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South Africa's effort to eliminate malaria is significantly challenged by a large number of imported malaria cases, especially from neighbouring Mozambique. The country has a funding gap to achieve its malaria elimination goals (prior to 2019) and is ineligible to receive a national allocation from the Global Fund. The findings of an IC were utilised to successfully mobilise resources for malaria elimination in South Africa in 2018. A five-step resource mobilisation strategy was implemented to highlight financing challenges and leverage the economic evidence from an IC for malaria elimination in South Africa. South Africa's malaria programme implements control and elimination activities in three malaria-endemic provinces (KwaZulu Natal, Limpopo, and Mpumalanga). Driven by the IC findings, the South African government took an unprecedented step and increased total domestic malaria financing by approximately 36%, from the 2018/19 to the 2019/20 financial years through the creation of a new conditional grant for malaria. The IC findings predicted that malaria control in southern Mozambique is a prerequisite to eliminate malaria in South Africa. Based on this, the South African government also allocated funding towards a co-financing mechanism to support malaria control efforts in southern Mozambique. The IC findings assisted the South African National Department of Health to make a convincing case to key government decision-makers to invest in national malaria elimination and maximise economic returns in the long run. The South African government is the first in Southern Africa to mobilise a significant increase in domestic malaria financing to address the financial sustainability of both national and regional malaria elimination efforts. Continued surveillance activities will be required to prevent the re-establishment of malaria transmission even after malaria elimination is achieved in South Africa. Information sharing and close collaboration with provincial and national government officials were key to the successful outcome.

Objectives: To estimate the cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in a low endemic setting., Setting: The study was part of a 2×2 factorial design cluster randomised controlled trial within the catchment area of 11 primary health facilities in Zambezi, Namibia., Participants: Cost and outcome data were collected from the trial, which included 8948 community members that received interventions due to their residence within 500 m of malaria index cases., Outcome Measures: The primary outcome was incremental cost effectiveness ratio (ICER) per in incident case averted. ICER per prevalent case and per disability-adjusted life years (DALY) averted were secondary outcomes, as were per unit interventions costs and personnel time. Outcomes were compared as: (1) rfMDA versus RACD, (2) RAVC versus no RAVC and (3) rfMDA+RAVC versus RACD only., Results: rfMDA cost 1.1× more than RACD, and RAVC cost 1.7× more than no RAVC. Relative to RACD only, the cost of rfMDA+RAVC was double ($3082 vs $1553 per event). The ICERs for rfMDA versus RACD, RAVC versus no RAVC and rfMDA+RAVC versus RACD only were $114, $1472 and $842, per incident case averted, respectively. Using prevalent infections and DALYs as outcomes, trends were similar. The median personnel time to implement rfMDA was 20% lower than for RACD (30 vs 38 min per person). The median personnel time for RAVC was 34 min per structure sprayed., Conclusion: Implemented alone or in combination, rfMDA and RAVC were cost effective in reducing malaria incidence and prevalence despite higher implementation costs in the intervention compared with control arms. Compared with RACD, rfMDA was time saving. Cost and time requirements for the combined intervention could be decreased by implementing rfMDA and RAVC simultaneously by a single team., Trial Registration Number: NCT02610400; Post-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Highly sensitive molecular techniques for the detection of low-level Plasmodium falciparum parasitemia are highly useful for various clinical and epidemiological studies. However, differences in how blood samples are preserved, the quantity of blood stored, as well as genomic DNA extraction methods used may compromise the potential usefulness of these methodologies. This study compared diagnostic sensitivity based on microscopy and malaria rapid diagnostic tests (mRDTs), with quantitative polymerase chain reaction (qPCR) P. falciparum positivity of dried blood spots (DBS) or whole blood pellets (WBP) from pregnant women using different DNA extraction protocols (Chelex-saponin or a commercial kit). Samples from 129 pregnant women were analyzed, of which 13 were P. falciparum positive by mRDT and 5 by microscopy. By using extraction kit on WBP and on DBS, qPCR positivity was 27 (20.9%) and 16 (12.4%), respectively, whereas Chelex extraction on DBS only resulted in 4 (3.1%) P. falciparum positive samples. Thus, extraction using commercial kits greatly improve the likelihood of detecting P. falciparum infections.

