The economic cost of malaria in Africa.

Although malaria is the major health problem in Africa, there is little research on its economic impact. This study adapts a framework for assessing the economic costs of illness to available data on malaria. Direct costs of illness are the costs of treatment and control activities, and indirect costs are the value of lost time due to morbidity and premature mortality. Direct costs were estimated by applying the average estimated health systems costs per case to the number of cases. Indirect costs were assessed by multiplying adult output per day times the estimated productive time lost through both adult and childhood cases. As data are not available to assess the economic impact of malaria in Africa as a whole, four case studies were performed on countries or regions for which needed data could be found. The four sites (Rwanda, Solenzo medical district of Burkina Faso, Mayo-Kebbi district, Chad, and Brazzaville, Congo) were chosen to illustrate the diversity in kinds of data which can be used (aggregate national health statistics versus household surveys) and in locations (urban versus rural). Costs were calculated for the recent past and were projected to 1995 based on recent epidemiological trends. Estimates for all sub-Saharan Africa were derived from the averages of these sites. In 1987, a case of malaria cost $9.84 (in 1987 US dollars)--$1.83 in direct costs and $ 8.01 in indirect costs. As the average value of goods and services produced per day in Africa was $0.82, this cost is equivalent to 12 days of output.(ABSTRACT TRUNCATED AT 250 WORDS)

Economic cost of malaria in Rwanda.

Although malaria is widely recognized as a major public health problem in much of Africa, its impact on a specific national or regional economy has proved difficult to assess. This paper demonstrates the kind of analysis possible given available national aggregate statistics on epidemiology and economic indicators, the type of data most readily available. An economic model which applies the average cost of malaria per case to the known number of cases in Rwanda for 1989 estimated the total cost to be $ 2.88 per capita (in 1987 US dollars). Of this cost, $0.63 per capita represents the direct cost of treatment, including care of outpatients and hospitalized cases in both government and private facilities, as well as self-treatment. The other $ 2.25 per capita represents the indirect costs of productive time lost to malaria morbidity in adults and to care for sick children, and the cost of lifetime earnings lost through premature malaria mortality. The average output per day of the Rwandan economy was $0.83 in 1989. Thus, the per capita malaria cost equals 3.5 days of production or 1% of GDP. The average cost of each of the 1,722,271 reported malaria cases in 1989 was $11.82: $2.58 in direct and $9.24 in indirect cost. The direct cost per case is equal to 160% of the per capita budget of the Ministry of Health. Economic and epidemiological projections to 1995 yield an increase in malaria cases to over 4 million at a cost of $7.11 per capita. Direct costs are projected to rise over 200% due to increasing costs of drugs and supplies to treat increasingly drug-resistant cases. Indirect costs, which are tied to a declining economy, are projected to rise by just over 100%. By 1995, malaria is projected to cost 2.4% of the Rwandan GDP, exacerbating an already serious impact.

Estimating the direct and indirect economic costs of malaria in a rural district of Burkina Faso.

Comprehensive estimates of the direct economic costs of malaria should include not only the costs of care at established health facilities, but also other expenditures, such as travel and out-of-pocket costs of drugs. They should include all episodes of illness, whether or not the patient attended a health facility. Also, the indirect economic costs, which are based on the value of time lost due to illness, consider seasonal variations in the marginal product of labor according to the agricultural season. A 1985 representative survey of 626 households in Solenzo medical district, Burkina Faso, provided household data on health service utilization, expenditures, and agricultural production with which to implement these refinements. Numbers of malaria deaths and cases were estimated by adjusting survey totals according to monthly patterns of reported malaria deaths. The marginal product of labor was valued according to typical activities in each of three agricultural seasons: brewing millet beer during the maintenance period (January-February), growing cotton during the cash crop season (March-April), and growing millet and sorghum during the food crop season (May-December). The resulting values were $0.28, $1.09, and $0.55 per day, respectively. Cost per case averaged $5.96 and cost per capita $1.15. Indirect cost due to mortality was the largest cost component ($0.79 per capita), followed by direct costs incurred by the user (e.g. transportation costs and drug purchases, $0.22 per capita). Direct costs paid by providers were small, only $0.04 per capita. A household survey provides the necessary data for more comprehensive population-based estimates of costs of malaria.

Economic analysis of several types of malaria clinics in Thailand.

