In rural Kenya, where qualified pharmacists are rare, many people buy medicines from general shops to treat themselves at home. Often they receive incorrect medication or doses. Would the training of shopkeepers, who help treat the majority of children with fevers, be cost-effective in improving malaria treatment in young children?

At a summit in Abuja in 2000, African leaders agreed that by 2005 at least 60 percent of people ill with malaria in sub-Saharan Africa should be able to access affordable treatment within 24 hours of developing the symptoms. Yet research in 28 African countries showed that on average, only 42 percent of children under five years old were given anti-malarial treatment for a fever, and many of them received incorrect doses. As up to 60 percent of childhood fevers are treated with medicine bought from general retailers, shopkeepers could play a significant role in improving the treatment of malaria in young children.

Research by the Kenya Medical Research Institute (KEMRI)-Wellcome Trust Collaborative Research Programme and Kenya’s Ministry of Health assessed the cost and cost-effectiveness of a recent programme that involved training shopkeepers and community mobilisation for treating childhood fevers in the rural Kilifi District in Kenya. The programme offered workshops for shopkeepers on appropriate treatment for malaria in young children and also ran community information activities, with impact maintained through refresher training and monitoring.

The evaluation assessed the programme’s cost-effectiveness during the early phase of implementation at sub-division level, and estimated the cost-effectiveness for government run district level implementation. A simple model was used to predict the cost per death and per disability adjusted life year (DALY) averted.

The study found the following:

• The proportion of young children receiving a sufficient dose of the recommended multidose anti-malarial from shopkeepers rose from two percent to 15 percent in the early implementation phase, at a cost of US$ 4 per additional case treated correctly.
• It was estimated that if the same impact was achieved at district level, the cost would be cheaper US$ 0.84 per additional case treated correctly.
• The programme’s estimated economic cost per death averted was US$ 505.42 for the early phase and US$ 105.92 at the district level, with a cost per DALY averted of US$ 18.38 and US$ 3.85 respectively.
• The initial financial expense for development of the programme at district level was estimated at US$ 11,477. The first year of running the programme at district level was estimated to cost US$ 81,450, with an annual running cost thereafter of US$ 18,129.

The study indicated that the shopkeeper training programme is likely to be highly cost-effective if an effective anti-malarial is used, when compared with standards for similar interventions in low-income countries. It suggested four key policy lessons:

• Efforts to ensure this intervention was sustainable were successful. Surveys in the second and third year of the programme showed that the intervention had become consistently more effective.
• The intervention showed that shopkeeper training could be used for over-the-counter sales of other anti-malarial drugs, and possibly for introducing combination anti-malarial therapies.
• The programme’s relatively expensive start-up costs suggest a need for donor organisation funding and possibly contributions from the pharmaceutical industry. The smaller annual running cost could be covered by district budgets.
• The cost per DALY averted for both phases of the programme was well below the “highly attractive” cost per DALY averted of US$ 30 for interventions in low-income countries.

Source(s):
‘The cost-effectiveness of improving malaria home management: shopkeeper training in rural Kenya’, Health Policy and Planning 21(4), pages 275-288, by Catherine Goodman, Wilfred Mutemi, Karisa Baya, Annie Willets and Vicki Marsh, 2006
HINARI subscribers can access the full-text article here. Full document.

Funded by: UK’s Department for International Development (DFID); Kenya Medical Research Institute (KEMRI); the Wellcome Trust, UK; UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases (TDR)

id21 Research Highlight: 15 December 2006

Further Information:
Catherine Goodman
KEMRI/Wellcome Trust Collaborative Programme
PO Box 43640
Nairobi
Kenya

Tel: +254 20 2720163
Fax: +254 20 2711673

Kenya Medical Research Institute - Wellcome Trust Collaborative Programme

Other related links:
'Friend or foe? Private sector sales of anti-malarial drugs in rural Tanzania'

'Private sector drug retailers and malaria control in Kenya'

'Can Tanzania’s malaria control strategy profit from private drug sellers?'

'Can malaria be controlled where basic health services are not used?'

'No place like home – treating childhood malaria in The Gambia'

'What mothers do: responses to childhood fever on the Kenyan Coast'