Cost Effectiveness of Seasonal Intermittent Preventive Treatment Using Amodiaquine & Artesunate or Sulphadoxine-Pyrimethamine in Ghanaian Children
et al. (2010) Cost Effectiveness of Seasonal Intermittent Preventive Treatment Using
Amodiaquine & Artesunate or Sulphadoxine-Pyrimethamine in Ghanaian Children. PLoS ONE 5(8): e12223. doi:10.1371/journal.pone.0012223
Cost Effectiveness of Seasonal Intermittent Preventive Treatment Using Amodiaquine & Artesunate or Sulphadoxine-Pyrimethamine in Ghanaian Children
Lesong Conteh 0
Edith Patouillard 0
Margaret Kweku 0
Rosa Legood 0
Brian Greenwood 0
Daniel Chandramohan 0
Pieter H. M. van Baal, Erasmus University Rotterdam, Netherlands
0 1 London School of Hygiene and Tropical Medicine , London , United Kingdom , 2 Imperial College London , London , United Kingdom , 3 Ghana Health Service, University of Ghana , Legon, Accra , Ghana
Background: Intermittent preventive treatment for malaria in children (IPTc) involves the administration of a full course of an anti-malarial treatment to children under 5 years old at specified time points regardless of whether or not they are known to be infected, in areas where malaria transmission is seasonal. It is important to determine the costs associated with IPTc delivery via community based volunteers and also the potential savings to health care providers and caretakers due to malaria episodes averted as a consequence of IPTc. Methods: Two thousand four hundred and fifty-one children aged 3-59 months were randomly allocated to four groups to receive: three days of artesunate plus amodiaquine (AS+AQ) monthly, three days of AS+AQ bimonthly, one dose of sulphadoxine-pyrimethamine (SP) bi-monthly or placebo. This paper focuses on incremental cost effectiveness ratios (ICERs) of the three IPTc drug regimens as delivered by community based volunteers (CBV) in Hohoe, Ghana compared to current practice, i.e. case management in the absence of IPTc. Financial and economic costs from the publicly funded health system perspective are presented. Treatment costs borne by patients and their caretakers are also estimated to present societal costs. The costs and effects of IPTc during the intervention period were considered with and without a one year follow up. Probabilistic sensitivity analysis was undertaken to account for uncertainty. Results: Economic costs per child receiving at least the first dose of each course of IPTc show SP bimonthly, at US$8.19, is the cheapest to deliver, followed by AS+AQ bimonthly at US$10.67 and then by AS+AQ monthly at US$14.79. Training, drug delivery and supervision accounted for approximately 20-30% each of total unit costs. During the intervention period AS & AQ monthly was the most cost effective IPTc drug regimen at US$67.77 (61.71-74.75, CI 95%) per malaria case averted based on intervention costs only, US$64.93 (58.92-71.92, CI 95%) per malaria case averted once the provider cost savings are included and US$61.00 (54.98, 67.99, CI 95%) when direct household cost savings are also taken into account. SP bimonthly was US$105.35 (75.01-157.31, CI 95%) and AS & AQ bimonthly US$211.80 (127.05-399.14, CI 95%) per malaria case averted based on intervention costs only. The incidence of malaria in the post intervention period was higher in children who were ,1 year old when they received AS+AQ monthly compared to the placebo group leading to higher cost effectiveness ratios when one year follow up is included. The cost per child enrolled fell considerably when modelled to district level as compared to those encountered under trial conditions. Conclusions: We demonstrate how cost-effective IPTc is using three different drug regimens and the possibilities for reducing costs further if the intervention was to be scaled up to the district level. The need for effective training, drug delivery channels and supervision to support a strong network of community based volunteers is emphasised.
Funding: The overall effectiveness study had ClinicalTrials.gov Identifier: NCT00119132. This work was funded by the Gates Malaria Partnership. The funders had
no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
It is estimated that 300500 million malaria episodes are
recorded each year, 90% of which occur in sub Saharan Africa,
causing approximately 800,000 deaths [1,2]. In addition to its
impact on the health of individuals, malaria places considerable
costs on households , communities and nations [7,8]. In
Ghana, the setting of this study, malaria is the leading cause of
morbidity, accounting for 4060% of outpatient visits and it is the
leading cause of mortality in children under five.
Intermittent preventive treatment for malaria in children (IPTc)
is a promising new approach to malaria control in areas where
malaria transmission is seasonal. IPTc involves the
administration of a full course of an anti-malarial treatment to children at
specified time points regardless of whether or not they are known
to be infected. Studies of IPTc conducted in Senegal and Mali
have shown that IPTc with sulphadoxine-pyrimethamine (SP) plus
artesunate (AS), SP plus three daily doses of amodiaquine (AQ) or
SP alone is an efficacious and safe intervention for reducing the
burden of malaria in children in high transmission areas with short
transmission periods. A recent study in Senegal suggests
that seasonal IPTc with SP plus piperaquine is highly effective and
well tolerated.To date IPTc has been shown to be efficacious
in reducing the incidence of malaria in areas with a short malaria
transmission season. The purpose of this study in Hohoe, Ghana
was to investigate the ability of IPTc to reduce the burden of
malaria in an area with a more prolonged transmission season.
In addition to showing the efficacy and effectiveness of IPTc, it
is important to determine the costs associated with IPTc in terms
of the total expenditure needed to provide IPTc and also the
potential savings to providers and caretakers achieved by reducing
the number of children who present at health facilities for inpatient
or outpatient care.
