Effects of malaria control on the health facility: Changes in costs and hospitalizations in two hospitals in Zambia

1. Abt Associates Inc.
In collaboration with:
Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI
International | Training Resources Group, Inc. (TRG)
Alison Comfort, Ph.D.
Abt Associates
Effects of malaria control on the health facility:
Changes in costs and hospitalizations in two
hospitals in Zambia
ASTMH 62nd Annual Meeting
Washington, D.C.
November 15th, 2013

2. Background
Limited evidence on impact of malaria control on the health system
 Substantial evidence demonstrating the effect of malaria control on mortality and morbidity
 Evidence on changes in malaria admissions, but mixed results for other diseases
 Evidence on costs of malaria admissions, but not on changes in costs after malaria control
 No study that comprehensively ties this evidence together

3. Research question
Does the scale-up of malaria control affect the
health system, at the facility level? If so, how?
 Outpatient visits and inpatient admissions for malaria
 Proportion of admissions for malaria relative to other
diseases
 Estimated hospital spending over time on malaria
admissions
 Estimated cost savings
© Jessica Scranton

4. Site selection
Zambia has a high prevalence of malaria
 4.5 million cases in 2011, and 4,600 deaths attributed to
malaria
 Early adopter of ACTs, as well as introduction of ITNs,
IRS, and use of RDTs
 Substantial progress in reducing malaria during the last
decade, but recent resurgence in certain areas
Two hospitals in Zambia’s Southern Province where
there was substantial scale-up of malaria control
 Macha Mission Hospital (Choma District)
 Livingstone General Hospital (Livingstone District)
Source: Malaria Atlas Project 2010
Macha and
Livingstone

5. Analytical approach
 Pre-post comparison:
 Outpatient visits for malaria
 Inpatient admissions for malaria
 Estimated per patient cost for testing and treating malaria:
 Inpatient malaria admissions
 By complication / over time / by age group
 Costs include drugs, diagnostics, supplies, labor, overhead
 Total estimated hospital financial resources for malaria admissions
 Total hospital expenditures on malaria admissions relative to total hospital spending
 Estimated cumulative savings
 Data from patient records and facility cost data

6. Malaria control in Macha’s catchment area
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
National: ACTs designated
first-line treatment
National: IPTp used in pregnancy
Macha uses ACT as first-line therapy
Macha implements test-and-treat campaign
ACTs rolled-out
in Macha catchment
districts
Macha uses quinine with DhART for severe malaria cases
MIAM distributes
24,000 ITNs in
catchment area
RDTs available at catchment area
National shortage
of ACTs
Pre malaria
control
Post malaria control

7. Malaria control in Livingstone’s catchment area
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
National: ACTs designated
first-line treatment
National: IPTp used in pregnancy
LGH uses ACT as first-line therapy
Livingstone District ITN campaigns
Kazungula CHWs trained in home care with RDTs and
ACTs
National Stock
outs of ACTs
Kazungula District IRS
Livingstone District IRS
Kazungula District ITN campaigns
Pre malaria
control
Post malaria
control

8. Under-5 admissions for malaria at Macha
0
200
400
600
800
1000
1200
1400
1600
2003 2004 2005 2006 2007 2008
Inpatientadmissions
Year
Malaria

9. Under-5 admissions for malaria at Livingstone
0
50
100
150
200
250
300
350
400
450
500
2005 2006 2007 2008
Inpatientadmissions
Year
Malaria

10. Main results (visits and admissions)
Substantial reduction in both outpatient visits and inpatient admissions for
malaria with scale-up of malaria control
Malaria admissions and malaria outpatient visits make up smaller share of total
visits and admissions over time
Under-5 admissions for malaria as a proportion of total admissions
Before malaria control Post malaria
control
Percentage change
Macha Mission Hospital 20% 1% 95% reduction
Livingstone General Hospital 18% 2% 89% reduction

11. Cost estimates per malaria admission
Cost estimates per inpatient pediatric malaria admissions
Macha 2003
Uncomplicated malaria
$32.40
Severe malaria
$40.12
Malaria with anemia
$37.49
Malaria with severe anemia
$76.50
Cerebral malaria
$52.36
Cerebral malaria with moderate anemia
$58.24
Cerebral malaria with severe anemia
$96.64

12. Main results (spending on malaria)
Total yearly expenditures on malaria admissions fall over time as malaria control is
scaled-up
Total estimated yearly hospital expenditures on malaria admissions
Before malaria control Post malaria control Percentage change
Macha Mission Hospital $86,018 $4,631 95% reduction
Livingstone General Hospital $50,008 $9,346 81% reduction

13. Main results (spending on malaria)
Reduction over time in proportion of yearly total hospital spending on malaria
admissions
At Macha, cumulative savings of $340,000 over 5 year period from reduction in
malaria admissions
Estimated proportion of yearly total hospital spending on malaria admissions
Before malaria control Post malaria control Percentage change
Macha Mission Hospital 11% <1% 91% reduction
Livingstone General Hospital 2% 0.3% 85% reduction

14. Policy implications
As malaria control is scaled-up, hospital admissions for malaria fall
As a result of fewer malaria admissions, hospital spending on malaria
admissions decreases substantially
Need for maintaining malaria control in
catchment area
 Fewer hospital resources used for malaria
admissions
 Potentially making hospital resources (including
financial resources) available for other patients and
health conditions
© Jessica Scranton

15. Acknowledgements
 We would like to thank our funders:
 President’s Malaria Initiative/ USAID
 Sonali Korde (USAID/DC) and Allen Craig (USAID/Zambia)
 USAID/Health Systems 20/20 project and Health Finance and Governance project
 Jodi Charles, Scott Stewart
 Co-authors :
 PMI/USAID: Sonali Korde
 Macha Mission Hospital: Phil Thuma, Janneke van Dijk, and Sungano Mharakurwa
 Livingstone General Hospital: Khozya Zyambo
 Abt Associates: Nancy Nachbar, Kathryn Stillman, Petan Hamazakaza, Rose Gabert, Steve Musau, and Yann Derriennic
 Zambia Integrated Services Strengthening Program: Nancy Zyongwe
 National Malaria Control Center: Busiku Hamainza
 Collaborators:
 Allen Craig (PMI/CDC), Kathleen Poer and Peter Mumba.

16. Abt Associates Inc.
In collaboration with:
Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI
International | Training Resources Group, Inc. (TRG)
Thank you
Study published on-line at American Journal of Tropical Medicine and Hygiene
http://www.ajtmh.org/content/early/2013/11/07/ajtmh.13-0019.full.pdf+html
Alison_Comfort@abtassoc.com