KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

SUSTAINABILITY AND COST 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

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 ..

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.

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 AdjeiBaah, 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.

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.

TABLE OF CONTENTS Page

Declaration.....ii

Dedication.....iii

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

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

Table of Contents......vi

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

Acronyms......xii

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.4 1.1.4 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

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 2.4 Sustainability 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

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

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

6.0 Introduction.71 6.1. 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

6.3 Concluding Remarks...75

LIST OF BIBLOGRAPHY...76

APPENDIX..

84

LIST OF TABLES AND FIGURES

TABLE

PAGE

3.4.3.1 Logical framework/indicators32 4.1 Background Characteristics.38 4.2 Household Cost ......42 4.3 Sources of treatment ....44 4.4 Satisfaction of HBMM.44 4.5 Cost incurred and time spent by caregivers at health facility...45 4.6 Clients reactions to Change in Cost of Treatment....47 4.7 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

Acronyms ACTs CMDs CHRPE DDT FCA GHS GDP HBMM HMM HCA ITM(s) ITNs IPTp IVM MHMT MPL MCL NMCP ORS PSI RDT RA RBM SPSS SDHT TDR VHC WHO WTP Artemisinin-based Combination Therapies Community-based Medicine Distributors Committee for Human Research, Publications and Ethics Dichloro-Diphenyl-Trichlorethane Friction Cost Approach Ghana Health Service Gross Domestic Product Home Base Management of Malaria Home Management of Malaria Human Capital Approach Insecticide Treated Material(s) Insecticide Treated Nets Intermittent Preventive Treatment in Pregnancy Integrated Vector Management Municipal Health Management Team Marginal Product Labour Marginal Cost Labour National Malaria Control Programme Oral Rehydration Salt Population Service International Rapid Diagnostic Testing kit Rectal Artesunate Roll Back Malaria Statistical Package for Social Sciences software Sub-District Health Team Tropical Disease Research Village Health Committee World Health Organisation Willingness to Pay

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

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 parasite vectorhuman 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

(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

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 of acute or chronic 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

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 to treatment, peace of mind, quality of life among others. In considering the ideas of both Joel (2006) and Hanson (2002), cost of illness differs from health care costs. Thus, cost in health care is restricted to providing services related to the delivery of health care rather than an impact on the personal life 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).

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

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

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

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.

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 nationwide 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

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.

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.

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

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 parasite vectorhuman 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. malariae and P. ovale P. falciparum causes 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 SubSaharan 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

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

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.

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 sitespecific 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).

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,

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

in various studies that use of ITMs leads to a 19% reduction in child mortality and 40-60% reduction in infection. Drugs like plasmoquine could destroy gametocyte of Plasmodium, prophylaxis was used to protect from clinical manifestations of the disease and Plaudrine could be taken weekly once for prophylactic treatment while staying in endemic areas of malaria (Parsad, 2003). Again, Guyatte (2004) wrote that, Paris green, pyrethrum spray and DDT (Dichloro- Diphenyl Trichlorethane could be used as control measures.

2.3 Cost of Illness As earlier stated by Hanson (2002) the personal cost of acute or chronic disease contributes to the cost of illness. It differed from health care costs in that this concept was restricted to the cost of providing services related to the delivery of health care rather than an impact on the personal life of the patient. The financial cost was the out-of-pocket expenditures on treatment, and cost of transportation (round-trip) associated with receiving medical care. In this case, treatment costs include expenses on consultation (including laboratory test where relevant) and purchase of drugs. According to Talisuna et al (2007), all households irrespective of sector of employment bear an average financial cost after a holistic analysis in households.

Charges are often higher than costs to cover losses from patients who are unable to fully pay their expenses, such as procedures not covered by insurance companies, and to cover the rising costs of replacing and updating medical equipment. On the other hand, economic cost as defined by Hodgson et al (1982, 2003) was the value of the forgone opportunity to use in a different way those resources that were used or lost due to illness. Opportunity costs represent the other portion of estimated costs. These included mortality costs; morbidity costs due to absenteeism;

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

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

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 out of - 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

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 CobbDouglas 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).

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.

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 care hospitals 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 prescribed treatments, as well as expenses that patients pay fully out of pocket (Hadi, 2003).

2.3.5. Cost Drivers of Home-Based Management of Malaria Issues influencing cost of home-based management of malaria vary from one point to the other. Such factors can either increase or decrease the size of cost. According to Collette (1994), level of severity of the illness, distant to the homes, kind of the interventions received (intensive or standard case management), time spent in travelling and in the consumers homes as well as the size of each of population each CMDs handles could affect the cost of HBMM. From the article of Joel (2006), there was an ideal that, the length of illness before getting a treatment was the key factor that gives to either a high or low cost of health care. In that, the longer length of illness the higher the cost of treatment hence vice versa.

In 1994, Lipsey studies have showed that, the cost of illness for outpatients who received early diagnosis and prompt treatment was four to seven times cheaper than the cost of illness for those who were hospitalized. Therefore, people from malaria endemic sectors should be educated in seeking early treatment from health facilities. Again, primary health care services were made more reachable to people who live in malaria endemic communities. Hence, this would be helpful in planning future malaria management programs. This would also influence policy makers to concentrate on timely and effective treatment of uncomplicated cases. In the long round, this could save large amount of economic loss. According to some agencies in the cost involve in the various forms of activities within the HBMM were the factors which decrease or increase the cost of programme. These activities included the administrative support, photo copies, stationery, telephone and supervision, meetings, training, as well as monitoring, interest and salaries for facilitators of CMDs.

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.

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.

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 friction period was applied only to patients on permanent retirement for 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 productivity losses 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.

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

prescribe medicine. However, these are critical for the implementation of home-based management of malaria. Hence, these knowledge gaps informed the study.

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.

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

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. Sampling 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=Z2 p (1-p) d/e2, where Z= (1.96), p=proportion of event of interest, and e= required error, d=design effect.

3.4.2. Selection 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 Data collection variables tools sources of data 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, , cross tabulations, means, Outcome Statistical analysis

and measures/ indicators

and treatment of malaria

& severity), drugs, RDTs,

health documents and

accessing the whole level of diagnosing and treatment of malaria. Adolescents; mean cost; total cost etc

standard deviations, etc

incentives for literature CMDs, prompt/ delayed action, etc

Objective

Dependent variable

Independent Data collection variables tools sources of data

Outcome

Statistical analysis

and measures/ indicators

ii

To

measure

the Household cost

Transport, care,

Questionnaire,

% household per

Descriptive; tables cross tabulations, means, standard deviation, etc

household cost per febrile episode in home management of malaria

drugs, parents, providers, health

service cost febrile episode in HBMM, mean cost;

accompanied relative, distance, etc

documents and literature

total cost etc

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 Data collection variables tools sources of data

Outcome

Statistical analysis

and measures/ indicators

Types of iv. O4. To assess the Ability to medicines, level ability CMDs knowledge and skills, of CDDs to prescribe to prescribe competency

Questionnaires, records of of CMDs

% of CMDs competence, knowledge and skills to prescribe medicines in

Descriptive; tables cross tabulations, means, standard deviation, etc

medicines in HBMM HBM

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 health providers in HBMM

Descriptive; tables

and 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

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

(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 confidential and used for research purposes only. The Committee for Human

Research, Publications and Ethics (CHRPE) of the KNUST provided ethical and clearance in line with the Helsinki Declaration for the study. The participants were appreciated by the efficiency in the home based management of malaria 3.9. Limitations Throughout the study, the respondents were busy. They were running business whilst most of them were at funerals. These factors and others delayed data collection. 3.10. Outputs and application possibility Outputs from this research are thesis and manuscript for publication.

3.11. Dissemination of findings The findings were disseminated through power point presentation at the DHMT meeting and through publications in peer reviewed Journals.

3.12. Conclusion Finally, the methods employed by this study were consistent with literature available. The study findings were achieved through these methods and concepts.

CHAPTER FOUR RESULTS

4.0 Introduction This chapter presents the main findings of the study. The results are presented in text and tables in the order of the specific objectives of the study.

4.1. Socio-demographics The socio-demographics detail several characteristics; age, sex, occupation, marital status and religion of the health consumers otherwise known as caregivers, the health providers and the community medicine distributors (CMDs), Table 4.1. Table 4.1: Background Characteristics Health Consumers Characteristic (n=400) Health staff Providers (n=10) Sex Community Medicine Distributors (n=90)

Female Male Age (years) 18-29 30-49

234 (58.5) 166 (41.5%)

4 (40%) 6 (60%)

48(53.3%) 42 (46.7%)

203 (50.7%) 103 (25.7%)

3 (30%) 7 (70%)

46 (51.1) 44 (48.8%)

50-69 Mean age Standard deviation

94 (23.5%) 34.9 16.63 34.2 6.19 28.9 7.23

Marital status Married Not married Length of stay (years) Less than 5 6-10 Over 20 Occupation Farmer Trader Artisan 126 (31.5%) 129 (32.2%) 119 (29.8%) 124 (31%) 56 (14%) 220 (55%) 10 (100%) 62 (68.8%) 28 (31.1%) 277 (69.2%) 123 (30.8) 5 (50%) 5 (50%) 43 (47.3%) 47 (51.6%)

Civil/Public Servant

26 (6.5%)

Nurse Administration Medical Officer Disease Control

4 (40%) 3 (30%) 2(20%) 1(10%)

Level of formal Education Illiterate 137 (34.2%) -

Basic

166 (41.5%)

45 (50.0)

Professional/Tertiary

97 (24.2%)

10(100%)

45 (50.0)

Religion

Islam

151 (37.8%)

32 (35.6%)

Christian

249 (62.2%)

10 (100%)

53 (58.9%)

Traditionalist

5 (5.6%)

Institution of work

Ejisu Government Hospital Health centre

2 (20%) 2 (20%) 2 (20%) 2 (20%) 2 (20%)

Juaben Government Hospital Private clinic Private hospital

Source: Authors Fieldwork, 2009.

