Discussion:

prevention
In Uganda, non-users of nets (likely to be poorer) were more likely to use traditional medicine for malaria prevention and treatment of episodes, and were less likely to undergo blood slide examination than net users (Nuwaha, 2001) Inrealtion /ses and malaria Education not a predictor of prevention: The level of education in an urban Kenyan setting was an unimportant predictor of whether the household used multiple methods of protection or whether everyone in the house slept under a net determinants o f mosquito avoidance) Knowledge, education and prevention:discussion: There is evidence to suggest that education levels and explicit knowledge of transmission may not be prerequisites to the uptke of mosquitoe or malaria prevention activity, determinants o f mosquito avoidance) ***** Despite recognizing mosquito as the sourse of malaria , very few individuals reported using any consistent means of malaria prevention. While the majority of individual did report using a bed net very few nets had been impregnated(care seeking and cost) more attention is needed from the international health community emphasizing the need to get bed nets and other protective methods subsidized by local and national governments or by other dondors and NGOs. determinants o f mosquito avoidance) Social marketing and community programmes increased use: The higher bed use in malindi as compared to the other city and higher multiple bed net use , this may be a consequence of increased social marketing of bed nets and intense community based programme activity in the area. determinants o f mosquito avoidance) Malaria prevention tools do not always remain out of reach to all of the poorest households. In rural Tanzania, data have suggested that a mbination of social marketing with active private sector participation was able to achieve net ownership in two-thirds of the poorest households. The ratio of net ownership in the poor to least poor households (equity ratio) was 0.54-0.69 at baseline before 3 years of social marketing and 0.60-0.73 after 3 years of activity. It is important to note, though, that the study took place in a small area, inviting the possibility that the population studied was relatively homogeneous, and that net treatment and re-treatment rates, among the poor and least poor, remained quite low (Abdulla et al., 2001). A similar picture was seen in Tanzania for the larger SMITN social marketing project, with the equity ratio improving over time as coverage increased(realatioan SES and malaria))

Data on income Data of income: Measuring SES in developing countries is challenging. The generally accepted gold standard approach to estimating household welfare is to use data on household income or expenditure. (realatioan SES and malaria)) difficulyty in obtaining cost data: people may be unwilling to disclose financial data and what they do disclose may be biased. (realatioan SES and malaria))

Cost of facility higher than self treatment: In urban survey in Cameroon self tt with antimalarials purchased in shops was judeged the least expensive option when fees and transportation costa were included ttt at a dispebsary was 2.6times higer than self ttt and hospital ttt, was 10 times giher than self ttt>(rev seeking No difference in incidence there is difference in effects by SES: Although malaria incidence by socio-economic group within countries does not show any clear poor-rich gradient the evidence about the economic consequences of the high income group and use contradicting results: The effect of the income and wealth on health behaviour is not clear across the litriture . studies in Malaysia and phillipines found no impact of income on the demand for health care. The result here indicates that the households in the upper social class may have a greater chance of having or reporting a malaria patient ()benin) Poverty does not prevent use: there is no evidence of gross lack of utilization of health care by people in lower income households . the lowest income quintile was in fact more likely to seek ttt though not from shops and public services not private facilities(inequality in thailand) material: use of mean vs median: Related to the above point, cost of illness studies face difficulties in how the data should be presented, in particular whether measures of central tendency best reflect or represent the cost burdens facing the study population. Illness and illness costs are usually distributed very unevenly across households, with a minority incurring very high costs, so measures of central tendency conceal wide variations in cost burdens. The use of mean cost figures, in particular, often exaggerates the cost burdens faced by most households because a minority of high values pull the mean above the median. Median figures may therefore reflect more accurately the costs facing the majority of households, but in many studies only the mean is presented. ec burden on households)

skewed ness
*It is important to note that all cost variables show a highly skewed distribution. This is due to the fact that (i) illness clusters in a relatively small number of households. Ofthose, only a minority incurs any costs at all. Households must be helped to channel their expenditure more rationally (a broader view of malaria)

