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Discussion:prevention

In Uganda, non-users of nets (likely to be poorer) weremore likely to use traditional medicine for malaria prevention and treatment ofepisodes, and were less likely to undergo blood slide examination than netusers (Nuwaha, 2001) Inrealtion /ses and malariaEducation not a predictor of prevention:The level of education in an urban Kenyan setting was an unimportant predictor ofwhether the household used multiple methods of protection or whether everyone inthe house slept under a net determinants o f mosquito avoidance) Knowledge,education and prevention:discussion:There is evidence to suggest that education levels and explicit knowledge oftransmission may not be prerequisites to the uptke of mosquitoe or malaria preventionactivity, determinants o f mosquito avoidance)

*****Despite recognizing mosquito as the sourse of malaria , very few individuals reportedusing any consistent means of malaria prevention. While the majority of individualdid report using a bed net very few nets had been impregnated(care seeking and cost)more attention is needed from the international health community emphasizing theneed to get bed nets and other protective methods subsidized by local and nationalgovernments or by other dondors and NGOs. determinants o f mosquito avoidance)Social marketing and community programmes increased use:

The higher bed use in malindi as compared to the other city and higher multiple bednet use , this may be a consequence of increased social marketing of bed nets andintense community based programme activity in the area. determinants o f mosquito

avoidance)Malaria prevention tools do not always remain out of reach to all of the pooresthouseholds. In rural Tanzania, data have suggested that a mbination of socialmarketing with active private sector participation was able to achieve net ownershipin two-thirds of the poorest households. The ratio of net ownership in the poor to least

poor households (equity ratio) was 0.54-0.69 at baseline before 3 years of socialmarketing and 0.60-0.73 after 3 years of activity. It is important to note, though, thatthe study took place in a small area, inviting the possibility that the population studiedwas relatively homogeneous, and that net treatment and re-treatment rates, among the

poor and least poor, remained quite low (Abdulla et al., 2001). A similar picture wasseen in Tanzania for the larger SMITN social marketing project, with the equity ratio

improving over time as coverage increased(realatioan SES and malaria))

Data on income

Data of income:Measuring SES in developing countries is challenging. The generallyaccepted gold standard approach to estimating household welfare is to usedata on household income or expenditure. (realatioan SES and malaria))difficulyty in obtaining cost data:

people may be unwilling to disclose financial data and whatthey do disclose may be biased. (realatioan SES and malaria))


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Cost of facility higher than self treatment:

In urban survey in Cameroon self tt with antimalarials purchased in shops wasjudeged the least expensive option when fees and transportation costa were includedttt at a dispebsary was 2.6times higer than self ttt and hospital ttt, was 10 times giherthan self ttt>(rev seeking

No difference in incidence there is difference in effects by SES:Although malaria incidence by socio-economic group withincountries does not show any clear poor-rich gradient the evidenceabout the economic consequences of thehigh income group and use contradicting results:

The effect of the income and wealth on health behaviour is not clear across thelitriture . studies in Malaysia and phillipines found no impact of income on thedemand for health care. The result here indicates that the households in the uppersocial class may have a greater chance of having or reporting a malaria patient()benin)Poverty does not prevent use:

there is no evidence of gross lack of utilization of health care by people in lowerincome households . the lowest income quintile was in fact more likely to seek tttthough not from shops and public services not private facilities(inequality in thailand)

material: use of mean vs median:Related to the above point, cost of illness studies face difficulties in how the datashould be presented, in particular whether measures of central tendency best reflect orrepresent the cost burdens facing the study population. Illness and illness costs areusually distributed very unevenly across households, with a minority incurring veryhigh costs, so measures of central tendency conceal wide variations in cost burdens.

The use of mean cost figures, in particular, often exaggerates the cost burdens facedby most households because a minority of high values pull the mean above themedian. Median figures may therefore reflect more accurately the costs facing themajority of households, but in many studies only the mean is presented. ec burden onhouseholds)

skewed ness*It is important to note that all cost variables show a highly skewed distribution. Thisis due to the fact that (i) illness clusters in a relatively small number of households.Ofthose, only a minority incurs any costs at all.Households must be helped to channel their expenditure more rationally (a broaderview of malaria)

Seeking care:Percent using of formal sector:Frequency of use of the formal health sector was higher thanexpected; 415 of 1014 children (41%, 3745) who had been sick inthe previous 2 weeks had been taken to an appropriate provider ofcare.(inequality among the poor)

discouraging of self ttt:

As part of a strategy to control cost, public education must be intensified to

discourage selfmedication which leads to misuse of antimalara drugs and therebypromote resistance of the malaria parasite to drugs>. Also public education regarding


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that early signs of the disease are reported to hhealth care providers before it becomessevere and therefore more expensive to manage.No traditional use for malaria ttt:

A number of studies suggest that the majority of people recognize the value ofmodern drugs in the treatment of malaria.(rev seeking)

Percent for self ttt, and facility use:(46% or 57:123), with use of clinic medicine at home the secondmost common choice of treatment (29%). Seventeen percent(21:123) would go to the clinic first, while only 5% said they wouldgo the hospital first (malaria 16)RDF decrease cost and increase use:

