SUSTAINABILITY AND COST OF HOME-BASED MANAGEMENT OF MALARIA IN CHILDREN UNDER FIVE YEARS IN EJISU-JUABEN MUNICIPALITYGHANA-MSC Thesis-KNUST

8/12/2019 SUSTAINABILITY AND COST OF HOME-BASED MANAGEMENT OF MALARIA IN CHILDREN UNDER FIVE YEARS IN EJISU-J

1/129

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

SUSTAINABILITY ANDCOST OF HOME-BASED MANAGEMENT OF

MALARIA IN CHILDREN UNDER FIVE YEARS IN EJISU-JUABEN

MUNICIPALITY

GHANA

A SUMMARY OF THESIS SUBMITTED TO THE DEPARTMENT OF

COMMUNITY HEALTH,

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

IN PARTIAL FULFILMENT OF

MASTERS IN PUBLIC HEALTH (HEALTH SERVICES PLANNING AND

MANAGEMENT)

SCHOOL OF MEDICAL SCIENCES, COLLEGE OF HEALTH SCIENCES,

COMMUNITY HEALTH, KUMASI, GHANA

SUBMITTED BY

BENEDICTA OFOSUHEMAA ASANTE

2010


2/129

DECLARATION

I declare that I have personally undertaken this research under the supervision of

Dr. Agyei-Baffour Peter herein submitted.

I take full responsibility for errors, misinterpretation, misrepresentation and other

shortcomings.

Benedicta O. Asante ..

Certified by:

Supervisor:

Dr. Agyei-Baffour Peter ..

Certified by:

Head of Department

Dr. Easmon Otupiri ..


3/129

DEDICATION

This dissertation is dedicated to my mum Mrs. Emma Adjei-Baah and my siblings Asante Sasu

Sylvester, Asante Aboagyewaa Grace and Asante Kwame Andrew, as well as the inhabitants of

Ejisu- Juaben Municipality most especially the surrounding villages.


4/129

ACKNOWLEDGEMENTS

More than a few people have helped me in the writing of this dissertation. First and foremost, I

owe a debt of gratefulness to the Almighty God for giving me the vigor and familiarities.

I am particularly grateful to Dr. Agyei-Baffour Peter, my supervisor, for the hale and hearty

criticism, advice, instructions and useful suggestions I received from him.

My thanks also go to my parents, Mr. and Mrs. Asante, my Grandmother; Madam Felicia Adjei-

Baah, Mrs. Mary Nkrumah Asante, and to my uncle Nana Adjei Francis for their prayers and

financial support and inspiration for my education.

In addition, I wish to express my profound gratitude to Mr. Jacob Amoa, the District Director of

Ejura in the Ashanti-Region for his contribution to my research. To my lecturers, especially

Professor (Mrs.) E. A. Addey, Dr. E.A. Edusei, and Dr. Easmon Otupiri, my friends and my

course mates, I say thank you!

As for any errors, substantial or marginal which may be found in the dissertation, I am entirely

responsible for them.


5/129

ABSTRACT

Malaria, one of the world's most common and serious tropical diseases, causes at least one

million deaths every year. This proportion increases each year because of deteriorating health

systems, growing drug and insecticide resistance, climate change, natural disasters and armed

conflicts. In Ghana however, statistics shows that one in five childhood deaths is as a result of

malaria. The cost of treatment of malaria alone is crippling the health budget, in that in 2007

alone the cost of treating malaria amounted to about US $772 million. HBMM was introduced to

ensure prompt and effective treatment of malaria at the household level.

The potency of HBMM has been established but little was known about the cost and

sustainability of HBMM. A cross sectional study involving the use of quantitative and qualitative

surveys with caregivers, community medicine distributors (CMDs) was designed and

implemented from July-September 2010. The study involved a population sample of 500 people.

Questionnaires were administered for data collection. Data was entered and analyzed with SPSS.

Female CMDs dominated and affordability of HBMM was associated with the type of

occupation; traders could afford price range of GHp10 to GHp20 while majority of the farmers

could afford it at GHp5. Supplies and incentives to CMDs were the two key factors influencing

cost of HBMM. Cost incurred in accessing HBMM was less as compared to the one sought from

the health facilities. The study revealed that the sustainability of HBMM is bleak as the upkeep

of volunteers; their kits, incentives, communal support and ownership remained unknown.

Perceptions about who owns HBMM were mixed.

There is attrition among CMDs and could affect smooth implementation of HBMM. Delays in

supplies, unattractive CMDs incentives and cost were the barriers to the implementation and

sustainability of the HBMM. The monthly allowances giving to the CMDs compared to the

national salary wage was far less. The CMDs lose more money for being on HBMM programme

than they would have received if they were working elsewhere. Efforts should be made to

increase community ownership of HBMM, supervisory visit, improve CMDs incentives, and

early supplies of medicines and logistics in HBMM.


6/129

TABLE OF CONTENTS

Page

Declaration.....ii

Dedication.....iii

Acknowledgement.............iv

Abstract..............v

Table of Contents......vi

List of Tables..............xi

Acronyms......xii


7/129

CHAPTER 1 Introduction...........1

1.1 Current state of knowledge..1

1.1.1 Malaria burden .........................................................................................................1

1.1.2 Home management of malaria strategy.2

1.1.4 Cost of illness.41.1.4 Cost of malaria..5

1.1.5. Cost drivers of illness and home management of malaria...6

1.1.6. Measurement of household cost of malaria.7

1.1.7. Measurement of opportunity costs of malaria..7

1.2. Problem Statement..8

1.3 Rationale of study9

1.4 Study Hypothesis10

1.5 Study Questions..10

1.6 General objective..10

1.6.1 Specific Objectives...10

1.7 Links to other studies......10

CHAPTER 2 LITERATURE REVIEW...12

2.0 Introduction.....12

2.1 Malaria..12


8/129

2.2 Malaria Control Strategies..14

2.2.1. Insecticide Treated Material.14

2.2.2. Vector Control..15

2.2.3. Home based Management of Malaria..16

2.2.4. Other Control Measure....17

2.3 Cost of Illness ......18

2.3.1. Cost of Malaria....19

2.3.2. Household Cost of Malaria.....21

2.3.3. Opportunity Cost of Malaria...22

2.3.4. Cost Drivers of Illness....23

2.3.5. Cost Drivers of HBMM......24

2.4Sustainability of Home- base management of malaria................................................25