The respondents interviewed for the study included; health consumers, health providers and the community medicine distributors. Among the health consumers, the females dominated the

males. There were 10 health providers majority of who were males 6 (60%). Most, 48 (53.3%), of CMDs were female with a mean age of 28.9 years and a standard deviation of 7.23. The age of the health consumers ranged from 18 - 69 years with a mean age of 34.9 years and a standard deviation of 16.63. Again, the age of the health providers ranged from 18-49 with mean age of 34.2 years and a standard deviation of 6.19.

About 42% of the health consumers had basic education and 62% of them were Christians. The CMDs also had basic and tertiary education and about 53 (58.9%) of the CMDs were Christians. All these health providers had a professional or tertiary education. There were equal proportions of marital status attained among the health providers. Majority of the health consumers were married and their occupation ranged from farming, trading, artisan and civil servants. Trading 129 (32.2%) was the dominant occupation. Majority of the health consumers had stayed in the Municipality for over 20 years 220 (55%).

The health providers were made up of 4 (40%) nurses, 3 (30%) administrators, 2 (20%) medical officers and 1(10%) from disease control officer. The health providers had all stayed in the Municipality for less than five years and were all Christians. Among the CMDs, approximately 52% were not married. About 62 (68.8%) of the CMDs had stayed in the Municipality and had been involved in disease surveillance or health activities in the community for over five years. Community trusted and selected them due to their experience in health activities and commitment to work.

4.2 Household Cost of malaria Household costs as used here were both financial and opportunity cost incurred while seeking treatment for malaria. The main components of the household cost of malaria were that incurred during treatment, transport and time and or visits in seeking health care. Table 4.2 presents detailed household costs incurred in seeking malaria treatment in the Municipality. Table 4.2 Household cost Household cost Health Consumers (n=400) CMDs who confirmed cost (n=90)

Cost of Treatment 0.1-1.00 27 (6.8%) 47 (100%)

1.10-2.0

328 (82.0%)

22 (5.5%)

2.10-3.0 Average Standard deviation Perception on affordability Expensive Cheap Very cheap Bearer of cost of Treatment

45 (11.2%) 1.0788 0.35140

21 (5.25%) -

211(52.8%) 189(47.2%) -

33(36.7%) 43 (47.8%) 14 (15.6%)

Mother Father Others Distance from the CMDs (Km) 0.5 1 Time spent with the CMDs (minutes) 5 10 15 30 Visit to the CMDs 1 2 3

305(76.2%) 68(17.0%) 27(6.8%)

213(53.2%) 187 (46.8%)

57(14.2%) 169(42.2%) 134(33.5%) 40(100%)

85(21.2%) 274(68.5%) 41(10.2%) Total number interviewed = 400

Source: Authors Fieldwork, 2009.

The cost of treatment varied among caregivers, however, the cost of seeking treatment ranged from GHp 20 (82%) and GHp 30 (11.2%). However, approximately 52.8% claimed that homebased management of malaria (HBMM) was expensive. Mothers (76.2%) mostly paid these costs. About 53.2% of the caregivers walked about 0.5 km and 46.8% walked about 1 km distance to seek treatment from the CMDs. Again, majority spent a minimum of 5 minutes

(14.2%) and a maximum of 30 minutes (10%) while 68.5% paid 2 visits to the CMDs before their children got treated.

Table 4.3. Sources of treatment. Source Health Consumers (n=400) Source of treatment CMDs (n=90)

Home Chemical seller CMDs

Source: Authors Fieldwork, 2009.

100(25%) 152(38.0%) 148(37%)

According to health consumers, they mostly sought treatment for malaria from the chemist shop (38%) and (37%) from the CMDs. Table 4.4. Satisfaction of HBMM. Source Health Consumers (n=400) Level of satisfaction of treatment Very Satisfied Not Satisfied Not Sure
Source: Authors Fieldwork, 2009.

CMDs (n=90)

290(72.5%) 82 (20.5%) 28 (7.0%)

About 73% of the respondents were very satisfied with home-based management of malaria programme while 7.0% were not sure if they were satisfied or not. 4.2.1. Cost incurred and time spent by caregivers at health providers facility and CMDs The components of cost incurred and time spent by caregivers at health providers facilities and CMDs are presented in Table 4.5. Table 4.5 Cost/Time Cost incurred by caregivers at health providers facility and CMDs Health Providers (n=10) Uncomplicated malaria Cost (GHC/P) 0.5 1 2 3 4 6 7 8 8.5 Average cost 6.4000 4(40%) 1(10%) 1(10%) 2(20%) 47(100%) 22(5.5%) 21(5.25%) CMDs (n=90)

Standard deviation

1.62959

Severe Malaria 8 9 10 13 Average cost Standard deviation Time spent by caregivers (uncomplicated malaria) (minutes) 1(10%) 3(30%) 4(40%) 2(20%) 10.1000 1.66333 -

1- 20 21-25 26-30 31-35 Time spent by caregivers (severe malaria) 15-27 28-39 40-50

2 3 4 1

63 (70%) 12 (13.3%) 5 (5.6%) 10 (11.1%)

36(40%) 37(41%) 17(18.8%)

Source: Authors Fieldwork, 2009. Table 4.5 shows the cost of managing uncomplicated malaria by health providers in the various hospitals. The treatment cost of uncomplicated malaria ranged from GHC4.00 to GHC 8.50.

About 40% of the health providers quoted the cost of treating severe malaria as GHC 6.00 whilst 40% of the health providers quoted GHC 10.00 as the cost incurred on severe malaria. However, all the CMDs quoted the minimum cost of treatment of any form of malaria in HBMM as 10 GP and the maximum of 30 GP. About 48% of them described the programme as very affordable. For uncomplicated malaria, majority (70%) of CMDs spent 3 to 20 minutes on each child while 41% of the CMDs spent 28 to 39 minutes with pre-referral activities for children suffering from severe malaria.

4.2.2. Clients reaction to change in cost of treatment in HBMM The study further explored the possible outcome of a change (reduction or an increase) in cost of treatment of malaria among health providers and CMDs. Table 4.6 shows the outcome of either an increase or decrease in cost of treatment of malaria. Table 4.6.clients reactions to change in cost of treatment Change in cost Health Providers (n=10) CMDS (n=90)

Reduction in cost

Increase in consumption

6(60%)

61(67.8%)

Re allocation of resources to other

4(20%)

5(5.6%)

treatment

Decrease in malaria Cases -

24(26.6%)

Increase in cost

Reduction in Consumption Increase in mortality

2(20%)

30(33.3%)

8(80%)

14(15.6%)

Reduction of resources for other treatment

46(51.1%)

Source: Authors Fieldwork, 2009. As much as 60% of the health providers and 68% of the CMDs suggested that, a reduction in the cost of treating malaria would lead to an increase in consumption. Again, 20% of the health providers and 6% of the CMDs suggested that, there could be re-allocation of resources if there was a reduction in the cost of treatment. Thus, if there is a reduction in the cost of treatment of malaria, money as well as time will be saved for other ventures such as education or health related programmes. Nevertheless, approximately 27% of the CMDs purported that, there would be a reduction in malaria cases if there was a reduction of cost of preventive materials in the Municipality. The affordability of these preventive materials such as insecticide nets, repellents,

will enable health consumers to save themselves from the bite of the mosquito hence reduction in malaria cases.

4.3 Cost Drivers in HBMM This section presents the factors that influence a change in the cost of treatment of malaria in HBMM. It also looked at the trend of cost and approaches to attain least cost of treatment of malaria among caregivers, Table 4.7.

Table 4.7 Factors influencing cost of home base management of malaria Factors Health Consumers (n=400) Factors that decrease Health Providers (n=10) CMDs (n=90)

Suppliers

7(70%)

47(52.2%)

Personnel (incentives) Type of health facility

2(20%)

43(47.8%)

100(25%)

Type of treatment Not sure

258(64.5%) 42(10.5%)

1(10%)

Factors that increase the cost of treatment Suppliers Personnel (incentives) Health facility Not sure 3(30%) 2(20%) 3(30%) 2(20%) 30(33.3% 60(66.7%) -

Reasons for increase or decrease in cost of treatment Type of equipment/ drugs available Type and number of personnel Trend of cost Increase Decrease Approaches to ensure least cost of 8(80%) 2(20%) 2(20%) 6(60%) 90(100%)

treatment

Find additional source of Funds Outsource for staffs Educate clients to seeks early treatment Source: Authors Fieldwork, 2009. -

2(20%)

2(20%) 6(60%)

The health consumers stated that, type of health facility and type of treatment were the factors which influenced the cost of HBMM. About 64.5% and 10% reiterated that, the type of health facility and treatment respectively contributes to the cost of treatment of HBMM. Both the health providers (70%) and CMDs (52.2%) stated suppliers as the major factors that influence cost of HBMM. Furthermore, 60% of the health providers and all the CMDs indicated that, type of equipments and drugs availability were the reasons for increase or decrease of the cost HBMM. In General, 80% of the health providers suggested that the trend of malaria was increasing.

4.4. Sustainability of HBMM Sustaining home-based management of malaria programme involves community ownership and engagement in its implementation. Table 4.8 presents issues of how the HBMM could be sustained.

