1. Cost-effectiveness of treating malaria following three methods of diagnosis: implications for scaling-up use of Rapid Diagnostic Tests in Uganda Vincent Batwala, Mbarara University, Uganda Pascal Magnussen, Copenhagen University, Denmark Fred Nuwaha, Makerere University, Uganda ICIUM2011, Antalya, Turkey. November 16 th 1

2. Background  Use of high-cost Artemisinin-based Combination Therapy (ACT) for treatment of malaria stimulated the need for accurate diagnosis in Africa  Presumptive diagnosis leads to drug expenditure on treatment of non-parasitaemic patients  We assessed the cost-effectiveness of treating malaria with ACT based on rapid test [RDT], microscopy & presumptive diagnosis (Clinicaltrials.gov, NCT00565071) 2

3.  Design: Randomized trial, 6 health centers  Population: 22052 patients were enrolled  In intervention arms finger-prick blood was examined pre-treatment  Data on costs was collected from March 2010 to Feb. 2011 2 trial districts: high & low transmission 3 Methods

4. Costing (Step-down + Ingredients approach) Available Resources Activities at the HC Personnel Medicines Stationery Transport Building Equipment Utilities Administration Records Cleaning Clinical Diagnostics Dispensary Overhead Support MCH Counseling Outreach OPD Final services Patient costs: only direct non-medical & indirect costs 4

5.  Measure of effectiveness Proportion of patients correctly identified & treated  The cost-effectiveness model Comprehensive decision analytical model in TreeAge, to calculate the Incremental Cost- Effectiveness Ratios (ICER) from societal perspective 5 Methods (cont.)

6. Major cost categories Results 6

7. Cost-effectiveness model report StrategyCost ($)Inc. costEff.Inc. eff.ACERICER Presump tive 4.04 0.643 6.28 RDT 5.221.17 0.877 0.2345.955.0 Microsc opy 5.531.48 0.797 0.1546.949.61 Dominance report The strategy “microscopy” is dominated by “RDT” 7

8. Sensitivity analysis 8

9.  Key lessons The major determinants of cost-effectiveness results were: cost of drugs, cost of diagnostics and cost of personnel Cost-effectiveness of RDT greatly improves with reduction in costs of personnel & diagnostics There was a significant improvement in antimalarial prescription with parasitological-based diagnosis 9

10.  Policy implications to improve use of medicines There is need to reconsider scaling up use of RDT rather than microscopy  Future research agenda More data is needed on comparative operational feasibility of RDT and microscopy, whether clinicians use results of parasite-based diagnosis in treating patients who test negative 10