2.5 Theoretical basis .....26

2.6 Knowledge gaps..28

CHAPTER 3 Methodology......29

3.0 Introduction.................29

3.1. Study Type 29

3.2. Study Site29

3.3. Study Population.31

3.4. Sampling ........31

3.4.1. Sampling Size..31

3.4.2. Selection of Respondents31


9/129

3.4.3. Study Variables...32

3.5. Data Collection ..34

3.6. Data Handling and Analysis......36

3.7. Sensitivity Analysis36

3.8 Ethical Consideration.36

3.9. Limitations 36

3.10. Outputs and application possibility..37

3.11. Dissemination of findings37

3.12. Conclusion.37

CHAPTER 4 Results.38

4.0 Introduction..38

4.1. Socio-demographics38

4.2 Household Cost of malaria..41

4.2.1. Cost incurred and time spent by caregivers at health providers facility and CMDs..45

4.2.2. Clients reaction to change in cost of treatment47

4.3 Cost Drivers..48

4.4. Sustainability of HBMM..51

4.5. Ability of CMDs...56

4.6. Sensitivity Analysis of Cost Estimates.58

4.7. Opportunity Cost of CMD...59

4.8 Inferential Statistics....60


10/129

CHAPTER 5 Discussions64

5.0 Introduction ..64

5.1 Socio-demographics..64

5.2 Household Cost65

5.3 Cost Drivers..67

5.4 Sustainability68

5.5 Ability of CMDs..69

5.6 Opportunity cost of CMDs..70

CHAPTER 6 Conclusions and Recommendations..........71

6.0Introduction.716.1. Conclusions....71

6.1.1. Socio-demographic..71

6.1.2. Cost Drivers.71

6.1.3. Household Cost...71

6.1.4. Sustainability72

6.1.5. Ability of the CMDs....73

6.1.6. Opportunity Cost of CMDs in HBMM73

6.2 Recommendations73

6.3. MOH/GHS and NMCP...73

6.4. MHMT and Municipal Assembly....74

6.5. Community Leaders....74

6.6. CMDs.74

6.7. Households.75


11/129

6.3 Concluding Remarks...75

LIST OF BIBLOGRAPHY...76

APPENDIX.. 84


12/129

LIST OF TABLES AND FIGURES

TABLE PAGE

3.4.3.1 Logical framework/indicators32

4.1 Background Characteristics.384.2 Household Cost ......424.3Sources of treatment ....444.4Satisfaction of HBMM.444.5Cost incurred and time spent by caregivers at health facility...454.6 Clients reactions to Change in Cost of Treatment....474.7 Factors influencing Cost of HBMM...........49

4.8 Sustaining HBMM..51

4.9 Ability of the CMDs in Treatment of Malaria................56

4.10 Effect of change of cost .......58

4.11 Estimate value of Opportunity cost time of involving the CMDs59

4.12 Relationship between Cost of treatment and Educational background61

4.13. Relationship between gender and Factors that Decrease/increase the Cost of

HBMM62

FIGURE

1.1 Map of Ejisu-Juaben Municipal.. 83


13/129

Acronyms

ACTs Artemisinin-based Combination Therapies

CMDs Community-based Medicine Distributors

CHRPE Committee for Human Research, Publications and Ethics

DDT Dichloro-Diphenyl-Trichlorethane

FCA Friction Cost Approach

GHS Ghana Health Service

GDP Gross Domestic Product

HBMM Home Base Management of Malaria

HMM Home Management of Malaria

HCA Human Capital Approach

ITM(s) Insecticide Treated Material(s)

ITNs Insecticide Treated Nets

IPTp Intermittent Preventive Treatment in Pregnancy

IVM Integrated Vector Management

MHMT Municipal Health Management Team

MPL Marginal Product Labour

MCL Marginal Cost Labour

NMCP National Malaria Control Programme

ORS Oral Rehydration Salt

PSI Population Service International

RDT Rapid Diagnostic Testing kit

RA Rectal Artesunate

RBM Roll Back Malaria

SPSS Statistical Package for Social Sciences software

SDHT Sub-District Health Team

TDR Tropical Disease Research

VHC Village Health Committee

WHO World Health Organisation

WTP Willingness to Pay


14/129

CHAPTER ONE

INTRODUCTION

Chapter one presents the overview of the study. It starts with the current state of knowledge of

malaria and home-based management strategy, costs of illness and their measurements, the

problem statement, study objectives, and links to other studies.

1.1 Current state of knowledge

1.1.1 Malaria burden

Malaria remains one of the major public health problems worldwide, and of the estimated 400 to

900 million episodes of fever occurring yearly in African children, probably about half are due to

malaria, resulting in over one million deaths. However, the proportion of deaths due to malaria

varies widely with malaria transmission (Heidi et al, 2007). According to Kiszewski et al (2007),

malaria remains the most vital in the global health morbidity and mortality debates, and the

number one public health problem in most endemic areas. However, access to effective

interventions that reduce death and illness from malaria is still problematic in most malaria

endemic countries.

The World Health Assembly in 2005 urged Member States to establish policies and operational

plans to ensure that at least 80% of those at risk of or suffering from malaria benefit by 2010

from major preventive and curative interventions. This would ensure a reduction in the burden of

malaria of at least 50% by 2010 and 75% by 2015. Kiszewski, et al (2007) estimated US$ 38 to

45 billion for the period 2006-2015 as the global resource requirement to achieve this goal. The


15/129

average annual costs for Africa as well as its exterior was about US$ 1.7-2.2 billion and cost was

US$ 2.1- 2.4 billion per year.

The extensive disparity seen in the burden of malaria between different regions of the world is driven

by several factors. First, there is great variation in parasitevectorhuman transmission dynamics that

favour or limit the transmission of malaria infection and the associated risk of disease and death. The

second factor is climatic variation. While the tropical humid climate favours the bleeding and survival

of mosquitoes, this does not happen in the temperate regions. For instance, the most competent and

efficient malaria vector, Anopheles gambiae,occurs exclusively in Africa and is also one of the most

difficult to control.

Climatic conditions determine the presence or absence of anopheles vectors. Tropical areas of the

world have the best combination of adequate rainfall, temperature and humidity allowing for breeding

and survival of anopheles. Malaria control strategies vary in both methods and content. The methods

range from vector control (spraying, larviciding, ITNs) through personal to case management at the

health facility and household level. The strength of HBMM lies in the control of malaria at latter level

(Kiszewski, et al., 2007).

1.1.2 Home-based management of malaria strategy

Home-based management of malaria (HBMM) is promoted as a major strategy to improve

prompt delivery of effective malaria treatment in Africa. HBMM involves presumptively treating

febrile children with pre-packaged antimalarial drugs distributed by members of the community.

Several African countries have implemented HBMM with artemisinin-based combination

therapies (ACTs) therefore ACT is likely to be introduced into these programmes on a wide scale


16/129

(Heidi et al, 2007). There are four main components of HBMM. One, ensuring that there is an

effective communication strategy for behaviour change to enable caretakers to recognize malaria

illness early and take an appropriate action. Secondly, ensuring that CMDs have the necessary

skills and knowledge to manage malaria fever cases and thirdly, ensuring availability and access

to effective good quality preferably pre-packed antimalarial medicines at the community level

close to the home as possible and lastly, ensuring a good mechanism for supervision and

monitoring of the community activities (RBM/ WHO, 2004).

The use of well-trained community health workers to provide prompt and adequate care to

patients closer to their homes is the main thrust of the strategy of home-based management of

malaria. The strategy was showed to reduce malaria mortality and severe morbidity and was

adopted by the World Health Organization as a cornerstone of malaria control in Africa

(RBM/WHO, 2004). In addition Samba (2001), indicated that, home based management of

malaria strategy was used in the communities of Nigeria, Uganda, Ghana, and Kenya to manage

malaria. In most African and other malaria endemic countries of which Ghana is part, most

malaria cases is managed at the household level lately and inappropriately. In Ghana and most

African countries, when children are sick, heads of households, friends as well as relatives are

consulted on the type and dosage of medicine to give; this is a common practise among

households. These activities not only lengthen the delay in seeking medication but they also are

recipes of mistreatment.

In most cases, after the initial therapy has failed, caregivers seek treatment from pharmacist or

licensed chemical seller (registered suppliers of specified over-the-counter-medicines) in the


17/129

community. As a result, uncomplicated cases turn out to be severe. Children with severe malaria

are then rushed to the hospital and based on the facilities and the technical know-how of the staff

available, the child fate would be determined (Samba, 2001). According to Browne et al. (2006),

home-based management of malaria is feasible and acceptable with the use of artemisinin-based

combination therapies (ACTs). On the other hand, according to DAlessandro et al. (2005), the

household management of malaria was often inadequate, inappropriate and ineffective, and may

lead to drug resistance. The caregivers readiness to use varying methods in seeking care could

be from proximity, previous experience, and cost of care.