Table 4.8.Sustaining HBMM Sustainability Health Consumers (n=400) Ownership MHMT 167(41.8%) 10(100%) Health Providers (n=10) CMDs (n=90)

Municipality assembly

192 (48%)

27 (30%)

University

41 (10.2%)

Government

63 (70%)

Measures in Place Yes No Not sure Frequency of Medicine Supply 56(14%) 317(79.2%) 27(6.8%) 10(100%) 63(70%) 27(30%) -

Regularly By request

139(34.8%) 261(65.2%)

2(20%) 8(80%)

21(23.3%) 69(76.7%)

Attrition of CMDs Yes No Not sure Factors influencing attrition Less incentives Delays of drugs Existence of Barriers to to HBMM Yes No Not sure Type of the Barrier Cost Absenteeism 245(61.2%) 155(38.7%) 3(30%) 55(61.1%) 384(96%) 16(4%) 3(30%) 4(40%) 3(30%) 78(86.7%) 12(13.3%) 155(38.7%) 245(61.2%) 2(20%) 8(80%) 63(70%) 27(30%) 358(89.5%) 42(10.5%) 2(20%) 4(40%) 6(60%) 86(95.6%) 4(4.4%) -

Unattractive incentives What should be Done Cost reduction Increase CMDs Training Funding Increase incentives Continuity of HBMM Yes No CMDs Incentives available Yes No Forms of Incentives Monetary Award scheme CMDs perception Incentives Satisfied Not satisfied

7(70%)

35(38.8%)

94(23.5%) 210(52.5%) 96(24%) -

2(20%) 2(20%) -

52(57.7%) 38(42.2%) -

10(100%) -

68(75.6%) 22(24.4%)

6(60%) 4(40%)

66(75.6%) 24(26.6%)

10(100%) -

79(87.7%) 11(12.2%)

10(100%)

46(51.1%) 14(15.6%)

Not sure Source of Incentives Caregivers MHMT Community

30(33.3%)

39(43.3%) 16(17.85%) 35(38.9%)

Source: Authors Fieldwork, 2009. Perception about who owns HBMM was mixed. According to 41% of the health consumers, the MHMT owned the programme, 48% said that the Municipality Assembly owned it while 10% thought Kwame Nkrumah University of Science and Technology (KNUST) owned it. All the health providers suggested that, the HBMM belonged to the MHMT. Again, another 30% of the CMDs stated that the Municipal Assembly owned it while 70% of CMDs said the government of Ghana owned it. Just about 79% of the health consumers stated that measures were put in place to straighten the structures of the programme while 70% of the CMDs confirmed this. However, the health providers stated that they were not sure if there were some measures in place.

The drugs for the CMDs were supplied to them by the MHMT based on request as stated by 65.2% of the health consumers, 80% of the health providers and 76.7% of the CMDs. How well the HBMM could be sustained largely depends on the number and commitment of the CMDs as the blood stream of the programme. However, the number of the CMDs was reducing as stated by 89.5% of the health consumers, and 95.6% of the CMDs. About 60% of the health providers were not sure if there were attrition among the CMDs. On what account for attrition among CMDs, sixty-one percent of the health consumers and 80% of health providers stated that the

delay of supplies. However, 70% of the CMDs stated that, lack of incentives for them influenced the attrition.

A whooping proportion, 96%, of the health consumers and 87.8% of the CMDs indicated that there were barriers to the implementation of the HBMM. However, 40% of the health providers indicated that, there were no barriers to the implementation of the programme. There were several reasons ascribed to these barriers of HBMM. About 61.2 % of the health consumers stated that, cost of treating malaria in HBMM was the major barrier and 38.7% of the health providers stated that unavailability of the CMDs was also a barrier to the implementation. About 70% of the health providers stated lack of incentives giving to the CMDs as the cause of the problem while 61% of the CMDs suggested that most of them are not readily accessible. To overcome the barriers, 52.5% of the health consumers and 57.7% of the CMDs suggested that an increase in the number of the CMDs would improve the sustainability of the HBMM programme. Organized regular training session for the CMDs was also suggested by 24% of the health consumers and 42.2% of the CMDs.

As low as 30% of the health providers suggested increase in source of funding while 30% again suggested increase in allowances to the CMDs would help at least minimise the barriers. Majority of the respondents suggested that there should be continuity of the programme as indicated by all the health providers and 76% of the CMDs. Again, majority of the CMDs indicated that they receive incentives in the form of money. All the health providers interviewed, were not sure if the CMDs were satisfied or not with the incentives. However approximately, 51% of the community medicine distributors said they were satisfied with the incentives. Just

about 43% of the community medicine distributors stated that they received some kind of incentives from some caregivers while 39% said they received some form of incentives from the community as a whole.

4.5. Ability of CMDs The capabilities of the community medicine distributors to diagnose and give the right dosage of medicine to treat children under five years are presented in Table 4.9. Table 4.9 Ability of the CMDs in treatment of malaria Ability Health Consumers (n=400) Detect Malaria (fever) Yes No Level of education Illiteracy Basic Tertiary Outcome of treatment from CMDs 45(50%) 45(50%) 191(47.7%) 209(52.2%) 67(74.4%) 23(25.6%) CMDs (n=90)

Very well Not too well

248(62%) 152(38%)

76(84.4%) 14(15.6%)

Ability to give the right dosage Medicine Yes No 88(97.8%) 2(20%)

Symptoms identified Headache Weakness Vomiting Loss of appetite 25(27.8%) 38(36.7%) 23(25.6%) 9(10%)

Source: Authors Fieldwork, 2009. According to 74% of the CMDs, they are able to treat children suffering from malaria. However, just about 52.2% of caregivers stated that, CMDs are not able to diagnose and treat their children of malaria. About 50% of the CMDs had basic education and the rest had tertiary education, it could be concluded that with adequate training, CMDs have ample knowledge to managed children under five suffering from malaria (fever). Approximately 98% of the CMDs said that, they were able to give the right dosage of medicine. Their ability to give the right dosage was verified with reference to the HBMM protocol and over 90% of the CMDs were right. Again, 62% of the caregivers stated that, the health of their children improved after they have sought treatment from the CMDs. While 38% of the health consumers stated that, their wards do not get

well. About 84.4% of the CMDs indicated that majority of the children get very well after treatment. Again just about 36.7% of the CMDs identified weakness of the children as symptoms of malaria, 27.8% indicated headache, 25.6% indicated frequent vomiting and 10% indicated loss of appetite of children as a sign of malaria.

4.6. Sensitivity Analysis of Cost Estimates Table 4.10 presents the sensitivity analysis performed on the cost estimates. It was performed under the assumptions that costs would vary between a minimum of 3% discount and maximum of 5% for a five years implementation of HBMM. Table 4.10 Effect of change of cost within 5 years with discount rate of 3% and 5%.

3% discount rate Cost of treatment of malaria in HBMM (GP) 0.5 1 2 3 1.20986 2.41971 4.83942 7.25913 0.15833 0.31666 0.63332 0.94998 1.18491 2.36982 4.73964 7.10946 + + Change in cost +/- 20.06%*

5% discount rate Change in cost +/-20.06%*

0.15507 0.31013 0.62026 0.93039

Source: Authors Fieldwork, 2009. * Inflation rate Ghana Statistical Service

{(TC*(1+IR) ^ N)*(1-DF), (TC*(1-IR) ^ N)*(1-DF), (where, SA: sensitivity analysis, TC: Initial Cost, IR: Inflation rate, DF: Discounting factor, N: Number of years). Sensitivity analysis in this context shows how discount rate of 3% minimum and 5% maximum affects the cost of HBMM. With the assumption that HBMM would be implemented for five years and with a +/-5% change in inflation within the period, the cost of HBMM would vary within the ranges shown in the table. Again, cost of HBMM would have a slight variation between 3% and 5% discount rates in the next five years. Thus, the cost as shown in the table could be relied on for policy formulation using cost figures within the ranges. 4.7. Opportunity Cost of CMDs time in HBMM The opportunity cost of CMDs involved in HBMM is the forgone economic returns to them. That is the lost of what they could have earned from using their time in alternative economics activities instead of HBMM, table 4.11.

Table 4.11: Estimated value of opportunity cost of time of involving CMDs Summary of Time and Motion variables Average number of children per CMDS per Day Average minutes spent per child Number of minutes on children seen per day Average minutes spent on children/per month Number of children seen per month Wage per 60 minutes (1 hour) as per national minimum wage Wage per 60 minutes (1 hour) as per village wage rate 59 minutes 200.6 (3.4*59) 6018 (200.6*30) 102 (30*3.4) 0.24 (1.92/8hours) 0.9 (4.5/5hours) Time and rate 3.4

Opportunity cost per national minimum wage rate per day Opportunity cost per national minimum wage rate per month Opportunity cost per village wage rate per day Opportunity cost per village wage rate per month Source: Authors Fieldwork, 2009.

0.816GH(0.24*3.4) 24.48 (0.816*30) 3.06GH(0.9*3.4) 91.8GH(3.06*30)

There were 90 CMDs interviewed. The average number of children treated by CMDs per day was 3.4 within an average of 59 minutes on each child. Again, the average number of minutes spent on children seen by the CMDs per day was 200.6. Accordingly, the CMDs saw a total of 102 children per a 30- day month. The wage per 60 minutes as per 2009 national minimum wage rate (GH1.92) was GH 0.24 therefore the opportunity cost per the national minimum wage rate was 0.816GH per day while GH24.48 per month.

The CMDs would have received a monthly wage of GH24.48 as per the national minimum wage if they were working elsewhere. The individual who works by-day (village labourer contract) earn an average of GH4.50 (minimum of GH4.00 and maximum of GH5.00). The wage per 60 minutes as per village wage rate was GH0.9 while the opportunity cost for the village was 3.06GH per day and GH 91.8 per month. From this, the CMDs have forgone GH61.8 if the HBMM paid them GH3.00 as monthly incentives.