Ministry of Health has offered generic drugs through co-managed communityrevolving drug funds at prices below those of private pharmacies. This policy,inspired by experience elsewhere in sub-Saharan Africa (for a review see [33, has

been shown to reduce the total financial cost of a health care visit and to increasehealth care utilization [15]. . (variation in burkina)Use of health centers:Public medical centres were the most commonly used treatmentsource.Cuz for using private facility:The reasons for this tendency include the lack of services afterworking hours and long waiting times at public medical centres aswell as better attention at the private clinics of public doctors.Infact, 22% of patient visits were made to the private clinics ofpublic doctors. .(matale)People pay more for high quality care:

people are prepared to pay higher for the high quality health acre(ghana)availability of facilities within the community decrease transport cost:

the availability of drug stores in the communities has therefore cutdown on thedistance traveled to purchased drugs. The little time spent intravelling suggest that

people do not generally travelfar from their communities to purchase drugs.

Percent of self ttt dis:Self-treatment was common among all patients, with 97% involvedin it before or after formal treat-ment. .(matale)Percent using public and private facilities:demonstrates that 46% of patients sought care only from the public

facilities as outpatients, and that 25% sought care from privatesources only. Only 11% of patients used a combination of public andprivate services..(matale)private sector should be included in policies/::

The study has also shown the importance of private sector provisionfor treating malaria at the household level. These two facts alonesuggest that both donors and policy makers need to pay specialattention to private as well as pub-lic providers of services whenformulating control strategies and measures. It also highlights theimportance of consider-ing a variety of viewpoints when conductingeconomic evalu-ations of health services. To exclude the patients


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viewpoint may encourage shifting of costs onto a population alreadybearing significant financial burdens from the disease. .(matale)Improve quality in public facility to reduce costs:

Improve quality of care at public facilities, focusing on reducing waiting times andbetter inter-personal quality of care, in order to attract patients from the private to the

public sector and reduce direct costs. Building community and patient trust in lowerlevel public facilities is a key challenge. ec burden on householdsLow self ttt and high compliance due to high access:

The relatevly low level of self tt and high compliance can be explained by the wideaccessibility of public helth services in Guyana an(care seeking and cost)Cuz of delay diss:

Individuals did not thik they have malariaMost stdies found distance to health services and finacial costs to be the reasons fordelay(care seeking and cost)Compliance, percent of dis:

Rate of completion of antimalarias ttt regimen is known to be poor through out the

malaria endemic countries however there are reports with high compliance rates 70%,the limiting factor is that compliance had been assessed through subjective meansnevertheless noncompliance is widely acnowlegede problem(care seeking and cost)Causes of Non compliance didd:

Non compliance with anm. Has been found to to be related to 4 factors: adverseaffects, ealy resolution of symptoms, saving of drugs for future use and inadequatedosing instructions(care seeking and cost)

Low self ttt due to free and close by facilities:

Discussion low self treatment rates are due to free servise at public health facilitiesand facilities are close to the homes of most affected people. (care seeking and cost)No Use of public facilities which are available:

Free or very low cost health services were available to the survey populations, whichcalls into question who benifis most from public subsidies or health, what are theimplications for public sector intervention when the private sector expenditures onhealth are greater than those f the public sector? .(economic and demographicresearch) Percent of self ttt:

However studies in Guatemala Ethiopia and Kenya found that 60% of individuals

selftreated and did not seek medical attention(care seeking and costdirect cost:

SESIncidence , no difference by SES:Malaria, unlike diseases resulting from poverty, does not discriminate between richand poor victims.

Cuz of no difference of incidence by SES:The lack of consistent socio-economic differentials in malaria incidence is notnecessarily counterintuitive. Given the epidemiology of malaria transmission,particularly its environmental aspects, it should not be surprising that variablessuch as housing type had an impact on incidence, given the importance ofhousing in limiting vector/human contact. That most of the other variablesyielded, at best, conflicting data on their impact on malaria incidence could bea testament to the high degree of exposure to the mosquito vector regardless

of SES, particularly in areas and periods of high transmission. Vulnerability tothe consequences of infection, on the other hand, has much less to do with


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progressive fee scedukes and subsided services for OOP:such as progressive fee schedules, highly subsidised or freehospital services, and the provision of certain health services to thepoor. (household catastrophic expend)

heath insurance for OOP and access:National health systems can be financed in ways that protecthouseholds from catastrophic spending and provide access toneeded services. The most straightforward approach is to reduceout-of-pocket spending through the development of social insuranceor funding through general taxes. (household catastrophic expend)

User fees worse than HI:Both reasons are important for arguing that health systems arebetter financed through prepayment mechanisms such as socialinsurance and general taxation than through user-fees. . (householdcatastrophic expend)

High income will not reduce OOP as HI:The problem of catastrophic health payments will not simply goaway with rising income; rather, the complex process of developingsocial institutions to effectively pool financial risk must be placed onthe agenda. (household catastrophic expend)