1.1.3 Cost of illness

Microsoft Encarta (2007) explains cost as the total expenditure incurred in the normal course of a

business in bringing a product or service to its current location or condition. Cost in this context

explains the expenditure incurred in receiving and providing care. With reference to Hanson

(2002), the genuine cost of an illness was the personal cost ofacute orchronic diseases. The cost

of illness might be an economic, social,or psychological cost or loss to the patient, family,or

community. A comprehensive cost-of-illness includes both financial and economic costs,

although the specific focus of the study might make one or the other unnecessary. Financial costs

measures the monetary value of resources used for treating a particular illness, whereas

economic cost measures both financial and the value of resources forgone due to a particular

illness.

According to Hanson (2002), the financial cost is the cost of resources used rather than net a

direct cost which subtracts the future medical costs avoided because of the death of a patient

from total costs. Such costs include hospital in-patient, and outpatient, emergency department
http://cancerweb.ncl.ac.uk/cgi-bin/omd?acutehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?chronic+diseasehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?socialhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?psychologicalhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?familyhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?communityhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?communityhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?familyhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?psychologicalhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?socialhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?chronic+diseasehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?acute


18/129

outpatient, and nursing home care. Others include rehabilitation care, health professionals care,

diagnostic tests, prescription drugs, drug sundries, and medical supplies. In addition, the cost of

illness may include intangible costs of pain and suffering, usually in the form of quality of life

measures. This category of costs was omitted because of the difficulty in accurately quantifying

it in monetary terms.

Also Joel (2006), emphasises that economic cost includes, mortality costs; morbidity costs due

to absenteeism, informal care costs; in terms of the cost of hiring outside care and, for the few

relevant cases such as substance use or violence. The cost of illness may be reflected in

absenteeism,productivity,response totreatment,peace ofmind,quality of life among others. In

considering the ideas of both Joel (2006) and Hanson (2002), cost of illness differs fromhealth

care costs.Thus, cost in health care is restricted to providingservices related to thedelivery of

health care rather than animpact on the personallife of the patient.

1.1.4 Cost of malaria

Malaria constitutes for 10% of Africas disease burden generally and estimates to cost the

continent over $12 billion every twelve months (WHO/RBM, 2001). Over one-third of clinical

malaria cases occur in Asia as well as 3% occurs in the America. WHO/RBM (2001) revealed

the estimated cost to effective control of malaria in the 82 countries with the highest burden to be

about $3.2 billion every twelve months. In Ghana however, statistics show that one in five

childhood deaths result from malaria. With this, it could be confirmed that the health budget was

affected by the cost of treatment. For example, in 2007, the cost of treating malaria was about US

$772 million in Ghana (Quashigah, 2007).
http://cancerweb.ncl.ac.uk/cgi-bin/omd?illnesshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?absenteeismhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?productivityhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?responsehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?treatmenthttp://cancerweb.ncl.ac.uk/cgi-bin/omd?peacehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?mindhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?quality+of+lifehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?differshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?health+care+costshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?health+care+costshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?serviceshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?relatedhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?delivery+of+health+carehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?delivery+of+health+carehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?impacthttp://cancerweb.ncl.ac.uk/cgi-bin/omd?lifehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?lifehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?impacthttp://cancerweb.ncl.ac.uk/cgi-bin/omd?delivery+of+health+carehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?delivery+of+health+carehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?relatedhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?serviceshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?health+care+costshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?health+care+costshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?differshttp://cancerweb.ncl.ac.uk/cgi-bin/omd?quality+of+lifehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?mindhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?peacehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?treatmenthttp://cancerweb.ncl.ac.uk/cgi-bin/omd?responsehttp://cancerweb.ncl.ac.uk/cgi-bin/omd?productivityhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?absenteeismhttp://cancerweb.ncl.ac.uk/cgi-bin/omd?illness


19/129

In support, the WHO/RBM (2001) and WHO/RBM/UNICEF, (2005) revealed that, economists

estimated malaria to be responsible for a growth penalty of up to 1.3% per year in most African

countries in lots of Gross Domestic Product. Malaria also accounts for 40% of public health

expenditure. The financial and economic costs at household level range from US$2 to $25 for

treatment and $0.2 and $15 for prevention per every four weeks. The WHO (2007) and Akazili

(2002) described this as unaffordable for the rural and poor population communities.

Malaria was considered a cause of poverty in most African communities (WHO/RBM, 2003).

Thus, resources needed for development was drained out by the cost related with malaria. This

cost burden of malaria was not only high at the global level but also at the household level, hence

barriers to access of good health care. Goodman et al. (2000), Akazili (2002) and Hanson et al

(2004), revealed this. Again, they revealed that, malaria has been recently shown to be a key

constraint to economic development and has an important measurable financial and economic

cost. The financial cost of malaria includes a combination of personal and public expenditures on

both prevention and treatment of the disease. Personal expenditures include individual or family

spending on insecticide treated mosquito nets (ITNs), doctors fees, anti-malarial drugs, transport

to health facilities, and support for the patient and sometimes an accompanying family member

during hospital stays. Public expenditures according to Scholte (2005) include spending by

government on maintaining health facilities, health care infrastructure, publicly managed vector

control, education and research. It is important to note that the magnitude of cost depends

largely on the type and content of malaria control strategy. Thus, the cost associated with


20/129

insecticide treated nets (ITNs) might be different from that associated with home-based

management.

1.1.5 Cost drivers of illness and home-based management of malaria

All inclusively, various factors pressurise the cost of illness as well as cost in home-based

management of malaria. Such factors may include, lack of insight by clinicians into test prices,

lack of transparency into test costing and cross subsidization, unnecessary testing, active and

passive providers. Others include, supplies, distance, type of health facility, type of treatment,

and severity of condition, Also, the waiting time, food, diagnostic tests, prescription drugs and

drug sundries, rate of mortality and morbidity (Joel, 2006).

Hundreds of health economists, researchers, policy analysts, and others have spent tremendous

amount of energy on the issue of the rising cost of health care and equally challenging issue of

how to pay for it. Guest (1997) emphasizes that, it is impossible to consider individual cost

drivers in isolation. Many factors impact each component of the health care delivery system and

a shift in one area necessitates variation in another. According to her, researches have uncovered

a range of possible influences on rising costs.

1.1.6 Measurement of household cost of malaria

Time and cost are the terms which may be used in measuring household costs in association to

malaria. There was an effect on families if the household cost of malaria was negative. The idea

of Bloom et al., (2000) as well as Sauerborn et al (1996) showed that, the interactions between

household and healthcare providers and ensuing costs associated were not only the central


21/129

determinant of demand for health. In addition, they were essential in the performance of

healthcare interventions, mainly coverage; prompt access, and equity dimensions in demand and

supply of healthcare analysis. A well known issue was the implication of costs of illness on

demand for healthcare among the poor.

Again research debaters like Bloom et al (2000) and Sauerborn et al (1996) recognized that

household costs limit access to quality healthcare and at the same time encourage exploitation of

inappropriate healthcare. Averagely, family unit incurred a total cost of 318 (US$) per patient

who fully recovered from `malaria, 24% of this was direct cost and 44% economic costs for the

patient as well as 32% economic cost.

1.1.7 Measurement of opportunity costs of malaria

Opportunity cost or economic cost, the most frequent words economists use in describing

the forgone alternative. The use of opportunity cost approach could usually be seen as preferable

to other approaches. This gives a true sense of the economic costs of the disease hypothetically.

From the books of Hodgson et al (1982, 2003), opportunity cost defines the value of the forgone

opportunity to use in a different way those resources that are used or forgone due to illness.

However, measuring opportunity cost of an illness was not an easy assignment but estimation of

the lost productivity attributable to the illness was the most difficult issues. Thus, the human

capital methodology, Gross National Product per capita or wage rates were used to estimate

productivity loss resulting from morbidity and mortality.

