title: Impact of Improving Community-Based Access to Malaria Diagnosis and Treatment on Household Costs.
abstract: BACKGROUND
  Community health workers (CHWs) were trained in Burkina Faso, Nigeria, and Uganda to diagnose febrile children using malaria rapid diagnostic tests, and treat positive malaria cases with artemisinin-based combination therapy (ACT) and those who could not take oral medicines with rectal artesunate. We quantified the impact of this intervention on private household costs for childhood febrile illness.
  
  
  METHODS
  Households with recent febrile illness in a young child in previous 2 weeks were selected randomly before and during the intervention and data obtained on household costs for the illness episode. Household costs included consultation fees, registration costs, user fees, diagnosis, bed, drugs, food, and transport costs. Private household costs per episode before and during the intervention were compared. The intervention's impact on household costs per episode was calculated and projected to districtwide impacts on household costs.
  
  
  RESULTS
  Use of CHWs increased from 35% of illness episodes before the intervention to 50% during the intervention (P < .0001), and total household costs per episode decreased significantly in each country: from US Dollars (USD) $4.36 to USD $1.54 in Burkina Faso, from USD $3.90 to USD $2.04 in Nigeria, and from USD $4.46 to USD $1.42 in Uganda (all P < .0001). There was no difference in the time used by the child's caregiver to care for a sick child (59% before intervention vs 51% during intervention spent ≤2 days). Using the most recent population figures for each study district, we estimate that the intervention could save households a total of USD $29 965, USD $254 268, and USD $303 467, respectively, in the study districts in Burkina Faso, Nigeria, and Uganda.
  
  
  CONCLUSIONS
  Improving access to malaria diagnostics and treatments in malaria-endemic areas substantially reduces private household costs. The key challenge is to develop and strengthen community human resources to deliver the intervention, and ensure adequate supplies of commodities and supervision. We demonstrate feasibility and benefit to populations living in difficult circumstances.
  
  
  BACKGROUND
  ISRCTN13858170.
authors.affiliation: Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands.
authors.forename: Joëlle
authors.initials: J
authors.lastname: Castellani
authors.affiliation: Child Health Division, Ministry of Health, Kampala, Uganda.
authors.forename: Jesca
authors.initials: J
authors.lastname: Nsungwa-Sabiiti
authors.affiliation: Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, United Kingdom.
authors.forename: Borislava
authors.initials: B
authors.lastname: Mihaylova
authors.affiliation: Department of Epidemiology and Medical Statistics.
authors.forename: IkeOluwapo O
authors.initials: IO
authors.lastname: Ajayi
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Mohamadou
authors.initials: M
authors.lastname: Siribié
authors.affiliation: Epidemiology and Biostatistics Research Unit, Institute of Advanced Medical Research and Training.
authors.forename: Chinenye
authors.initials: C
authors.lastname: Afonne
authors.affiliation: Child Health Division, Ministry of Health, Kampala, Uganda.
authors.forename: Andrew
authors.initials: A
authors.lastname: Balyeku
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Luc
authors.initials: L
authors.lastname: Sermé
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Armande K
authors.initials: AK
authors.lastname: Sanou
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Sombié
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Alfred B
authors.initials: AB
authors.lastname: Tiono
authors.affiliation: Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso.
authors.forename: Sodiomon B
authors.initials: SB
authors.lastname: Sirima
authors.affiliation: Child Health Division, Ministry of Health, Kampala, Uganda.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Kabarungi
authors.affiliation: Department of Pharmacology and Therapeutics, College of Medicine, University of Ibadan, Nigeria.
authors.forename: Catherine O
authors.initials: CO
authors.lastname: Falade
authors.affiliation: Child Health Division, Ministry of Health, Kampala, Uganda.
authors.forename: Josephine
authors.initials: J
authors.lastname: Kyaligonza
authors.affiliation: Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands.
authors.forename: Silvia M A A
authors.initials: SM
authors.lastname: Evers
authors.affiliation: Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands.
authors.forename: Aggie T G
authors.initials: AT
authors.lastname: Paulus
authors.affiliation: Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
authors.forename: Max
authors.initials: M
authors.lastname: Petzold
authors.affiliation: UNICEF/UNDP/World Bank/WHO/Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Jan
authors.initials: J
authors.lastname: Singlovic
authors.affiliation: UNICEF/UNDP/World Bank/WHO/Special Programme for Research & Training in Tropical Diseases, World Health Organization, Geneva, Switzerland.
authors.forename: Melba
authors.initials: M
authors.lastname: Gomes
mesh_terms: D000293:Adolescent; D000328:Adult; D000962:Antimalarials / Q000191:economics / Q000627:therapeutic use*; D037621:Artemisinins / Q000191:economics / Q000627:therapeutic use; D000077332:Artesunate; D002050:Burkina Faso / Q000453:epidemiology; D002675:Child, Preschool; D003150:Community Health Workers / Q000706:statistics & numerical data; D005191:Family Characteristics; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008288:Malaria / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009549:Nigeria / Q000453:epidemiology; D011795:Surveys and Questionnaires; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D000077332:Artesunate; C031327:artemisinin
keywords: ACTs; CHW; access; economics; malaria