What, how and who: Cost-effectiveness analyses of COVID-19 vaccination to inform key policies in Nigeria.

While safe and efficacious COVID-19 vaccines have achieved high coverage in high-income settings, roll-out remains slow in sub-Saharan Africa. By April 2022, Nigeria, a country of over 200 million people, had only distributed 34 million doses. To ensure the optimal use of health resources, cost-effectiveness analyses can inform key policy questions in the health technology assessment process. We carried out several cost-effectiveness analyses exploring different COVID-19 vaccination scenarios in Nigeria. In consultation with Nigerian stakeholders, we addressed three key questions: what vaccines to buy, how to deliver them and what age groups to target. We combined an epidemiological model of virus transmission parameterised with Nigeria specific data with a costing model that incorporated local resource use assumptions and prices, both for vaccine delivery as well as costs associated with care and treatment of COVID-19. Scenarios of vaccination were compared with no vaccination. Incremental cost-effectiveness ratios were estimated in terms of costs per disability-adjusted life years averted and compared to commonly used cost-effectiveness ratios. Viral vector vaccines are cost-effective (or cost saving), particularly when targeting older adults. Despite higher efficacy, vaccines employing mRNA technologies are less cost-effective due to high current dose prices. The method of delivery of vaccines makes little difference to the cost-effectiveness of the vaccine. COVID-19 vaccines can be highly effective and cost-effective (as well as cost-saving), although an important determinant of the latter is the price per dose and the age groups prioritised for vaccination. From a health system perspective, viral vector vaccines may represent most cost-effective choices for Nigeria, although this may change with price negotiation.

Factors Associated With Coverage of Health Insurance Among Women in Malawi.

Introduction: Access to healthcare for the vulnerable groups including women has long been a theme encouraged worldwide from the first general assembly on health to the current sustainable development goals. Despite many countries having a free public healthcare system, there are inequalities in access to care and significant out-of-pocket spending, pushing most women into poverty against the principles of universal health coverage. Coverage of Malawian women with health insurance is poor; thus, there is limited cushioning and high risk of poverty, as women bear costs of care as primary caregivers. There is need to explore determinants of coverage of health insurance among women in Malawi to inform health policy. Methodology: This study was quantitative in nature, using cross-sectional secondary data from the 2015 to 2016 Malawi Demographic and Health Survey involving women aged between 15 and 49 years. We assessed factors associated with insurance coverage by comparing women with and without insurance schemes using binary logistic regression. Analysis was done using STATA statistical package version 13. Results: The analysis included a total of 24,562 women with a mean age of 28 SD (9.3). Of these cases, 1.5% had health insurance. High education attainment, occupation, and wealth were significantly associated with health insurance ownership, with all having p-values of < 0.01. On the other hand, a woman's residence, marital status, and who heads a household were not associated with ownership of health insurance significantly. Conclusion: Education, occupation, and wealth have a key role in influencing a woman's choice in owning health insurance. This informs policymakers and health insurance providers on how best to approach women's health financing and factors to target in social security programs and health insurance products that speak to women's needs and capacity.

Health technology assessment and priority setting for universal health coverage: a qualitative study of stakeholders' capacity, needs, policy areas of demand and perspectives in Nigeria.

INTRODUCTION: Health technology assessment (HTA) is an effective tool to support priority setting and generate evidence for decision making especially en route to achieving universal health coverage (UHC). We assessed the capacity needs, policy areas of demand, and perspectives of key stakeholders for evidence-informed decision making in Nigeria where HTA is still new. METHODS: We surveyed 31 participants including decision makers, policy makers, academic researchers, civil society organizations, community-based organizations, development partners, health professional organizations. We revised an existing survey to qualitatively examine the need, policy areas of demand, and perspectives of stakeholders on HTA. We then analyzed responses and explored key themes. RESULTS: Most respondents were associated with organizations that generated or facilitated health services research. Research institutes highlighted their ability to provide expertise and skills for HTA research but some respondents noted a lack of human capacity for HTA. HTA was considered an important and valuable priority-setting tool with a key role in the design of health benefits packages, clinical guideline development, and service improvement. Public health programs, medicines and vaccines were the three main technology types that would especially benefit from the application of HTA. The perceived availability and accessibility of suitable local data to support HTA varied widely but was mostly considered inadequate and limited. Respondents needed evidence on health system financing, health service provision, burden of disease and noted a need for training support in research methodology, HTA and data management. CONCLUSION: The use of HTA by policymakers and communities in Nigeria is very limited mainly due to inadequate and insufficient capacity to produce and use HTA. Developing sustainable and institutionalized HTA systems requires in-country expertise and active participation from a range of stakeholders. Stakeholder participation in identifying HTA topics and conducting relevant research will enhance the use of HTA evidence produced for decision making. Therefore, the identified training needs for HTA and possible research topics should be considered a priority in establishing HTA for evidence-informed policy making for achieving UHC particularly among the most vulnerable people in Nigeria.