Nevertheless, Kamrul (2000) and Agyei-Baffour (2008) indicated in their study that, in the case

of wage rates it was frequently revealed that imperfections occur in the labour market so that a


22/129

persons earnings differ from the actual value of ones output or productivity. Consequently,

wages might not be a good measure to be used in estimating productivity losses, in a developing

country where their labour market was not all that developed. Estimating the foregone income

which might be due to mortality may have serious technical problems. To Kamrul (2000), the

capitalized value of lost wages, associated with the inward shift of the labour supply curve was

appraised by using the human capital method. To add to this, the costs of grief and distress were

evaluated by using this method. Once more, opportunity cost associated itself with forgone

opportunities. For instance, the opportunity cost of a hospital stay would be the value of the

productive and or leisure time lost during the hospital stay.

1.2 Problem Statement

Lately, several reports have appeared in the Ghanaian media on the prevalence of malaria in Africa

(WHO/RBM, 2003). The high cost associated with malaria in Africa was a drain on its resources

needed for development. There was significant negative association between malaria morbidity and the

growth rate of GDP per capita which was a robust to a number of modifications, including controlling

for reverse causation (WHO/RBM, 2003). Majority of symptomatic infections were treated at home.

Given that most cases of malaria were treated at home, the home-based management of malaria

(HBMM) strategy is effective for early treatment. About 50-70%, childhood deaths occurred without

contact with the public health services. Majority of children who die from malaria do so within 48

hours of illness; referral to the health care facility could take several hours (MOH, 2004). HBMM was

a relief, since it led to 53% reduction in severe malaria lately.


23/129

Furthermore, the National Malaria Control Programme (NMCP) of the Ghana Health Service (GHS)

has identified the disease as a drain on productivity (MOH, 2004). There is enough evidence to suggest

that, malaria is a cause of poverty (MOH, 2004). Consequently, costs associated with malaria treatment

and diagnosing limits access to and widen inequalities among rural communities. Majority of

caregivers living in the rural areas lived in poverty. In that, costs of healthcare including malaria

interventions are prohibitive. They resort to informal source of care, the quality of which is not been

guaranteed (MOH, 2004).

This leads to inappropriate and late treatment of malaria, hence increase in deaths. The effect of costs

related to malaria do not only fall on the sick, but it also falls on the other members of the household

(on accompanying, and members who care for the sick and or accompany them to get treatment), an

well as other members who depend on the resources for survival. Therefore large scale implementation

of home-based management of malaria interventions to reach many people is timely but there is the

need to critically assess costs and its sustainability of the package to inform the programme.

1.3. Rationale of Study

It has been established that, most deaths associated with malaria occur at home and that if

caregivers have prompt access to appropriate medications, these deaths could be averted.

Therefore, proven efficacious malaria control strategy such as home-based management of

malaria needs to be scaled up to improve access. The Ghana Health Service has started a nation-

wide home-based management of malaria implementation. Therefore, the need to investigate into

sustainability and cost issues of HBMM to inform policy becomes paramount. The study was


24/129

designed to measure the cost and sustainability of home-based management of malaria in the

Ejisu-Juaben of Ghana.

1.4 Study Hypothesis

The following working hypotheses guided the study:

1. Cost drivers of the treatment package for HBMM increase or decrease the cost of treatment of

malaria.

2. The affordability of HBMM is related to caregivers occupation.

1.5 Study Questions

1. What are the cost drivers of home management of malaria?

2. What is the household cost under home management of malaria?

3. What are the problems associated with the sustainability of HBMM?

1.6 General objective

To measure the cost and assess the sustainability of home based management of malaria in the

Ejisu-Juaben of Ghana (HBMM+).

1.6.1 Specific Objectives

O1. To identify cost drivers in integrated package for home management of malaria at household

level.

O2. To measure the household cost in seeking care in home management of malaria.

O3. To assess whether or not HBMM is sustainable.

O4. To assess the ability of CMDs to prescribe medicines in HBMM.

5. To estimate the opportunity costs of CMDs and health providers in HBMM.


25/129

1.7 Links to other studies

In substance, the study was a sub-study and an improvement of already completed and ongoing

home management studies; Feasibility and acceptability of a package for home diagnosis and

management of uncomplicated and severe malaria in rural Ghana, Feasibility, acceptability, costs

and policy contextual issues in home management of malaria in children aged 6 59 months in

the city of Kumasi, Ghana(TDR Project No. A50450) and Access, use and cost implications

for equity of home management of malaria in rural Ghana (PhD Research) all completed.


26/129

CHAPTER TWO

LITERATURE REVIEW

2.0. Introduction

This chapter highlights the various ideas and experiences of other works done by researchers in

the subject matter. It also assesses the linkages between studies across settings and domains.

Finally, the chapter evaluates past research and shows knowledge gaps.

2.1. Malaria

The Microsoft Encarta (2007) defined malaria as a tropical disease characterized by fever,

anaemia, spleenomegaly and excessive sweating. Again, malaria explains

the debilitating infectious disease characterized by chills, shaking and periodic bouts of intense

fever (Glover, 1993). Worldwide, there are about 300500 million episodes of clinical malarial

each year, resulting in over a million deaths. Over 90% of these deaths occur in Africa south of

the Sahara, and almost all of them were in children. Effectual interventions against malaria were

in existence, hitherto the burdens continue due to the fact that most people at risk of malaria were

poor and ignorant of interventions. In addition, lack of education, information, and access to

effective interventions had affected the success of Roll Back Malaria (RBM) programmes,

especially among the poor, and in poorer countries (RBM/WHO, 2004).

As of 2004, 107 countries and territories had reported areas at risk of malaria transmission.

Although this number was considerably less than in the 1950s with 140 endemic countries or


27/129

territories, 3.2 billion people were still at risk. Presently, around 350500 million clinical

malarial episodes occur annually. Around 60% of these cases are clinical malaria and over 80%

of the deaths occur in Africa. More than one million Africans die from malaria each year most

are children under 5 years of age. In addition to acute disease episodes and deaths in Africa,

malaria also contributes significantly to anaemia in children and pregnant women, adverse birth

outcomes such as spontaneous abortion, stillbirth, premature delivery and low birth weight, and

overall child mortality. The disease estimated to be responsible for an estimated average annual

reduction of 1.3% in economic growth for those countries with the highest burden (RBM/WHO,

2004).

There was great variation in parasitevectorhuman transmission dynamics that favour or limit

the transmission of malaria infection and the associated risk of disease and death. Of the four

species of Plasmodium that infect humansP. falciparum,P. vivax,P. malariaeandP. ovale

P. falciparumcauses most of the severe disease and deaths attributable to malaria and was most

prevalent in Africa south of the Sahara and in certain areas of South- East Asia and the Western

Pacific (WMR, 2005). There was significant negative association between malaria morbidity and

the growth rate of GDP per capita which was a robust to a number of modifications, including

controlling for reverse causation. The estimated negative impact of malaria 0.55% in Sub-

Saharan Africa was the average annual growth (RBM, 2001; UN, 2005).

The economic growth in GDP in malaria endemic countries was slow and was accounting for the

widening prosperity gap between countries with malaria and without malaria (WHO/RBM,

2003). Malaney, et al (2004) and Hanson, et al (2004) indicated that, the consequential might


28/129

comprise of high morbidity and mortality, low productivity, low foreign investment (this was

because investors may be scared to work in countries in endemic with malaria). For instance, the

effects on the socio-economic expansion in a malaria endemic country like Ghana were

shattering. Malaria management should be at the head of their development agenda if fewer

developing countries want to virtually accomplish their developmental objectives.

2.2 Malaria Control Strategies

The Ministerial Conference on Malaria in Amsterdam adopted the global Malaria Control Strategy in

1992. Plans of action for its implementation were updated in 1995. In 1994, the United Nations

General Assembly invited WHO, as the lead agency in this field, to promote international mobilization

of technical, medical and financial assistance to intensify the struggle against malaria. Some of the

control priorities were development of global and regional goals and strategies, provision of guidelines

and standards, technical assistance to countries, and development of training programmes (WHO,

2004).

