eight working hours as per the national minimum wage rate of Ghana. It means that the wage per hour was estimated as GHC 1.92/8 hours which amounted to GHC 0.24. This is consistent with similar method employed by Asenso-Okyere and Dzator (1997).

Data pertaining to objective three (O3), assessing whether HBMM was sustainable; information was collected from caregivers and the project office. These were collected using questionnaires. To assess the ability of CDDs to prescribe medicines in HBMM was collected on participants. These were done using

questionnaires, forms and interview guides. Information on objective five (5), estimating the opportunity costs of CDD and health providers in HBMM was collected using questionnaires, forms and interview guides.

3. Data Handling And Analysis

Structured questionnaires were employed to collect these data. The data was analysed using descriptive statistics, summarised and displayed in tables. Frequencies were further analysed using chi-square test to test for associations between some selected variables. For continuous variables, the estimates were for difference

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in means with 95% confidence levels. Data was entered and analyzed into descriptive statistics with SPSS version 17 software.Test for associations were done at 95% confidence interval.

3.1 Sensitivity Analysis

Sensitivity analysis was an important feature of economic evaluations in which study results were sensitive to the values taken by key parameters. (Drummond et al, 2004) Sensitivity shows how the variation in the output of a mathematical model was apportioned, qualitatively or quantitatively, to different sources of variation in the input of a mode (Saltell et al, 2008). Sensitivity analysis was done using discount rates of 3% as a minimum and 5% for the upper ceiling with an estimated change in cost of +/-5%. This analysis indicated the possible change in cost as a result of change in discount rate. It thus measures the effects of economic conditions on cost of treatment for malaria.

3.2 Results
This study was done to identify the cost drivers influencing the cost of malaria as well as HBMM. Household cost as used here were both financial and opportunity cost one incurred whiles seeking treatment for malaria. The main component of the household cost of malaria were the source of treatment, cost of treatment, distance and time, days spent among the caregivers, health providers and CMDs. Table 1.1 presents detailed household cost incurred in seeking malaria treatment in the district.

Table 1.1 Household cost Variables Indicators Health Consumers Community Medicine Distributors 47 (100%) 22 (5.5%) 21 (5.25%) 0.9111 0.67299 33 (36.7%) 43 (47.8%) 14 (15.6%)

Source of treatment of malaria

Home Chemical sellers CMDs

100 (25%) 152 (38.0) 148 (37%) 27 (6.8%) 328 (82.0%) 45 (11.2%) 1.0788 0.35140 211 (52.8%) 189 (47.2%) -

Cost of treatment

0.1-1.00 1.10-2.0 2.10-3.0

Average cost Standard deviation Consideration of cost

Expensive Cheap Very cheap

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Bearer of cost of treatment

Mother Father Other 0.5km

305 (76.2%) 68 (17.0%) 27 (6.8%) 213 (53.2%)

Distance from the CMDs

Time spent with the CMDs

1km 5

187 (46.8%) 57 (14.2%)

10

169 (42.2%)

15

134 (33.5%)

Level of satisfaction of treatment

30 Very satisfied Not satisfied Not sure 1day 2days 3days

40 (10.0%) 290 (72.5%) 82 (20.5%) 28 (7.0%) 85 (21.2%) 274 (68.5%) 41 (10.2%)

Days spent with the CMDs

Source: Authors Fieldwork, 2009 Household cost of seeking treatment of malaria includes monetary cost incurred, distance, as well as time spent expressed in monetary cost. The household cost for seeking treatment ranges from 10Gp-30Gp per each episode of malaria. According to 82% of the health consumers, they pay between 20Gp and 30Gp for treatment of malaria of their children under five with a mean cost of 1.0788 and standard deviation of 0.35140. Whiles the CMDs also indicate the cost of treatment to be between 10-30Gp with the average cost of 0.9111 and its standard deviation of 0.67299. Again, 53.2% of the caregivers walk a distance of 0.5km, 42.2% spent 10 minutes and 68.5% spend a maximum of two (2) days with the CMDs. Also for uncomplicated and severe malaria, 70% and 41% of the CMDs spent 3-20 minutes and 28-39 minutes respectively with children under five years. However, the costs of the health providers charge for treatment for malaria in their various hospitals differ and hence expensive as compared to the home based management of malaria. About 40% of the health providers indicate the cost of treatment to be 6.00GH for uncomplicated malaria with an average cost of6.4000 and a standard deviation of 1.62959.Also, 40% of the health providers indicates the cost of

