Is community-based malaria prevention for pregnant women in Uganda cost-effective?

International malaria control policy recommends that all mothers at risk from malaria receive intermittent preventive treatment in pregnancy with the antimalarial sulfadoxine-pyrimethamine (SP). However, costs incurred in accessing SP at health centres could deter pregnant women from seeking care. Researchers in Uganda considered an alternative approach to delivering the treatment.

Researchersfrom the Ugandan Ministry of Health, and Aarhus and Copenhagen University, bothin Denmark, assessed the cost-effectiveness of a community-based approach to deliveringintermittent preventive treatment in pregnancy (IPTp)in Uganda. They compared this approach with delivery of treatment as part ofroutine care at health centres or antenatal clinics.

Thestudy involved 2,785 pregnant women and took place in the rural lake shoreregion of Mukono district, central Uganda. Community-basedworkers administered 500 mg of sulfadoxine and 25 mgof pyrimethamine to the women in the second and thirdtrimester of pregnancy in line with Ugandan health policy. The workers includedtraditional birth attendants, drug-shop vendors, community reproductive healthworkers and adolescent peer mobilisers. The newdelivery system emphasised follow-up of pregnantwomen in the community in order to ensure higher compliance with treatment.

Theresearchers found that two-thirds of the women receiving community-based care receivedSP early and adhered to the two recommended doses compared with 39.9 percent athealth centres. They also had fewer episodes of anaemia or parasitaemia (parasites in the blood) and fewer low birthweight babies.Overall the new delivery system improved access to and use of IPTp. Findings showed that:

• thosefollowing the community-based approach received IPTp at21 weeks into their pregnancies compared with 23 weeks for the other group
• the majorityof women (92.4 percent) at community centres received the first dose of IPTp during the second trimester as recommended by theUgandan policy compared with 76.1 percent of those at health centres
• the cost per woman receiving the fullcourse of IPTp was higher when delivered viacommunity care at US$2.60 compared with US$2.30 at health centres, due to theadditional training costs
• the added effort oftraining and enabling community workers had an estimated incremental cost-effectivenessratio of Uganda shillings 1,869, or just above US$1.1 per lostdisability-adjusted life-year (DALY) averted,which is normally considered very cost-effective.

Theresearchers conclude that community-based delivery increased access andadherence to IPTp among women most at risk frommalaria. Training community-based workers to distribute SP for IPTp as an extra service in addition to IPTpat health centres was also cost-effective in the district studied. They suggestthat:

• policymakersneed to review the current policy on malaria prevention in pregnancy to allowprovision of IPTp and other preventive measures suchas insecticide-treated nets via the new delivery system
• policymakerswill need to link community-based delivery to the health system; this willrequire them to improve the quality of antenatal care by ensuring that basicsupplies and drugs are available
• in orderto improve community-based distribution of IPTp, the workersmay need longer training to ensure effective monitoring
• performance-relatedpay may be necessary to motivate them to distribute IPTpand follow up women.