The findings in this paper are based on a randomised, placebo
controlled trial designed to evaluate the effectiveness of IPTc in
reducing anaemia and malaria in an area with up to 6 months of
transmission in Ghana. Two thousand four hundred and fifty-one
children aged 359 months were randomly allocated to four
groups to receive: three treatments with artesunate plus
amodiaquine (AS+AQ) monthly, three with AS+AQ bimonthly, one dose
of SP given bi-monthly or placebo. Compared to placebo, trial
results showed that monthly AS+AQ reduced the incidence of
malaria by 69% (95% CI: 63%, 74%) and anaemia by 45% (95%
CI: 25%,60%), bimonthly AS+AQ reduced the incidence of
malaria by 17% (95% CI: 6%, 27%) and anaemia by 32% (95%
CI: 7%, 50%) and bimonthly SP reduced the incidence of malaria
by 24% (95% CI: 14%,33%) and anaemia by 30% (95% CI: 6%,
49%). This paper focuses on incremental cost effectiveness
ratios (ICERs) of the three IPTc drug regimens as delivered by
community based volunteers (CBV) in Hohoe, Ghana compared
to current practice, i.e. case management in the absence of IPTc.
It is the first cost effectiveness analysis of IPTc to our knowledge.
The cost analysis is from the perspective of the publicly funded
health system and includes both financial and economic costs.
Treatment costs borne by patients and their caretakers are also
estimated to present societal costs.
The study was approved by ethical committees of the Ghana
Health Service/Ministry of Health (GHS/MOH) and the London
School of Hygiene & Tropical Medicine. After obtaining written,
informed consent, data on malaria treatment costs were collected
from the families of children involved in the study. Verbal consent
was sought from the health care professionals before they were asked,
or observed, in an attempt to assess the resource use and associated
costs of treating children with malaria. Verbal consent was
considered sufficient for health care workers as the socio economic
analysis came at the end of the wider efficacy study and thus facility
staff had a history of working with those in the study and were
already sensitized to the aims and objectives of the cost effectiveness
sub study. The ethics committees in Ghana and London were made
aware of the use of both verbal and written consent.
Study Area and Population
This study was carried out in Hohoe district, Ghana. A full
description of the study area has been published elsewhere .
The transmission of malaria in the area is intense with two
seasonal peaks. The major wet season lasts from April to July and
the minor one from September to November. The entomological
inoculation rate during the study period was approximately 65
infective bites per person per year (unpublished data). The fist line
treatment drug in Ghana has been amodiaquine plus artesunate
The study was a randomized, placebo-controlled trial of IPTc
conducted in children aged 359 months who resided in the study
district. The trial took place during the six months of the high
malaria transmission season. From April to September 2005, 2451
children were randomised to receive one of the following three
IPTc regimens under direct supervision of the CBVs every 28 days
(placebo or active drug): (i) a single dose of SP every two months,
(ii) a three-day course of AS+AQ every two months and (iii) a
three-day course of AS+AQ every month. All single and multiple
doses of SP and AS+AQ respectively were administered by the
CBVs. Children were followed for one year after stopping IPTc to
monitor the possibility of a rebound in malaria morbidity.
Field workers visited study children once a week during the
period of drug administration to enquire about their health and
completed a morbidity form if a child had any illness. A passive
surveillance system to monitor malaria and anaemia in study
children throughout the study period was set up in the district
hospital and in 21 health centres in the study area. If a child who
presented at one of these facilities had fever or any features
suggestive of malaria, a finger prick blood sample was collected for
malaria parasite examination before treatment was given. Blood
slides were read at the respective health facility to decide on
treatment and read again in a central laboratory to confirm the
diagnosis. Children with proven or presumptive malaria were
treated with oral quinine according to the Ministry of Health
(MOH) treatment guidelines.
Three main areas of costing were determined - the cost of
delivering IPTc, the cost of malaria case management from the
provider perspective (inpatient and outpatient visits to a
government facility) and the costs incurred by the caretakers of
the children visiting the inpatient and outpatient facilities. Care
was taken to exclude resources related to research activities.
Financial and economic total costs are presented. Financial costs
reflect the additional resources required to deliver IPTc in terms of
the actual expenditures incurred. For example the payment of
resources such as IPTc drugs, incentives, materials and supplies.
Straight line depreciation of capital costs is used in the financial
cost estimates. The economic costs capture the opportunity cost of
all resources used to provide IPTc, whether or not they incur a
financial cost. For example, the time health personnel are involved
in IPTc delivery represents an economic cost to the programme,
because although they are already receiving a salary from the
Ministry of Health, they could have spent their time in other
activities. An annualisation and discount rate of 3% is used to
calculate economic costs.
Costs of IPTc. The cost of delivering (i.e. ensuring the supply
of IPTc drugs from central medical stores to the CBV) and
administering IPTc during the six months of the intervention was
identified using components of the trial budget and data collected
on resource use. Costs categories included those of IPTc drugs,
training of health personnel and CBVs, health personnel staff time,
utilities (such as any water, gas, electricity and telephone bills),
supplies, transport supervision and incentives. Children aged 35
months received a quarter of a tablet, those aged 611 months half
a tablet, those aged 1223 months three quarters of a tablet and
those aged 24 months and above received one tablet each of SP,
co-formulated AS+AQ or placebo. The full tablet was costed
across all age groups to allow for wastage.
The volunteers who had been selected by the caretakers of the
children in each community to administer the IPTc drugs were
paid an allowance of approximately US$10 a month. This was
based on the amount paid to volunteers who administer vaccines
during poliomyelitis, measles and neonatal tetanus campaigns
(US$3 per day for three days).The training of volunteers took place
at the Hohoe District Health Directorate for five days. The
volunteers were trained on how to identify drugs packaged for
each child, administer drugs, complete drug administration and
morbidity forms and when to refer patients to the health facility.
Two field supervisors visited the volunteers to provide support and
supervise the administration of every first dose of drug
administration. They also visited the each volunteer every week to collect
adverse event and morbidity forms. They used the forms to
followup the adverse event cases.
Health personnel costs associated with IPTc delivery were
obtained from the 2005 records of salaries and allowances and
2006 consolidated salaries paid at the Hohoe district hospital and
district health centres. Although not collected in Hohoe, the cost to
the caretaker of accessing IPTc was explored in a similar study in
The Gambia and found to be negligible (unpublished data).
Having undertaken a detailed costing of delivering IPTc to the
study population, the costs of scaling up the intervention to Hohoe
district were modelled. This involved increasing the potential
number of children receiving IPTc from 2451 (total number in the
trial) to 33,000 (total number of under fives in the district).
