Direct Cost of Severe Malaria Treatment Borne by the Families of Children Aged 0 - 5 Years at the Fana Reference Health Centre, Mali ()
1. Introduction
Malaria affects the health and wealth of countries and people; the mere presence of malaria in a community or country is also detrimental to individual and national prosperity because of its influence on social and economic decisions [1]. The World Malaria Report, published in December 2016, recalls that nearly half of the world’s population was at risk of contracting malaria in 2015 in 91 countries, with 212 million cases of malaria and 429,000 deaths [2]. In Africa today, it is recognized that malaria is both a disease of poverty and a cause of poverty; annual economic growth in countries with high malaria transmission has always been lower than in malaria-free countries, and economists attribute malaria to an annual growth deficit of up to 1.3% in some African countries [1]. Indeed, it consumes 40% of public health expenditures in Africa and hinders the schooling of children and social development [3]. Malaria is the leading cause of morbidity and mortality in Mali and is among the ten countries with the highest number of malaria cases and deaths (3% of cases and deaths in the world, and 6% of cases in West Africa) [4]. In addition to the human burden, malaria affects the national economy by reducing gross national product (GNP) due to working days lost by working people and hinders children’s schooling and social development. According to a study conducted by the National Institute of Research in Public Health (INRSP), the economic losses due to malaria are estimated at 72 billion CFA francs per year. It is thus considered a disease of poverty and a cause of poverty [5]. The direct cost of malaria care covers individual and public expenditure on malaria prevention and treatment. In some highly malarial countries, expenses can account for up to 40% of public health expenditure, 30% - 50% of hospital admissions and up to 50% of outpatient consultations [6]. Fana is a rural area with a poor population whose economy is mainly based on agriculture dependent on the rainy season. In this context, what would be the cost of treating severe malaria? Can this cost affect this fragile family economy? In the absence of data on the cost of managing severe malaria, we set ourselves the objective of estimating the direct economic cost borne by families in the management of severe malaria in children aged 0 to 5 years hospitalized in pediatrics at the Fana Reference Health Center.
2. Material and Method
2.1. Framework
The study took place in the Fana Health District Reference Health Centre in the pediatric unit. The Fana health district was established in 1999 in Koulikoro region (Mali republic). It covers the districts of Béléco, Mena and Fana, divided into 13 rural communes with an area of 7319 km2. It is currently composed of twenty-two (22) functional health areas; 2 private clinics; 5 private medical practices. The target population estimated in 2020 was 328,801 inhabitants according to the revised General Census of Population and Housing (RGPH 2009 révisé) [7].
2.2. Type and Period
This was a cross-sectional, descriptive study with prospective data collection, which ran from July 2017 to June 2018.
2.3. Population
The study concerned children aged 0 to 5 years hospitalized and treated for severe malaria in the pediatric unit of the Reference health center of Fana.
2.4. Inclusion Criteria
Were included in this study:
• Children aged 0 to 59 months hospitalized and treated for severe malaria;
• The full availability of justification of expense (consultation and hospitalization ticket, prescription, analysis sheets, restaurant subscription);
• The obtaining informed parental consent.
2.5. Non-Inclusion Criteria: Not Included in This Study
• Cases of evacuation, abandonment or death during care;
• A hospitalization period of less than 24 hours.
2.6. Sampling
The sample size was determined by making a comprehensive sampling based on the inclusion and non-inclusion criteria.
2.7. Data Collection and Analysis Technique
2.7.1. Operationalization of Variables
Variables operationalization table:
The methodology used was based on the method of estimating the quantified economic cost of severe malaria.
2.7.2. Data Collection, Processing and Analysis
The survey and collection tools are previously established and tested in order to obtain all the essential information for the study. The data were collected from a pre-established questionnaire administered to the parents or accompanying persons of hospitalized children and primary data sources which are, individual patient records, hospitalization and consultation records, authorizing officers, receipts for payment of consultation and hospitalization, analysis sheets, stock sheets of medicines in the basket, the state of payment restoration. Patient data is entered into a pre-established canvas in the Excel 2013 calculation file with automatic review rules.