4.8 Inferential Statistics Inferential statistics showed how the conclusion drawn from evidence of reasoning was made. In this study, it indicates the associations between cost of treatment and occupational background as well as the association between gender and cost drives that influence HBMM. A Cross

tabulations was used to test for associations and chi-square test for homogeneity. Table 4.12 presents the relationship between cost of treatment and occupational background of health consumers.

Table 4.12. Relationship between cost of treatment and occupational background of health consumers.

Occupation

Cost of treatment of malaria for children GHp5 Frequency (%) GHp 10 Frequency (%) 99 (24.7%) 84 (21%) 119 (29.7%) 26 (6.5%) GHp 20 Frequency (%) 0 (0%) 45 (11.3%) 0 (0%) 0 (0%) 0.0001 p-value <

Famer Trader Artisan civil/public servant Total

27 (6.75% ) 0 (0%) 0 (0%) 0 (0%)

27

328

45

Source: Authors Fieldwork, 2009. Table 4.12, presents the relationship between occupation of the caregivers and the amount paid for seeking fever treatment for their children. Twenty-seven of the farmers representing 7% paid 5 GHp for treatment, and 99 (25%) paid GH 1.00 for treatment. Twenty-one and eleven percents of the traders paid GH 1.00 and GH 2.00 respectively for treatment. Just about 30% of the artisans and 7% of the civil or public servants paid GH 1.00. There were significant differences between the type of

occupation and the cost paid for treatment, p-value <0.0001 at 95 confidence interval. Based on these, it could be concluded that, caregivers who were traders could afford the price range of 5GHp to 20GHp. However, more farmers could buy at 5GHp and none at 20GHp.but all most all caregivers could afford it if it is 10GHp.

4.8.2. Association between gender and factors that decrease/decrease the cost of HBMM. Table 4.13 illustrates a connection between the gender and the factors which either decrease or increase the cost of HBMM. Table 4.13. Relationship between the gender and the cost drivers that decrease/increase HBMM Gender, n=90 Increase cost of HBMM Supplies Incentives Decreases cost of HBMM Supplies Incentives 17(18.9%) 25(27.8%) 30(33.3%) 18(20.0%) 14(15.6%) 28(31.1%) Male 16(17.8%) 32(35.6%) Females 0.030 Male Females P-value 1.000

Source: Authors Fieldwork, 2009. For factors that increase cost of HBMM, 15.6% and 17.8% males and females CMDs respectively indicated that increase in supplies would influence the cost of HBMM positively. In addition, 31.1% and 35.6% males and females CMDs respectively show that incentives can

influence the cost of HBMM positively. There were no significant differences between the cost of HBMM and the cost drivers (supplies and incentives), P-value 1.000 at 95 confidence interval. Based on this, it could be concluded that, largely, incentives giving to the CMDs has no bearing on the cost of HBMM.

Furthermore, a decrease in supply of HBMM materials and incentives giving to the CMDs can reduce the cost of running HBMM programme. In support to this, 18.9% and 33.3% males and females CMDs respectively show that, a decrease in supplies could reduce the cost of HBMM. In addition, 27.8% and 20.0% males and females CMDs respectively show that, a decrease in the incentives giving to the CMDs could help reduce the cost of HBMM. There were significant difference between the cost of HBMM and the cost drivers (supplies and incentives) with Pvalue 0.030 at 95 confidence interval. Based on this, it could be concluded that, decrease in supplies could reduce the cost of HBMM. Thus, the price on the supplies of stationery, bicycles, motor bikes, repairs incurred on motor bikes, and bicycles, boots, 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) can contribute to the total cost incurred in implementing HBMM.

CHAPTER FIVE

DISCUSSION

5.0 Introduction This chapter seeks to discuss the findings of the study in relation to previous work done by others, and inferences from the findings as well as policy implications.

5.1 Socio-demographics of Respondents The age distribution of the study respondents varied. It was realized that majority of the health consumers were between the economically active population of 18-49 years. The mean ages (in years) of the health consumers, health providers and CMDs were 34.9, 34.2 and 28.9 respectively. Females and married caregivers were more dominant in seeking malaria treatment for their children under five years of age. This verified that females were the primary caretakers of children in the Municipality which also typified most Ghanaian communities (GSS, 2009). Most caregivers had no education but approximately 42% had basic education and lived in mean household size of 4, again, depicting a typical rural Ghanaian community (GSS, 2009). Christianity was dominant among the caregivers. Most of them had stayed in the communities for over 20 years. Trading was the occupational trait of most of the caregivers in the Municipality.

Community medicine distributors were trusted and chosen by the members of their communities from a range of backgrounds, including farmers, chemical/medicine sellers, teachers, traders,

community health workers, artisans, 'mother trainers', and opinion leaders. Most, (48%), of CMDs were females with a mean age of 28.9 years. The CMDs had basic and tertiary education. About 62(68.8%) had stayed in the Municipality and have been involved in disease surveillance or health activities in the community for the past five or more years. This study confirms Dobson and Gaskin (1997) assertion that, females volunteer are more than their male counterparts. In all more females were engage in HBMM, this is a positive sign since they are the primary caregivers of children under five years. Therefore, if women are empowered by HBMM, they would be able to identify early signs and symptoms of malaria fever, seek prompt appropriate treatment, and thus improve the health statuses of children.

5.2 Household Cost of HBMM Household cost of seeking treatment of malaria fever included monetary and economic costs. From the study, the household cost for seeking treatment ranged from GHp 10 - GHp 30 per each episode of malaria while the CMDs also indicated the cost of treatment to be between GHp 1030. However, the costs of the health providers such as those at health facilities and chemical sellers charges for treatment for malaria differed and hen ce expensive as compared to the charges of the CMDs. About 40% of the health providers indicated the cost of treatment to be GH 6.00 for uncomplicated malaria. In addition, 40% of the health providers indicated the cost of treatment to be GH 10.00 for severe malaria.

From the cost of the HBMM and the health providers, it was seen that HBMM was less costly and affordable. A similar study done by Akazili, (2002) and WHO (2006), found that household cost of malaria treatment was estimated at 34% and 1% respectively of household income among

the poor and the rich. This does not make the burden of malaria heavy on the household. However, a study done by Goodman et al., (2000); Akazili, (2002); Hanson et al., (2004) ) showed that, the economic burden of malaria was not high at the worldwide, but it was seen greatly in the various households and this was the barrier to accessing health care as stated earlier.

Transportation cost is an important cost of seeking care, however in HBMM, CMDs are located within a walking distance of 0.5 to 1km and no transport cost is incurred. Proximity to source of care (CMDs) meant that time is saved in travelling. It follows that more time would be made available for economic activities. This confirms a study by Sauerborn et al, (1995) confirms that that reducing time spent in seeking treatment meant saving money since the time costs of seeking care was far lower than the value of time lost to care. In 2007, a WHOs comparison between HBMM and a non-HBMM revealed that, household in HBMM saves more time than in non-HBMM as walking time to access healthcare was not more than five minutes. This insinuated that HBMM promotes the prompt access goal of the WHO. According to Xavier (2007), although malaria (fever as commonly referred to) was a major cause of morbidity and mortality in Ghana, there was no documentation. The study by Xavier (2007) in two Municipalities in Ghana which estimated the economic and opportunity costs of malaria treatment found that substantial amount of time was spent in seeking malaria care and taking care of the sick, which made the indirect cost per case of fever represent 79% of the total cost of seeking treatment.

The average cost of treating an episode of the disease included the economic costs and the opportunity costs of travel and waiting time amounted to $8.67 or 3.7 days of male output or 4.7 days of female output. When compared with the average five days loss of output for the patient due to malaria

morbidity and caretaking, Xavier concluded that the cost of controlling malaria was lower than the lost earnings or the value of output among the households, making his study agreeable to this study. The sensitivity analysis performed on the cost estimates in this study showed that the cost of HBMM would vary slight under the assumptions under chapter three. Caregivers who were traders could afford the price range of GHp 5 to GHp 20. However, more farmers could buy at GHp 5 and none at GHp 20. In all most caregivers could afford HBMM services if was GHp 10. These findings thus reinforce the obvious fact that HBMM was affordable hence making the research hypothesis true.

5.3 Cost Drivers A study by Guest (1997) emphasizes that, it was 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. Supporting Guests studies, this study uncovered supplies and incentives giving to CMDs as the major factors influencing the cost of HBMM positively or negatively. Contrary to this study, the study of Collette (1994), showed that the level of severity of the illness, distant to the homes, the kind of interventions received (either intensive or standard case management) time spent in travelling and the size of people each CMDs handles were the factors which either increase or decrease the cost of HBMM.

In support of Collettes studies, the article of Joel (2006) confirmed an ideal statement that, the length of illness before getting a treatment is the key factor that gives to either a high or low cost

of health care. Thus, the longer the length of the illness the higher the cost of treatment, hence vice versa. In 1994, Lipsey showed that, the cost of illness for outpatients who received early diagnosis and prompt treatment were four to seven times lower than the cost of illness for those who were hospitalized. Therefore, people especially those living in malaria endemic sectors should be educated on seeking early treatment from CMDs since they promote prompt appropriate treatment.