Resources used and their associated costs were based on
information from the study budget, other community based
programmes such as poliomyelitis, measles and neonatal tetanus
campaigns underway in the Hohoe district and estimates form the
principal investigator involved in the original IPTc clinical trial.
Provider costs of malaria treatment. Provider costs were
based on detailed retrospective cost data obtained from
government facilities. Costs were identified using records
supplied by the Ministry of Health and the Ministry of Finance,
together with components of the study budget and patient folders
in the study site in Hohoe. An ingredients approach was used and
costs included personnel, materials and supplies, transport, utilities
and buildings [16,17].
Staff time required for the management of children with clinical
malaria and/or anaemia was estimated by direct observation and
interviews undertaken with staff at the hospital and health centres.
Once verbal consent was obtained from the health workers and
parent/guardian of patient, children were tracked from the time of
arrival at the out-patients department and time spent with each
health worker was recorded. More general costs were apportioned
based on the number of under 5 year old malaria (severe or
clinical) cases as a proportion of the total number of outpatient and
inpatient visits recorded at the facilities.
Household costs of malaria treatment. Having given
informed consent, structured interviews with primary caretakers
of children were conducted to determine any costs related to
malaria treatment incurred at the household level. All children in
the IPTc study who visited the outpatient department during the
intervention period with clinical malaria or malaria with anaemia
were visited at home up to 12 months after the intervention. Only
207 out of the 448 (46%) children were available at the time of the
survey. Ten out of 44 (25%) of those admitted to the hospital with
a diagnosis of malaria or malaria with severe anaemia were also
interviewed at home. Families of patients incurred both indirect
and direct costs. Direct costs included out-of-pocket expenses on
items such as formal hospital fees (admission fees, blood
transfusions), informal hospital fees (locally known as the welfare
ward fund commonly associated with outpatient visits),
medication, food and transport costs. Due to the long recall
period, once the mode of transport used by the career and the sick
infant was identified a standard fare was applied to the number of
journeys reported (based on reported Ghana private road and
transport union standard taxi and bus fares). Similarly the market
rate for an adult meal was used as a proxy for the direct cost of
food. Drug costs were calculated using the records of study patients
who had received inpatient or outpatient care respectively. The
drug costs borne by the household were cross referenced with costs
identified at the district hospital pharmacy, the district health
directorate store and published market drug prices . Indirect
costs included time lost as a result of caring for a sick child at
home, traveling to hospital, and the time spent at the facility while
the child in their care was receiving treatment. Time lost was
valued at the prevailing minimum subsistence wage rate in Ghana
in 2005 (i.e. 15,200 old Ghanaian Cedis/1.68 US$ per day). This
is one approach to costing lost productivity amid a lack of
consensus on how best to value unpaid work.
Care was taken to avoid double counting costs when combining
both provider and household direct costs as certain costs were
considered cross subsidisations, for example the admission fees
paid by the household was a transfer of funds to subsidise certain
provider costs. Using the total costs (Table 1) and later the unit
costs (Table 2) of the intervention, the unit costs associated with
treating malaria (Table 3), and the effectiveness data (Table 4), the
estimates of cost effectiveness of IPTc during the intervention time
and up to one year after its completion are presented (Table 5).
Costs and incremental cost effectiveness ratios (ICERs) are
expressed in US$ 2008. Expenses were converted into the local
Ghanaian Cedis. An average value of the Cedi was taken over the
time of the analysis. This translated into costs spanning from March
2005 until November 2005, with an average of Cedis 9074 = 1US$
(ranging from Cedis 8617 to Cedis 9150) . The costs based in
2005 were then inflated to 2008 using US inflation rates for tradable
goods and Ghanaian inflation rates for non tradable goods .
ICERs were calculated as probability distributions rather than
as point estimates; 10,000 iterations were run. Normal
distribution was used for the original trial efficacy data and rates
of events combined with the observed cost estimates. In addition,
cost effective acceptability curves (CEACs) are presented for each
of the drug regimens to help demonstrate the likelihood that IPTc
would be cost effective at various levels of willingness to pay
compared to current practice without IPTc for a range of values of
l. A cost effectiveness plane is presented to explore if one of
the IPTc drug regimens is dominant.
The total costs of giving SP bimonthly to 613 children, AS+AQ
monthly to 626 children and AS+AQ bi-monthly to 562 study
children are presented in Table 1. As would be expected, SP
bimonthly costs the least to deliver, followed by AS+AQ
bimonthly and then AS+AQ monthly. The most significant
difference in the economic and financial costs appears in the
training cost centres. The financial costs of training refer to the per
diems and expenditure spent directly on facilitating the training.
Economic costs also include the opportunity cost (the salaries) of
everyone involved in the training, accounting for the time that
they were unable to carry out their usual duties.
SP Bimonthly (n = 613 children)
AQ & AS Monthly (n = 626 children)
AQ & AS Bimonthly (n = 562 children)
Table 2 divides the total costs by the number of children who
received at least the first dose of each monthly course of IPTc by
drug regimen. In Table 2, and subsequent results, only the
economic costs are presented as these represent the true costs of
delivering IPTc. SP bimonthly, at US$8.19, is the cheapest to
deliver, followed by AS+AQ bimonthly at US$10.67 and then by
AS+AQ monthly at US$14.79. As to be expected, doubling the
frequency of delivering the intervention did not double the unit
costs, as activities such as training were a fixed cost regardless of
the frequency of the intervention. The cost of the AS+AQ drug
was considerably higher than SP. Training, drug delivery and
supervision accounted for approximately 2030% each of total
The unit costs of an inpatient or outpatient visit for malaria with
or without anaemia are presented in Table 3. The majority of costs
of treating malaria are borne by the household and not by the
AQ & AS Monthly
AQ & AS Bimonthly
*A dose reflects the act of the child taking each daily IPTc tablet (one day for SP and three days for AQ& AS), a course reflects the monthly taking of all doses of IPTc.
