Household and Health System Cost of malaria in Sub Sahara Africa: Systematic review analysis

Household and Health System Cost of malaria in Sub Sahara Africa: Systematic review analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Household and Health System Cost of malaria in Sub Sahara Africa: Systematic review analysis Yirgalem Baruda, Yihalem Belay, Lelisa Assebe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8858635/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 17 You are reading this latest preprint version Abstract Background Malaria is a significant public health problem in sub-Saharan Africa (SSA), causing a substantial burden on households and population. This systematic review aims to analyze the cost burden faced by malaria patients and health systems in sub-Saharan Africa (SSA) Methods We conducted the current review according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guideline. Studies reporting direct and indirect outpatient and inpatient costs incurred by malaria patients and the health system in SSA were included in the review. A pooled mean estimate for household and health system costs of malaria was conducted using random effects model of the Dersimonia_Laird method using Stata version 17 software. Results We included 43 studies in the current analysis. Nearly a quarter of studies (21.74%) reported costs using both household and health system perspectives. The pooled outpatient household cost per episode of malaria was $ 23.03 (range $ 17.64– $ 28.42). For inpatient care of severe malaria, the average household cost per episode from the studies was $ 90.79 (range $ 64.93– $ 116.65). For health system costs, the average outpatient cost was $ 20.58 (range $ 5.88– $ 35.29), and the average inpatient cost was $ 94.18 (range $ 55.22– $ 133.15). Conclusions Our study found that malaria had a significant economic burden to households and health systems in SSA. Our findings provide important evidence for the planning of malaria programs and health insurance policies to optimise resource allocation and healthcare strategies for malaria in SSA. Cost Health System Household Malaria sub-Saharan Africa Review Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Deaths and illnesses caused by malaria remain unacceptably high (1). It remains as a significant global health concern with substantial impacts on human health, social well-being, and economic development (WHO). Globally, an estimated 263 million cases and 597 000deaths were reported in 2023 (2). Nearly half of all cases worldwide were reported from four countries in Sub-Saharan Africa (SSA) - Nigeria (30.9%), the Democratic Republic of the Congo (11.3%), Niger (5.9%) and Tanzania (4.3%) (2). According to US Centers for Disease Control and Prevention, malaria disproportionately affects vulnerable populations, including young children and pregnant women. The disease not only leads to acute illness and mortality but also contributes to long-term health complications and disabilities. Malaria-related anaemia, cognitive impairment in children, and adverse pregnancy outcomes are some of the consequences that hinder individual and societal well-being (3). The economic impact of malaria on individuals and households in SSA is profound and far-reaching according to WHO. The SSA is plagued by malaria not merely as a disease, but as a persistent public health crisis. The burden of malaria in endemic regions not only results in high prevention and treatment costs and lost wages, but it also changes social and economic behaviour, which can further worsen economic consequences (4) Firstly, malaria imposes a significant financial burden on individuals and households (5). The direct costs of seeking treatment, including medical consultations, diagnostic tests, and antimalarial medications, become quickly accumulate, resulting in families struggling to make ends meet. These expenses can push them further into poverty or force them to make difficult choices, such as forgoing other essential needs like food or education (6). Malaria has a considerable impact on household productivity and economic development. It leads to lost workdays and decreased productivity, as affected individuals cannot fulfil their work responsibilities, resulting in income losses for affected individuals and their households (7). Moreover, malaria-related absenteeism from schools can disrupt children's education and hinder their future economic prospects. Lastly, the economic impact of malaria extends beyond individual households. It affects communities and national economies by reducing workforce productivity, increasing healthcare expenditures, and hindering economic growth (8). The high prevalence of malaria in SSA undermines efforts to improve agricultural productivity, as farmers and laborers are frequently incapacitated by the disease. This not only affects their income but also leads to food insecurity and economic instability (9). Addressing the economic impact of malaria requires comprehensive strategies that focus on prevention, treatment, and strengthening health systems. Investing in effective preventive measures, such as insecticide-treated bed nets and indoor residual spraying, can reduce the incidence of malaria and its associated economic burden. Accessible and affordable diagnosis and