From another perspective, HBMM helps the few health workforces to concentrate on complicated and other aspects of health care by taken care of the uncomplicated conditions. In the long round, this would improve efficiency of the health staffs. From the study, there was a significant difference between the cost of HBMM and the cost drivers (supplies), P-value = 0.030 at 95 confidence interval. The implication is that, a decrease in supplies could reduce the cost of HBMM and vice-versa. Thus, the price on the supplies of stationery, bicycles, motor bikes, repairs incurred on motor bikes, and bicycles, boots, 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) can contribute to the total cost incurred in implementing HBMM. However, another test statistics showed that, there was no significant difference between the cost of HBMM and the cost drivers (incentives), Pvalue =1.000 at 95 confidence interval. This means that, increase in incentives to the CMDs could increase the cost of HBMM.

5.4 Sustainability How well the programme of HBMM could be sustained or not was determined by so many factors of interest. This included the delays and long procedures which were followed in requesting for supplies as well as less amount of incentives giving to the CMDs. In the study of McCombie (1996), it was noted that in Africa, where more than 70% of malaria episodes in rural areas and more than 50% in urban areas are self-treated, home-based management of malaria was likely to succeed and sustained. Confirming to the finding of this study, McCombie (1996) showed that HBMM strategy could probably be sustained if it uses the existing community and health structures rather than implementing as a parallel programme.

A cursory review of the strategy showed 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. In addition, McCombie asserted that, what makes HBMM groundbreaking was that the effectiveness of the home-based approach for delivering. ACT has not yet been widely available, particularly for the most poor and vulnerable people. By measuring the health impact of home-based management of malaria (HBMM) with ACT over the next 2-3 years, PSI and TDR believe that the results of the project would serve as a powerful catalyst for the adoption and expansion of HBMM across sub-Saharan Africa. Moreover, Staedke et al (2009) studies showed that, although home -based management of malaria led to prompt treatment, there was little effect on clinical outcomes which might not let the programme sustainable. In their study, the substantial over-treatment suggested that artemether-lumefantrine provided in the home might not be appropriate for large urban areas or settings with fairly low malaria transmission." To them, to achieve the best possible effect on

health and to keep unnecessary over-treatment to a minimum, approaches that target treatment to laboratory-confirmed cases of malaria and strengthen delivery of care via health facilities might be preferable. To them a universal approach to deploying home- based management of malaria was unlikely to be appropriate."

Staedke and colleagues concluded that home-based management for malaria with artemetherlumefantrine was not the answer, and argued that health facilities handle fevers well. However, Ajayi et al (2008) established that HBMM with ACT is feasible, acceptable and promote early appropriate treatment for fever in children under five years in four African countries.

5.5 Ability of CMDs From the result, 33 of the CMDs had only basic education and 43 had tertiary and were capable of diagnosing and treating children with malaria. According to Ajayi et al, 2008, a study conducted in Nigeria, Uganda, Kenya and Ghana revealed that CMDs have the potentials of treating children under five with malaria. In their study, some 20,000 fever episodes in young children were treated with ACT by CMDs across the four study sites. Cross-sectional surveys identified 2,190 children with fever in the two preceding weeks, of whom 1,289 (59%) were reported to have received ACT from the CMDs. Overall, the proportion of febrile children who received prompt treatment and the correct dose for the assigned duration of treatment ranged from 71% to 87% (average 77%). Almost all caregivers perceived ACT to be effective, and no severe adverse events were reported. The study of Ajayi et al, (2008) showed that, CMDs were effective just as the findings of this study. To support the findings of this study and the contributions of Ajayi et al, (2008), a report

of PSI/TDR (2008), confirmed that a very high proportion of children received the correct dose of ACTs (97% or greater in all sites) based on the information recorded by the CMDs in their registers. From the survey data, CMDs were reported to have explained the dosing schedule on a very high proportion of occasions (>90% in all sites), but performed less well with respect to explaining danger signs or possible adverse events. This was confirmed in Ejisu-Juaben Municipality in Ghana. Availability of CMDs was reported to be good, with 85% or more of caretakers reporting that they found the CMDS at the first time of visiting. From these findings of the PSI and TDR, CMDs were highly qualified to administer drugs to children under five with malaria in the Municipality. Similarly, the findings of this study showed that 97.8% of the CMDs have the ability to treat children with the appropriate dosage.

5.6 Opportunity cost of CMDs effort in HBMM The opportunity cost of the CMDs was higher than the amount of money received as incentives in HBMM programme. The ideas of Sauerborn et al, (1995) were quite related to this study. 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. In addition to the above, 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 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. These were consistent with the steps employed in calculating the opportunity cost of the CMDs effort in HBMM in this study. Away from the above, intra household labour substitution was employed by Sauerborn et al (1996). In policy assessment there should be a consideration of the opportunity cost of time spent on HBMM by CMDs. From the findings, the value of lost opportunity of the CMDs per day based on the village labourer wage was twenty times higher than what they receive. Sauerborn, (1997) and Asenso-Okyere, (1997), confirmed this.

CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS

6.0. Introduction Chapter six presents the conclusions and policy recommendations.

6.1. Conclusions Following are the conclusions from the study as per the study objectives. 6.1.1 Socio-demographics Female CMDs dominated and affordability of HBMM was associated with the type of occupation; traders could afford price range of GHp 5 to GH 2.0 while farmers could afford it at GHp 5.

6.1.2 Cost drivers of HBMM Supplies and incentives to CMDs were the two key factors influencing cost of HBMM. Other factors such as transport, distance and cost though expected as important, respondents did not mention them. 6.1.3 Household cost in HBMM From the findings and discussions, cost incurred in accessing HBMM was less as compared to the one sought from the health facilities. All the caregivers could afford the price range of HBMM; GHp 5 to GH2.0.

6.1.4 Sustainability of HBMM 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. About 60% of the health providers were not sure if there were attrition among the CMDs. Delays in supplies, unattractive CMDs incentives and cost were the barriers to the implementation of the HBMM.

6.1.5 Ability to CMDs to prescribe Trained community medicine distributors have the ability to detect, treat and give the right dosage of medicines to the children.

6.1.6 Opportunity costs of CMDs in HBMM The monthly allowances giving to the CMDs compared to the national salary wage was far less. Therefore, the CMDs loose more money for being on HBMM programme than they would have received if they were working elsewhere.

6.2 Recommendations The section deals with suggestions both major and minor stakeholders as well as people with common interest should consider.

6.2.1 MOH/GHS and NMCP In general, MOH/GHS and NMCP should educate communities on the awareness of malaria and potency of HBMM in controlling. To ensure the continuity of HBMM, these agencies should periodically organise forums as well as workshops to find sustainable way of keeping CMDs

desire to work on the HBMM. Attempts should be made to introduce the use of RDT in detecting malaria in HBMM.

Finally, the MOH and the relevant ministries should team up to increase the income generation of caregivers so that HBMM could be affordable to them. The MOH and NMCP should look for alternative means of supplies to help reduce the cost of HBMM. The household cost of HBMM was affordable to caregivers; therefore, MOH/GHS and NMCP should maintain the range of cost. Lastly, the payment of incentives should be made more attractive with reference to the opportunity cost as per the national minimum wage rate or the village wage rate.

6.2.2 MHMT & Municipal Assembly To improve the economic statuses of caregivers, the MHMT should dialogue with the community leaders to increase income generating activities and also find attractive and sustainable incentives for CMDs. In addition, the MHMT should sensitise its members on HBMM and intensify its supervisory activities. It is important to note that the CMDs are working in are where professional health staffs are not ready to go and therefore should be compensated by way of attractive incentives.

6.2.3 Community Leaders Community leaders should take active part in the planning, implementation of health interventions. They should own HBMM and thus devise ways of motivating CMDs. They should also educate the households in their community on the need to use HBMM as it is less expensive and closer to their homes.

6.2.4. CMDs CMDs should see their role in HBMM as service to their communities and should not let economic gains override the desire of volunteerism. Incentives should not only be estimated in monetary terms but it should include social capital such as recognition, as the village doctor and access to friends from the city (teams outside the municipality and the country). 6.2.5. Households Caregivers should assess CMDs as first point of call after recognising signs and symptoms of their children. They should trust and support CMDs to deliver their service in HBMM. They should also adhere to all the instructions given to them by the CMDs.

6.3 Concluding Remarks Cost of care in HBMM is much more affordable to caregivers than cost from other sources of health care. CMDs are a force to be reckoned in HBMM. However, their efforts are not well compensated as manifested in the high opportunity cost amidst low incentives. HBMM has been shown to be more potent in promoting early appropriate treatment in rural areas. However, the sustainability of HBMM is bleak as the upkeep of volunteers; their kits, incentives, communal support and ownership remained unknown. We stand the risk of losing the enviable benefits of HBMM if more measures are not taken to sustain it.

REFERENCES Agyei-Baffour, P. (2008): Access, use and cost implications for equity of home management of malaria in children under five years in rural Ghana (PhD Thesis). Ajayi IO, Browne EN, Garshong B, Bateganya F, Yusuf B, Agyei-Baffour P, Doamekpor L, Balyeku A, Munguti K, Cousens S, Pagnoni F (2008): Feasibility and acceptability of artemisinin-based combination therapy for the home management of malaria in four African sites. Akazili, (2002): Costs to households of seeking malaria care in the Kassena-Nankana Municipality of Northern Ghana. In: Third MIM Pan-African Conference on Malaria, Arusha, Tanzania, and 17-22 November 2002. Bethesda, MD, Multilateral Initiative on Malaria: Abstract 473. Asante and Asenso-Okyere (2003). Economic Burden of Malaria in Ghana, Institute of Social and Economic Research, University of Ghana, Technical Report submitted to the WHO data Idriss, O (2007) Methodology for Calculating the Economic Cost of Malaria. Asenso-Okyere, W. K. and Dzator, J. A. (1997). Household cost of seeking malaria care. A retrospective study of two Municipalitys in Ghana. Soc. Sci. Med. Vol. 45, No. 5, pp. 659-667. Ahmed K (1989) Malaria in Ghana-Overview. Ghana Med J, 22:190-196. Browne, E. N. L. (2003). Home management of malaria in rural Ghana using pre-packed Chloroquine. Brieger, W, Unwin, A., Greer, G. and Meek, S. (2004) Interventions to improve the role of medicine sellers in malaria case management for children in Africa. Chima, R., Goodman, A. and Mills, A. (2003). The economic impact of malaria in Africa: A critical review of the evidence, Health Policy, 63:1, 17-36.