**The slight differences in training costs reflect the different number of children assigned to each trial arm.
Material & Supplies costs
Subtotal Provider Costs:
Fixed Consultation Fee
Antimalarial drug costs:
Non-malarial drug costs:
Additional Medical Expenses
Subtotal Direct Household Costs
Subtotal Indirect Household Costs *
Subtotal All Household Costs
TOTAL UNIT COSTS
Provider and Direct Household Costs **
Provider and Direct and Indirect Household
**Care has been taken to avoid double counting certain provider and household costs.
health provider. The average cost to the provider of treating a case
of uncomplicated clinical malaria or malaria with anaemia as an
outpatient was US$2.88 and US$2.94 respectively and the costs of
treating severe malaria or severe malaria anaemia were US$27.48
and US$64.08 respectively. These costs increased substantially
when direct out of pocket household costs are added due to the
costs of drugs and medical supplies such as purchasing blood to
treat severe anaemia. Outpatient costs for both the health care
provider and household directly were US$6.82 and US$7.76 for
treating uncomplicated clinical malaria and malaria with anaemia
respectively whilst the costs of inpatient care was US$39.36 for
severe malaria alone and US$98.49 for malaria with severe
anaemia. Treatment cost increased even further when indirect
costs associated with lost productivity were added.
Table 4 presents the effectiveness results from the trial .
Note that there were no statistically significant reductions in
episodes of all cause or malaria specific hospital admissions in any
of the intervention groups. ICERs based on the statistically
significant impact IPTc had on clinical (outpatient) malaria only,
had narrower confidence intervals, but were not very different
from the ICERs that included both clinical and severe (inpatient)
episodes, due to the small number of severe cases averted. The
estimates of cost effectiveness of IPTc during the intervention time
and during the year after its completion are presented in Table 5.
There are three main areas worth noting in this table. Firstly,
although AS & AQ monthly is the most costly IPTc regimen to
deliver (at US$13.16 per child enrolled or US$14.79 per child fully
adherent, it is the most cost effective option given its substantially
higher protective efficacy. Secondly, the cost effectiveness ratios
decrease when the costs incurred not only by providers but also by
household are included. Thirdly, there was no significant increase
in the incidence of clinical malaria in the post intervention period
in children who were .1 year old when they received IPTc
compared to the placebo group. However the incidence of malaria
in the post intervention period was higher in children who
were ,1 year old when they received AS+AQ monthly compared
to the placebo group . This is shown by the slight increase in
treatment costs and increase in the net costs of IPTc for SP
bimonthly and AS+AQ bimonthly when findings are compared
for the intervention period to alone with those that also include the
one year follow up.
The acceptability curves of the three IPTc drug regimens are
presented in Figure 1 depicting the cumulative distribution of
costeffectiveness ratios (Y axis) against a decision makers hypothetical
willingness to pay for every malaria episode averted (X axis). A
willingness to pay at least US$67 to avert a malaria episode
appears the minimum investment needed to improve on the
placebo (i.e. the current practice of routine treatment and no
IPTc). A willingness to pay of US$77 per episode averted shows
AS+AQ monthly as the most cost effective strategy. The cost
Protective Efficacy 95% CI
Table 4. Effectiveness of different IPTc regimens.
(a) During Six Month Intervention Period
No. of children enrolled in start of 6 months
No. of children involved at end of 6 months
Clinical malaria only
Clinical malaria & anaemia
Severe malaria only
Severe malaria & severe anaemia
Malaria with any parasitaemia
All cause admissions
No. of children followed up
Clinical malaria only
Clinical malaria & anaemia
Severe malaria only
Severe malaria & Severe anaemia
(b) Intervention period and One Year Follow Up (includes rainy and dry season)
effectiveness plane presented in Figure 2 shows AS+AQ monthly
as the dominant strategy; able to avert more malaria cases for less
cost than both IPTc SP bimonthly and AS+AQ bimonthly.
Scaling Up IPTc
The costs of delivering IPTc presented here are based on a well
funded, small scale research study. In an attempt to better
understand the costs of operationalising this intervention on a
district wide scale, a model was develop to scale up costs (both
fixed and variable) and explore potential savings from economies
of scale. Costs reflect the amount required by the health care
system to implement IPTc in the whole district with an estimated
total of 33,000 children aged less than five years. To try and
calculate a realistic level of IPTc coverage the total number of
children in the district under five is multiplied by 74% to reflect
the coverage rate reported for Ivermectin delivery (the only other
recorded community health volunteer led intervention distributing
medication, albeit to non pregnant women and persons aged five
years and above ). This figure was then multiplied by the
adherence rate in each of the trial IPTc drug regimen arms: 85%
for SP bimonthly, 89% for AS & AQ monthly, and 88% for AS &
AQ bimonthly . The assumptions for the scale up are provided in
Table 6 and the unit costs of delivering the intervention district
wide are reported in Table 7. The cost per child enrolled fell
considerably when modelled to district level as compared to under
trial conditions. For SP, the unit costs fell from US$8.19 to US$
1.86 (a fall of 77%), for AS & AQ monthly the costs fell from
US$14.79 to US$4.33 (a fall of 71%) and for AS& AQ bimonthly
costs fell from US$10.67 to US$2.69 (a fall of 75%). Based on these
unit costs and intervention costs, this translates to US$28.23
(19.97, 42.11, CI 95%) per malaria case averted using SP,
US$22.31 (20.30, 24.54, CI 95%) using AS & AQ monthly and
US$59.61 (36.40, 113.57) using AS & AQ bimonthly. As the
population increases by more than forty times, the costs fall on
average four times. This is due to certain fixed costs such as
incentives to CBV and facility based staff remaining constant
regardless of the number of children who receive IPTc. Semi fixed
costs such as training, drug delivery and supervision benefited
from economies of scale. In this modelling exercise the efficacy of
IPTc has been assumed to be the same as that observed in the
clinical trial although it cannot be guaranteed that this would be
At between US$8.19 and US$14.79 the annual cost of
delivering at least the first one dose of each course of IPTc under
trial conditions is higher than that of other interventions designed
to protect children against malaria. However, when the unit costs
are scaled up to a district wide level, costs of delivery fall to
between US$1.86 and US$4.33 per child; these costs are within
the range of the costs associated with delivering existing
interventions. For example, the costs per year of protection in
US$ 2008 associated with insecticide treated nets (ITNs) are
reported to be US$1.464.00 , US$3.626.06 for indoor
residual spraying (IRS), US$0.75 for intermittent treatment of
malaria (IPT) in infants using SP , US$2.02 for IPT in school
children  and US$2.70 when delivering 2 doses of IPT to
pregnant woman (using SP) via community care and US$2.39 via
health centres. Comparisons of ICERs across studies should
be interpreted with caution due to methodological differences (e.g.
some take account of resource savings and some do not, some take
a societal perspective while others take a provider perspective),
cultural and epidemiological profiles may differ. With this in mind,
Table 5. Cost Effectiveness of IPTc.