treatment services are crucial to ensure prompt and appropriate care for affected individuals. Therefore, reducing the economic impact of malaria in SSA countries can create healthier and more economically prosperous communities. The previous review assesses the patient cost of inpatient and outpatient management of malaria in SSA. These reviews focused on presenting minimum and maximum treatment costs from household, health system, and societal perspectives but did not estimate average costs for inpatient and outpatient household and health system malaria treatment (10,11). In addition, there is limited evidence on the pooled estimates of patients’ and health systems’ malaria-related costs across the region, hindering prioritization of efforts to alleviate the malaria burden. The rationale for conducting this systematic review is to assess the pooled estimate of costs incurred by household and health system for malaria treatment in SSA. Such knowledge is essential for prioritizing healthcare policy and intervention to reduce the economic burden of malaria in SSA. Methods 3.1 Data Sources and Search Strategies A comprehensive search was conducted in the following electronic databases: PubMed, Scopus, Embase, Web of Science, and google scholar. Using the PECO framework (Population, Exposure, Comparator, and Out comes), both simple and advanced search was conducted in each of the databases using a combination of keywords related to malaria, patient costs, economic burden, SSA, as well as Medical Subject Headings (MeSH) terms. The search terms were adapted according to the specific requirements of each database by incorporating appropriate Boolean operators (AND, OR) and truncation symbols. The search strategy also included citation tracking of relevant articles and a manual search of the reference lists of included studies to identify additional potentially relevant studies. Grey literature sources, such as government reports, conference abstracts, and dissertations, were searched to minimize publication bias. The search strategy used in PubMed is shown in 3.2. Data Extraction Data were extracted using a Microsoft Excel extraction sheet intended for this purpose. The data extraction included study characteristics (author, publication year, study design), participant characteristics (demographics, socioeconomic status), intervention details (if applicable), outcome measures (direct costs). The data extraction process was conducted independently by two reviewers. 3.2. Eligibility Criteria Quantitative studies, including cross-sectional, cohort, case-control, and randomized controlled trials (RCTs) were eligible for inclusion. Qualitative studies were also considered if they provide relevant information on the experiences and perspectives of malaria patients and their caregivers regarding costs incurred. Studies focusing on individuals of any age group, gender, or socioeconomic background who have been diagnosed with malaria in SSA were eligible for inclusion. By encompassing a broad population range, the review aimed to capture the diverse experiences and costs incurred by different demographic groups. Studies that assessed the direct and indirect costs incurred by malaria patients or their caregivers were included. 3.3. Study Selection Two independent reviewers (LF, and YB) screened the identified studies based on predefined inclusion and exclusion criteria. All retrieved records were imported to EndNote version 20 software and duplicates were removed. All authors screened the titles and abstracts of retrieved studies. Then, the full texts of included studies were reviewed against the eligibility criteria. Disagreements between two screeners were resolved through discussion. 3.4. Quality Assessment and risk of bias The quality assessment was performed using appropriate tools based on the study design. Ottowa’s critical Appraisal of Cross-Sectional Studies, NIH’s Quality assessment tool for observational cohort and cross-sectional studies, were used to assess the quality the studies. These checklists consist of items related to study design, sample size calculation, data collection methods, statistical analysis, and interpretation of results. Each item was evaluated for its presence and adequacy in the included studies. For qualitative studies, the Critical Appraisal Skills Programme (CASP) qualitative checklist was used to assess the methodological rigor, credibility, and relevance of the studies. The CASP checklist includes items related to research design, data collection methods, data analysis, interpretation of findings, and consideration of ethical aspects. For mixed-methods studies, a combination of appropriate tools was used to assess both qualitative and quantitative components, ensuring a comprehensive evaluation of the study quality. The risk of bias assessment was conducted to identify potential sources of bias that may impact the validity of the included studies. The assessment was performed using appropriate tools specific to the study design. For randomized controlled trials (RCTs), the Cochrane Collaboration's tool for assessing the risk of bias was employed. This tool evaluates several domains of bias, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias. Each domain was assessed for the risk of bias as low, high, or unclear. 