Seeking care:
Percent using of formal sector: Frequency of use of the formal health sector was higher than expected; 415 of 1014 children (41%, 3745) who had been sick in the previous 2 weeks had been taken to an appropriate provider of care .(inequality among the poor) discouraging of self ttt: As part of a strategy to control cost, public education must be intensified to discourage selfmedication which leads to misuse of antimalara drugs and thereby promote resistance of the malaria parasite to drugs>. Also public education regarding

that early signs of the disease are reported to hhealth care providers before it becomes severe and therefore more expensive to manage. No traditional use for malaria ttt: A number of studies suggest that the majority of people recognize the value of modern drugs in the treatment of malaria.(rev seeking)

Percent for self ttt, and facility use:

(46% or 57:123), with use of clinic medicine at home the second most common choice of treatment (29%). Seventeen percent (21:123) would go to the clinic first, while only 5% said they would go the hospital first (malaria 16) RDF decrease cost and increase use: Ministry of Health has offered generic drugs through co-managed community revolving drug funds at prices below those of private pharmacies. This policy, inspired by experience elsewhere in sub-Saharan Africa (for a review see [33, has been shown to reduce the total financial cost of a health care visit and to increase health care utilization [15]. . (variation in burkina) Use of health centers: Public medical centres were the most commonly used treatment source. Cuz for using private facility: The reasons for this tendency include the lack of services after working hours and long waiting times at public medical centres as well as better attention at the private clinics of public doctors. Infact, 22% of patient visits were made to the private clinics of public doctors. .(matale) People pay more for high quality care: people are prepared to pay higher for the high quality health acre(ghana) availability of facilities within the community decrease transport cost: the availability of drug stores in the communities has therefore cutdown on the distance traveled to purchased drugs. The little time spent intravelling suggest that people do not generally travelfar from their communities to purchase drugs. Percent of self ttt dis: Self-treatment was common among all patients, with 97% involved in it before or after formal treat-ment. .(matale) Percent using public and private facilities: demonstrates that 46% of patients sought care only from the public facilities as outpatients, and that 25% sought care from private sources only. Only 11% of patients used a combination of public and private services..(matale) private sector should be included in policies/:: The study has also shown the importance of private sector provision for treating malaria at the household level. These two facts alone suggest that both donors and policy makers need to pay special attention to private as well as pub-lic providers of services when formulating control strategies and measures. It also highlights the importance of consider-ing a variety of viewpoints when conducting economic evalu-ations of health services. To exclude the patients

viewpoint may encourage shifting of costs onto a population already bearing significant financial burdens from the disease. .(matale) Improve quality in public facility to reduce costs: Improve quality of care at public facilities, focusing on reducing waiting times and better inter-personal quality of care, in order to attract patients from the private to the public sector and reduce direct costs. Building community and patient trust in lower level public facilities is a key challenge. ec burden on households Low self ttt and high compliance due to high access: The relatevly low level of self tt and high compliance can be explained by the wide accessibility of public helth services in Guyana an(care seeking and cost) Cuz of delay diss: Individuals did not thik they have malaria Most stdies found distance to health services and finacial costs to be the reasons for delay(care seeking and cost) Compliance, percent of dis: Rate of completion of antimalarias ttt regimen is known to be poor through out the malaria endemic countries however there are reports with high compliance rates 70%, the limiting factor is that compliance had been assessed through subjective means nevertheless noncompliance is widely acnowlegede problem(care seeking and cost) Causes of Non compliance didd: Non compliance with anm. Has been found to to be related to 4 factors: adverse affects, ealy resolution of symptoms, saving of drugs for future use and inadequate dosing instructions(care seeking and cost) Low self ttt due to free and close by facilities: Discussion low self treatment rates are due to free servise at public health facilities and facilities are close to the homes of most affected people. (care seeking and cost) No Use of public facilities which are available: Free or very low cost health services were available to the survey populations, which calls into question who benifis most from public subsidies or health, what are the implications for public sector intervention when the private sector expenditures on health are greater than those f the public sector? .(economic and demographic research) Percent of self ttt: However studies in Guatemala Ethiopia and Kenya found that 60% of individuals selftreated and did not seek medical attention(care seeking and costdirect cost:

SES
Incidence , no difference by SES: Malaria, unlike diseases resulting from poverty, does not discriminate between rich and poor victims. Cuz of no difference of incidence by SES: The lack of consistent socio-economic differentials in malaria incidence is not necessarily counterintuitive. Given the epidemiology of malaria transmission, particularly its environmental aspects, it should not be surprising that variables such as housing type had an impact on incidence, given the importance of housing in limiting vector/human contact. That most of the other variables yielded, at best, conflicting data on their impact on malaria incidence could be a testament to the high degree of exposure to the mosquito vector regardless of SES, particularly in areas and periods of high transmission. Vulnerability to the consequences of infection, on the other hand, has much less to do with

non-discriminatory environmental factors, and more to do with inequities in access to prevention and treatment. realatioan SES and malaria)) disease does show that poor people suffer more serious consequences due to lack of access to prevention and treatment and higher cost burdens. There is a need to target anti-malaria campaigns so that the poor gain better access to prevention and treatment at lower cost. ec burden on households Cost affects poor more than rich:regression: discussion: it also means that if one is attemting to show that the disease affects earnings and economic growth , the measured income effect will be lower than it would be if it affected hiher income groups to an equal extent.( economic and demoghraphic) effect of SES on income poor can not afford preventive measures ttt expenses: This leads to two forms of inequity: first, the poor are less likely to benefit from preventive measures due to their inability to afford them; and second, the burden of any given level of expenditure on treatment will be greater for those on low incomes. realatioan SES and malaria)) ) High coverage by services and OOP: Interpretation People, particularly in poor households, can be protected from catastrophic health expenditures by reducing a health systems reliance on out-of-pocket payments and providing more financial risk protection. Increase in the availability of health services is critical to improving health in poor countries, but this approach could raise the proportion of households facing catastrophic expenditure; risk protection policies would be especially important in this situation. (household catastrophic expend)

Health insurance:
HI: and improved quality and political commitment: Risk-sharing prepayment schemes have long thought to be impractical in rural subSaharan Africa.* However, they have recently received increasing attention [35-40]. The few documented ongoing prepayment schemes stress the need for community involvement, the use of funds--inter alia--for quality improvement of services and the need for political commitment from national policy makers to support the schemes [35 (variation in burkina HI: to reduce OOP and increased use: To reduce or mitigate direct medical costs, the service delivery weaknesses that increase direct costs to households need to be addressed, for example: Expand coverage of tax- or insurance-based financing systems to protect poor households from out-of-pocket payments for health care, since these payments impose significant barriers to access and considerable cost burdens on the poor. ec burden on households

progressive fee scedukes and subsided services for OOP: such as progressive fee schedules, highly subsidised or free hospital services, and the provision of certain health services to the poor. (household catastrophic expend) heath insurance for OOP and access: National health systems can be financed in ways that protect households from catastrophic spending and provide access to needed services. The most straightforward approach is to reduce out-of-pocket spending through the development of social insurance or funding through general taxes. (household catastrophic expend) User fees worse than HI: Both reasons are important for arguing that health systems are better financed through prepayment mechanisms such as social insurance and general taxation than through user-fees. . (household catastrophic expend) High income will not reduce OOP as HI: The problem of catastrophic health payments will not simply go away with rising income; rather, the complex process of developing social institutions to effectively pool financial risk must be placed on the agenda. (household catastrophic expend) High coverage, poverty, and no HI increase OOP: Out-of-pocket payments are not, however, the only important determinant of catastrophic payments. The triad of poverty, healthservice access and use, and the failure of social mechanisms to pool financial risks account for most of the variation across countries. Catastrophic payments are the biggest issue when all three of these factors are strong. Therefore, we would expect to see high rates of catastrophic spending in countries with high rates of poverty, groups excluded from financial risk protection mechanisms such as social insurance, and moderate to high levels of health-care access and use. . (household catastrophic expend) HI among self-employed: The problems of insurance lie in unifyingthe current schemes, and especially in ensuring highcoverage amongst the self-employed and subsistencefarmers. HI in local organization is better(community based ): Neither the state nor the market is effective in providing health insurance to low-income people in rural and informal sectors. The for- mal providers are often at an informational disadvantage and face high transaction costs. On both these counts health insurance schemes rooted in local organizations potentially score better than alternate health insurance arrangements.