Gross Intervention Costs
Based on Intervention Costs only
Cost per child enrolled
Cost per child fully adherent
Cost per malaria case averted - clinical cases only
Resources Savings *
Provider and Direct Household
Provider and Direct and Indirect Household
Net Costs **
Provider and Direct Household
Provider and Direct and Indirect Household
Provider and Direct Household
Net Cost Effectiveness (Cost per malaria case averted) ***
Cost per malaria case averted - clinical & severe cases 107.46
During Six Month Intervention Period
Intervention Period & One Year Follow Up
Numbers in parenthesis are cost savings.
*This is based on the savings of averting treatment compared to the placebo (See Table 3).
**Net costs are calculated by subtracting resource savings from intervention costs.
***Net costs effectiveness is calculated by dividing costs by the protective efficacy against clinical malaria.
based on intervention costs alone, the cost of averting an episode
of malaria in Hohoe with IPTc is high (US$67.77) compared to
other malaria interventions which report the cost per malaria
episode averted among under fives (in US$ 2008) of between
US$3.71 for ITNs  and US$24.00 to US$26.58 for IRS .
Twenty years ago in The Gambia, mass chemoprophylaxis with
Maloprim administered over several years by primary health care
workers, with the support of village volunteers, to children aged 3
59 months reduced both malaria mortality and morbidity. When
inflated to US$ 2008, the cost per child protected per season was
US$ 4.75; the cost per childhood death averted was $239.
The high IPTc intervention costs in Hohoe are in part due to
the small scale and vertical nature of the study. If IPTc were to be
implemented routinely there is a greater likelihood of increased
shared costs as costs associated with IPTc specific supervision and
drug delivery could be expanded to include other non IPTc
activities that would help establish a CBV network . The
combination of SP & AQ used in several other studies of IPTc is
likely to be more cost effective because of the lower costs of SP
than AS and similar or higher levels of protective efficacy .
This study was not powered to detect an impact on hospital
admissions or mortality. However, subsequent larger studies of
IPTc with SP & AQ conducted in Burkina Faso and Mali have
shown a substantial reduction in hospital admissions with malaria
in children who received IPTc  suggesting increased cost
As reported previously  the overall incidence of malaria was
lower during the rainy season following the intervention than
during the intervention period. The reason for this reduction in
the incidence of malaria during the post intervention period is not
clear. Kweku and colleagues speculate that the high coverage of
IPTc, effective treatment and an increase in the use of ITNs in the
study area may have led to a reduction in the transmission of
malaria. The study did not suggest that there is a significant risk of
rebound of malaria if IPTc is given for just one year, however, it
will be important to determine whether this is also the case if IPTc
is given for a longer period.
This economic evaluation shows the importance of including
societal cost savings when deciding on the value of an intervention.
Based on intervention costs alone IPTc may appear costly,
however, once the savings to the health system and to households
are included IPTc appears more favourable. The cost savings
would have been more pronounced had there been more of an
impact on severe episodes as has been observed in larger studies
conducted in Burkina Faso and Mali.
Central to the success of IPTc is the sustainability of the
community health volunteer network. This study has shown that
this network can be sustained for a six month study but challenges
may appear if this network of people is to work effectively year on
year and on a larger scale. The challenges of scaling up a
community based health planning and services (CHPS) initiative
in Ghana from an experimental project to a national program
have been discussed elsewhere, and if IPTc is to be launched on a
larger scale in Ghana, those responsible for its implementation
could learn from some of the constraints to scaling up identified in
the CHPS study [34,35]. Constraints such as the time lag between
the onset of planning and the actual launch of services, as well as
discrepancies between the knowledge about the intervention held
by the different stakeholders and their perceived roles and
responsibilities, posed challenges. The need for additional
resources at the primary health care level in Ghana posed
problems, as staff, materials and supplies were already severely
constrained. Finally a technical gap was identified; this referred to
the understandable reluctance of district medical teams to launch
acceptability of the CBV based HMM strategy in Ghana seems
positive  and adherence to the multi dose drug regimen appears
high [41,42] which is encouraging for IPTc which also relies on a
clear understanding by both the CBV and the caretaker of the child,
as to the correct dosage of antimalarials. There is a concern,
however, that confusion might arise if a CBV is seen as a dispenser
of potentially the same drug for both malaria treatment and
prevention. For this, and other reasons, it may be best to use
different drug combinations for IPTc and for first line treatment.