2.2.1. Insecticide Treated Materials

Insecticide treated nets are the treated household materials use in protecting against mosquitoes

and invariably malaria. "Provision of insecticide-treated materials (ITMs) was universally

accepted as an efficacious and essential public health services (Scholte, 2005). Ghana had seen a

significant increase in ITMs use over the past five years (Scholte, 2005). ITMs used in children

under five years increased from 3.5% in 2003 (DHS) to 22% in 2006 (MICS). ITMs used in

pregnant women increased from 3.3% in 2003 (DHS) to 46.5% in August 2006 (GFATM survey

in focus Municipal assemblies). The MOH applies different models for ITM distribution


29/129

including free net distribution, net subsidization, and commercial market access as well as

promotion. Seven different ITM brands in a variety of shapes, colours and styles were registered

in Ghana. The NMCP formulated an ITM policy in May 2002, which was updated in April 2007.

The updated policy states that Distribution of insecticide-treated materials (ITMs) in Ghana

takes into consideration the need to improve access to vulnerable groups while at the same time

creates an incentive for the private sector involvement to ensure sustainability. A dual approach

was therefore

using to distribute ITMs in Ghana and sale of ITMs at full commercial cost. These were

distributed through multiple retail outlets to ensure increased availability to these products and

sale at subsidized prices to persons in the target population (children under five and pregnant

women) who cannot afford the full cost of ITMs (WHO, 2004).

2.2.2. Vector Control

The Health and Safety code defined a vector as "any animal capable of transmitting the causative

agent of human disease or capable of producing human discomfort or injury, including, but not

limited to, mosquitoes, flies, other insects, ticks, mites, and rats, but not including any domestic

animal"(MacDonald, 1957). WHO recommended a systematic approach to vector control based

on evidence and knowledge of the local situation. This approach was called the integrated vector

management (IVM). Vector control aimed to decrease contacts between humans and vectors of

human disease. Vector control remained the most generally effective measure to prevent malaria

transmission and therefore is one of the four basic technical elements of the Global Malaria

Control Strategy.


30/129

The principal objective of vector control was the reduction of malaria morbidity and mortality by

reducing the levels of transmission. The choice of vector control would depend on the magnitude

of the malaria burden, the feasibility of timely and correct application of the required

interventions and the possibility of sustaining the resulting modified epidemiological situation.

Control of mosquitoes might prevent malaria as well as several other mosquito-borne diseases.

There were four basic technical elements to the strategy. The first element was to provide drugs

and treatment to those infected. Second was to implement sustainable and effective preventive

measures which included vector control. Knowing that, these measures are difficult and costly.

Hence, it is important to be quite selective. The third one was to prevent or detect and contain

epidemics in high-risk areas. The fourth was to strengthen local capacities in research and

development.

To do this we need effective vector control, which defines as the application of targeted site-

specific activities that are cost-effective. There were some concerns about the environment,

which needed some consideration. We therefore need an environmentally sustainable method for

vector control aimed at reducing reliance on chemical insecticides and involving intersectional

collaboration. According to MacDonald (1957), environmental control could used to prevent

breeding, nesting, and feeding of vectors by source reduction and even through better housing,

windows, doors, screening. Environmental changes from road, dam, or pipeline construction,

deforestation, agriculture, and irrigation could generate larval breeding sites. Environmental

control was mostly be used in urban and peri-urban areas, and mostly required community

participation and intersectoral collaboration (Caldas, 2004).


31/129

2.2.3. Home-Based Management of Malaria

Home-Based Management of Malaria (HBMM) is one of the key strategies to reduce the burden of

malaria for vulnerable population in endemic countries. The role of home-based management of

malaria can help in reducing the deaths of over one million children annually (WHO, 2003). In April

2000, the African heads of state committed their governments that by the year 2005, 60% of malaria

episodes should be treating within 24 hours of onset of symptom. A strong healthcare delivery system

would ideally provide early reliable diagnosis and appropriate prompt effective treatment. However, in

most malaria-endemic countries access to curative and diagnostic services is limited.

Early effective appropriate treatment was a key RBM strategy and based on the widespread recognition

that untreated Plasmodium. falciparum malaria contributed to both directly and indirectly to death,

particularly in the non-immune. According to Marsh (1999), other benefits of early treatment include

reduction of malaria associated with anaemia, reduction in debilitation and the days off work or school

leading to increased school attendance, productivity and hence economic growth (RBM, 2004).

Furthermore, as treatment removes the infected person from the reservoir of infection, it postulated that

early and effective treatment with Artemesinin-based combination therapy (ACTs) might also have an

impact on malaria transmission as has been shown in areas of unstable malaria.

The implementation of HBMM programme requires detailed preparation including a situation analysis,

setting objectives, in-depth planning, strategy development, effective advocacy and building

partnerships at all levels. Critical decisions was needed on such aspects as what and how to scale up,

which community cadres to be trained as providers, engaging communities, policy issues on medicines

and pre-packaging and financial access, cost and pricing, drug procurement and distribution, and

programme monitoring. These issues place heavy demands on resources, planning and management,


32/129

and require intensive support from the public health services, particularly from the peripheral health

facilities (Ansah, 2001).

2.2.4. Other Control Measures

The strategy broadly suggests de-emphasis on vector control and renewed emphasis on case

treatment, early diagnosis and treatment; prevention of deaths; promotion of personal protection

measures like the use of ITMs; epidemic forecasting, early detection and control; monitoring,

evaluation and operative research and integration of activity in Primary Health Centres were the

salient aspects of this strategy (WHO, 2004). In fact, early detection and treatment of the disease

itself was enough to control this epidemic in its early stages. By this, the parasite load in the

community would reduce, thereby reducing the transmission of the disease. Presumptive

treatment of all cases of fever is very important. Tests for malaria parasite were done in all cases

of fever, and presumptive treatment with first full dose of chloroquine should be administered

(Parsad, 2003).

According to Russell (1934), personal protection was another way to control malaria. Man

should be encouraged to protect himself against malaria. Personal protection measures include

protection against mosquito bites and chemoprophylaxis against malaria. People living in

endemic areas as well as travellers to such areas should be educated and encouraged to use

protective measures against mosquito bites. These included closing the doors and windows in the

evenings to prevent entry of mosquitoes into human dwellings, using mosquito repellent lotions,

creams, mats or coils and regular use of bed nets. Using bed nets was one of the safest methods

of preventing and controlling malaria. Now Insecticide Treated Bed nets were available and were


33/129


34/129

informal care costs (in terms of the violence, losses due to crime, example incarceration,

policing, legal, and costs to victims of crime). The economic cost again looked at lost

productivity or income associated with illness or death. This might expressed as the cost of lost

workdays or absenteeism from formal employment and the value of unpaid work done in the

home by both men and women.

In the case of death, the economic cost included the discounted future lifetime earnings of those

who die (Collette, 1994). Malaria had a greater impact on Africa's human resources than simple

lost earnings. Although difficult to express in dollar terms, another cost of malaria was the

human pain and suffering caused by the disease. Malaria also hampers children's schooling and

social development through both absenteeism and permanent neurological and other damage

associated with severe episodes of the disease.

2.3.1. Cost of Malaria

Malaria mortality and morbidity had been experimental to slow up economic enlargement by

dropping the aptitude and competence of a countrys labour force. This have revealed through

macroeconomic perspective. In Gallup and Sachs (2001) cross-country econometric assessment

of the effects of malaria on national income specified that countries with considerable level of

malaria grew 1.3% less per person per year for the period 1965 - 1990. Their studies too

established that, 10% decrease in malaria was linked with 0.3% higher growth in the economy.