Investigating socio-economic inequity in access to and expenditures on routine immunization services in Anambra state.

BACKGROUND: Addressing existing inequities in the utilization of priority health services such as routine immunization is a current public health priority. Increasing access to routine immunization from the current low levels amongst all socio-economic status groups in Nigeria is challenging. However, little is known on the level of SES inequity in utilization of routine immunization services and such information which will inform the development of strategies for ensuring equitable provision of routine immunization services in the country. The study was a cross sectional household survey, which was undertaken in two randomly selected communities in Anambra State, southeast Nigeria. A pre-tested interviewer administered questionnaire was used to collect data on levels of access to RI by children under-2 years from randomly selected households. In each household, data was collected from the primary care givers or their representative (in their absence). The relationship between access to routine immunization and socio-economic status of households and other key variables was explored in data analysis. RESULT: Households from high socio-economic status (well-off) groups utilized routine immunization services more than those that belong to low socio-economic status (poor) groups (X2 = 9.97, p < 0.002). It was found that higher percentage of low socio-economic status households compared to the high socio-economic status households received routine immunization services at public health facilities. Households that belong to low socio-economic status groups had to travel longer distance to get to health facilities consequently incurring some transportation cost. The mean expenditures on service charge for routine immunization services (mostly informal payments) and transportation were US$1.84 and US$1.27 respectively. Logistic regression showed that access to routine immunization was positively related to socio-economic status and negatively related to distant of a household to a health facility. CONCLUSION: Ability to pay affects access to services, even when such services are free at point of consumption with lower socio-economic status groups having less access to services and also having other constraints such as transportation. Hence, innovative provision methods that will bring routine immunization services closer to the people and eliminate all formal and informal user fees for routine immunization will help to increase and improve equitable coverage with routine immunization services.

Quality of care for the treatment for uncomplicated malaria in South-East Nigeria: how important is socioeconomic status?

INTRODUCTION: Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups. METHODS: A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey. RESULTS: Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p < 0.01). Very few of those in the richest SES group used public health centres (4%) instead choosing to go to pharmacies (44%) and patent medicine dealers (52%, p < 0.001). During consultations with a healthcare provider, the poorest compared to the richest were significantly more likely to discuss symptoms with the provider, be physically examined and rely on providers for diagnosis and treatment rather than request a specific medicine. Those from the poorest SES group were however, least likely to request or to receive an antimalarial (p < 0.001). The use of artemisinin combination therapy (ACT), the recommended treatment for uncomplicated malaria, was low across all SES groups. CONCLUSIONS: The quality of malaria treatment is sub-optimal for all febrile patients. Having greater interaction with the provider also did not translate to better quality care for the poor. The poor face a number of significant barriers to accessing quality treatment especially in relation to treatment seeking behaviour and type of treatment received. Strategies to address these inequities are fundamental to achieving universal coverage of effective malaria treatment and ensuring that the most vulnerable people are not left behind.

Patent medicine dealers and irrational use of medicines in children: the economic cost and implications for reducing childhood mortality in southeast Nigeria.