The recognition that the CBV needs to be compensated was
central to the success of this study and this has been reported as an
important factor in other successful community health
interventions . In this study, a payment of approximately $10 was
given to the CBV per month for a period of 6 months. This sum
may be too high as it is more generous than the watches, raincoats,
torches, t-shirts and $8 given every quarter to CBVs involved in
the HMM. This could have implications on the equilibrium
market price of CBV services.
same regardless of no. of children enrolled 5% of their total salary
Recurrent Costs of delivering and supervising IPTc
Number of children receiving IPTc
Cost of drugs IPTc per child
AS+AQ monthly (1tab/day during 3 days/month for 6 months)
AS+AQ bimonthly (1 tab/day during 3days every 2 month for 6 months)
SP (one tab/day/bimonthly for 6 months)
Drug Administration CBVs
Total Number of Communities
Total Number of CBVs involved in IPTc
Number of days each CBV involved in IPTc per month
District Medical Health Team Supervision & Delivery
District Director of Health Services proportion of DHS salary as buy in
Senior Nurse employed full time to coordinate all IPTc related activities district wide
Number of people involved in IPTc per month for supervision and delivery
Number of days per month each team member spends supervising IPTc
Number of days per month each team member spends delivering drugs for IPTc
Incentive over and above the salary of those involved in supervising and
delivering IPTc per month
Driver (to deliver/distribute drugs and supplies)
Number of Drivers involved in IPTc
Total Number of days involved
Incentive over and above the salary of those involved in driving IPTc per month
Days of Vehicle use for drug delivery and supervision per month
Number of senior nurses/doctors involved in giving IPTc training
Time CBVs spent receiving training
Number CBVs involved in receiving training
Total Per Diem for each CBVs attending the training
Time DTHM staff involved in receiving sensitisation and training
Number DHTM staff involved in receiving sensitisation and training
Total Per Diem for each DHTM staff attending training
programmes that they feared would require technical skills (such as
logistical system and management information systems) not
currently available. Even amid these challenges the CHPS
Initiative reported take up over a 2 year period in 104 out of
110 districts in Ghana .
Increasing attention is being given to the role of community
health workers and community health volunteers in public health
programmes [36,37]. In Ghana, a national community health
volunteer network does not exist. Other programmes that rely on
the services of volunteers tend to including health workers, teachers,
students and community members who are willing to participate.
CBVs have been studied recently in Ghana in the context of home
based management of malaria (HMM) . In HMM, as for
IPTc, it is the responsibility of community based volunteer to
dispense artemisinin based antimalarial drugs among their
community and it may be feasible for CBVs to take on both roles
providing treatment whenever this is needed and giving IPTc
during the period of maximum risk of malaria. The feasibility and
Scale up to District Wide
AQ & AS Monthly
AQ & AS Bimonthly
Cost of IPTc Drugs
Drug Administration (CBVs)
DHMT and surveillance staff
The literature on the costs of scaling up health interventions is
scarce and difficult to compare across studies . When
modeling the costs of scaling up IPTc, care was taken to follow
some of the guiding principles set out by Johns and Tan Torres
(2005): (1) fixed and variable costs were identified and scaled up to
reflect economies and diseconomies of scale, (2) the availably of
human resources, in this case community health workers and
trained health professionals needed to oversee delivery, was
assessed and thought to be realistic, (3) administrative costs were
given specific attention and not assumed to remain constant. The
scale up of costs did, however, fail to identify the impact of an
urban delivery network as the community health workers were
considered rural, in addition intra-country variation in costs and
cost effectiveness were not considered.
This study is one of the few conducted in Ghana that has
investigated the costs of treating malaria from both the provider
and household perspective and the only one to use primary cost
data to calculate the costs of treating severe malaria and anemia.
The provider costs of malaria treatment in this study are
comparable to the costs presented for WHO Choice Ghanaian
inpatient visits and slightly lower for outpatient visits (having taken
into account that drug and diagnostic costs have to be added to
CHOICE country specific bed day cost estimates to reflect total
provider treatment costs) . For household expenditure on
malaria treatment (direct and indirect) the results of this study
appear comparable to the direct clinical/mild malaria episodes
found in other estimates for Ghana [3,46] but far higher when
considering the severe and indirect costs of treatment. It is
important to note the high indirect costs to households associated
with inpatient care; 2325% of total inpatient costs. A childs
malaria episode has indirect costs associated with a reduction in a
caretakers paid and unpaid production. There is no consensus on
how micro-economic tools help best reflect these costs .
The main professions in the study area were subsistence farming,
gardening or domestic activities; to assume no costs were
associated with these activities would underestimate the economic
impact of childhood malaria on households. Therefore,
formallypaid wages were used as proxies for unpaid work. All indirect costs
were considered to contribute to income whether the products
were eventually sold or consumed within the household, as has
been done elsewhere [51,52]. The costs of treatment in this study
are most pronounced in the treatment of severe malaria and severe
anaemia. This may in part be due to the small sample of
households available for interview in this study. The authors of this
study are not aware of any costing study using primary data that
has looked at the costs of treating this group (severe malaria and
anaemia) so comparisons are hard to draw. The costs of treating
malaria and anaemia were modelled separately in Tanzania.
Provider costs of managing cases of severe anemia and clinical
malaria in infants were US$ (2008) $22.45 and $20.11 respectively.
Household costs per episode of severe anemia and clinical malaria
were each US$6.20 . These costs were higher than the costs
found in Hohoe for clinical malaria and significantly lower for the
treatment costs of severe malaria.
IPTc has proved to be a safe and effective approach to
reduction of the burden of malaria in Hohoe, an area of Ghana
with a prolonged, intense malaria transmission season. In this
paper we also demonstrate how cost-effective the intervention is
using three different drug regimens and the possibilities for
reducing costs further if the intervention was to be scaled up to the
district level. Supervision, training and remuneration of CBVs and
ensuring IPTc drug delivery are identified as the main cost
components and key determinants to the success of the delivery
We are grateful to the parents and guardians of the children who
participated in the study. We thank the community-based volunteers whose
dedication and support made this study possible. We also thank the
hospital and health centre staff in the Hohoe district who managed adverse
events and the sick project children. We would like to thank Elisa Sicuri,
Anne Wilson and the reviewers for their helpful comments.
Conceived and designed the experiments: LC EP MK BG DC. Performed
the experiments: EP MK. Analyzed the data: LC EP RL. Wrote the paper:
LC EP. Commented on drafts of the manuscript: MK BG DC.
1. Snow RW , Guerra CA , Noor AM , Myint HY , Hay SI ( 2005 ) The global distribution of clinical episodes of Plasmodium falciparum malaria . Nature 434 ( 7030 ): 214 - 7 .
2. WHO ( 2000 ) Expert Committee on Malaria Twentieth Report . Geneva, WHO Report No: Technical Report Series , No. 892 .