The costs of three types of malaria clinics in Maesot District, north-west Thailand, for a one-year period in 1985-86 were compared from the institutional, community and social (institutional plus community) perspectives. The greatest number of patients at the lowest average institutional cost per smear and per positive case diagnosed (US$ 0.82) were seen at the large central clinic in Maesot town. The peripheral clinic in Popphra, a subdistrict town, had moderate institutional costs per smear and per positive case (US$ 1.58). The periodic mobile clinic, which served five villages on a fixed weekly schedule, had low average institutional costs per smear, but the highest cost per positive case (US$ 3.53). Community costs (those paid by patients and their families) were lowest in the periodic clinic. Addition of a periodic clinic to a system of central and peripheral clinics increased the number of malaria cases treated, particularly those involving women and under-16-year-olds. Although the periodic clinic entailed a modest increase in institutional costs, it minimized social costs. The results of the study suggest that use of a combination of central, peripheral, and periodic clinics, which maximizes access to malaria treatment, minimizes the social costs of malaria.

PIP: The costs of 3 types of malaria clinics in Maesot District, northwest Thailand, for a 1 year period in 1985-86 were compared from the institutional, community, and social (institutional + community) perspectives. The greatest number of patients at the lowest average institutional cost/smear and per positive case diagnosed (US $0.82) were seen at the large central clinic in Maesot town. The peripheral clinic in Popphra, a subdistrict town, had moderate institutional costs/smear and per positive case (US $1.58). The periodic mobile clinic which served 5 villages on a fixed weekly schedule had low average institutional costs/smear, but the highest cost/positive case (US $3.53). Community costs (those paid by patients and their families) were lowest in the periodic clinic. The addition of a periodic clinic to a system of central and peripheral clinics increased the number of malaria cases treated, particularly those involving women and under-16 year olds. Although the periodic clinic entailed a modest increase in institutional costs, it minimized social costs. The results of the study suggest that the use of a combination of central, peripheral, and periodic clinics, which maximizes access to malaria treatment, minimizes the social costs of the disease. (author's modified)

Malaria clinics in Mae Sot, Thailand: factors affecting clinic attendance.

Clinics of the Anti-Malaria Program of Thailand play an important part in the control of malaria morbidity and mortality, treating over 60% of reported cases yearly. Interviews were conducted both with attenders at three clinics in Mae Sot District and among those reporting malaria illness but not attending. Distance travelled to the clinic, costs of travel and frequency of other treatment prior to clinic attendance were all highest among patients at the large centralized clinic, moderate in a peripheral fixed clinic, and lowest in a village-based mobile clinic. Reported length of illness prior to attendance was similar for all three clinics. As many as 91% of villagers interviewed chose not to treat their illness in a malaria clinic. These non-attenders reported longer illness time and higher expenditures on treatment than clinic patients. Provision of village-based clinics can improve access. However, the widespread reliance on non-Program treatment of malaria suggests the need for policies to address these alternative therapeutic modes.

Evaluation of malaria clinics in Maesot, Thailand: use of serology to assess coverage.

The clinics of the anti-malaria programme in Thailand serve an increasingly important role in the strategy for control of malaria within a context of multi-drug resistant falciparum malaria. Figures from clinics in Maesot District show a predominance of young males among positive cases treated (56% of all cases). In contrast, sero-epidemiological findings from a random sample of over 500 villagers in the area show similar exposure rates among males and females of equal age. There were no statistically significant differences between males and females 0-15 and 16-30 years old in percentages positive by indirect fluorescent antibody tests or enzyme-linked immunosorbent assays (ELISA), mean level of ELISA positivity, or rate of sero-conversion. Differences in level of positivity did occur between males and females over 30. An index constructed from the serological findings indicated under-representation of children and women of all ages in clinics but suggested that coverage of children could be improved by the provision of a community-based, fixed-schedule mobile clinic.

Development of two indices of postoperative morbidity.

Two indices of postoperative morbidity, Nursing Assessment Index and Observed Treatment Index, are described and evaluated in this study of 4,182 consecutive anesthetics. The use of these indices in studies of the quality and effectiveness of surgical and anesthetic care should increase the economy and precision with which the causes of unsatisfactory outcome are identified. Specific illustrations of the relationship of the preanesthetic status of patients to their postoperative morbidity as measured by these indices and mortality rates are given. In addition these two indices of morbidity measured on the seventh postoperative day are shown to be strongly co-related with subsequent in-hospital deaths. Thus, of the 100 patients with a Nursing Assessment Index worse than 3, 19 percent died; only 0.4 percent of the 550 patients who had no morbidity as measured by this index died. Although they ultimately survive, about an equal number of patients become seriously ill as die follow operations.