Once the data was entered, the processing was done using the Excel calculation file. The method of calculation was based on the methods of estimating the quantified economic cost of severe malaria.
2.8. Ethical Considerations
An authorization has been submitted and approved by the health officials of the Fana Health District. A document in which the objectives, purpose and confidentiality of the study are narrated, was presented or explained verbally to each participant in order to obtain informed consent. The observation of anonymity in the dissemination of results guarantees professional secrecy.
3. Result
3.1. Epidemiological and Clinical Aspects
3.1.1. Distribution of Cases by Age Groups and Sex
The most affected age group was 25 - 36 months and the number of cases was identical in both sexes (16 cases). The least affected age group was 0 - 6 months also in both sexes. The total number of cases was higher in male than in female (Figure 1).
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Figure 1. The age pyramid of severe malaria cases in 0 - 5 years old.
3.1.2. Distribution of Cases by Complications of Severe Malaria
The complications frequently encountered were severe anemia (50 cases) or 45.8%; convulsions (35 cases) or 32.1% and finally severe sepsis (8 cases) or 7.3% (Table 1).
3.1.3. Distribution of Cases by Length of Hospital Stay
According to the length of stay, 60 children stayed for 3 days, 29 children 5 days and 20 children stayed more than 5 days in the health center hospitalized for severe malaria (Figure 2).
3.1.4. Distribution of Cases by Means of Transport Used
The means of transport used to transport sick children were motorcycles, 87% of cases, public transport 8% of cases and 2% of cases were transported by ambulance (Figure 3).
3.2. Estimated Economic Cost of Care
3.2.1. The Cost of Medicines and Consumables (C.M)
The total cost (TC) of medical drugs and consumables was 1,808,440 Franc CFA. This amount corresponds to the management of the 109 cases of severe malaria (Table 2).
3.2.2. The Total Direct Cost (TRQ) of Para-Clinical Analyses in Case Management
The total cost of para-clinical analyses was 354,950 Franc CFA for the 109 cases of severe malaria. The main analyses were: hemoglobin (136,720 Franc CFA), blood grouping (109,000 Franc CFA), blood glucose (109,000 Franc CFA) and thick drop (10,200 Franc CFA). Rapid diagnosis Test (RDTs) are carried out to all sick children and its supply is provided by the center free of charge. This represented an average direct cost of 3256 Franc CFA per child (Table 3).
3.2.3. The Cost of Transporting Sick Children
The total cost for the transport of the children from their home to the CSRéf de Fana, round trip was 312,500 Franc CFA (Table 4). This sum corresponded according to the means of transport, 89.4% for motorcycle transport, 6.4% for ambulance transport and 4.1% for public transport respectively. For the 2 cases transported by ambulance, the cost of their return is not included in the total cost as well as for the 3 cases that used other means of transport.
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Table 1. Distribution of cases by complications of severe malaria.
Sources: Patient Records.
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Table 2. Total direct cost (TRQ) of drugs and consumables in case management.
Sources: Patient prescriptions; stock sheets DV CSREF FANA, transfusion register.
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Table 3. The direct cost of para-clinical analyses.
Sources: Analysis sheets, patient medical record.
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Figure 3. Breakdown by means of transport. Sources: Fact Sheets.
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Table 4. The total direct cost (TRQ) of transporting sick children.
Sources: Fact sheets.
3.2.4. The Average Direct Cost (CD) Borne by the Family in the Management of Severe Malaria Cases at the CSRéf de Fana
The average direct cost of managing hospitalization for severe malaria was 25,324 Franc CFA. This sum was distributed as follows: 1000 Franc CFA for consultation, 1500 Franc CFA for hospitalization, 3256 Franc CFA for paramedical analysis and 2976 Franc CFA for transport. Taking into account the exemption from the cost of consultation and hospitalization for children under 5 years of age, the average direct cost is 22,824 Franc CFA (Table 5).