In the books of Gallup and Sachs (2001) there was an indication that, a similar study exploited

the impact of macro policy variables on malaria morbidity across countries and the importance of

indirect effects of malaria on total factor productivity, McGuire (2000), found a negative
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35


35/129

association between higher malaria morbidity and GDP per capita growth rate. Most of the Sub-

Saharan African countries used in the study incurred an average annual growth reduction of

0.55%. Again, Sachs and Malaney (2002) have also experimented that areas where malaria

flourishes, the inhabitants are not able to accomplish their ultimate wants of life. The financial

cost of illness to the household was an exercise which was obtained through recalls hence this

doesnt create any debate or argument. However, this was not simple in terms of the direct costs

of a specific disease with reference to the health system. Some costs were combined by some

activities which make the assessment of the institutional cost of a specific disease difficult with

regards to the nature of the health system. The health system provides general treatment and

therefore malaria-related expenditures were often not separated from other health service costs in

budgeting and accounting systems.

Documenting the exact inputs required to treatment or prevention of a disease can be the best

approach to the estimation of the institutional cost but this could be complicated and also be

difficult. The above could contribute to the ideas of Drummond et al (1987). With reference to

Drummond et al (1987), the joint costs were calculated among the various services by

monitoring the total costs and allocating them using morbidity facts. According to Creese et al

(1994), for personnel costs was the fraction of time spent by staff dedicated to a disease of

interest was observed and measured for the proportional calculation of the cost to the disease.

The resources that were been spent straight or not directly by a variety of institutions like local

governments, Non-Governmental Organisations (NGOs) and communities might be included in

the financial cost.


36/129

An individual may stop work or work incompletely as a result of the weakness associated with

the disease on temporary bases during the period of the sickness. When it happens this way,

household production would be greatly be influence negatively. Sometimes, a member of the

household has to leave his or her duties to make available for the sick. Indirectly, cost was

incurred in terms of a turn down in output hence this showed a loss of productivity. This was not

an outof - pocket payment but the opportunity cost of both market and non-market productive

time lost to the household. Through the human capital approach, the indirect cost of illness was

approximated. The worth of lost productivity as a result of illness and premature mortality was

considered by the human capital approach. This was footed on the claim of "neo-classical"

market oriented economic ideologies. Within the opportunity cost framework, the human capital

approach is applied. This is the essential concept in market economics (McGuire,2000).

To McGuire (2000), there was an equation between the worth of time lost and the earnings

people could have earned if they were not ill. The human capital approach applied the forgone

wages to estimate lost productivity. The opportunity cost of time was evaluated as the marginal

cost of labour. In support of the above, Bradely (2004) gave a scenario that in subsistence

agriculture with easily availability of land, labour was by far the most important input variable to

production. Because of this, the marginal product of labour (MPL) approximated the marginal

cost of labour (MCL).

In a perfect market economy, the marginal product of labour was equal to the worker's earnings

per day on the particular job at which he/she was working. This was however not likely to be so

due to the imperfections in the market especially in the economies of developing countries. For
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35


37/129

this reason, various proxies were used to value the marginal product of labour. According to

Mills (2004) the methods that was used to appraise the lost productive time was varied and

include average agricultural wage, salaries, marginal productivity calculated from a Cobb-

Douglas production function, income per capita, legislated minimum wage among others.

2.3.2. Household Cost of Malaria

According to these researchers (Goodman et al, (2000), Akazili, (2002) and Hanson et al, (2004))

the economic burden of malaria was not high at the worldwide, but it was seen greatly in the

various household and this was the barrier to accessing health care as stated earlier. Lots of

studies on malaria management are throwing more light on the importance of wealth position on

malaria burden as well as access to treatment and prevention actions. In other studies, they value

and measured economic cost basis on output or income losses incurred in the household rather

than using a general indicator such as average wage rate. Loss of output and wages accounted for

the highest proportion of the economic cost of the patients as well as the households.

Relative to children, more young adults and middle-aged people had `malaria' which also caused

greater economic loss in these age groups. Women tended to care for patients rather than

substitute their labour to cover productive work lost due to illness. Comparing the methods used

by other researchers for valuing economic cost, demonstrating the significant impact that

methods of measurement and valuation could have on the estimation of economic cost, and

justify the recommendation for methodological research in this area (Lipsey, 1994).


38/129

2.3.3. Opportunity Cost of Malaria

The forgone alternative of lost fruitful labour time as result of illness compels costs burden on

household. During that time of illness, the ability to make enough income declines, hence

households find it difficult meeting the needs and expenses of medical resources. Time spent

seeking treatment by the children as well as their caregiver, the morbidity time during which the

children or caregiver stops or minimise their daily activities, and the cost of mortality in terms of

the number of year they would have spent forms of opportunity cost. As the opportunity costs

moves run the households it affect them economically too. Thus, there is economic implication

in the households as well as the nation as a whole (Chima et al., 2003). In Chima books, an

example was made in a study on schistosomiasis, the implications of the serious sequelae of

urinary schistosomiasis such as renal failures, bladder cancer, and infertility, can trigger

borrowing asset, sales or withdrawal of children from school, responses which have long term

income earning implications. This was to support the above statements.

Coping strategies was defined as a set of actions that aim to manage the costs of an event or

process that threatens the welfare of a number of the household members, this was revealed in

the books of Sauerborn et al (1996). The following were all forms of strategies to cope with the

costs of illness, making to do with savings, selling jewellery, borrowing monies from friends as

well as banks, selling unproductive assets, reducing investments, selling productive property

such as cattle, sheep, goat, farm crops such as cocoa, palm nuts, land and machinery (Sauerborn

et al., 1996). In Burkina Faso, Sauerborn et al (1995) indicated that, the opportunity costs of

seeking care was by far the largest proportion (73%) of total costs, and time lost by healthy

caregivers was equal to the time lost by the sick.


39/129

In measuring opportunity cost, countless studies focus their estimates on the amount of time lost

by the caregiver in the case of a child multiplied by number of days of work lost or spend in

treatment. Thinking through the ideas of Sauerborn et al (1995), and Asenso-Okyere and Dzator,

1997, there was a detailed specification of the wage rate method thus based on marginal rate of

labour productivity of measuring the time costs of illness. To them, cost was the sum of the

opportunity costs of wages forgone by individual as a result of illness, as well as the opportunity

cost of non-sick members of the household time spent on treating or attending to the sick

person. The researchers equated the opportunity cost of time with the marginal cost of labour.

2.3.4. Cost Drivers of Illness

According to Hadi (2003), there were various variables that affected cost of illness. Such of

these variables were employment opportunities, allocation of education, income, the current state

of medical technology and the features of the institutions through which medical services were

bought and sold. Cost evaluation was performed from the three major fundamentals. This

includes the consumer, provider as well as the societal perspective. Fees charge for visits to

doctors, drug and non-drug treatments,surgery, imaging techniques and inpatient stays in acute

carehospitals and rehabilitation clinics was considered as factors which influence cost of illness.

Once more, direct cost components might consist of the patients additional payments for

prescribedtreatments, as well as expenses that patientspay fully out of pocket (Hadi, 2003).


40/129


41/129

In addition, buying of bicycles, motor bikes, repairs incurred on vehicles, motor bikes, and

bicycles, boots. Others included raincoats, torch lights and tool kits (made up of a box, cups and

spoons, a torch light, napkins, stop watches, registers, treatment charts and blister packs of

artesunate-amodiaquine, referral and tally cards) for distributors were also factors which

pressurises the cost of the programme. Again, at home, factors of late reporting of cases, adult

wanting to take medicines when ill, mothers not completing medicines, and mothers refusing

referral for lack of money as well as food and period of recovery, influence cost of home- based

management. In budgetary, policy and theory formulation as well as service-planning decisions,

the above could serve as the basis.

