Real world costs and barriers to the successful implementation of rectal artesunate as pre-referral treatment for severe malaria in Sub-Saharan Africa

Abstract

Background Rectal artesunate (RAS), an efficacious pre-referral treatment for severe malaria in children, was deployed at scale in Uganda, Nigeria and DR Congo. In addition to distributing RAS, implementation required additional investments in crucial but neglected components in the care for severe malaria. We examined the real-world costs and barriers to RAS implementation. Methods We collected primary data on baseline health system gaps and subsequent RAS implementation expenditures. We calculated the equivalent annual cost of RAS implementation per child under 5 at risk of severe malaria, from a health system perspective, separating neglected routine health system components from incremental RAS introduction costs. Findings The largest baseline gaps were irregular health worker supervisions, inadequate referral facility worker training, and inadequate malaria commodity supplies. Health worker training and behaviour change campaigns were the largest startup costs, while supervision and supply chain management accounted for most annual routine costs. The equivalent annual costs of preparing the health system for treating severe malaria with RAS were $2.31, $2.20 and 4.15 per child at risk in Uganda, Nigeria and DRC. The incremental costs of introducing RAS, net of routine neglected components, accounted for a minority at $0.72, $0.59 and $0.94. Interpretation While RAS has been touted as a cost-effective pre-referral treatment for severe malaria in children, its real-world potential is limited by weak and under-financed continuums of care. Scaling up RAS or other interventions relying on community healthcare providers only makes sense alongside additional, essential health system investments sustained over the long-term. Funding Unitaid

Community access to rectal artesunate for malaria (CARAMAL): A large-scale observational implementation study in the Democratic Republic of the Congo, Nigeria and Uganda

“…Here we present a general description of the CARAMAL project, its research questions, detailed methodology and overall operational results. The key findings and recommendations from the scientific investigations of the CARAMAL project are presented in series of other publications, with a focus on the health impact of the large-scale RAS roll-out [25], referral processes and completion rates [26], the quality of treatment at referral health facilities [27], and costing [28]. Given its size (over 14,000 episodes of severe fever observed), its ability to follow these children for 28 days after enrolment into the study, and the multiplicity of research tools, CARAMAL offered unique insight into the fate of children experiencing severe febrile illnesses (including severe malaria) in remote locations in Africa.…”

“…The methodology for this component is described in detail in [28]. Of note, funding from the CARAMAL project was always additional to funding provided by government resources and support by other partners.…”

“…Detailed information on operational aspects of RAS rollout is forthcoming in [28]. Some key results are reported below.…”