title: Household burden of malaria in South Africa and Mozambique: is there a catastrophic impact?
abstract: OBJECTIVE
  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.
authors.affiliation: Health Economic Unit, Department of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. marianela.castillo-riquelme@uct.ac.za
authors.forename: Marianela
authors.initials: M
authors.lastname: Castillo-Riquelme
authors.forename: Diane
authors.initials: D
authors.lastname: McIntyre
authors.forename: Karen
authors.initials: K
authors.lastname: Barnes
mesh_terms: D000293:Adolescent; D000328:Adult; D000962:Antimalarials / Q000191:economics / Q000627:therapeutic use; D002388:Catastrophic Illness / Q000191:economics / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D017281:Cost of Illness; D017050:Episode of Care; D005191:Family Characteristics; D005260:Female; D019538:Health Care Surveys; D005102:Health Expenditures; D006801:Humans; D008288:Malaria / Q000188:drug therapy / Q000191:economics / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009073:Mozambique / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011203:Poverty; D017150:Public Sector; D012424:Rural Population; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology
chemical_list: D000962:Antimalarials