This study assessed the economic costs of irrational medicine use by Patent Medicine Dealers (PMDs) for malaria, acute respiratory infection (ARI) and diarrhea diseases (DD) in Nigeria. Exit interviews were conducted with 395 respondents who sought care for their children from 15 PMDs in Abakpa district of Enugu state Nigeria. Of the total respondents, 80.0% received treatment for malaria while 12.0% and 8.0% received treatment for DD and ARI respectively. The average number of drugs dispensed per patient was 6.8, average percentage of patients given injections was 72.5%, average percentage of patients given one or more antibiotics was 59.7%, while the percentage of patients given non essential drugs was 45.9%. The additional costs to the standard treatment in Naira was 255, 350 and 175 for malaria, ARI and DD respectively. The losses attributable to irrational dispensing was 4,500 Naira. However, more than half of the drugs were on essential drug list, implying some cost savings for the consumers, but the high number of drugs (6.8) on average/patient is likely to increase the total cost of drugs cancelling out the cost savings to consumers arising from dispensing essential drugs.

Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria.

BACKGROUND: The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees. METHODS: This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders. RESULTS: Although the programme's benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program. CONCLUSIONS: The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens.

How do health workers perceive and practice monitoring and evaluation of malaria control interventions in South-east Nigeria?

BACKGROUND: The Anambra state Malaria Control Booster Project (ANMCBP) depends on an effective monitoring and evaluation (M&E) system to continuously improve the implementation of the malaria control interventions. However, it is not clear how the health workers that are expected to be the fulcrum of the malaria M&E perceive and practise M&E. The study was carried out to determine the knowledge, perception, and practice of Malaria M&E among selected health staff, and to identify related socio-demographic factors, including cadre of staff. METHODS: A semi-structured questionnaire and an observation checklist were used to collect information from selected health workers in public primary health centres in all 21 local government areas of the State. Multistage sampling technique was used in selection of respondents. The questionnaire explored knowledge, perception and practice of malaria M&E from 213 health workers. The observation checklist was used to record the actual practice of malaria M&E as observed by trained supervisors. RESULTS: Over 80% of health workers interviewed were able to correctly identify the malaria M&E forms; 25.4% knew the basis for categorizing Artemisinin-based combination therapy (ACT) into ACT1 - ACT4; 97.6% of the respondents felt there was need to keep proper records to have information available and 7.5% of them kept records because they were asked to do so. Over 90% of respondents reported correct practice of M&E, but on verification of actual practice, 55.6% of the respondents had at least one wrongly filled form, and half of these had none of their forms properly filled; about 68.4% of respondents had met specified timeline for data transmission. Differences observed in knowledge, perception and practice of M&E across age categories and cadres were only significant in ability to identify malaria M&E forms; diagnosis of malaria based on blood film microscopy result; perception of how age should be recorded; and reported practice of keeping data till they are requested. Among lower cadre of staff, gaps still exist in knowledge, perception and practice of malaria M&E. CONCLUSIONS: Gaps still exist in health workers' understanding of malaria data management, perception of efficient data transmission and observed practice of malaria M&E.

Sub-optimal delivery of intermittent preventive treatment for malaria in pregnancy in Nigeria: influence of provider factors.

BACKGROUND: The level of access to intermittent preventive treatment for malaria in pregnancy (IPTp) in Nigeria is still low despite relatively high antenatal care coverage in the study area. This paper presents information on provider factors that affect the delivery of IPTp in Nigeria. METHODS: Data were collected from heads of maternal health units of 28 public and six private health facilities offering antenatal care (ANC) services in two districts in Enugu State, south-east Nigeria. Provider knowledge of guidelines for IPTp was assessed with regard to four components: the drug used for IPTp, time of first dose administration, of second dose administration, and the strategy for sulphadoxine-pyrimethamine (SP) administration (directly observed treatment, DOT). Provider practices regarding IPTp and facility-related factors that may explain observations such as availability of SP and water were also examined. RESULTS: Only five (14.7%) of all 34 providers had correct knowledge of all four recommendations for provision of IPTp. None of them was a private provider. DOT strategy was practiced in only one and six private and public providers respectively. Overall, 22 providers supplied women with SP in the facility and women were allowed to take it at home. The most common reason for doing so amongst public providers was that women were required to come for antenatal care on empty stomachs to enhance the validity of manual fundal height estimation. Two private providers did not think it was necessary to use the DOT strategy because they assumed that women would take their drugs at home. Availability of SP and water in the facility, and concerns about side effects were not considered impediments to delivery of IPTp. CONCLUSION: There was low level of knowledge of the guidelines for implementation of IPTp by all providers, especially those in the private sector. This had negative effects such as non-practice of DOT strategy by most of the providers, which can lead to low levels of adherence to IPTp and ineffectiveness of IPTp. Capacity development and regular supportive supervisory visits by programme managers could help improve the provision of IPTp.