Creese, A., Parker, D. Collette, A. (1994): Cost analysis in primary health care: a training manual for programme managers, WHO, Geneva. Deepak, S., Sharma, M. (2001): Volunteers and Community-Based Rehabilitation. Asia Pacific Distabi. Rehab. J.; 12(2): 141-148. Drummond, M., Aguiar-Ibez, Nixon (2006): Economic evaluation. Evidence-Based Medicine and Healthcare, Singapore Med J; 47(6): 456 Gallup and Sachs, (2001); The Economic Burden of malaria. Centre for International Development at Harvard University. Goodman, C., Kachur, P., Abdulla, S., Mwageni, E., Nyoni, J., Schellenberg, A., Mills, A. & Bloland, P. (2004) Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities . Tropical Medicine and International Health 9: 655-663. Gaskin, K., Dobson, B., (1997): The economic equation of volunteering. Soc. Pol. Res. 110:1-4. York: Joseph Rowntree Foundation. Guyatt, H.L. and Snow, R.W., (2004): The management of fevers in Kenyan children and adults in an area of seasonal malaria transmission. Trans. R. Soc. Trop. Med. Hyg. 98, pp. 111115 Hanson, K., Goodman, C., Line, J., Meek, S., Bradely, D., and Mills, A. (2004): The economics of malaria control interventions. Global Forum for Health Research, Geneva, Switzerland. Hadi, A. (2003). Management of acute respiratory infections by CMDs: experience of Bangladesh Rural Advancement Committee (BRAC). Bull. of W H O; 81; 183-189. Hanson, M. K. (2002) Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat, India: Current experiences and challenges, Bull. of the WHO (8), pp. 613621.

Health Promotion Capacity-Building Assistance Team (2007): A Guide to Integrating Community Health Workers into Health Disparities Collaborative. Health Promotion & Migrant Clinicians Network, [www.migrantclinicians.org, Feb, 2009]. Hopkins, H., Talisuna, A., Whitty, C. J.M. and Staedke, S. G. (2007): Impact of home-based management of malaria on health outcomes in Africa: a systematic review of the evidence. Mal. J. 6:134. Hodgson T, Meiners M. Cost-of-illness methodology: a guide to current practices and procedures. Milbank Memorial Fund Quarterly/Health and Society 1982; 60(3):42962. Joel, E. S. (2006) RTI International RTI-UNC Centre of Excellence in Health Promotion Economics. Kamrul, M. (2000): Gerdtham Department of Community Medicine, Lund University,

Malm, Sweden. Kiszewski, A., Johns B., Schapira, A., Delacollette, C., Crowell V., Tan-Torres, T., Ameneshewa, B., Teklehaimanot, A., & Nafo-Traor, F. (2007). Estimated global resources needed to attain

international malaria control goals. Bull. of WHO; 85:623630. Kidane G. & Morrow, R.H. (2000) Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia, a randomised trial. Lancet 356: 550-55. Kentner, N., Lange, C., Reifschneider, E., & Takacs, A. (2003): The Cost and Benefits of Volunteers.

Volunteerism Area of Expertise. White Paper. 1-10 Michigan: Michigan State University Extension. Kllander K, Guenther T, Wells G, (2006): Case management of childhood fevers in the community. Exploring malaria pneumonia care in Uganda. Karoliska Instituttet, Stockholm.

Kipp, W. Kamugisha, J., Jacobs, P., Burnham, G., and Rubaale, T. (2001): User fees, health staff incentives, and service utilization in Kabarole Municipality, Uganda. Bull. of WHO, 79: 1032 1037. Kolaczinski, J. H., Ojok, N., Opwonya, J., Meek, S., Collins, A. (2006): Adherence of community caretakers of children to pre-packaged antimalarial medicines (HOMAPAK) among internally displaced people in Gulu Municipality, Uganda. Mal. J., 5:40 Lipsey, R. G. (1994). An Introduction to Positive Economics. Seventh Edition Oxford University, London. Marsh, V. & Kachur, S.P. (2003 draft) Malaria Home Management Policy to Strategy and Implementation Brief (Series Editor: S. Mehra) Marsh. V.M., Mutemi, W.M., Muturi, J., Haaland, A., Watkins, W.M., Otieno, G. & Marsh, K. (1999) Changing home treatment of childhood fevers by training shop keepers in rural Kenya. Trop. Med. and Int. Hea. 4: 383-389. Marsh, V.M., Mutemi, W.M., Willetts, A., Bayah, K., Were, S., Ross, A. & Marsh, K. (2004) Improving malaria home treatment by training drug retailers in rural Kenya. Trop. Med. and Int. Hea. 9: 451-460. Malaney, P., Spielman, A., and Sachs, J. (2004): The Malaria Gap. Amer. J. of Trop. Med. and Hyg, 71 (Suppl 2), pp. 141146. McGuire, T., (2000): Physician agency. In: New house, J., Culyer, A. (Eds.), Handbook of Health Economics, Vol. 1. North-Holland, Amsterdam McCombie, S.C. (2002) Self Treatment for malaria: the evidence and methodological issues. Hea. Pol. and Plan. 17: 333-344. MOH (2004): Transport Policy. Ministry of Health Ghana Policy Document Municipal Health Management Team Annual Report, (2008) Ejusi-Juaben, Ghana.

Ofosu, P. (2006): Pride of Ashanti, Dsezyn origin. Onwujekwe, El-Fatih, M., Sara, H. and Abraham, M. (2005): Socio-economic inequity in demand for insecticide-treated nets, in-door residual house spraying, larviciding and fogging in Sudan. Mal. J., 4:62 Riley, M. J., Schott, G., Schultinik, J., (2002). Determining Volunteer Motivations - A Key to Success, [www.msue.msu.edu ,January 2008]. RBM, (2001): Malaria: Progress in Rolling Back Malaria in the African Region, Lia. Bul. of Mal. Pro.WHO/AFRO, 4:4. Russell, S. (2004). The economic burden of illness for households in developing countries: A review of studies focusing on malaria, tuberculosis and human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome, Am. J. of Trop. Med. and Hyg. 7sSuppl. 2, pp. 147155. RBM/WHO/UNICEF, (2005): World Malaria Report. Geneva, Switzerland. Sauerborn R, (1995). Estiamting the direct and indirect economic costs of malaria in rural Burkina Faso. Trop. Med. and Para. 42:219-233. Sauerborn R, Adams A, Hien M (1996): Household strategies to cope with the economic costs of illness. Soc. Sci. Med, 43:291-301. Samba, E., (2001): African countries urged to scale up malaria control. WHO/AFRO Press Release (9 May 2001, Harare. Sachs J. and Malaney Pia (2002); The Economic and Social Burden of Malaria. Nature 415, 680 - 685. Macmillan Pub. Ltd. Sarah G Staedke, Norah Mwebaza, Moses R Kamya, Tamara D Clark, Grant Dorsey, Philip J Rosenthal, Christopher J M Whitty (2009): Home management of malaria with artemether-

lumefantrine compared with standard care in urban Ugandan children: a randomized controlled trial. Sirima, S.B., Onate, A., Tiono, A.B., Convelbo, N., Cousens, S. & Pagnoni, F. (2003) Early treatment of childhood fevers with pre-packaged antimalarial drugs in the home reduces severe malaria morbidity in Burkina Faso. Trop. Med. and Int. Hea. 8: 133-139. Sharma, M., Deepak, S. (2003): An Inter-Country Study of Expectations Roles, Attitudes and Behaviours of Community-Based Rehabilitation Volunteers. As. Pac. Disabi. Rehab. J. 179 Vol. 14 No. 2. Ungar, W. J. (2007).Paediatric health economic evaluations: a world view. Healthcare Q: 10(1):134-40, 142-5; discussion 145-6. WHO/UNICEF/RBM, (2005): World Malaria Report. WHO, (2006): The Africa Malaria Report. Regional Offices for Africa and Eastern Mediterranean. WHO, (2007): Health Action in Crises, Highlights- 9:9-15. WHO, (2006): The World Health Report Working together for health. World Health Organization, Geneva, Switzerland.

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY/COLLEGE OF HEALTH SCIENCES/DEPARTMENT OF COMMUNITY HEALTH

SUSTAINABILITY

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COST

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INTEGRATED

PACKAGE

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DIAGNOSIS AND MANAGEMENT OF UNCOMPLICATED MALARIA IN THE EJISU-JUABEN MUNICIPALITY IN GHANA

Core Questionnaire-Health Providers

INTRODUCTION:

Good Morning. My Name is .............................., we are involved in malaria research being undertaking by Department of Community Health, SMS, and KNUST. The aim of this study is to assess the sustainability and cost of integrated package for home diagnosis and management of uncomplicated malaria to improve efficiency for smooth quality health care delivery in Ghana. We are organizing meetings of this nature with people like you. We would therefore be very grateful if you could take a few minutes to answer some questions. There are no wrong or right answers. Whatever you say would help us analyze the issues. You are free to refuse to answer any question which may appear embarrassing to you. Your responses would be kept confidential and would be used for academic and research purposes. Thank you.