the emergence of many community-based health insurance schemes (CBHI)in different regions of developing countries, particularly in sub-Saharan The decentralization process unleashed in these countries to empower lower layers of government and the local community further fueled their emergence The success of community-based micro- credit schemes may have also contributed to the emergence of community-based health initiatives designed to improve the access through risk and resource sharing (HI and access) CBHI schemes are a potential instrument of protection from the impoverishing effects of health expenditures for low-income populations. It is argued that CBHI schemes are effective in reaching a large number of poor people who would otherwise have no .financial protection against the cost of illness

Cost of private sector more than public facilities:s Deindividuals treated ta private clinics paid significantly more for ttt than those ttted at public health facilities (care seeking and cost) Start: . .(matale) Percent of montly income Cost of transport and ttt reprsent 10-20% of aveage monthly income(care seeking Cost per pt, food, travel private vs public: and cost)cost / patient = 75 / 48 $ food = 28 ttt= 23 travel cost = 9 . higest cost for those attending purely private clinic 91/48 per pt, private vs public This tablealso shows that, for the same patients, the cost of receiving treatment was Rs. 37 (SD 112) per patient and the cost of complementary goods/services (CC) was Rs. 38 (SD 40). Patients who had received treatment only from private west-ern sources had the highest average cost of treatment (Rs. 86) followed by the combination of public inpatient or outpatient care with private western treatment (Rs. 73). .(matale) Transport cost: Transport was another siziable expense for the population the mean cost of transport was $ 7.22(care seeking and cost) availability of facilities within the community decrease transport cost: the availability of drug stores in the communities has therefore cutdown on the distance traveled to purchased drugs. The little time spent intravelling suggest that people do not generally travelfar from their communities to purchase drugs. cost of health facility and drug ranking first: As regards policies aiming to reduce the financial costs of illness, the current study has shown that professional health services account for the largest share of households' expenditures for care, with drug expenditures ranking first. (variation in burkina)

Cost per pt per episode: On average the total treatment costs per patient per episode was 1.81$.(ghana) Facility costs rank first: Facility costs formed a major component of hosehold expenditre on treatment of malaria 49% of total costs(ghana) Malaria expenditure per households: Average malaria expenditure: average malaria expenditure was $ 1.84 per household per month (nigeria Drug costs: Considering the components of costs reported the cost of drugs comprise a significant proportion of total cost of treating fever . 64.8% of total ttt costs(ghana) Lab costs: 0.86$ (ghana) transport cost: 0.25$ (ghana) High drug costs will increase more: The cost of drug are expected to rise in the future as p. falciparum chloroquine resistance increases requiring more potent and therefore more expensive drugs than chloroquine(ghana) Variations in cost due to care sourse: The variations in average cost are a function of the source of care in that there were substantial differences in travel cost to private clinics located far away from the patients residence as well as in length of stay as inpatients. .(matale) Even if the cost is not high the high prevalence increased the cost: The problem of the direct cost is not so much that the unit costs are high, but rather that prevelance is very high and incomes are very low( malaria in new colonization project brazil) : target poor people: Such high cost burdens for the poor are likely to trigger asset or borrowing strategies, and a recent review of malaria and poverty has argued that malaria prevention and treatment programmes need to have more of an equity focus and better targeted to the poor (Worrall et al., 2002). ec burden on households) Subsidies for the poor: "seasonal cross-subsidies" into existing price sched-ules of health services. This would mean charging lower prices for services and drugs in the rainy season and higher prices in the dry seasons, as suggested by Fabricant [16]. (variation in burkina Policy: expenditure in developing countries: To illustrate ,public expenditures on health in most developing countries can be as little as $ 1 per person per year. .(economic and demographic research)

Direct cost: / Start: fever . Using a recall period of one month data on 888cases were obtained usig a structured questionnaire. Recommendations: Improving dosing pattern requires education of patients and caretakers ** results : ther is consistent gradient from from poor to rich