The economic burden of malaria on households and the health system in a high transmission district of Mozambique.

BACKGROUND: Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique. METHODS: Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses. RESULTS: Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$3.46 (IQR US$ 0.07-22.41) and US$81.08 (IQR US$ 39.34-88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$1.63 (IQR US$ 0.00-7.79) per uncomplicated case and US$64.90 (IQR US$ 49.76-80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$4.34 (IQR US$ 4.32-4.35) per uncomplicated case and US$26.56 (IQR US$ 18.03-44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$332,286.24 (IQR US$ 186,355.84-1,091,212.90) per year only in Mopeia. CONCLUSIONS: Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region

Combination of indoor residual spraying with long-lasting insecticide-treated nets for malaria control in Zambezia, Mozambique: a cluster randomised trial and cost-effectiveness study protocol.

Background: Most of the reduction in malaria prevalence seen in Africa since 2000 has been attributed to vector control interventions. Yet increases in the distribution and intensity of insecticide resistance and higher costs of newer insecticides pose a challenge to sustaining these gains. Thus, endemic countries face challenging decisions regarding the choice of vector control interventions. Methods: A cluster randomised trial is being carried out in Mopeia District in the Zambezia Province of Mozambique, where malaria prevalence in children under 5 is high (68% in 2015), despite continuous and campaign distribution of long-lasting insecticide-treated nets (LLINs). Study arm 1 will continue to use the standard, LLIN-based National Malaria Control Programme vector control strategy (LLINs only), while study arm 2 will receive indoor residual spraying (IRS) once a year for 2 years with a microencapsulated formulation of pirimiphos-methyl (Actellic 300 CS), in addition to the standard LLIN strategy (LLINs+IRS). Prior to the 2016 IRS implementation (the first of two IRS campaigns in this study), 146 clusters were defined and stratified per number of households. Clusters were then randomised 1:1 into the two study arms. The public health impact and cost-effectiveness of IRS intervention will be evaluated over 2 years using multiple methods: (1) monthly active malaria case detection in a cohort of 1548 total children aged 6-59 months; (2) enhanced passive surveillance at health facilities and with community health workers; (3) annual cross-sectional surveys; and (4) entomological surveillance. Prospective microcosting of the intervention and provider and societal costs will be conducted. Insecticide resistance status pattern and changes in local Anopheline populations will be included as important supportive outcomes. Discussion: By evaluating the public health impact and cost-effectiveness of IRS with a non-pyrethroid insecticide in a high-transmission setting with high LLIN ownership, it is expected that this study will provide programmatic and policy-relevant data to guide national and global vector control strategies. Trial registration number: NCT02910934

Syndromic management of sexually transmitted diseases at primary care level, Mozambique

Methods: In 26 health facilities in selected sites, we observed management of all STD patients presenting in the adult general or STD clinic. We assessed the referral system by analysing patient registers. Results: 408 STD patients (65% in STD and 35% in general clinics) were observed. 70% were women. Women were examined less (26% against 75%, p<0.0001), had laboratory tests ordered more (74% against 45%, p=0.0002), were more often diagnosed syndromically (57% against 38%, p=0.008), and received less advice on condom use (19% against 87%, p<0.001) and contact treatment (47% against 81%, p=0.04). Examination, laboratory requests, diagnosis, and treatment were not significantly different in the STD and general clinic. Health education was better in the STD clinic (condom advice 47% against 8%, p <0.001). Only 41% of referred patients presented to the STD clinic. Conclusions: The better performance of STD clinics in health education was offset by high referral losses. A proposed integration of STD treatment into general outpatient clinics and better implementation of syndromic management and health education should improve STD case management at primary level in Mozambique