2.4 Sustainability of Home-based management of malaria

Sustainability explained the ability to maintain, this was according to the Encarta Dictionary (2007).

The sustainability or otherwise of a programme such as home-based management of malaria depends

on its fundamentals or its apparatus. The HBMM uses community resources, volunteers and communal

support. Thus, it would be sustainable depending on its resources. However, McCombie (1996)

indicated that this might not be necessarily. It was important to note that, in Africa, where more than

70% of malaria episodes occur in rural areas and more than 50% in urban areas were self-treated, home

based management of malaria was likely to succeed and sustained.

The HBMM strategy could be sustained if it uses the existing community and health structures rather

than been implemented as a parallel programme. A brief review of the strategy shows that some

activities or items under the strategy might have sustainability problem. For instance, the upkeep of

volunteers; their kits, incentives, communal support and ownership remained unknown.


42/129

2.5. Theoretical basis for identification and measurement of cost of health care

Since the United Nations Millennium Summit in 2000, there had been little improvement though

much effort had been put into decreasing the mortality of children under five years. For instance

in 2007, WHO revealed that there was increase, claiming more than a million deaths annually as

a result of malaria related issues. Wide-scale implementation demonstrates that cost-effective

measures of health interventions were needed. This have supported by Ungar, (2007) when he

grieved that even though approximately 99% of neonatal deaths take place in developing

countries, mostly in homes and communities, not much large scale implementation of evidence

based intervention for neonatal health and survival had been reported.

In the economic world, resources were scarce as compared to individuals, firms and nations

needs. As a result of this, there was a need for prioritization and best possible use of resources as

well as to ensure efficiency in the provision of goods and services. This would make policy vital.

To these researchers, (Drummond et al., 2006; Kamrul and Gerdtha, 2006; Hansen, 2005),

economic evaluations have established of efficacious interventions in which costs and

consequences of alternatives are compared was one of the best ways of achieving this. Thus, an

economic evaluation offers a systematic way of comparing the costs and consequences of

interventions to improve the allocation of resources, and enhances the understanding of the

factors which influence consumers and suppliers behaviour, as well as the coverage of effective

interventions. This was explained by Hanson et al (2004). It was established by Mcguire (2000),

Garber and Phelps (1997), Garber (2000) that the welfare economic theory provides the

background for costing. In this theory, most favourable use of resources was measured by

ranking goods and services, given states of economies, and guided by defined criteria.


43/129

Sick leave and early retirement were all involve in economic costs of which there was a

productivity loss.

The human capital approach (HCA) and the friction cost approach (FCA) could be used in the

assessment of productivity losses. The FCA was used in addition to the internationally more

common HCA to generate transparent. This was easily compared to economic cost data in

accordance with the German guidelines for socioeconomic evaluation as stated in Collettes

article in 1994. The use of a friction period takes into account that no economy achieves full

employment. Therefore, productivity losses were counted in the period only until the

productivity of the patient is replaced by that of an initial person without a job. The friction

period of 58 days is the mean time before a vacancy reported to the employment office was

filled.

The frictionperiod was applied only to patients on permanent retirementfor health reasons, not

to those on sick leave. The sick leave days were the cumulated numbers of absence days due to

the respective disease. These productivitylosses were then appraised by assuming that a day of

lost productivity costs society as much as the average daily German wage estimated by

population data. In calculating the average daily wage in Germany, the gross income from

dependent work was divided by the number of people employed in dependent jobs for 2002

divided by365 days, resulting in 95 a day. Periods of income loss were calculated for 7 days per

week. The above scenario was made in Collettes article in 1994.


44/129

In addition,McGuire (2000), indicated that, the human capital approach had been used for many

years, predominantly in the estimation of the total cost of illness associated with a particular

disease. The HCA is an approach to the value of a health programme based on a model of health

investment. For instance, an individual was seen as investing in future health by using health

care resources and at least part of the return on that investment in future healthy time was the

increased productive ability of the individual. This measured by the value of future earnings. The

HCA has three critical issues. The first was if the worth of time is a right measure of the outcome

of a health programme. The second was if the universal worth of time was the same as the worth

of healthy time. Lastly, if the market wage was a good substitute for money worth of time for

those in and out of the paid works forces. Again, there is a question as to whether there was such

a thing as the value of time as well as the appropriate value of healthy time if the practical

problems in estimating the shadow price of time were left (McGuire , 2000).

Furthermore, healthcare costs were measured at macro and micro levels. In most costs

measurement, identification of the various resources employed by the intervention thus the

identification stage and this might be the activity-based thus tracing costs to the various activities

in producing health care or through the traditional approach thus based on production level. In

this case, the volume of health care was measured and assessed to reflect the actual resource used

(Asenso-Okyere, 1997; Hanson et al., 2004; Hansen 2005).

2.5. Knowledge gaps

From the discussions, it was evident that not much had been done in the area of sustainability of

HBMM particularly, cost drivers, household cost, opportunity cost, and CMDs ability to
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8K-447N1RD-1&_user=6447644&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000034378&_version=1&_urlVersion=0&_userid=6447644&md5=9d14f0810c0db517101aad56512f3c9f#bbib35#bbib35


45/129

prescribe medicine. However, these are critical for the implementation of home-based

management of malaria. Hence, these knowledge gaps informed the study.


46/129

CHAPTER THREE

METHODOLOGY

3.0. Introduction

This chapter provides a description of the methods which were employed in the study. It

described the study type and design, study population, sampling data collection and analysis

among others.

3.1. Study Type

The study was part of on-going HBMM intervention in the Ejisu-Juaben Municipality. It was a

cross-sectional in design, which involved the use of quantitative and qualitative surveys to study

the cost and sustainability of home based management of malaria in the municipality. The study

involved caregivers, health staff and community-based medicine distributors (CMDs).

3.2. Study Site

Ejisu-Juaben Municipality considered being one of the 26 political Municipalities of Ashanti

Region. Its 2007 population was estimated at 162,256, with a growth rate of 3.4%. The

population aged below one year was 4% and pre-school children for 20% of the population.

Malaria was the leading cause of outpatient visits and accounts for 44.3% of OPD visits. Malaria

was hyper endemic (Browne et al., 2000), thus malaria is widely spread in the municipality. It

has 26 health facilities including 3 hospitals. It has 90 communities with 39 of them having

functional village health committees.


47/129

There were about 100 community-based medicine distributors (CMDs) who had been trained in

home based management of malaria (HBMM) using pre-packed artesunate-amodiaquine (in the

recent HBMM study), acute respiratory infections (ARI) and diarrhoea case management using

ORS. The Municipality has patient-doctor ratio of 31344:1 and patient- nurse ratio of 4124:1.

The current malaria interventions were case management, home management of malaria,

distribution of insecticides treated nets (ITNs), and intermittent preventive treatment in

pregnancy (IPTp). The Municipality capital, Ejisu is 20 km from Kumasi, the regional capital. It

was a predominantly rural Municipality, with the main of occupation of the people being

subsistence farming. A few farmers engaged in commercial farming, mainly cocoa and oil palm.

The climate is tropical; temperature variation is 20oC - 36oC with monthly rainfall varying from

2.0 mm in February to 400 mm in July. It has 2 rainy seasons; a major one extending from April

to August and a minor one from October to November. The local economy was based on cash

crops like cocoa, coffee and oil palm, although subsistence farming is the main occupation.

Small-scale mining, logging and saw-milling were also important commercial activities.

Weaving was also an important occupation in one of the communities Bonwire, the historic

centre for Kente weaving in the country.