3. Asenso-Okyere WK , Dzator JA ( 1997 ) Household cost of seeking malaria care. A retrospective study of two districts in Ghana . Social Science & Medicine 45 ( 5 ): 659 - 67 .
4. Deressa W , Hailemariam D , Ali A ( 2007 ) Economic costs of epidemic malaria to households in rural Ethiopia . Trop Med Int Health 12 ( 10 ): 1148 - 56 .
5. Wiseman V , McElroy B , Conteh L , Stevens W ( 2006 ) Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level . Tropical Medicine and International Health 11 ( 4 ): 419 - 31 .
6. Owusu-Agyei S , Awini E , Anto F , Mensah-Afful T , Adjuik M , et al. ( 2007 ) Assessing malaria control in the Kassena-Nankana district of northern Ghana through repeated surveys using the RBM tools . Malaria Journal 6 : 103 .
7. Kiszewski A , Johns B , Schapira A , Delacollette C , Crowell V , et al. ( 2007 ) Estimated global resources needed to attain international malaria control goals . Bull World Health Organ 85 ( 8 ): 623 - 30 .
8. Sachs J ( 2001 ) Macroeconomics and Health: Investing in Health for Economic Development . Geneva: World Health Organisation.
9. Ankomah Asante F , Asenso-Okyere WK ( 2003 ) Economic Burden of Malaria in Ghana . Institute of Statistical, Social and Economic Research (ISSER) : University of Ghana. http://www.who.int/countries/gha/publications/Economic_ Burden_of_Malaria_in_ Ghana_Final_Report_Nov03 .pdf.
10. Cisse B , Sokhna C , Boulanger D , Milet J , Ba EH , et al. ( 2006 ) Seasonal intermittent preventive treatment with artesunate and sulfadoxine-pyrimethamine for prevention of malaria in Senegalese children: a randomised, placebocontrolled, double-blind trial . The Lancet 367 ( 9511 ): 659 - 67 .
11. Dicko A , Sagara S , Sissoko MS , Guindo O , Diallo ABI , et al. ( 2004 ) Impact of intermittent preventive treatment with sulfadoxine pyrimethamine targetting the transmission season on the incidence of clinical malaria in children of 6 months to 10 years in Kambila , Mali. American Journal Tropical Medicine and Hygiene 71 : 1 - 79 .
12. Sokhna C , Cisse B, Ba E , Milligan P , Hallett R , et al. ( 2008 ) A Trial of the Efficacy, Safety and Impact on Drug Resistance of Four Drug Regimens for Seasonal Intermittent Preventive Treatment for Malaria in Senegalese Children . PLoS ONE 3 ( 1 ): e1471 .
13. Cisse B , Cairns M , Faye E , Ndiaye O , Faye B , et al. ( 2009 ) Randomized Trial of Piperaquine with Sulfadoxine-Pyrimethamine or Dihydroartemisinin for Malaria Intermittent Preventive Treatment in Children . PLoS ONE 4 ( 9 ): e7164 .
14. Kweku M , Liu D , Adjuik M , Binka F , Seidu M , et al. ( 2008 ) Seasonal Intermittent Preventive Treatment for the Prevention of Anaemia and Malaria in Ghanaian Children: A Randomized, Placebo Controlled Trial . PLoS ONE 3 ( 12 ): e4000 .
15. Johns B , Baltussen R , Hutubessy R ( 2003 ) Programme costs in the economic evaluation of health interventions . Cost Effectiveness and Resource Allocation ; 1 ( 1 ): 1 .
16. Creese A , Parker D ( 1994 ) Cost analysis of primary health care: a training manual for programme managers Geneva: World Health Organisation. .
17. Phillips M , Mills A , Dye C ( 1993 ) Guidelines for Cost-Effectiveness Analysis of Vector Control . Geneva: World Health Organisation.
18. OANDA Historic Currency Converter Website ( 2010 ) http://www.oanda.com/ convert/fxhistory.
19. Budlender D ( 2002 ) Why should we care about unpaid work? A guidebook prepared for the Unitd Nations Development Fund for Women . HarareZambia: Southern African Region Office.
20. International Monetary Fund. Data Mapper Website ( 2009 ) http://www.imf. org/external/datamapper/index.php].
21. Doubilet P , Begg CB , Weinstein MC , Braun P , McNeil BJ ( 1985 ) Probabilistic sensitivity analysis using Monte Carlo simulation. A practical approach. Med Decis Making . Summer; 5 ( 2 ): 157 - 77 .
22. Fenwick E , Marshall D , Levy A , Nichol G ( 2006 ) Using and interpreting costeffectiveness acceptability curves: an example using data from a trial of management strategies for atrial fibrillation . BMC Health Services Research 6(52).
23. Ghanaian Ministry of Health (2007) Hohoe District Medical Health Annual Report . .
24. Kolaczinski J , Hanson K ( 2006 ) Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology . 5 : 37 .
25. Conteh L , Sharp BL , Streat E , Barreto A , Konar S ( 2004 ) The cost and costeffectiveness of malaria vector control by residual insecticide house-spraying in southern Mozambique: a rural and urban analysis . Trop Med Int Health 9 ( 1 ): 125 - 32 .
26. Manzi F , Hutton G , Schellenberg J , Tanner M , Alsono P , et al. ( 2008 ) From strategy development to routine implementation: the cost of Intermittent Preventive Treatment in Infants for malaria control . BMC Health Services Research 8(165).
27. Temperley M , Mueller D , Njagi JK , Akhwale W , Clarke S , et al. ( 2008 ) Costs and cost-effectiveness of delivering intermittent preventive treatment through schools in western Kenya . Malaria Journal 7 : 196 .
28. Mbonye AK , Hansen KS , Bygbjerg IC , Magnussen P ( 2008 ) Intermittent preventive treatment of malaria in pregnancy: the incremental cost-effectiveness of a new delivery system in Uganda . Transactions of the Royal Society of Tropical Medicine and Hygiene 102 ( 7 ): 685 - 93 .