Background: With 71% of Malawians living on < $1.90 a day, high household costs associated with severe malaria are likely a major economic burden for low income families and may constitute an important barrier to care seeking. Nevertheless, few efforts have been made to examine these costs. This paper describes household costs associated with seeking and receiving inpatient care for malaria in health facilities in Malawi., Methods: A cross-sectional survey was conducted in a representative nationwide sample of 36 health facilities providing inpatient treatment for malaria from June-August, 2012. Patients admitted at least 12 h before study team visits who had been prescribed an antimalarial after admission were eligible to provide cost information for their malaria episode, including care seeking at previous health facilities. An ingredients-based approach was used to estimate direct costs. Indirect costs were estimated using a human capital approach. Key drivers of total household costs for illness episodes resulting in malaria admission were assessed by fitting a generalized linear model, accounting for clustering at the health facility level., Results: Out of 100 patients who met the eligibility criteria, 80 (80%) provided cost information for their entire illness episode to date and were included: 39% of patients were under 5 years old and 75% had sought care for the malaria episode at other facilities prior to coming to the current facility. Total household costs averaged $17.48 per patient; direct and indirect household costs averaged $7.59 and $9.90, respectively. Facility management type, household distance from the health facility, patient age, high household wealth, and duration of hospital stay were all significant drivers of overall costs., Conclusions: Although malaria treatment is supposed to be free in public health facilities, households in Malawi still incur high direct and indirect costs for malaria illness episodes that result in hospital admission. Finding ways to minimize the economic burden of inpatient malaria care is crucial to protect households from potentially catastrophic health expenditures.

Malaria imposes a substantial global disease burden. It disproportionately affects sub-Saharan Africans, particularly young children. In an effort to improve disease management, the World Health Organization (WHO) recommended in 2010 that countries test children younger than age five who present with suspected malaria fever to confirm the diagnosis instead of treating them presumptively with antimalarial drugs. Costs and concerns about the overall health impact of such diagnostic testing for malaria in children remain barriers to full implementation. Using data from national Malaria Indicator Surveys, we estimated two-stage microsimulation models for Angola, Tanzania, and Uganda to assess the policy's cost-effectiveness. We found that diagnostic testing for malaria in children younger than five is cost-saving in Angola. In Tanzania and Uganda the cost per life-year gained is $5.54 and $94.28, respectively. The costs projected for Tanzania and Uganda are less than the WHO standard of $150 per life-year gained. Our results were robust under varying assumptions about cost, prevalence of malaria, and behavior, and they strongly suggest the pursuit of policies that facilitate full implementation of testing for malaria in children younger than five., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To assess the degree to which policy changes to artemisinin-based combination therapies (ACTs) as first-line treatment for uncomplicated malaria translate into effective ACT delivery., Methods: Prospective observational study of drug dispensing practices at baseline and during the 3 years following introduction of ACT with sulfadoxine-pyrimethamine (SP) plus artesunate (AS) in Rufiji District, compared with two neighbouring districts where SP monotherapy remained the first-line treatment, was carried out. Demographic and dispensing data were collected from all patients at the dispensing units of selected facilities for 1 month per quarter, documenting a total of 271, 953 patient encounters in the three districts., Results: In Rufiji, the proportion of patients who received a clinical diagnosis of malaria increased from 47.6% to 57.0%. A majority (75.9%) of these received SP + AS during the intervention period. Of patients who received SP + AS, 94.6% received the correct dose of both. Among patients in Rufiji who received SP, 14.2% received SP monotherapy, and among patients who received AS, 0.3% received AS monotherapy., Conclusions: The uptake of SP + AS in Rufiji was rapid and sustained. Although some SP monotherapy occurred, AS monotherapy was rare, and most received the correct dose of both drugs. These results suggest that implementation of an artemisinin combination therapy, accompanied by training, job aids and assistance in stock management, can rapidly increase access to effective antimalarial treatment., (© 2011 Blackwell Publishing Ltd.)