Increasing access to modern contraceptives: the potential role of community solidarity through altruistic contributions.

BACKGROUND: There is an urgent need for universal access to modern contraceptives in Nigeria, to facilitate the achievement of the Millennium Development Goals and other national goals. This study provides information on the potential role of community solidarity in increasing access to contraceptives for the most-poor people through exploration of the role of altruism by determining level of altruistic willingness to pay (WTP) for modern contraceptives across different geographic contexts in Nigeria. METHODS: It was a cross-sectional national survey which took place in six states spread across the six-geopolitical zones of the country. In each state, an urban and a rural area were selected for the study, giving a total of 6 urban and 6 rural sites. A pre-tested interviewer-administered questionnaire was used to collect information from at least 720 randomly selected householders from each state. The targeted respondent in a household was a female primary care giver of child bearing age (usually the wives), or in her absence, another female household member of child bearing age. A scenario on altruistic WTP was presented before the value was elicited using a binary with open-ended follow-up question format. Test of validity of elicited altruistic WTP was undertaken using Tobit regression. FINDINGS: More than 50 % of the respondents across all the states were willing to contribute some money so that the very poor would be provided with modern contraceptives. The average amount of money that people were willing to contribute annually was 650 Naira (US$4.5). Mean altruistic WTP differed across SES quintiles and urban-rural divide (p < .01). Multiple regression analysis showed that age was negatively related to altruistic WTP (p < 0.05). However, years of schooling, being employed by government or being a big business person, prior experience of paying for contraceptives and socioeconomic status had statistically significant effects on altruistic WTP (p < 0.05). CONCLUSION: There is room for community solidarity to ensure that the very poor benefit from modern contraceptives and assure universal coverage with modern contraceptives. The factors that determine altruistic WTP should be harnessed to ensure that altruistic contributions are actually made. The challenge will be how to collect and pool the altruistic contributions for purchasing and delivering modern contraceptives to the most-poor, within the context of community financing.

Examining equity in access to long-lasting insecticide nets and artemisinin-based combination therapy in Anambra State, Nigeria.

BACKGROUND: In order to achieve universal health coverage, the government of Anambra State, southeast Nigeria has distributed free Long-lasting Insecticide treated Nets (LLINs) to the general population and delivered free Artemisinin-based Combination Therapy (ACT) to pregnant women and children less than 5 years. However, the levels of coverage with LLINS and ACTs is not clear, especially coverage of different socio-economic status (SES) population groups. This study was carried out to determine the level of coverage and access to LLINs and ACTs amongst different SES groups. METHODS: A questionnaire was used to collect data from randomly selected households in 19 local government areas of the State. Selected households had a pregnant woman and/or a child less than 5 years. The lot quality assurance sampling (LQAS) methodology was used in sampling. The questionnaire explored the availability and utilization of LLINs and ACTs from 2394 households. An asset-based SES index was used to examine the level of access of LLINS and ACTs to different SES quintiles. RESULTS: It was found that 80.5% of the households had an LLIN and 64.4% of the households stated that they actually used the nets the previous night. The findings showed that 42.3% of pregnant women who had fever within the past month received ACTs, while 37.5% of children<5 years old who had malaria in the past month had received ACTs. There was equity in ownership of nets for the range 1-5 nets per household. No significant SES difference was found in use of ACTs for treatment of malaria in children under five years old and in pregnant women. CONCLUSIONS: The free distribution of LLINs and ACTs increased household coverage of both malaria control interventions and bridged the equity gap in access to them among the most vulnerable groups.

Towards universal coverage: examining costs of illness, payment, and coping strategies to different population groups in southeast Nigeria.

