The introduction of injectable Artesunate by governments requires effective communications on its effectiveness and benefits in the context of each country, for a clear definition of the projected national funding requirements and availability of financial sources. The cost of severe malaria treatment is high and households bear a greater portion of this cost due to a high level of indirect costs. To some households this may be catastrophic. There is need to buffer this with some sort of financial risk protection mechanisms and the health care system needs to be strengthened to function more effectively and decrease overall out of pocket payments to aid in alleviating economic burden of malaria.
Severe Malaria in Children has been shown to account for over 45% of the total monthly curative healthcare costs incurred by households compared to the mean per capita monthly income. On the other hand, the cost of treating severe malaria depleted 7.67% of the monthly average household income . In addition, the cost attributed to loss of income in taking care of a sick child is the highest contributor $10.5 of total cost followed by direct medical costs $7.75 as shown in Table 2. Similar findings were reported by the central statistical office of Zambia in the 2015 living condition monitory survey showing the average amount spent on medication and/or consultation by person consulted. At national level, the average amount spent on consultation or medication was about $12.while, Rural/urban analysis indicated on average $8 and $19.5 respectively. Household spending on malaria can be classified into expenditure on prevention and expenditure on treatment. Individual or household direct cost of malaria treatment include direct payment of drugs, consultation, laboratory tests, transportation fees to and from the health facility, and the caregiver’s productive time lost due to malaria.
In our study, the cost of Artesunate was $65.6 which was costly than the quinine arm, this result compares favorably to the mean costs from studies by Lubell et al. who recorded $66.5 for the Artesunate arm and 61.4 for the quinine arm respectively . According to the 2015 living condition monitoring survey by the central statistics of Zambia, the mean per capita monthly household income as defined by the total household income divided by the number of persons in the household was $40. thus, treatment of malaria with possess a financial burden on families as it costs more than the estimated monthly total expenditure, hence the need for government to sustain the provision of free malaria treatment .On the other hand, our model-based analyses suggest that the health benefits associated with the use of Artesunate in children with severe malaria is cost-effective when compared with the use of quinine at commonly accepted willingness-to-pay thresholds derived from the gross domestic product per capita .As shown in figure 3 treatment with Artesunate over quinine indicating increased costs and increased effectiveness as well as some cases showing dominance. Moreover, use of Artesunate could significantly have cost savings through avoided drug administration costs and nursing care to alleviate risk of cardiotoxicity, as intravenous quinine administration needs rate-controlled infusion over four hours, three times a day, accompanied by cardiac monitoring if possible. A study examining malaria deaths showed that one in four patients had received incorrect dosing. . in addition, due to high mortality rate among children, the benefits of expanded use of Artesunate could be a right step in the right direction to reduce the malaria burden . The cost of averting malaria-related deaths in Zambia by switching from quinine to Artesunate had a value of ICER US$ 105 per death averted which is in line with the world health organization cost effectiveness for malaria interventions Table 3.To add on, the results are similar to the incremental cost per death averted in children in sub-Saharan African, estimated on average to be US$123   . This compares very favorably with other interventions, such as the use of insecticide-treated nets, with a cost per death averted of US$ 254 to US$ 3437, . On the other hand, costs of the drug used in the analysis and the costs associated with nursing time, Laboratory diagnostic tests, and costs of consumables like examination gloves, syringes, needles cannulas and infusion sets/solutions, were in-cooperated into the model. Other researchers also suggest that administrative cost and nursing care time are more on the quinine arm and would even favor Artesunate to be more cost effective . Not only Artesunate is cost effective but injectable Artesunate is simpler to administer, and given once a day while the comparative drug requires multiple dosing and close monitoring for cardiotoxicity. To add on, Artesunate also reduces episodes of hypoglycemia during treatment by 45% hence a cost saving therapy . Consequently, the use of Artesunate in the management of severe malaria in children is seen to have more monetary benefits.
Furthermore, the robustness of our results over a range of varying assumptions was tested in the sensitivity analysis, even with conservative estimates around the parameters used in the model for sensitivity analysis, the findings remain cost-effective across a range of estimates in the model on assumptions at the threshold of willingness to pay. This threshold has been used frequently in similar studies and the World Health Organization recognizing 3 times the gross domestic product per capita as an upper threshold . This study also revealed the cost-effectiveness acceptability curve having the probability of Artesunate being cost-effective being approximately 12% without any additional investment. In addition, with a willingness-to-pay of $150 and $300, Artesunate therapy produces a probability around 70%, and above 95% respectively. Figure 3.
Our assessment had considerable limitations that are expected in the construction of any decision model. Firstly, societal perspective of economic evaluation has a more comprehensive framework for analysis but we took a healthcare perspective because Malaria treatment is free of charge from all government hospitals. Also, our assumptions were that of a patient having only one episode of severe malaria during the one year cycle.
Owing to the fact that cost effectiveness models can be sensitive to time horizon of the analysis, and in most cases covering a life expectancy time horizon. In the case the incremental cost comparisons may be somewhat accurate, but the cumulated incremental benefits may be significantly underestimated.