Date.././2009

Time Interview Started.

Place of Interviewed..

Name of Interviewer.. SECTION A: BACKGROUND INFORMATION Community Code: a. 1 ( ) b. 2 ( ) c. 3 ( ) d. 4 ( ) e. 5 ( ) f. 6 ( )

1. Age of Respondent . (In complete Years)

2. Status of Respondent 1) Nurse ( ), 2) Administrator ( ), 3) Medical Officer ( ), 4.Pharmacist ( ), 5. Disease control ( ), 6) others (specify)..

3. Sex of respondent [ 0 = male 1 = female

4. Type of Institution..

5. Marital Status of Respondent a) Married ( ) (b) Not married ( )

6. What is your Highest Educational level? 1) None ( ) 2) Basic ( ) 3) Tertiary ( ) 7. Religion1) Islam ( ) 2) Christian ( ) 3) Traditional ( ) 4) Other ( ).

8. Length of stay at the facility.

SECTION B: COST OFHOME DIAGNOSING AND TREATMENT OF MALARIA 9. How would you describe the level of malaria cases in the Municipality? A. increasing ( ) b. decreasing ( ) c. moderate ( ) d. cant tell ( ) 10. How is the severity of malaria in the Municipality? A. uncomplicated ( ) b. moderate to severe ( ) c. severe ( )

11. What could account for this situation?.....................................................................

12. What is the chain of activities involved in the management of malaria in this facility? Children Activities Registration Give card Take history Check temperature Check weight Laboratory Dispensary Other (specify) Uncomplicated Severe

13. What types of cost are involved in diagnosing and treatment of malaria?

a. Capital cost ( ) b. Recurrent cost (

) c. Others ( )

14. How much will it cost () in total to manage malaria in. Uncomplicated Children Adults Severe

15. How long in minutes do you spend on a patient who presents with Uncomplicated Children Severe

16. How would you describe the cost involved in diagnosing and treatment of malaria? A. expensive ( ) b. cheap ( ) c. very cheap ( ) cant tell

17. What else could you be doing if you had not seen patients today? A. research ( ) b. out of office ( ) c. Supervision ( ) d. other (specify)

SECTION C: COST DRIVERS IN HOME DIAGNOSING AND TREATMENT OF MALARIA 18. What are the factors which may decrease the treatment cost of malaria? a. Supplies ( ) b. personnel ( ) c. Health centre ( ) d. Others (specify)............ 19. What are the factors which may increase the treatment cost of malaria? a. Supplies ( ) b. personnel ( ) c. Health centre ( ) d. Others (specify)............ 20. From what you have chosen above, could you explain the reasons why these factors increase or decrease the cost of treating malaria? 21. What is the trend of these costs? a. Increasing ( ) b. decreasing ( ) c. stagnating ( ) d. fluctuating ( ) e. Cant tell ( )

22. What could be the possible outcome when there is reduction in the treatment cost? a. Increase in consumption ( other. ) b. reallocation of resources to other treatment ( ) c.

23. What could be the possible outcome when there is an increase in the treatment cost? A. reduction in consumption ( ) b. increase in mortality ( ) c. shortage of resources for other treatment (

24. Do you engage the services of community-based volunteers? a. Yes ( ), b. No ( ), c. others (specify)..

25. How many volunteers do you supervise? ................................ .......... 26. How helpful are volunteers? A. mobilization ( ) b. management of uncomplicated cases ( ) c. recordings ( ) d. Others (specify)..........................................................................

27. Are the volunteers given incentives for their activities? a. Yes ( ), b. No ( (specify).. 28. What form does compensation take? a. Monetary ( ) b. award scheme ( ) c. in kind ( ) d. Others ( )

), c. others

29. How do volunteers accept this incentive? a. Satisfied ( ) b. not satisfied ( ) c. Cant tell ( ) d. Others (specify)......................

30. Are volunteers able to provide all the appropriate medicines required for the treatment of malaria always? a. Yes ( ), b. No ( ), c. others (specify)..

31. If yes, which of these are given?

a. Paracetamol ( ) b. Amodiaquine only ( ) c. Artesunate only ( ) d. Artesuante-Amodiaquine ( ) e. Chloroquine ( ) others (specify)

32. What other supplements do the hospitals add to the treatment of malaria? Vitamins ( ) b. Pain killers ( ) c. ORS ( ) others (specify)

33. What approach should we use to ensure the least cost in diagnosing and treatment of malaria? a. To use diagnostic which provides maximum results at least cost ( ) b. To find additional sources of funds ( ) c. To outsource for staff ( ) d. educate clients to seek treatment early ( ) e. others (specify).

SECTION D: SUSTAINABILITY OF HOME MANAGEMENT OF MALARIA 34. Who owns the running of the home management of malaria in the Municipality? a. MHMT ( ) b. the Municipality assembly ( ) c. university ( ) d. others ( ) (specify)

35. What existing structures are in place to sustain this programme? ........................................ .................

36. Are there measures put in place to encourage the CMDs to work? a. Yes ( ), b. No ( ) c. Cant tell

37.

If

yes,

specify..................................................................................................................................... ............................................................................................................................................................ ...........

38. How do you supply medicine to the CMDs? A. regularly ( ) b. request ( ) c. other (specify)

39. Who does the monitoring and supervision of the programme? . 40. Is the size of the CMDs reducing? a. Yes ( ), b. No ( )

41. If yes, what could be the cause? ........................................ ................

42. In general, what do you think about the whole package of diagnosing and treatment of malaria in the Municipality? .................... .....

 ........ .............. 43. Do you think the HMM programme should be carried out continuously? a. Yes ( ), b. No ( ), c. others (specify)..

44. Are there some barriers to the implementation and sustainability of the HMM programme? a. Yes ( ), b. No ( ), c. others (specify)..

45. If yes, what are they?

46. What do you think should be done to sustain the programme?

THANK YOU

TIME ENDED..

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY/COLLEGE OF HEALTH SCIENCES/DEPARTMENT OF COMMUNITY HEALTH

SUSTAINABILITY

AND

COST

OF

INTEGRATED

PACKAGE

FOR

HOME

DIAGNOSIS AND MANAGEMENT OF UNCOMPLICATED MALARIA IN THE EJISU-JUABEN MUNICIPALITY IN GHANA

Core Questionnaire-Health Consumers

INTRODUCTION: Good Morning. My Name is .............................., we are involved in malaria research being undertaking by Department of Community Health, SMS, and KNUST. The aim of this study is to assess the sustainability and cost of integrated package for home diagnosis and management of uncomplicated malaria to improve efficiency for smooth quality health care delivery in Ghana. We are organizing meetings of this nature with people like you. We would therefore be very grateful if you could take a few minutes to answer some questions. There are no wrong or right answers. Whatever you say would help us analyze the issues. You are free to refuse to answer any question which may appear embarrassing to you. Your responses would be kept confidential and would be used for academic and research purposes. Thank you.

Date.././2009

Time Interview Started.

Place of Interviewed..

Name of Interviewer.. SECTION A: BACKGROUND INFORMATION Community Code: a. 1 ( ) b. 2 ( ) c. 3 ( ) d. 4 ( ) e. 5 ( ) f. 6 ( )

1. Age of Respondent . (In complete Years)

2. Occupation 1) Farmer ( ), 2) trader ( ), 3) artisan ( ), 4) civil/public servant ( ) 5) others (specify)..

3. Sex of Respondent 0 = male 1 = female

4. Marital Status of Respondent 1) Married ( ) 2) Not married ( )

5. What is your Highest Educational level? 1) None ( ) 2) Basic ( ) 30Tertiary ( )

6. Religion.1) Islam ( ) 2) Christian ( ) 3) Traditional ( ) 4) Other ( ).

7) Role in community 1) opinion leader ( ), 2) religious ( ) 3) leaders ( ), 4) spiritualist ( ) 5) Caregiver ( )

SECTION B: HOUSEHOLD COSTS 8. Where do you seek treatment for malaria in children? a. Home ( ) b. Chemical sellers ( ) c. CMDs ( ) 4.Others (specify)..

9. How much will it cost () in total to seek treatment for malaria in. Uncomplicated Children Adults Severe

10. How would you consider the cost of home diagnosis and treatment of malaria? A. expensive ( ) b. cheap ( ) c. very cheap ( )

11. Who pays for your health cost? A. self ( ) b. mother ( ) c. father ( ) d. spouse ( ) e. children ( ) f. NHIS ( )

12. How much of your income goes into payment for home diagnosis and treatment of malaria? A. all ( ) b. Half ( ) c. two-thirds ( ) Not sure ( )

13. How far in km is your house from the volunteers? A. 1/2km ( ) b.1km ( ) c. 2km ( ) d. 3km e. 4km f. 5 and over km ( )

14. How long in minutes do you spend form your house to and from the CDD

a. 5 ( ), b. 10 ( ), c. 15 ( ), d. 30 ( ), e. 1+ ( ), f. others (specify)..

15. Are you satisfied with the procedures in home diagnosing and treatment of malaria? A. very satisfied ( ) b. not satisfied ( ) c. not sure ( )

16. How many days do you spend in total for seeking care for your sick child? A. 1 day ( ), b. 2 days ( ), c. 3 days ( ), d. Others (specify). SECTION C: COST DRIVERS 17. What in your opinion determines the treatment cost of malaria? a. Distance ( ), b. Type of health facility ( ), c. type treatment ( ), d. severity of condition ( ), e. other (specify)

18. From what you have chosen above, can you explain the reasons why that is the factor which increase the cost of malaria treatment?............................ ........................................ .............. 19. From what you have chosen above, can you explain the reasons why that is the factor which decrease the cost of malaria treatment? ........................................ ..................

