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Socio Economic Aspects

Source: TropIKA

Title of the session: Socio Economic Aspects

Date: 2nd November 2009

Agenda item: Scientific Session 6

Session theme: Socio Economic Aspects

Meeting room: Shimba

Chair(s): Dr Martin Alilio, Washington DC

Presenters:

• Maduka Ughasoro, University of Nigeria Teaching Hospital – Presentation

• Sorayya Khan, Royal Holloway, University of London – Presentation

• Adeniyi Adeneye, Nigerian Institute of Medical Research – Presentation

• Paul Bangirana, Dept. of Psychiatry, Makerere University Medical School, Kampala, Uganda – Presentation

• Obinna Onwujekwe, University of Nigeria – Presentation

• Aurelia Souares, Dept of Tropical Hygiene and Public Health, Heidelberg University, Germany – Presentation

• Ane Haaland, University of Oslo – Presentation

• Eric Obikeze, Health Policy Research Group

TropIKA rapporteur: Bidemi Yusuf

Major topics:

• Health Seeking behaviour and the cost of presumptive diagnosis compared to rapid diagnostic testing in malaria treatment in South East Nigeria in the era of combination therapy
• Community participation in malaria management in Mali
• Evaluation of awareness, accessibility and use of malaria control interventions in Ogun state, Nigeria
• Immediate neuropsychological and behavioral benefits of computerized cognitive rehabilitation in Ugandan pediatric cerebral malaria survivors
• Are malaria treatment expenditures catastrophic to different socio-economic and geographic groups and how do they cope with payment? A study in South-East Nigeria
• Financial impact of new antimalarial combination on health insurance
• Studies on visual instructions to improve patient understanding of malaria treatment through public and private health providers in East Africa
• Willingness to pay for Rapid Diagnostic Test (RDT) for malaria in the South-East Nigeria

Keywords:

• Malaria Diagnosis
• Community participation
• Expenditure
• Visual instruction
• Control interventions

Scope:

• Public health implications
• policy impact

REPORT ON ORIGINAL SESSION

Overview

Socio economic aspects of malaria were examined including health seeking behavior, process of community participation in management, accessibility and use of control interventions. Outcome of treatment expenditures were determined including financial impact of increased cost of ACT and willingness to pay for RDT. In addition, feasibility and potential benefits of computerized cognitive rehabilitation training on neuropsychological and behavioral functioning of children surviving cerebral malaria were reported. Both quantitative and qualitative methods were applied. Findings showed that presumptive treatment were higher in rural than urban areas. Awareness of HMM and use were still low. ITNs/LLINs use was poor. Chloroquine was still in use in the rural areas. ACT supply and use was still very low compared to the 2005 and 2010 RBM targets. Limited transfer of financial and human resources affect the provision of community health services. Despite the awareness of the people about community health workers (CHW), access to malaria knowledge was poor. In conclusion, practice of laboratory confirmed diagnosis should be encouraged, and the possibility of deploying RDTs to patent medicine sellers should be considered. Furthermore, community participation based primarily on CHW is not enough to sustain participation. Efforts should be put in place to increase awareness and control interventions should be made available and accessible.

CONTEXT AND ISSUE

Malaria still remains a major burden in Africa. Studies were carried out in Nigeria, Mali, Uganda, Tanzania and Burkina Faso among under fives, pregnant women and adults to examine issues on socio economic aspects of the disease; such as:

• Cost of diagnosis, health seeking behaviour, awareness and use of control interventions,

• Outcome of treatment expenditures on household income,

• Improving patient understanding and willingness to pay for diagnosis.

Key facts and figures

Average cost of single malaria test with either RDT or microscopy was $1.57; Two hundred and seventy one (84.4%) were presumptively diagnosed in rural compared to 218(68.7%) in urban areas; Cost of RDT was $1.57; cost of adult course of ACT was $5.5

CHW as a source of information on malaria was zero in Mali; CHW were unaware of knowledge of treatment regime at community level

32.4% of mothers of <5 children were aware of HMM compared to the 60% and 80% expected in the 2005 and 2010 RBM targets respectively; 27.9% of mothers of <5 children used ITN

19.8% of pregnant women also used ITN; ITN use was more prevalent in public than private hospitals (26.8% vs. 9.5%); 43.5% pregnant women have received IPT

Malaria Treatment accounted for 7.1% and 5.0% of non food expenditures for rural and urban dwellers respectively.

Average cost of antimalarial treatment almost doubled after implementation of ACT; The deficit of health insurance was $7885 which amounted to 170.8% of premium income in 2008 compared to 25.8% in 2007 in Burkina Faso

Mean willingness to pay for RDT was $1.79(SD= $1.53).