This study investigated the costs of illness to households in different socio-economic status (SES) groups and geographic places of abode in addition to the mechanisms that the different population groups used to pay for health services and cope with payments. A cross-sectional descriptive study of 3,200 households selected from six communities in two states was conducted using interviewer-administered pre-tested questionnaires. An SES index was used to divide the households into quartiles, and χ(2) analysis was used to determine the relationship of SES and geographic abode of households with cost of illness, payment mechanism, and coping strategies. The results show that malaria was the illness that most people had. The average cost of transportation for malaria was 86 Naira ($0.6 US), and the total cost of treatment was 2,819.9 Naira ($20 US); of this cost, drug costs alone contributed more than 90%. Out of pocket was the main method of payment. Treatment costs differed by geographic location and socio-economic status. Policy measures should establish targeted mechanisms to protect the general population, especially rural dwellers and poorer households, against the financial burden of direct healthcare payments.

Examining catastrophic health expenditures at variable thresholds using household consumption expenditure diaries.

OBJECTIVE: Using uniform thresholds and a set of variable threshold levels, this study examined the incidence of catastrophe amongst households of different socio-economic status (SES) quintiles. METHODS: A household diary was used to collect illness and household consumption expenditure data from 1128 households over 1 month. Catastrophic health expenditure was examined based on uniform threshold levels of non-food expenditure and a novel set of variable thresholds in which the levels for various SES groups were weighted by the ratio of household expenditure on food. RESULTS: A total of 167 households (14.8%) experienced catastrophe at a non-food expenditure threshold of 40%, with 22.6% and 7.6% of the poorest and richest household quintiles experiencing catastrophe. For the first set of variable scenarios, the thresholds for the poorest and richest household quintiles were 5% and 29.6% and levels of catastrophe were 44.7% and 12.0%, respectively, while the overall level was 36.5%. In the second scenario, the thresholds were 6.8% and 40%, and the levels of catastrophe were 42.5% and 7.6%, respectively, while the overall level was 32.0%. CONCLUSIONS: High levels of catastrophic expenditure exist in Nigeria. Use of variable thresholds to measure catastrophe led to higher overall and disaggregated levels of catastrophe. Such a measure is argued to be more appropriate for the examination of catastrophe.

Investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast Nigeria.

BACKGROUND: Out-of-pocket spending (OOPS) is the major payment strategy for healthcare in Nigeria. Hence, the paper assessed the determinants socio-economic status (SES) of OOPS and strategies for coping with payments for healthcare in urban, semi-urban and rural areas of southeast Nigeria. This paper provides information that would be required to improve financial accessibility and equity in financing within the public health care system. METHODS: The study areas were three rural and three urban areas from Ebonyi and Enugu states in South-east Nigeria. Cross-sectional survey using interviewer-administered questionnaires to randomly selected householders was the study tool. A socio-economic status (SES) index that was developed using principal components analysis was used to examine levels of inequity in OOPS and regression analysis was used to examine the determinants of use of OOPS. RESULTS: All the SES groups equally sought healthcare when they needed to. However, the poorest households were most likely to use low level and informal providers such as traditional healers, whilst the least poor households were more likely to use the services of higher level and formal providers such as health centres and hospitals. The better-off SES more than worse-off SES groups used OOPS to pay for healthcare. The use of own money was the commonest payment-coping mechanism in the three communities. The sales of movable household assets or land were not commonly used as payment-coping mechanisms. Decreasing SES was associated with increased sale of household assets to cope with payment for healthcare in one of the communities. Fee exemptions and subsidies were almost non-existent as coping mechanisms in this study CONCLUSIONS: There is the need to reduce OOPS and channel and improve equity in healthcare financing by designing and implementing payment strategies that will assure financial risk protection of the poor such pre-payment mechanisms with government paying for the poor.

Do consumers' preferences for improved provision of malaria treatment services differ by their socio-economic status and geographic location? A study in southeast Nigeria.