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treatment to be 10.0GH for severe malaria with an average cost of 10.1000 and a standard deviation of 1.663333. Table 1.2: Relationship between cost of treatment and occupational background of health consumers Occupation Cost of treatment of malaria for children 0.5Gp Frequency (%) 27 (6.75% ) 0 (0%) 0 (0%) 0 (0%) 10Gp Frequency (%) 99 (24.7%) 84 (21%) 119 (29.7%) 26 (6.5%) 20Gp Frequency (%) 0 (0%) 45 (11.3%) 0 (0%) 0 (0%) p-value <

Famer Trader Artisan civil/public servant

0.0001

Total

27

328

45

Source: Authors Fieldwork, 2009 Table 1.2, presents the relationship between occupation of the caregivers and the amount paid for seeking fever treatment for their children. Twenty-seven of the farmers representing 7% paid 0.5 GP for treatment, and 99 (25%) paid GHC 1.00 for treatment. Twenty-one and eleven percent of the traders paid GHC 1.00 and GHC 2.00 respectively for treatment. Just about 30% of the artisans and 7% of the civil or public servants paid GHC 1.00. There were significant differences between the type of occupation and the cost paid for treatment, p-value <0.0001 at 95 confidence interval. Based on these, it could be concluded that, caregivers who were traders could afford the price range of 0.5Gp to 20Gp. However, more farmers could buy at 0.5Gp and none at 20Gp.but all most all caregivers could afford it if it is 10Gp.

3.3 Cost Drivers

This section covers the factors that influence the cost of treatment of malaria to either increase or decrease. It also looked at the trend of cost and approaches to attain least cost of treatment of malaria among caregivers. The table (1.3) presents the various factors of influence of cost for treatment of malaria. Table 1.3: Factors influencing cost of home base management of malaria Variables Indicators Health Consumers Health Providers 7 (70.0%) Community Medicine Distributors 47 (52.2%)

Factors decrease

that Suppliers

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the cost

Personnel(incentives) Distance Type of health facility

100 (25%)

2 (20.0%) -

43 (47.8%) -

Type of treatment Not sure Factors increase the cost that Suppliers 258 (64.5%) 42 (10.5%) 1 (10%) 3 (30%) 30 (33.3%)

Personnel(incentives) Health facility Not sure Reasons for increase /decrease of cost Type of equipment and drugs availability Type and number of personnel Increasing Decreasing Find additional source of funds Outsource for staff Educate clients to seek early treatment Source: Authors Fieldwork, 2009

2 (20%) 3 (30%) 2 (20%) 6 (60%)

60 (66.7%) 90 (100%)

2 (20%) 8 (80%) 2 (20%) 2 (20%)

Trend of cost Approaches to ensure least cost of treatment

2 (20%)

6 (60%)

Several factors influence the cost of home based management of malaria in the district. There were several factors either decreasing or increasing the effect of cost in home base management of malaria in the district. Suppliers, personnel, incentives, distance, type of health facility, type of treatment among others were the major factors influencing cost of diagnosing and treatment of malaria. For the health consumers, 64.5% of them indicate the type of health facility they sort treatment from as the cause of change in the cost of treatment of malaria. Again, 70% of the health providers indicate that the suppliers for the home based management of malaria influence the cost whiles 60% of CMDs indicates suppliers and the type of health facility affect the cost of HBMM. Also, 52.2% of the CMDs indicate suppliers as affecting the cost of treatment and 66.7% of them indicate incentives to the CMDs as another factor.

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Table 1.4: Relationship between the gender and the cost drivers that decrease/increase HBMM Gender, n=90 Increase cost of HBMM Supplies Incentives Decreases cost of HBMM Supplies Incentives 17(18.9%) 25(27.8%) 30(33.3%) 18(20.0%) 14(15.6%) 28(31.1%) Male 16(17.8%) 32(35.6%) Females 0.030 Male Females P-value 1.000

Source: Authors Fieldwork, 2009 There were no significant differences between the cost of HBMM and the cost drivers (supplies and incentives), P-value 1.000 at 95 confidence interval. Based on this, it could be concluded that, largely, incentives giving to the CMDs has no bearing on the cost of HBMM.There were significant difference between the cost of HBMM and the cost drivers (supplies and incentives). P-value 0.030 at 95 confidence interval. Based on this, it could be concluded that, decrease in supplies could reduce the cost of HBMM.

4. Discussions
From the cost of the HBMM and the health providers, it was seen that HBMM was less costly and affordable. A similar study done by Akazili, (2002) and WHO (2006), found that household cost of malaria treatment was estimated at 34% and 1% respectively of household income among the poor and the rich. This does not make the burden of malaria heavy on the household. However, a study done by Goodman et al., (2000); Akazili, (2002); Hanson et al., (2004) ) showed that, the economic burden of malaria was not high at the worldwide, but it was seen greatly in the various households and this was the barrier to accessing health care as stated earlier. Transportation cost is an important cost of seeking care, however in HBMM CMDs are located within a walking distance of 0.5 to 1km therefore, no transport cost is incurred. Proximity to source of care (CMDs) meant that time is saved in travelling. It follows that more time would be made available for economic activities. This confirms a study by Sauerborn et al, (1995) confirms that that reducing time spent in seeking treatment meant saving money since the time costs of seeking care was far lower than the value of time lost to care.