Use of visual instructions was better understood by respondents with 4+ years of schooling

Initiatives on the ground; experience/s derived

Both quantitative and qualitative methodologies were employed. Also randomized trial was conducted in the cerebral malaria study and use of registers was employed in the study of financial impact of antimalarial combination on health insurance.

Research Findings

Presumptive treatment was higher in rural than in urban areas. Chloroquine usage was still more prevalent in rural than urban areas. Socio economic and structural factors impinge heavily on the participation capability of the communities. Poor knowledge about malaria and the influence of culture affect social inclusion and access to health services. On the home management of malaria, knowledge about awareness and use was poor; and this was influenced by age and education of respondents. Use of ITN/LLIN was also poor. In general, results showed poor awareness and low use of malaria control interventions. Good RDT sensitivity and specificity were observed. The study on cerebral malaria showed that intervention group that received training sessions using the cognitive software performed better than the non treatment group. In addition, computerized cognitive training long after the cerebral malaria episode has immediate benefit on some neuropsychological and behavioral functions in African children. On treatment, cost of treating a case of malaria was $6.64 for adults and almost the same for children ($6.58). On treatment expenditure, there were socio economic and geographic inequities in the financial burden resulting from malaria treatment. In the study that compared the antimlarial prescriptions and their costs before and after the implementation of ACT, average cost of treatment almost doubled between 2007 and 2008. Deficit of the health insurance was $7885 which amounted to 170.8% of premium income in 2008 compared to 25.8% in 2007. On using visual instructions to improve patient understanding, majority with 4+ years of schooling understood dosage instructions correctly. Results of the study on the willingness to pay for RDT showed that about a quarter were willing to pay for malaria diagnosis using RDT.

Lessons learned

Use of RDT should be promoted and this will reduce over diagnosis of malaria and cost. Despite extensive debates on the benefits of participation, there has been a lack of in-depth analysis on participation in malaria control. Study has provided an understanding of how community participation can improve malaria management. Efforts should be intensified to make adequate information and materials on control interventions available and accessible at the community level. Malaria treatment expenditure depleted more of the aggregate income of the very poor. Long term benefit of using computerized cognitive rehabilitation training should be investigated. Study on catastrophic expenditure showed that government and donor agencies should institute the abolition of user fees for malaria. On the financial impact of ACT, mechanisms for increased and sustained financing are needed to maintain the sustainability of health insurance scheme. On use of visual instructions, adherence will cease to be a challenge as tested visual instructions increases comprehension of correct treatment.

Issues raised, obstacles, difficulties

Definition of catastrophic expenditure was controversial. Presenter reported that it was based on the percentage of people below level of poverty in his country. Some audience did not agree with this approach. One Ghanaian said that 60% of the populations are below the poverty level.

FINDINGS AND CONCLUSIONS

Practice of laboratory confirmed diagnosis should be encouraged, and the possibility of deploying RDTs to patent medicine sellers should be considered.

Poor awareness and low use of malaria control interventions were observed.

RDT usage will reduce over diagnosis of malaria.

Community participation can improve malaria management.

Average cost to treat a case of malaria was $6.64 for adults and $6.58 for children.

Tested visual instructions increases comprehension of correct treatment.

There are inequities in household income depletion as a result of malaria treatment expenditures.

From formal presentations

Public health Implications:

Appropriate diagnosis should be put in place to ensure efficient malaria management. Community participation especially in the rural areas will improve knowledge about the disease and eventually improve treatment. Malaria control strategies should be made available and accessible to be able to realize the RBM/MDGs targets.

Policy Impact:

ACT use should be promoted and RDT use should be recommended for diagnosis as this will reduce over diagnosis of malaria. User fees for malaria should be abolished.

Knowledge gap created:

Long term benefit of computerized cognitive rehabilitation training on neuropsychological and behavioural functioning of children surviving cerebral malaria should be explored.

From open discussions/debates

Identified conclusions

Malaria remains a major problem in Africa. A lot of work has been done to sensitize rural communities on knowledge and change in drug policy. Studies are now focused on expenditure and poverty.

Main points of agreement

• Use of CHW in informing the community about malaria.

• Willingness to pay for RDT should be measured in different socio economic and geographic groups.

Main points of divergence

Definition of catastrophic expenditure

Recommendations

• Policy makers should study dynamics of population before proposing interventions

Personal observations from rapporteur:

No official rapporteur was present. Only one chair was present.

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