Costs and Cost-effectiveness of Delivering Intermittent Preventive Treatment Through Schools in Western Kenya

Matilda Temperley; Dirk H Mueller; J Kiambo Njagi; Willis Akhwale; Siân E Clarke; Matthew CH Jukes; Benson BA Estambale; Simon Brooker

Disclosures

Malar J 

In This Article

Abstract and Introduction

Abstract

Background: Awareness of the potential impact of malaria among school-age children has stimulated investigation into malaria interventions that can be delivered through schools. However, little evidence is available on the costs and cost-effectiveness of intervention options. This paper evaluates the costs and cost-effectiveness of intermittent preventive treatment (IPT) as delivered by teachers in schools in western Kenya.
Methods: Information on actual drug and non-drug associated costs were collected from expenditure and salary records, government budgets and interviews with key district and national officials. Effectiveness data were derived from a cluster-randomised-controlled trial of IPT where a single dose of sulphadoxine-pyrimethamine and three daily doses of amodiaquine were provided three times in year (once termly). Both financial and economic costs were estimated from a provider perspective, and effectiveness was estimated in terms of anaemia cases averted. A sensitivity analysis was conducted to assess the impact of key assumptions on estimated cost-effectiveness.
Results: The delivery of IPT by teachers was estimated to cost US$ 1.88 per child treated per year, with drug and teacher training costs constituting the largest cost components. Set-up costs accounted for 13.2% of overall costs (equivalent to US$ 0.25 per child) whilst recurrent costs accounted for 86.8% (US$ 1.63 per child per year). The estimated cost per anaemia case averted was US$ 29.84 and the cost per case of Plasmodium falciparum parasitaemia averted was US$ 5.36, respectively. The cost per case of anaemia averted ranged between US$ 24.60 and 40.32 when the prices of antimalarial drugs and delivery costs were varied. Cost-effectiveness was most influenced by effectiveness of IPT and the background prevalence of anaemia. In settings where 30% and 50% of schoolchildren were anaemic, cost-effectiveness ratios were US$ 12.53 and 7.52, respectively.
Conclusion: This study provides the first evidence that IPT administered by teachers is a cost-effective school-based malaria intervention and merits investigation in other settings.

Introduction

In Africa, there is increasing evidence of the dramatic reductions in malaria mortality and morbidity in early childhood due to recent up-scaling of malaria control efforts.[1,2,3,4] There is however some concern that these gains in early childhood may, as a consequence of decreased transmission and a slower acquisition of exposure-dependent immunity, lead to an increased incidence of malaria among older children.[5] Coincidental with this changing epidemiology of malaria, there has been increased recognition of the consequences of malaria in children of school-age, including detrimental effects on haemoglobin levels[6,7] and learning and educational achievement.[8,9] Consequently, there has been a renewed interest in the control of malaria in older children who attend school.[10,11,12] However, there is currently little international consensus as to the optimal intervention approach. There is also a lack of evidence on the costs and cost-effectiveness of available options for school-based malaria control.

An initial crude cost analysis of options for malaria control in Kenyan schools in 2000 concluded that chemoprophylaxis using the then recommended drug (Proguanil) delivered through schools would be prohibitively expensive.[11] Instead it was suggested that the promotion of prompt and effective diagnosis and treatment in schools would represent an affordable approach to address malaria in schools. However, the practicality and effectiveness of such an approach has only been explored in pilot projects,[13,14,15] and there remain a number of operational challenges in the provision of treatment in schools, including the reliability of diagnosis by non-health personnel, the long term motivation of teachers to play a health role, and challenges associated with the recent introduction of artemisinin combination therapies.

An alternative school-based strategy, already proven effective for protecting pregnant women and infants from malaria-related morbidity, is intermittent preventive treatment (IPT). A recent proof-of-principle trial in western Kenya showed that mass administration of a full therapeutic course of anti-malarial drugs to schoolchildren once a term, irrespective of infection status, dramatically reduced malaria parasitaemia, almost halved the rates of anaemia, and significantly improved cognitive ability.[16] In light of these promising results, it is important to replicate the results in other epidemiological settings. It is also clearly important to obtain information on the operational costs and cost-effectiveness of a delivery model for school-based IPT which can be implemented as part of an integrated school health programme. School health programmes already provide school children with deworming and micronutrients[17] and offer major cost advantages because of the use of the existing school infrastructure and the fact that the target population represents an accessible and relatively stable group. Evidence from existing programmes indicates that school-based delivery of anthelmintics is extremely cost-effective.[18]

This paper aims to estimate the costs and cost-effectiveness of IPT delivered by teachers in Bondo District of Nyanza Province, western Kenya. Economic costs are calculated in order to help inform resource allocation and allow for comparison with alternative school-based intervention and across various health interventions, whereas financial costs are provided to inform replication of the approach. The analysis also explores how costs vary with the drug price and organization of delivery of the intervention as well as with differences in intervention effectiveness and background prevalence of anaemia.

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