In recognising the success attained through community-directed treatment with Ivermectin, there has been a growing interest to use a similar approach for delivery of interventions against other communicable diseases. This study was conducted in 2007 to evaluate the impact of community directed intervention (CDI) on delivering five health interventions namely Vitamin A supplementation (VAS), community-directed treatment with Ivermectin (CDTi), distribution of insecticide-treated nets (ITN), directly observed treatment of tuberculosis (DOTS), and home-based management of malaria (HMM). The study was carried out in onchocerciasis endemic districts of Kilosa, Muheza, Lushoto, Korogwe and Ulanga districts in Tanzania. A total of 250 households were involved in the study for the period of two years. During the first year, one new intervention was added in each study district. A second new intervention was then added in the same manner during the second study year. In the control district all interventions, with the exception of Ivermectin distribution, continued to be delivered in the traditional manner throughout the study period. Results showed that Ivermectin treatment coverage in the CDI districts (88%) was significantly (P<0.005) higher than in the control district (77%). The coverage of VAS was 84 +/- 7%, showing very little difference between control and intervention districts (P>0.05). The DOTS treatment completion rate was observed only in Korogwe where 4 out 7 patients had completed their treatment. The proportions of pregnant women and <5 years children sleeping under ITN in the CDI districts (range: 83-100%) were significantly higher (P< 0.05) than those in the control district (40-43%). There was also a higher proportion of malaria cases referred in the intervention districts (42%) than in the control district (21%) (P<0.005). Likewise, the proportion of <5 years children who were presumptively diagnosed with malaria and received appropriated treatment within 24 hours in the intervention districts (17-29%) was higher than those in the control district (4%) (P<0.005). The costs incurred per integrated programme in the intervention districts were much lower than those in the control district. In conclusion, our results showed higher coverage of interventions in the CDI districts without necessarily increasing the cost.

Malaria's relationship with socioeconomic status at the macroeconomic level has been established. This is the first study to explore this relationship at the microeconomic (household) level and estimate the direction of association. Malaria prevalence was measured by parasitemia, and household socioeconomic status was measured using an asset based index. Results from an instrumental variable probit model suggest that socioeconomic status is negatively associated with malaria parasitemia. Other variables that are significantly associated with parasitemia include age of the individual, use of a mosquito net on the night before interview, the number of people living in the household, whether the household was residing at their farm home at the time of interview, household wall construction, and the region of residence. Matching estimators indicate that malaria parasitemia is associated with reduced household socioeconomic status.

The Community Directed Intervention (CDI) is currently used for Ivermectin distribution for the treatment of onchocerciasis in Africa. This study was carried out to determine the extent to which the CDI process can be used for the delivery of other health interventions with different degrees of complexity. The study was conducted in five districts of Kilosa, Muheza, Lushoto, Korogwe and Ulanga in Tanzania and involved communities, health facility and district healthcare providers. Implementation of CDI across these health interventions involved addressing six major processes, namely, stakeholder processes, health system dynamics, engaging communities, empowering communities, engaging CDI implementers and broader system effects. Community and health systems changes were triggered, such that the inherent value of community involvement and empowerment could be internalized by communities and health workers, leading to a more receptive health system. The CDI process was accepted at the community levels as many were willing and ready to adopt the approach. Health workers at community levels were readily available and supportive of the process. Additionally, noted were the verified willingness and ability of community implementers to deliver multiple interventions; confirmed efficiency of CDI leading to cost savings at health systems level; increasing interest of the health system in CDI; interest of health workers in the process of integrated planning. However, there were factors that may have a negative influence on the CDI process. Drug and supply policy for CDI process was lacking at the national and district levels and the presence of parallel community-based programmes that provide financial incentives for community members to run them discouraged Community-directed distributors who in most cases are volunteers. In conclusion, the results have clearly and evidently demonstrated the potential of CDI approach for effectively and efficiently control of other diseases such as malaria, tuberculosis and childhood illnesses. The study has provided unique information on the feasibility and effectiveness of integrated delivery of interventions at the community level. [ABSTRACT FROM AUTHOR]

Objective To investigate the variation in malaria parasitaemia, reported fever, care seeking, antimalarials obtained and household expenditure by socio-economic status (SES), and to assess the implications for ensuring equitable and appropriate use of antimalarial combination therapy. Methods A total of 2500 households were surveyed in three rural districts in southern Tanzania in mid-2001. Blood samples and data on SES were collected from all households. Half the households completed a detailed questionnaire on care seeking and treatment costs. Households were categorised into SES thirds based on an index of household wealth derived using principal components analysis. Results Of individuals completing the detailed survey, 16% reported a fever episode in the previous 2 weeks. People from the better-off stratum were significantly less likely to be parasitaemic, and significantly more likely to obtain antimalarials than those in the middle or poor stratum. The better treatment obtained by the better off led them to spend two to three times more than the middle and poor third spent. This reflected greater use of non-governmental organisation (NGO) facilities, which were the most expensive source of care, and higher expenditure at NGO facilities and drug stores. Conclusion The coverage of appropriate malaria treatment was low in all SES groups, but the two poorer groups were particularly disadvantaged. As countries switch to antimalarial combination therapy, distribution must be targeted to ensure that the poorest groups fully benefit from these new and highly effective medicines. [ABSTRACT FROM AUTHOR]