Faculty: Pharmaceutical Sciences
Department: Pharm. Microbio & Biotech


Ezenduka, C. C.
Esimone, C. O.
Okonta, J.M


Background: Malaria officially remains a leading cause of death and disability in Nigeria, responsible for over 300,000 deaths annually, mostly in children and pregnant women with huge economic burden. Inefficiency in drug treatment leads to widespread resistance and treatment failures, undermining treatment goals and worsening disease burden. Pharmacoeconomics provides the basis for informed choices between treatment options and alternative medications based on a combination of information on their costs and health outcomes, to enhance the efficiency of treatment and improved therapeutic outcomes.
Objective: The study aimed to evaluate the efficiency of malaria treatment in south east Nigeria, using the principles of pharmacoeconomics to generate evidence-based information for improving the efficiency of malaria treatment in Nigeria.
Methods: An eclectic mix of methods were used to analyze the treatment for uncomplicated malaria at both the public and private health facilities in Enugu and Anambra states; ranging from cross-sectional observational studies in Enugu urban city, review of treatment practices at the Nnamdi Azikiwe Teaching Hospital Nnewi and University Health Center Awka, costs study to clinical evaluation of effectiveness at the University Health Center Awka. In the major clinical study, under routine clinical setting, the relative costs and clinical effects of commonly used antimalarial drugs: Artemeter-lumefantrine (AL), Dihydro-artemisinin-piperaquine (DHAPQ), artesunate-amodiaquine (ASAQ) and artesunate-sulphadoxine+pyridoxine (ASSP) were evaluated to determine their relative efficiencies in the treatment of uncomplicated malaria. Cost and effect data were collected from patients who presented at the Health Centre with uncomplicated malaria, and were randomized to a three-day course of treatment and followed-up for 28 days. Effects data were based on efficacy and compliance to treatment. Cost data were based on the direct costs of capital and recurrent expenditures. Results were presented as incremental cost-effectiveness ratio (ICER), in terms of additional cost per successfully treated malaria episode with each drug.
Results: Artemisinin-based combination therapies (ACTs) were the most widely used antimalarial drugs at both the private (72%) and public (93%) health facilities. Monotherapy accounted for up to 27% of drug use in the retail sector, while 48% of presumptive diagnosis of malaria cases was documented in the public health facilities. Treatment was characterized by substantial over-diagnosis of cases, poor and over use of medications and wastages. With a wide range of antimalarial drugs, AL followed by DHAPQ was the most prescribed antimalarial drug at both the public and private healthcare facilities. It cost an average of N4, 944 (US$31.49) to treat an episode of uncomplicated malaria in the health facility, with personnel and antimalarial drugs accounting for 82% and 6.6% of the total, respectively. The ICERs ranged between $4.10 (DHAPQ) and 6.73 (ASSP) per additional malaria case treated. Further results showed that DHAPQ generated the least cost per additional malaria case treated, dominating other ACTs as the most cost-effective agent. Diagnostic accuracy, cost of drugs and compliance to treatment were the key parameters that significantly influenced the cost-effectiveness results, without changing the order of magnitude.
Conclusion: Study suggests significant inefficiency in malaria treatment in the South East, indicating a wide scope for improving efficiency. Dihydro-artemisinin-piperaquine at a given budget, is the most cost-effective regimen for treating uncomplicated malaria, generating the most cost-savings and greatest number of malaria treatments, compared to other agents. This should inform policy on the choice of first line drug for improved efficiency in malaria treatment in Nigeria, to achieve treatment goals and reduced burden of malaria disease. Efficiency is achieved under strict adherence to treatment guidelines.