Generally, incomes turn to be unstable, employment was often seasonal and majority of the

people lack sufficient money to provide for non basic items such as bed nets, sprays. The

Municipality health system was based on a 3-tier Primary Health Care. These were the

Municipality, the sub-Municipality, and the community. The activities at the Municipality level

were headed by the MHMT while the Sub-Municipality Health Team (SDHT) oversees health


48/129

activities in the sub-Municipality. The Village Health Committee (VHC) managed the

community level. There were also community volunteers, who assisted in outreach clinics,

national immunization days, community surveillance and community health education (Source:

Population Reference Bureau/ Data Finder - Ghana, 2004).

3.3. Study Population

The study was done within a total population of about 162,256. The study population consisted

of caregivers of children less than five years, health providers and CMDs. They were consented

to be part after reading the informed consent and or the study protocols was interpreted to them

in a language best understood by them and in the presence of a witness (es).

3.4. Sampling

3.4.1. Sampl ing Size

The main outcome of the study was the proportion of the caregivers whose children presented

with fever and were taken to the community health workers otherwise known as community

medicine distributors (CMDs) for uncomplicated malaria treatment. Based on an unknown

parameter, a prevalence figure of 60% was used to calculate the sample size. With a power of

95% confidence level, 5% significance level, the required error of 0.002025, design effect of 1,

non respondents of 10%, the sample size was 455 rounded up to 500. This was estimated for the

survey using the, n=Z2p (1-p) d/e2, where Z= (1.96), p=proportion of event of interest, and e=

required error, d=design effect.


49/129

3.4.2. Selecti on of Respondents

Respondents from the households were randomly sampled; eligible households were sampled in

5 clusters (based on the sub-Municipalitys definition of a sub-municipality) of 100 households

each. For the purpose of this study, a household was defined as a group of people who eat from a

common bowl (GSS, 2004). The four sub-municipalities thus; Ejisu, Juaben,Besease and

Bonwire, 100 health consumers were interviewed in each sub-municipality. The essence of this

strategy was to avoid redundancy, improve distribution of sample and minimize design effect. In

addition, the CMDs and the health providers were selected through purposive sampling.

3.4.3. Study Variables

The variables in the study included cost drivers, household cost, sustainable, ability of CMDs to

prescribe, and opportunity costs of CMDs and health providers in HBMM. The variables are

shown in the Table 3.1, below.

Table 3.1 Logical framework/ indicators

Objective Dependent

variable

Independent

variables

Data collection

tools and

sources

of data

Outcome

measures/

indicators

Statistical

analysis

i. To identify cost drivers

in integrated package and

suggest the least cost in

accessing the

whole level of diagnosing

Cost

drivers

Disease

condition

(uncomplicat

ed

d

Questionnaire,

interview guide;

parents, s

service

providers,

% of the cost

drivers in

integrated

package and

least cost in

Descriptive;

tables,

, cros

tabulations,

means,


50/129

and treatment of malaria & severity),

drugs, RDTs,

incentives for

CMDs,

prompt/

delayed

action, etc

health

documents and

literature

accessing the

whole level of

diagnosing

and

treatment of

malaria.

Adolescents;

mean cost;

total cost etc

standard

deviations, etc

Objective Dependent

variable

Independent

variables

Data collection

tools and

sources

of data

Outcome

measures/

indicators

Statistical

analysis

ii To measure the

household

cost per febrile episode

in home management

of malaria

Household

cost

Transport,

care, drugs,

accompanied

relative,

distance, etc

Questionnaire,

parents, service

providers,

health

documents and

literature

% household

cost per

febrile

episode

in

HBMM,

mean cost;

total cost etc

Descriptive;

tables

cross

tabulations,

means,

standard

deviation, etc


51/129

iii. To assess whether

HBMM is sustainable.

sustainable Payment of

drugs,

ownership,

communal

support,

supply

of drugs,

training,

supervision.

Questionnaires

Parents,

CDDs

Providers

% of

community

and

leaders who

showed;

%of

supervisors

to a group of

CMDs, and

%of drug

supply and

training for

CMDs.

Descriptive;

Tables,

cross

tabulations,

means, standard

deviation, etc

Objective Dependent

variable

Independent

variables

Data collection

tools and

sources

of data

Outcome

measures/

indicators

Statistical

analysis


52/129

iv. O4. To assess the

ability

of CDDs to prescribe

medicines in HBMM

Ability to

CMDs

to prescribe

Types of

medicines,

level of

knowledge

and skills,

competency

Questionnaires,

records of

CMDs

% of CMDs

competence,

knowledge

and

skills to

prescribe

medicines in

HBM

Descriptive;

tables

cross

tabulations,

means,

standard

deviation, etc

v. To estimate the

opportunity costs of

CMDs and

health providers

in HBMM

Opportunit

y

costs of

CMDs and

health

providers

in

HBMM

Time of

transport,

care,

lost days

Questionnaires,

CMDs

Caregivers

%Opportunity

costs of

CMDs and

health

providers in

HBMM

Descriptive;

tables

cross

tabulations,

means,

standard

deviation, etc

3.5. Data Collection

Data on the cost and sustainability of HBMM were collected as per objectives (1-5) as follows:

Information on objective one (O1), identification of cost drivers, information were collected

from caregivers and health providers including CMDs. These were done using structured


53/129

questionnaires. For household cost, (O2), the cost of febrile episode receiving prompt treatment

from CMDs, household cost of transport to and from source of care, household time costs of

seeking care were collected. Structured questionnaires were employed to collect these data.

Costing of HBMM was done in three main stages:

Identification stage:

This stage involved grouping household costs into cost of care; drugs, food, transport and time.

However, cost of food and transport were valued at zero cost since caregivers never incurred

such costs.

Quantification stage:

At this stage, monetary values were assigned to the various items using 2008 prevailing market

prices to value.

Valuation stage:

The opportunity costs were estimated by multiplying the time spent in hours by wage rate per

hour. This was done as follows: first all caregivers and CMDs were assumed to be labourers

receiving a minimum wage rate of 1.92 for eight working hours as per the national minimum

wage rate of Ghana. It means that the wage per hour was estimated as GHC 1.92/8 hours which

amounted to GHC 0.24. This is consistent with similar method employed by Asenso-Okyere and

Dzator (1997).

Data pertaining to objective three (O3), assessing whether HBMM was sustainable; information

was collected from caregivers and the project office. These were collected using questionnaires.

To assess the ability of CMDs to prescribe medicines in HBMM was collected on participants.

These were done using questionnaires, forms and interview guides. Information on objective five


54/129

(5), estimating the opportunity costs of CMDs and health providers in HBMM was collected

using questionnaires, forms and interview guides.

3.6. Data Handling and Analysis

The data were analysed using descriptive statistics, summarised and displayed in tables.

Frequencies were further analysed using chi-square test to test for associations between some

selected variables. For continuous variables, the estimates were for difference in means with

95% confidence levels. Data entry and analysis was done in SPSS.

3.7. Sensitivity Analysis

Sensitivity analysis was an important feature of economic evaluations in which study results

were sensitive to the values taken by key parameters. (Drummond et al, 2004) Sensitivity shows

how the variation in the output of a mathematical model was apportioned, qualitatively or

quantitatively, to different sources of variation in the input of a mode (Saltell et al, 2008).

Sensitivity analysis was done using discount rates of 3% as a minimum and 5% for the upper

ceiling with an inflation rate of +/-20.06% as in July, 2009. This analysis indicated the possible

change in cost as a result of change in discount rate. It thus measures the effects of economic

conditions on cost of treatment for malaria.

3.8. Ethical Consideration

Community entry protocols were vigorously adhered to. Verbal informed consent for the study

was obtained from community leader, caregivers, CMDs and health staff. All information

collected remained confidentia

Documents

SUSTAINABILITY AND COST OF HOME-BASED MANAGEMENT OF MALARIA IN CHILDREN UNDER FIVE YEARS IN EJISU-JUABEN MUNICIPALITYGHANA-MSC Thesis-KNUST