According to Guest (1997), researches have uncovered a range of possible influences on rising costs. Supporting Guests studies, this study uncovered supplies and incentives giving to CMDs as the major factors influencing the cost of HBMM positively or negatively. Contrary to this study, the study of Collette (1994),

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showed that the level of severity of the illness, distant to the homes, the kind of interventions received (either intensive or standard case management) time spent in travelling and the size of people each CMDs handles were the factors which either increase or decrease the cost of HBMM. Table 4.8.3 and 4.8.4 evidently indicates that suppliers involve in HBMM and incentives given to the CMDs actually influence the cost of HBMM. Thus the suppliers and monthly incentives could either decrease or increase the cost of HBMM. The hypothesis that, the cost drivers of integrated diagnostic and treatment package for HBMM does not increase or decreases the cost of treatment was rejected.

5. Conclusion
From the findings and discussions, cost incurred in accessing HBMM was less as compared to the one sought from the health facilities. All the caregivers could afford the price range of HBMM; GHC0.5 to GHC2.0. Supplies and incentives to CMDs were the two key factors influencing cost of HBMM. Other factors such as transport, distance and cost though expected as important, respondents did not mention them. Cost incurred in accessing HBMM treatment was affordable to caregivers Drivers of treatment cost in HBMM varies from the caregivers and care seekers.
Authors Note This paper was prepared for Department of Community Health as a Masters Degree Thesis by Benedicta O. Asante.

6. References
Agyei-Baffour, P. (2008): Access, use and cost implications for equity of home management of malaria in children under five years in rural Ghana (PhD Thesis). Akazili, (2002): Costs to households of seeking malaria care in the Kassena-Nankana Municipality of Northern Ghana. In: Third MIM Pan-African Conference on Malaria Arusha, Tanzania, and 17-22 November 2002. Bethesda, MD, Multilateral Initiative on Malaria: Abstract 473. Asante and Asenso-Okyere (2003). Economic Burden of Malaria in Ghana, Institute of Social and Economic Research, University of Ghana, Technical Report submitted to the WHO- data Idriss, O (2007) Methodology for Calculating the Economic Cost of Malaria. Asenso-Okyere, W. K. and Dzator, J. A. (1997). Household cost of seeking malaria care. A Retrospective study of two Municipalitys in Ghana. Soc. Sci. Med. Vol. 45, No. 5,pp. 659-667. Ahmed K (1989) Malaria in Ghana-Overview. Ghana Med J, 22:190-196. Browne, E. N. L. (2003). Home management of malaria in rural Ghana using pre-packed Chloroquine (in preparation). Chima, R., Goodman, A. and Mills, A. (2003). The economic impact of malaria in Africa: A Critical review of the evidence, Health Policy, 63:1, 17-36.

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Creese, A., Parker, D. Collette, A. (1994): Cost analysis in primary health care: a training manual for programme managers, WHO, Geneva. Drummond, M., Aguiar-Ibez, Nixon (2006): Economic evaluation. Evidence-Based Medicine and Healthcare, Singapore Med J; 47(6): 456. Hanson, K., Goodman, C., Line, J., Meek, S., Bradely, D., and Mills, A. (2004): The economics of malaria control interventions. Global Forum for Health Research, Geneva, Switzerland. Hopkins, H., Talisuna, A., Whitty, C. J.M. and Staedke, S. G. (2007): Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence. Mal. J. 6:134. Joel, E. S. (2006) RTI International RTI-UNC Centre of Excellence in Health Promotion Economics. McGuire, T., (2000): Physician agency. In: New house, J., Culyer, A. (Eds.), Handbook of Health Economics, Vol. 1. North-Holland, Amsterdam. Ofosu, P. (2006): Pride of Ashanti, Dsezyn origin. RBM, (2001): Malaria: Progress in Rolling Back Malaria in the African Region, Lia. Bul. of Mal. Pro.WHO/AFRO, 4:4. Russell, S. (2004). The economic burden of illness for households in developing countries: A Review of studies focusing on malaria, tuberculosis and human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome, Am. J. of Trop. Med. and Hyg. 7s Suppl. 2, pp. 147155. WHO, (2006): The Africa Malaria Report. Regional Offices for Africa and Eastern Mediterranean.

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