Onwujekwe OE 1,2, Shu EN 2 , Uzochukwu BSC 3 , Okonkwo PO 2 1 Gates Malaria Partnership, LSHTM

1. IS A NOVEL COMMUNITY-BASED HEALTH WORKER STRATEGY FOR PROVIDING NEAR AND APPROPRIATE TREATMENT OF MALARIA FEASIBLE AND WORTHWHILE: AN ANALYSIS OF PROCESSES, COSTS AND OUTCOMES Onwujekwe OE1,2, Shu EN2, Uzochukwu BSC3, Okonkwo PO2 1 Gates Malaria Partnership, LSHTM 2 Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu 3 Department of Community Medicine, College of Medicine, University of Nigeria, Enugu

2. ABSTRACT Problem Statement: People have difficulty accessing proper treatment for malaria. An approach for bringing appropriate and timely treatment of malaria closer to home is through the use of community-based health workers (CBHWs). The processes, costs, and outcomes of the strategy are unknown. Objectives: To determine the processes, costs, and outcomes of the CBHW strategy. Design: A prospective study in four villages in Nigeria where holo-endemic malaria is present was used. The CBHW strategy was implemented in two villages (Adu and Ahani), while the other two villages (Amaetiti and Enugu-Akwu) were the controls. The study was conducted in five phases: (1) baseline survey; (2) design; (3) implementation, supervision, and monitoring; (4) evaluation; and (5) handing over of the project to the villages. Outcome Measures:The key outcome measures were the market share of the CBHWs, acceptability, referrals, morbidity and mortality, the socioeconomic differentials of the consumers, type of drug consumed, and payment strategies. Cost-benefit computations showed that the people found the services of the CBHWs to be worthwhile. Results:Processes: Discussions at village assemblies with a broad segment of community leaders and an interactive meeting with all the stakeholders were used to fine-tune the design of the CBHW strategy. Selected community members were trained to become CBHWs. The remuneration of the CBHWs was through commissions on their drug sales. Consumer costs: Nonfinancial costs were the highest contributor to consumer costs. The total cost in Ahani was approximately USD 2,548, while the cost in Adu was USD 1,585. Provider costs: Financial costs constituted more than 90% of provider costs in the two intervention villages. The total cost in Ahani was approximately USD 4,515, and in Adu it was USD 4,302. Aggregate costs: The aggregate cost in Ahani was approximately USD 7,062, and it was USD 5,886 in Adu. The unit cost was USD 1.40 in Ahani and USD 1.70 in Adu. The combined data from both villages showed a unit cost of USD 1.50. Outcomes: The CBHWs in the intervention villages had an increased market share, and no mortality from malaria was reported. Conclusions: The cost of starting up the CBHW strategy is very reasonable and in line with what malaria control programs and communities can afford. The study shows that the community-based health worker strategy is economically viable and a strong potential source for providing nearby, timely, and appropriate treatment of malaria in rural areas. The requirements now are further studies to fine-tune and scale up the use of the strategy in rural parts of Nigeria and sub-Saharan Africa.

3. INTRODUCTION • Malaria is the number one public health problem in Nigeria • People have difficulty accessing timely and appropriate treatment for malaria. • The Abuja African Heads of State meeting on Roll Back Malaria adopted effective treatment of malaria nearer the home as one of the strategies for malaria control in Africa (WHO, 2000). • Community-based health workers (CBHWs) could be used to bring appropriate and timely treatment of malaria closer to home • The processes, costs, and outcomes of the CBHW strategy are unknown. • An implementation research to determine the processes, costs and outcomes of a CBHW strategy was undertaken.

4. OBJECTIVES Aim: Analyze the processes, costs and outcomes of the CBHW strategy for providing near and appropriate treatment of malaria. Research questions: • What are the processes of establishing and sustaining a CBHW strategy for the treatment of malaria? • What are the financial and non-financial costs of establishing the CBHW strategy? • What are the outcomes of the CBHW strategy in the treatment of malaria?