BACKGROUND: Improvement of utilization of malaria treatment services will depend on provision of treatment services that different population groups of consumers prefer and would want to use. Treatment of malaria in Nigeria is still problematic and this contributes to worsening burden of the disease in the country. Therefore this study explores the socio-economic and geographic differences in consumers' preferences for improved treatment of malaria in Southeast Nigeria and how the results can be used to improve the deployment of malaria treatment services. METHODS: This study was undertaken in Anambra state, Southeast Nigeria in three rural and three urban areas. A total of 2,250 randomly selected householders were interviewed using a pre tested interviewer administered questionnaire. Preferences were elicited using both a rating scale and ranking of different treatment provision sources by the respondents. A socio-economic status (SES) index was used to examine for SES differences, whilst urban-rural comparison was used to examine for geographic differences, in preferences. RESULTS: The most preferred source of provision of malaria treatment services was public hospitals (30.5%), training of mothers (19%) and treatment in Primary healthcare centres (18.1%). Traditional healers (4.8%) and patent medicine dealers (4.2%) were the least preferred strategies for improving malaria treatment. Some of the preferences differed by SES and by a lesser extent, the geographic location of the respondents. CONCLUSION: Preferences for provision of improved malaria treatment services were influenced by SES and by geographic location. There should be re-invigoration of public facilities for appropriate diagnosis and treatment of malaria, in addition to improving the financial and geographic accessibility of such facilities. Training of mothers should be encouraged but home management will not work if the quality of services of patent medicine dealers and pharmacy shops where drugs for home management are purchased are not improved. Therefore, there is the need for a holistic improvement of malaria treatment services.

Cost-effectiveness analysis of rapid diagnostic test, microscopy and syndromic approach in the diagnosis of malaria in Nigeria: implications for scaling-up deployment of ACT.

BACKGROUND: The diagnosis and treatment of malaria is often based on syndromic presentation (presumptive treatment) and microscopic examination of blood films. Treatment based on syndromic approach has been found to be costly, and contributes to the development of drug resistance, while microscopic diagnosis of malaria is time-consuming and labour-intensive. Also, there is lack of trained microscopists and reliable equipment especially in rural areas of Nigeria. However, although rapid diagnostic tests (RDTs) have improved the ease of appropriate diagnosis of malaria diagnosis, the cost-effectiveness of RDTs in case management of malaria has not been evaluated in Nigeria. The study hence compares the cost-effectiveness of RDT versus syndromic diagnosis and microscopy. METHODS: A total of 638 patients with fever, clinically diagnosed as malaria (presumptive malaria) by health workers, were selected for examination with both RDT and microscopy. Patients positive on RDT received artemisinin-based combination therapy (ACT) and febrile patients negative on RDT received an antibiotic treatment. Using a decision tree model for a hypothetical cohort of 100,000 patients, the diagnostic alternatives considered were presumptive treatment (base strategy), RDT and microscopy. Costs were based on a consumer and provider perspective while the outcome measure was deaths averted. Information on costs and malaria epidemiology were locally generated, and along with available data on effectiveness of diagnostic tests, adherence level to drugs for treatment, and drug efficacy levels, cost-effectiveness estimates were computed using TreeAge programme. Results were reported based on costs and effects per strategy, and incremental cost-effectiveness ratios. RESULTS: The cost-effectiveness analysis at 43.1% prevalence level showed an incremental cost effectiveness ratio (ICER) of 221 per deaths averted between RDT and presumptive treatment, while microscopy is dominated at that level. There was also a lesser cost of RDT ($0.34 million) compared to presumptive treatment ($0.37 million) and microscopy ($0.39 million), with effectiveness values of 99,862, 99,735 and 99,851 for RDT, presumptive treatment and microscopy, respectively. Cost-effectiveness was affected by malaria prevalence level, ACT adherence level, cost of ACT, proportion of non-malaria febrile illness cases that were bacterial, and microscopy and RDT sensitivity. CONCLUSION: RDT is cost-effective when compared to other diagnostic strategies for malaria treatment at malaria prevalence of 43.1% and, therefore, a very good strategy for diagnosis of malaria in Nigeria. There is opportunity for cost savings if rapid diagnostic tests are introduced in health facilities in Nigeria for case management of malaria.

Inequities in incidence, morbidity and expenditures on prevention and treatment of malaria in southeast Nigeria.