29. Mueller D , Wiseman V , Bakusa D , Morgah K , Dare A ( 2008 ) Cost-effectiveness analysis of insecticide-treated net distribution as part of the Togo Integrated Child Health Campaign . Malaria Journal 7 ( 1 ): 73 .
30. Yukich J , Lengeler C , Tediosi F , Brown N , Mulligan J-A , et al. ( 2008 ) Costs and consequences of large-scale vector control for malaria . Malaria Journal 7 ( 1 ): 258 .
31. Picard J , Mills A , Greenwood B ( 1992 ) The cost-effectiveness of chemoprophylaxis with Maloprim administered by primary health care workers in preventing death from malaria amongst rural Gambian children aged less than five years old . Trans R Soc Trop Med Hyg 86 ( 6 ): 580 - 1 .
32. Molyneux DH , Hotez PJ , Fenwick A , Newman RD , Greenwood B ( 2009 ) Neglected tropical diseases and the Global Fund . The Lancet 373 ( 9660 ): 296 - 7 .
33. Diallo D , Konate A , Dicko A ( 2009 ) 'A trial of IPTc in children sleeping under an ITN in Burkina Faso and Mali: Background and study design; Results from Burkina Faso; Results from Mali'. 5th MIM Pan African Malaria Conference Website : http://www.mimalaria.org/pamc/ConferenceInformation/ ScientificProgram/SymposiumIPTCs/tabid/116/Default.aspx.
34. Nyonator FK , Awoonor-Williams JK , Phillips JF , Jones TC , Miller RA ( 2005 ) The Ghana Community-based Health Planning and Services Initiative for scaling up service delivery innovation . Health Policy and Planning 20 ( 1 ): 25 - 34 .
35. Nyonator FK , Badu Akosa A , Awoonor-Williams JK , Phillips JF , Jones TC ( 2008 ) Scaling Up Experimental Project Success with the Community-based Health Planning and Services Initiative in Ghana . In: Simmons R, Fajans P , Ghiron L, eds. Scaling Up Health Service Delivery: From Pilot Innovations to Policies and Programmes. Geneva: WHO.
36. Haines A , Sanders D , Lehmann U , Rowe AK , Lawn JE , et al. ( 2007 ) Achieving child survival goals: potential contribution of community health workers . The Lancet 369 ( 9579 ): 2121 - 31 .
37. Lewin S , Lavis JN , Oxman AD , Bastas G , Chopra M , et al. ( 2008 ) Supporting the delivery of cost-effective interventions in primary health-care systems in lowincome and middle-income countries: an overview of systematic reviews . The Lancet 372 ( 9642 ): 928 - 39 .
38. Tiono A , Kabore Y , Traore A , Convelbo N , Pagnoni F , al et ( 2008 ) Implementation of Home based management of malaria in children reduces the work load for peripheral health facilities in a rural district of Burkina Faso . Malaria Journal 7 : 201 .
39. Kidane G , Morrow RH ( 2000 ) Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial . The Lancet 356 ( 9229 ): 550 - 5 .
40. Pagnoni F , Kengeya-Kayondo J , Ridley R , Were W , Nafo-Traore F, et al. ( 2005 ) Letter to the Editor: Artemisinin-based combination treatment in homebased management of malaria . Trop Med Int Health 10 ( 6 ): 621 - 2 .
41. Chinbuah AM , Gyapong JO , Pagnoni F , Wellington EK , Gyapong M ( 2006 ) Feasibility and acceptability of the use of artemether-lumefantrine in the home management of uncomplicated malaria in children 6 months old in Ghana . Trop Med Int Health 11 ( 7 ): 1003 - 16 .
42. Ajayi I , Browne E , Bateganya F , Yar D , Happi C , et al. ( 2008 ) Effectiveness of artemisinin-based combination therapy used in the context of home management of malaria: A report from three study sites in sub-Saharan Africa . Malar J . 7 ( 1 ): 190 .
43. Brooker S , Kabatereine NB , Fleming F , Devlin N ( 2008 ) Cost and costeffectiveness of nationwide school-based helminth control in Uganda: intracountry variation and effects of scaling-up . Health Policy Plan 23 ( 1 ): 24 - 35 .
44. Johns B , Torres TT ( 2005 ) Costs of scaling up health interventions: A Systematic Review . Health Policy and Planning 20 ( 1 ): 1 - 13 .
45. WHO CHOICE Webiste ( 2010 ) http://www.who.int/choice/en/.
46. James J , Aikins M , Binka F ( 2007 ) Malaria treatment in Northern Ghana: What is the treatment cost per case to households? African Journal of Health Sciences 14 ( 1-2 ): 70 - 9 .
47. Weinstein MC , Siegel JE , Garber AM , Lipscomb J , Luce BR , et al. ( 1997 ) Productivity costs, time costs and health-related quality of life: a response to the Erasmus Group . Health Economics 6 ( 5 ): 505 - 10 .
48. Brouwer WBF , Koopmanschap MA , Rutten FFH ( 1997 ) Productivity costs in cost-effectiveness analysis: numerator or denominator: a further discussion . Health Economics 6 ( 5 ): 511 - 4 .
49. Koopmanschap MA , Rutten FFH , van Ineveld BM , van Roijen L ( 1995 ) The friction cost method for measuring indirect costs of disease . Journal of Health Economics 14 : 171 - 89 .
50. Becker GS ( 1965 ) A theory of the allocation of time . Economic Journal 75 : 493 - 517 .
51. Morel C , Thang N , Xa N , Hung LX , Thuan LK , et al. ( 2008 ) The economic burden of malaria on the household in south-central Vietnam . Malaria Journal 7 ( 1 ): 166 .
52. Sicuri E , Davy C , Oa O , Ome M , Siba P , et al. (Submitted) The economic burden of malaria among young children on households in Papua New Guinea. Health Policy and Planning .
53. Alonzo Gonzalez M , Menendez C , Font F , Kahigwa E , Kimario J , et al. ( 2000 ) Cost-effectiveness of iron supplementation and malaria chemoprophylaxis in the prevention of anaemia and malaria among Tanzanian infants . Bull-WorldHealth-Organ ; 78 ( 1 ): 97 - 107 .