5. RESEARCH METHODS • A prospective study in four rural villages from Achi community, Enugu State, Southeast Nigeria. • The villages have all year high malaria transmission rates and the major malaria vector in Achi is Anopheles Gambiense, while Plasodium falciparum causes more than 90% of all malaria cases (MVCU, 2000). • There is a paucity of formal health facilities in the two villages • The CBHW strategy was implemented in two villages (Adu and Ahani), while the other two villages (Amaetiti and Enugu-Akwu) were the controls. The study was conducted in five phases: (1) baseline study in four villages (2) design in two intervention villages (3) implementation, supervision, and monitoring in two intervention villages (4) evaluation in four villages (5) handing over of the project to the villages in two intervention villages Note: 125 Naira (local currency) = US$1.00

6. FINDINGS 1. PROCESSES Design: • Discussions at village assemblies with broad segment of community leaders and an interactive meeting with all the stakes-holders were used to fine-tune the design the CBHW strategy. Recruit: • 9 people and 13 people from Adu and Ahani were sent to us by the community leaders to be trained. • Two people were selected to supervise other community-based health workers. Train (divided into 2 parts): • The first part was devoted to teaching the people about the causes, symptoms and signs of malaria, together with management of malaria. • In the second part the candidates were trained about the managerial aspects of the project and further on malaria treatment.

7. FINDINGSCONT’D Payment to CBHWs: • They were paid commission on the drug sales, from a reasonable mark-up that was added to all the drugs. • The commission was paid to the CBHWs at the end of every month as their stipend. Community mobilization for the implementation: • Letters to the village heads and key community leaders to inform about the identity of the CBHWS and for them to spread the information in their respective villages. • Mobilization through the churches and the village developmental unions • Town criers announced the commencement of the project in the villages

8. Drugs, treatment and payment strategies: • Antimalarials were choloroquine and sulfadoxine-pyrimethamine (SP). • CBHWs were supplied tablet and syrup paracetamol, together with syrup formulation of a blood tonic. • People that had malaria or fever visited the CBHWs homes for treatment, but people that could not go there were treated at their homes by the CBHWs. • The CBHWs used treatment forms and registers to keep records of people that they treated. • The CBHWS used cash registers to record their revenues and issued receipts to people that paid for their services. • Two payment strategies: Full out-of-pocket payment installment out of pocket payment (maximum of 2 installments). • No exemptions or subsidies for treatment because it was not clear who will bear the costs

9. 2. COSTS • The total consumer cost in Ahani was approximately US$2548 while it was US$1585. • Non-financial costs represented the highest contributor of consumer costs in both villages. • Financial costs constituted more than 90% of provider costs in the two villages • The unit costs were calculated based on the estimated number of residents in both villages. Hence, in Ahani with about 5000 residents, the unit cost was 177 Naira ($1.4) and it was 210 Naira ($1.7) in Adu with about 3500 residents. • The combined data from both villages showed a unit cost of 190 Naira ($1.5) and this is likely to be the value of the unit cost of a start-up of the project if many villages were involved in the project.

10. 3. OUTCOMES: • A total of 392 and 393 patients were treated in Ahani and Adu respectively. • The highest numbers of patients were in the first month of the project probably due to the initial excitement of people about the project, which thereafter started recording lower coverage levels. • Children constituted approximately 35% of the patients that were treated. • There was no mortality from malaria during the implementation period of the project.

11. SUMMARY AND CONCLUSION • The CBHW strategy improved the access of the people to treatment of malaria and there was a shift from home treatment and other low quality treatment practices to community-based health workers. • The CBHW strategy is a strong potential source of providing near, timely and appropriate treatment of malaria in rural areas • The major resource requirement from the villages is moderate investment of time costs • If there are appropriate and credible treatment sources for malaria, the level of use of home treatment and patronization of some low level providers will be reduced or even eliminated.

12. AREA FOR FUTURE RESEARCH • Systematic cost-effectiveness analysis, acceptability and sustainability comparison of CBHW with other means of treating malaria nearer the homes, such as home treatment. Acknowledgements: IDRC for funding the study