BACKGROUND: Malaria places a great burden on households, but the extent to which this is tilted against the poor is unclear. However, the knowledge of the level of the burden of malaria amongst different population groups is vital for ensuring equitable control of malaria. This paper examined the inequities in occurrence, economic burden, prevention and treatment of malaria. METHODS: The study was undertaken in four malaria endemic villages in Enugu state, southeast Nigeria. Data was collected using interviewer-administered questionnaires. An asset-based index was used to categorize the households into socio-economic status (SES) quartiles: least poor; poor; very poor; and most poor. Chi-square analysis was used to determine the statistical significance of the SES differences in incidence, length of illness, ownership of treated nets, expenditures on treatment and prevention. RESULTS: All the SES quartiles had equal exposure to malaria. The pattern of health seeking for all the SES groups was almost similar, but in one of the villages the most poor, very poor and poor significantly used the services of patent medicine vendors and the least poor visited hospitals. The cost of treating malaria was similar across the SES quartiles. The average expenditure to treat an episode of malaria ranged from as low as 131 Naira ($1.09) to as high as 348 Naira ($2.9), while the transportation expenditure to receive treatment ranged from 26 Naira to 46 Naira (both less than $1). The level of expenditure to prevent malaria was low in the four villages, with less than 5% owning untreated nets and 10.4% with insecticide treated nets. CONCLUSION: Malaria constitutes a burden to all SES groups, though the poorer socio-economic groups were more affected, because a greater proportion of their financial resources compared to their income are spent on treating the disease. The expenditures to treat malaria by the poorest households could lead to catastrophic health expenditures. Effective pro-payment health financing and health delivery methods for the treatment and prevention of malaria are needed to decrease the burden of the disease to the most-poor people.

Households' perceptions and prioritization of tropical endemic diseases in Nigeria: implications for priority setting for resource allocation.

This study was undertaken to explore how rural households perceive and prioritize tropical endemic diseases in different Local Government Areas (LGAs) of Southeast Nigeria. Marked differences in perception and prioritization of endemic diseases exist across the LGAs. Malaria is ranked highest as the most serious disease, followed by typhoid fever and HIV/AIDS. In addition, malaria and other endemic diseases are wrongly perceived as not being serious in some population groups.

An in-depth study of patent medicine sellers' perspectives on malaria in a rural Nigerian community.

BACKGROUND: Malaria remains a major cause of mortality among under five children in Nigeria. Most of the early treatments for fever and malaria occur through self-medication with antimalarial drugs bought from medicine sellers. These have led to increasing calls for interventions to improve treatment obtained in these outlets. However, information about the current practices of these medicine sellers is needed before such interventions. This study aims to determine the medicine sellers' perspectives on malaria and the determinants that underlie their dispensing patterns of antimalarial drugs. METHODS: The study was conducted in Ugwugo-Nike, a rural community in south-east Nigeria. It involved in-depth interviews with 13 patent medicine sellers. RESULTS: A majority of the medicine sellers were not trained health professionals and malaria is recognized as a major health problem by them. There is poor knowledge and poor dispensing behaviour in relation to childhood malaria episodes. Although referral of severe malaria is common, there are those who will not refer. Verbal advice is rarely given to the care-givers. CONCLUSION: More action research and interventions to improve prescription and referral practices and giving verbal advice to care-givers is recommended. Ways to integrate the drug sellers in the health system are also recommended.

Exemption policies and community preferences for tropical endemic diseases in the Bamako initiative programme in Nigeria.

We determined the actual written policies/guidelines and practices of fee exemptions aimed at the primary health-care level for tropical diseases treatment within the Bamako initiative system and the community's and decision makers' preferences for exemption in Nigeria. Health policy documents from the federal and state ministries of health were reviewed to determine the guidelines for exemptions, services, goods and category of people to receive exemptions. The records of the local government areas, health centres and community health committees were also reviewed to check who had received exemptions and modalities for doing so. In addition, household surveys using questionnaires was conducted. There is no clear-cut national policy regarding exemption. In areas where exemption exists, these are largely unofficial, as no official documents exist to support exemption. A total of 1594 individuals were surveyed. Community members prefer pregnant women, children and patients with TB, malaria, onchocerciasis and leprosy to be exempted from payment of fees: decision makers prefer the poor, children and patients with malaria, TB and leprosy to be exempted from payment for drugs, registration, consultation and preventive services such as immunization and antenatal services. One area of divergence between the preferences of the community and decision makers is the issue of exempting people with malaria and HIV/AIDS.