SECTION D: SUSTAINABILITY OF HOME MANAGEMENT OF MALARIA

20. Who owns the running of the home management of malaria in the Municipality? a. MHMT ( ) b. the Municipality assembly ( ) c. university ( ) d. others ( ) (specify)

21. What existing structures are in place to sustain this programme? 22. Are there measures put in place to encourage the CMDs to work? a. Yes ( ), b. No ( ) c. Cant tell

23.

If

yes,

specify.................................................................................................................................... 24. How do you supply drugs to the CMDs? A. regularly ( ) b. request ( ) c. other

(specify).....................................................

25. Who does the monitoring and supervision of the programme? .................... .......... 26. Is the size of the CMDs reducing? a. Yes ( ), b. No ( )

27. If yes, what could be the cause?

 ........................................ ...............

28. In general, what do you think about the whole package of diagnosing and treatment of malaria in the Municipality? .................... .....

29. Do you think the HBMM programme should be carried out continuously? a. Yes ( ), b. No ( ), c. others (specify)..

30. Are there some barriers to the implementation and sustainability of the HMM programme? a. Yes ( ), b. No ( ), c. others (specify)..

31. If yes, what are they? ................................................................................................................ ...... 32. What do you think should be done to sustain the programme?

SECTION E: CMDs ABILITY TO DIAGNOSE CHILDREN FOR TREATMENT 33. Do the volunteer able to detect when one is suffering from malaria? a. Yes ( ), b. No ( ), c. others (specify)..

34. How do you know when your child gets well after treatment? a. Temperature runs down ( ) b. stop vomiting ( ) c. playing and eating well ( ) d. other (specify)

35. Do you prefer going to the clinic ( ) or self treatment ( ) or volunteer ( )

36. Where do you usually obtain your drugs from? A. volunteers ( ) b. chemical stores ( ) c. clinics ( ) d. leftovers ( ) e. herbs ( ) f. others (specify)..

37. Does your child get well when you self medicate? a. Yes ( ), b. No ( ), c. others (specify)..

38. Does your child get well when seen by the CMDs? a. Yes ( ), b. No ( ), c. others (specify)..

39. Are you given medicine whenever you visit CMDs? a. Yes ( ), b. No ( ), c. others (specify)..

40. If yes, what kind of medicine is given? a. Amodiaquine only ( ) b. Atersunate only ( ) artesuante-amodiaquine c. paracetamol ( ) d. ORS ( )

41. What do the CMDs always tell you when you visit him/her?

THANK YOU

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY/COLLEGE OF HEALTH SCIENCES/DEPARTMENT OF COMMUNITY HEALTH

SUSTAINABILITY

AND

COST

OF

INTEGRATED

PACKAGE

FOR

HOME

DIAGNOSIS AND MANAGEMENT OF UNCOMPLICATED MALARIA IN THE EJISU-JUABEN MUNICIPALITY IN GHANA

Core Questionnaire-Community Medicine Distributors

INTRODUCTION:

Good Morning. My Name is .............................., we are involved in malaria research being undertaking by Department of Community Health, SMS, and KNUST. The aim of this study is to assess the sustainability and cost of integrated package for home diagnosis and management of uncomplicated malaria to improve efficiency for smooth quality health care delivery in Ghana. We are organizing meetings of this nature with people like you. We would therefore be very grateful if you could take a few minutes to answer some questions. There are no wrong or right answers. Whatever you say would help us analyze the issues. You are free to refuse to answer any question which may appear embarrassing to you. Your responses would be kept confidential and would be used for academic and research purposes. Thank you.

Date.././2009

Time Interview Started.

Place of Interviewed..

Name of Interviewer.. SECTION A: BACKGROUND INFORMATION Community Code: a. 1 ( ) b. 2 ( ) c. 3 ( ) d. 4 ( ) e. 5 ( ) f. 6 ( ) 1. Age of Respondent . (In complete Years) 2. Sex of respondent [ 0 = male 1 = female ]

3. Marital Status of Respondent a) Married ( ) (b) Not married ( )

4. What is your Highest Educational level? 1) None ( ) 2) Basic ( ) 3) Tertiary ( ) 5. Religion.1) Islam ( ) 2) Christian ( ) 3) Traditional ( ) 4) Other ( ).

6. Length of stay in the community (years).

SECTION B: COST OFHOME DIAGNOSING AND TREATMENT OF MALARIA 7. How will you describe the level of malaria cases in the Municipality? A. increasing ( ) b. decreasing ( ) c. moderate ( ) d. cant tell ( )

8. How is the severity of malaria in the Municipality? A. uncomplicated ( ) b. moderate to severe ( ) c. severe ( )

9.

What

could

account

for

this

situation?....................................................................................................

10. What activities are involved in home management of malaria? Children Activities Take history Check temperature Check weight Laboratory/RDT Dispense Other (specify) . Uncomplicated Severe

11. What types of cost are involved in diagnosing and treatment of malaria? a. Capital cost ( ) b. Recurrent cost ( ) c. Others ( )

12. How much will it cost () in total to manage malaria in. Uncomplicated malaria Children Severe malaria

13. How long in minutes do you spend on a patient who presents with?

Uncomplicated malaria Children

Severe malaria

14. How would you describe the cost involved in diagnosing and treatment of malaria? A. expensive ( ) b. cheap ( ) c. very cheap ( ) cant tell

15. What else could you be doing if you had not seen patients today? A. go to by-day ( ) b. goes to farm ( ) c. organizes IEC ( ) d. other (specify)

SECTION C: COST DRIVERS IN HOME DIAGNOSING AND TREATMENT OF MALARIA 18. What are the factors which may decrease home-based management of malaria? a. Supplies ( ) b. CMDs incentives ( ) c. Others (specify)............

19. What are the factors which may increase home-based management of malaria? a. Supplies ( ) b. CMDs incentives ( ) c. Others (specify)............

20. From your answers, could you explain the reasons why these factors increase or decrease the cost of treating malaria? ........................................ .............. 21. What could be the possible outcome when there is reduction in the treatment cost?

a. Increase in consumption (

) b. reallocation of resources to other treatment (

) c.

other.d. decrease in malaria cases (mortality/ morbidity) 22. What could be the possible outcome when there is an increase in the treatment cost? A. reduction in consumption ( ) b. increase in mortality/ morbidity ( ) c. shortage of resources for other treatment ( )

23. How well do you relate to the health staffs who supervise you? A. excellent ( ), b. very good ( ), c. good ( ) d. poor ( )

24. How many volunteers do you work with in the community? .

25. How many caregivers visit you per day? a. 1 ( ) b. 2( ) _c. 3( ) d. 4 ( ) e. 5 or more _____________

26. Are you given incentives for their activities? a. Yes (

), b. No (

), c. others

(specify).. , by whom? A. caregivers ( ) b. Municipality assembly ( ) c. community (

27. What form does compensation take? a. Monetary ( ) b. award scheme ( ) c. in kind ( ) d. Others ( )

28. What would you say about the incentives?

a. Satisfied ( ) b. not satisfied ( ) c. Cant tell ( ) d. Others (specify)......................

29. Are you able to provide all the appropriate medicines required for the treatment of malaria always? a. Yes ( ), b. No ( ), c. others (specify)..

30. If yes, which of these are given? a. Paracetamol ( ) b. Amodiaquine only ( ) c. Artesunate only ( ) d. Artesuante-Amodiaquine ( ) e. Chloroquine ( ) others (specify)

31. How many tablets do you give to a child? a. less than 12 months b. 12-59 months

32. What other supplements do you add to the treatment of malaria? Vitamins ( ) b. Pain killers ( ) c. ORS ( ) others (specify) SECTION D: SUSTAINABILITY OF HOME-BASED MANAGEMENT OF MALARIA 33. Who owns the running of the home management of malaria in the Municipality? A. government ( ) b. the Municipality ( ) c. others (specify).

34. Are there measures put in place to encourage the CMDs to work? a. Yes ( ), b. No ( ) 35. If yes, specify......................................................................

............................................................................................................................................................ ....................................................................................................................... 36. How do you get your drug supplies? A. regularly ( ) b. request ( ) c. other (specify)

37. Who come to monitor and supervise the programme? . 38. Is the size of the CMDs reducing? a. Yes ( ), b. No ( )

39. Why would CMDs stop the HBMM programme? ........................................ .................

40. In general, what do you think about the whole package of diagnosing and treatment of malaria in the Municipality? ..

41. Do you think the programme should be carried out continuously? a. Yes ( ), b. No ( ), c. others (specify)..

42. Are there some barriers to the implementation and sustainability of the programme? a. Yes ( ), b. No ( ), c. others (specify)..

43. If yes, what are they? 44. What do you think should be done to sustain the programme?

SECTION E: CAPABILITIES OF CMDS IN HBMM 45. When a client visits you what do you first do? a. Take history ( ), b. touch patient ( ), c. take temp with thermometer ( ), d. administer drug ( ), e. other (specify)..............................

46. Are you able to detect when one is suffering from malaria? a. Yes ( ), b. No ( ), c. others (specify)..

47. What are the symptoms you identified? A. headache ( ) b. weakness ( ) c. vomiting ( ) d. lost of appetite ( ) e. dizziness ( ) f. others (specify)..

48. Where do you obtain your drugs from? A. government ( ) b. chemical stores ( ) c. clinics ( ) d. Others (specify)..

49. Does the patient get well when you give medication? a. Yes ( ), b. No ( ), c. others (specify)..

50. How do people in this community see your work? a. Helpful ( ), b. Not helpful ( ), c. Cant tell ( ), d. Others (specify).......................

THANK YOU

TIME ENDED..