Parasite-based Diagnosis for Malaria in Uganda: Feasibility and Cost-Effectiveness

The development of drug resistance in malaria parasites lead the Uganda Ministry of Health (MoH) to change the first-line anti-malarial treatment from the cheap Chloroquine/Sulfadoxine-Pyrimethamine combination to a more expensive Artemether-Lumefantrine. The MoH recommends treatment of all fever cases as malaria within 24 hours of illness with first-line drug. Under this policy, patients who do not have malaria but present with febrile illness will receive Coartem® resulting in significant drug wastage. With the increased cost of first-line drugs, this wastage places a substantial and potentially remediable burden on the health budget. As such, there is a need to gauge whether more accurate malaria diagnosis through microscopy and/or rapid diagnostic tests, might improve the cost-effectiveness of the new treatment regimes.

Specific objectives

1. To assess the feasibility of rapid test and microscopy in diagnosis of malaria at health centre III.
2. To compare the cost-effectiveness of treating malaria with Artemether- Lumefantrine based on microscopy, rapid test and presumptive diagnosis in different transmission intensities
3. To assess whether introduction of malaria parasite-based diagnosis (rapid test or microscopy) at government Health Centre III improves the overall cost-effectiveness of outpatient management of febrile illness

Sample size determination The sample size was determined using standard formula. Estimating the sensitivity of either test to be 90%, Zα =1.96 and after stratifying for age (<5 years and ≥5 years), the calculated sample is 272 per health centre. Therefore, the total number of patients for 6 health centres in two districts = 6 x 272 = 1632.

Baseline: Baseline data was collected on the current malaria treatment practices; clinicians' view of malaria diagnosis; concerns towards the new treatment; and health centre staffing. Geographical locations of all visited government health centres was recorded using Germin etrex global positioning system (Germin International Inc., Olathe, USA). At six selected health centres, social and demographic data was collected from 613 patients.