High coverage, poverty, and no HI increase OOP:Out-of-pocket payments are not, however, the only importantdeterminant of catastrophic payments. The triad of poverty, health-service access and use, and the failure of social mechanisms to poolfinancial risks account for most of the variation across countries.Catastrophic payments are the biggest issue when all three of thesefactors are strong. Therefore, we would expect to see high rates ofcatastrophic spending in countries with high rates of poverty,groups excluded from financial risk protection mechanisms such associal insurance, and moderate to high levels of health-care accessand use. . (household catastrophic expend)

HI among self-employed:The problems of insurance lie in unifyingthe current schemes, and especially inensuring highcoverage amongst the self-employed and subsistencefarmers.HI in local organization is better(community based ):

Neither the state nor the market is effective in providing healthinsurance to low-income people in rural and informal sectors. Thefor- mal providers are often at an informational disadvantage andface high transaction costs. On both these counts health insuranceschemes rooted in local organizations potentially score better thanalternate health insurance arrangements.


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the emergence of many community-based health insuranceschemes (CBHI)in different regions of developing countries,particularly in sub-Saharan The decentralization process unleashedin these countries to empower lower layers of government and thelocal community further fueled their emergence The success of

community-based micro- credit schemes may have also contributedto the emergence of community-based health initiatives designedto improve the access through risk and resource sharing (HI andaccess)CBHI schemes are a potential instrument of protection from theimpoverishing effects of health expenditures for low-incomepopulations. It is argued that CBHI schemes are effective in reachinga large number of poor people who would otherwise have no.financial protection against the cost of illness

Cost of private sector more than public facilities:s

Deindividuals treated ta private clinics paid significantly more for ttt than those tttedat public health facilities (care seeking and cost)Start:. .(matale)Percent of montly income

Cost of transport and ttt reprsent 10-20% of aveage monthly income(care seeking

Cost per pt, food, travel private vs public:and cost)cost / patient = 75 / 48 $ food = 28 ttt= 23 travel cost = 9 .higest cost for those attending purely private clinic 91/48

per pt, private vs publicThis tablealso shows that, for the same patients, the cost ofreceiving treatment was Rs. 37 (SD 112) per patient and the cost ofcomplementary goods/services (CC) was Rs. 38 (SD 40). Patientswho had received treatment only from private west-ern sources hadthe highest average cost of treatment (Rs. 86) followed by thecombination of public inpatient or outpatient care with privatewestern treatment (Rs. 73). .(matale)

Transport cost:Transport was another siziable expense for the population the mean cost of

transport was $ 7.22(care seeking and cost)availability of facilities within the community decrease transport cost:

the availability of drug stores in the communities has therefore cutdown on thedistance traveled to purchased drugs. The little time spent intravelling suggest that

people do not generally travelfar from their communities to purchase drugs.

cost of health facility and drug ranking first:

As regards policies aiming to reduce thefinancial costs of illness, the current studyhas shown that professional health services account for the largest share of

households' expenditures for care, with drug expenditures ranking first. (variation inburkina)


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Cost per pt per episode:

On average the total treatment costs per patient per episode was 1.81$.(ghana)

Facility costs rank first:

Facility costs formed a major component of hosehold expenditre on treatment ofmalaria 49% of total costs(ghana)

Malaria expenditure per households:Average malaria expenditure: average malaria expenditure was $ 1.84 per household

per month (nigeriaDrug costs:

Considering the components of costs reported the cost of drugs comprise a significantproportion of total cost of treating fever . 64.8% of total ttt costs(ghana)Lab costs:

0.86$ (ghana)transport cost:

0.25$ (ghana)High drug costs will increase more:

The cost of drug are expected to rise in the future as p. falciparum chloroquineresistance increases requiring more potent and therefore more expensive drugs thanchloroquine(ghana)

Variations in cost due to care sourse:The variations in average cost are a function of the source of care inthat there were substantial differences in travel cost to private clin-ics located far away from the patients residence as well as in lengthof stay as inpatients. .(matale)

Even if the cost is not high the high prevalence increasedthe cost:The problem of the direct cost is not so much that the unit costs arehigh, but rather that prevelance is very high and incomes are verylow( malaria in new colonization project brazil):target poor people:

Such high cost burdens for the poor are likely to trigger asset or borrowing strategies,and a recent review of malaria and poverty has argued that malaria prevention and

treatment programmes need to have more of an equity focus and bettertargeted to the poor (Worrall et al., 2002). ec burden on households)

Subsidies for the poor:

"seasonal cross-subsidies" into existing price sched-ules of health services. Thiswould mean charging lower prices for services and drugs in the rainy season andhigher prices in the dry seasons, as suggested by

Fabricant [16]. (variation in burkina

Policy: expenditure in developing countries:

To illustrate ,public expenditures on health in most developing countries can be aslittle as $ 1 per person per year. .(economic and demographic research)


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Direct cost:/Start:fever .Using a recall period of one month data on 888cases were obtained usig a structured

questionnaire.

Recommendations:Improving dosing pattern requires education of patients and caretakers**results :ther is consistent gradient from from poor to rich

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