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Table 5. The average direct cost of malaria care per hospitalized child attributable to patients.
Sources: Survey databases; NB: *cost exempted by the CSRéf de Fana.
3.2.5. Distribution of the Direct Average Cost According to the Different Activities
The proportion of the costs was as follows, 65% for the cost of medicines, 13% for the cost of paramedical analyzes, 12% for transport; 6% and 4% successively for hospitalization and consultation (Figure 4).
4. Discussions
4.1. In Relation to Epidemiological and Clinical Data
Children from 0 to 5 years old are part of the vulnerable population to malaria. In this study, the results showed that out of a total of 944 hospitalized cases (SLIS Fana) [8], 109 cases were included of which the most affected age group was 25 - 36 months or 3 years (Figure 1). This result is similar to the results of the study conducted by KAWELE Bouzoum [6] which showed a high number in children aged 3 years. Precisely at this age, the child begins to be no longer dependent on his mother but is not able to protect himself against mosquito bites. Due to the inattention of the parents, the disease is detected late. Even if the reality of trans-placental infection of the newborn is admitted, linked to the passage of parasitized red blood cells from the placenta congenital malaria-disease is rare. It appears after a variable delay of 5 to 60 days and the constant clinical sign is fever (Pierre Aubry et al.) [2]. The boys were the most exposed with a sex ratio of 1.4 to girls. The same result was obtained in a study conducted in the pediatric department of the Befelatanana Hospital in Antananarivo among children under 5 years old (Raobijaona H. et al. and by KAWELE Bouzoum) [6] [9]. This would show a vulnerability of boys compared to girls. The main complications were severe anemia (46%), convulsion (32%) and severe sepsis (7%). The most frequent and serious complications of P. falciparum infection in children are neuromalaria, severe anemia, respiratory distress (acidosis) and hypoglycemia (WHO Practical Guide 2013) [10].
4.2. In Relation to the Economic Costs of Managing Severe Malaria
The results of the Malaria Indicator Survey [5] showed that the economic well-
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Figure 4. Proportion of average direct cost burden for patients.
being index in rural areas is only 4%. The peak of malaria is reached during the winter season and this coincides with the lean season in rural areas, complicating the economic situation of families. In order to standardize the management of malaria, the reference documents were the Malian policies, standards and procedures (PNP-Malaria) [11] and the WHO 3rd edition practical guide. The three protocols for the management of severe malaria are based on the treatment with injectable quinine, injectable artesunate and intra-muscular artéméther. Thus, it was agreed to respect the medical prescription as much as possible towards the essential drugs (INN), as well as the indication of paramedical analyses to the strict necessary. The results of the study (Table 5) showed that the average direct cost of treating severe malaria in the pediatric ward of the CSRéf of Fana was 25,324 Franc CFA (58.9558 US Dollars) [12]. The costs of the consultation, hospitalization and rapid diagnostic test (RDT) were covered by the health center, so the average direct cost borne by patients is 22,824 Franc CFA or 53 US Dollars. This cost was lower than that of KAWELE Bouzoum conducted in Togo in 2013, which found an average direct cost of 55,215 Franc CFA (99.7256 US Dollars). It should be noted that the costs of transportation and catering were not included in the latter. Also, the cost of medical consultation 1000 Franc CFA (1.8061 US Dollars) and hospitalization 1500 Franc CFA (2.7092 US Dollars) are paid only once per hospitalization at the Fana pediatric hospital. Studies conducted in Côte d’Ivoire by G.L.S Couitchéré et al. [13] and Oshwa B. Mbalabu in DRC [14] found an average direct cost of 20,251 Franc CFA (36.5760 US Dollars) and 21,713 Franc CFA (39.2165 US Dollars) respectively. These amounts were lower than those obtained in our study. This can be explained by the fact that the cost of restoration was not taken into account in the study by G.L.S Couitchéré et al. and the cost of transport and restoration in the study by Oshwa B. Mbalabu in DRC.
A study on the cost evaluation of the treatment of severe malaria by M. Mtalimanja et al. [15] in Zambia revealed that the cost of the cure with artesunate was 65.6 US Dollars. Also the cost-effectiveness study by Y. Lubell et al. [16] showed a similar result with 66.5 US Dollars for artesunate versus 61.4 US Dollars for quinine. The drugs used and the care provided differed between the protocols. For example, the treatment with injectable quinine requires the use of glucose serum, infusion set and other adjuvant drugs in addition to close care of 4 hours of follow-up and risks of death are related to the incorrect use of this molecule (one in four deaths) [17]. While artesunate does not require the use of other drugs or long-term care; it is simple to administer and reduces the risk of hypoglycemic episodes during treatment by 45%, making it an economical treatment and, therefore, its use in the management of severe malaria in children is considered to have greater monetary benefits [18]. Thus the costs differ even though we did not take this into account in the calculation of the average cost.
Estimating the economic cost of severe malaria management is very complex and the context of a sick relative in hospital makes it difficult to interview parents. The estimated average cost of management of severe malaria in this study is more than half of the minimum wages in Mali (40,000 Franc CFA as of 2016) [19]. The study took place in a rural community whose main economic activity is agriculture dependent on the rainy season. So this estimate gives us some idea of the burden of managing severe malaria in children aged 0 - 5 years on the economy of the family.
5. Conclusion
The result obtained in this study gives us an estimate of the economic burden borne by families in the management of severe malaria cases in children in Fana district. So this estimate gives us some ideas of the burden of managing severe malaria in children aged 0 - 5 years on the economy of families. Support is needed for parents in the fight against malaria in rural Mali.
Appendix
Questionnaire:
Health District of Fana
Direct cost of severe malaria treatment borne by the families of children aged 0 - 5 years at the Fana Reference Health Centre
Questionnaire n˚1
I. Sorting sheet:
1.1. Date of tri: yy/mm/dd
1.2. Time of tri: ___h/____mn
1.3. Name: _______________________________________________________
1.4. Age: ____ months
1.5. Sex: male/female
1.6. Address: _____________________________________________________
1.7. Claims:
1.8. Temperature: ___˚C
1.9. Weight: ____ kg
1.10. Height: ______ cm
1.11. Brachial circumference: ____ cm
1.12. Z-score _____
1.13. Pulse rate: ____ beats/minute
1.14. Breathing rate: _____ /minute
1.15. Rapid Diagnostic Test: positive/negative
1.16. Conjunctival paleness: −/+ ++ +++
Questionnaire n˚2
II. Patient identification:
2.1. Case Id:
2.2. Patient’s name:
2.3. Age: ________ (month)
2.4. Sex: Male ( )/Female ( )
2.5. Address:
2.6. Siblings: _____/_____
2.7. Marital status of parents: Married ( ) Single ( ) Divorced ( )
2.8. Name of the health area:
3. Clinical information:
3.1. Diagnosis:
3.2. Date of hospitalization: year/month/day
3.3. Time: ___ h ___ mn
3.4. Evolution: healed ( ) referred/evacuated ( ) deceased ( )
3.5. Length of hospitalization: ______ day(s)
4. Transportation and food information:
4.1. Means of transport: Motorbike ( ); Ambulance ( ); Public transport ( ); Personal car ( ); Others to be specified ( )
4.2. Food support: Yes/No
4.3. Financing fund: Own ( ) Collective ( ) others to be specified ()
5. Analyzes carried out
5.1. Complete Blood Count ( )
5.2. Thick Drop and Thin Smear ( )
5.3. Hemoglobin level ( )
5.4. Group/Rhesus ( )
5.5. Others to be specified ( )
6. Treatment protocol:
6.1. Artesunate
6.2. Quinine infusion
6.3. Arthemeter
7. Drugs and consumables:
8. Acts and services:
Investigator
Date: ____YY____MM______DD