3.5. Data Synthesis A narrative synthesis was conducted to summarize the findings of the included studies. This was involving a systematic review and summary of the characteristics and results of individual studies, including the outpatient and inpatient costs incurred by malaria patients and health system in SSA. The findings were also quantitatively pooled based on systematic review principles. This involved the quantitative pooling and analysis of the direct and indirect outpatient and inpatient mean costs incurred by malaria patients and health system in SSA. Due to heterogeneity among the studies, random-effects models of the Dersimonia_Laird method using Stata version 16 software was used to calculate summary estimates of household and health system cost, along with their corresponding 95% confidence intervals. Heterogeneity among the studies was assessed using statistical tests (e.g., I^2 statistic), and meta regression. The results of both the narrative synthesis were interpreted collectively to provide a comprehensive overview of the economic impact associated with malaria in SSA. To assess publication bias, both visual and statistical methods were used. A funnel plot was generated, and Egger’s regression test was performed, with statistical significance set at p < 0.05. Cost estimates extracted from the included studies were converted and presented in 2023 cost rate. To get the country specific value of the cost with 2023 rate, cost estimates in the source literature were first collected, then multiplies with country-specific consumer pricing index rates of 2023. Consumer pricing index data series were obtained from the World Bank’s World Development Indicators database (12). 3.6. Ethical considerations Since the systematic review was only use published data, no ethical approval required. The study was adhered to relevant guidelines for systematic reviews and ensure the confidentiality, privacy and respect the original authors work and extracted data. Results Search results from review of the studies We identified 1,640 studies through our database search. Upon excluding duplicate records, we screened 1,082 studies for relevance of which only 46 were eligible for full text review. Forty-three of the studies met the inclusion criteria and were included in the final systematic review (Fig. 1 ) Characteristics of the Studies About 23% of the studies reported both the health system and household costs. Most studies (36/43, 83.7%) reported using either household or Heath system perspectives. Nineteen articles were focuses on both inpatients and outpatient cost of household and health system costs. The remaining articles reported costs to either the health system or households in inpatient or outpatient settings. Approximately half of the articles studied populations across all age groups. Half of the research articles were published between 2016 and 2023, with six studies appearing between 2022 and 2023( 13 – 18 ) (Table 1 ). Table 1 Characteristics of the included in the systematic review Pooled estimate of household and health system cost of malaria Article Year Country Cost perspective Study population Study focus [Inpatient (IP) /Outpatient (OP)/Both] 1 ( 19 ) 2022 Uganda, Mozambique Health System Under five Both 2 ( 20 ) 2009 Uganda Household Under five Both 3 ( 21 ) 2019 Uganda, Burkina Faso Ghana, Nigeria Household and Health System All age Both 4 ( 5 ) 2018 Mozambique Household and Health System Under five Both 5 ( 22 ) 2008 Mozambique, South Africa Household All age OP 6 ( 23 ) 2021 Kenya Household All age IP 7 ( 24 ) 2020 Kenya Household Under five IP 8 ( 25 ) 2009 Kenya Household and Health System Under five IP 9 ( 26 ) 2016 Cameroon Health System Children age < 15 IP 10 ( 27 ) 2015 Cameroon Household Under five OP 11 ( 28 ) 2014 Cameroon Household and Health System All age OP 12 ( 29 ) 2015 Zambia Household All age Both 13 ( 30 ) 2021 DR Congo Household Under five IP 14 ( 31 ) 2014 DR Congo Household Children age < 15 IP 15 ( 32 ) 2015 DR Congo Health System Under five IP 16 ( 14 ) 2023 DR Congo, Madagascar, Mozambique, Nigeria Household All age Both 17 ( 7 ) 2013 Nigeria Health system and Household All age Both 18 ( 33 ) 2017 Nigeria Health system All age OP 19 ( 15 ) 2023 Nigeria Household All age OP 20 ( 34 ) 2021 Gabon Household Under five IP 21 ( 35 ) 2017 Malawi Household All age IP 22 ( 36 ) 2011 Malawi Household Under five OP 23 ( 37 ) 2018 Ghana Household Under five OP 24 ( 38 ) 2016 Ghana Household All age OP 25 ( 39 ) 2013 Ghana. Tanzania, Kenya Health system and Household Under five Both 26 ( 40 ) 2014 Tanzanians Health system Under five Both 27 ( 16 ) 2022 Rwanda Health system All age Both 28 ( 41 ) 2017 Ethiopia Household All age OP 29 ( 42 ) 2020 Ethiopia Household All age OP 30 ( 43 ) 2021 Ethiopia Household All age OP 31 ( 44 ) 2019 Ethiopia Health system and Household All age OP 32 ( 45 ) 2017 Zimbabwe Household All age Both 33 ( 46 ) 2021 Gambia Household All age OP 34 ( 13 ) 2022 Gambia, Burkina Faso Household Under five Both 35 ( 47 ) 2010 Burkina Faso Household Under five Both 36 ( 48 ) 2018 Burkina Faso Household Under five OP 37 ( 49 ) 2017 Mali Health system Under five OP 38 ( 50 ) 2023 Mali Health system Under five IP 39 ( 51 ) 2016 Sudan Household All age OP 40 ( 39 ) 2012 Guinea Household All age Both 41 ( 52 ) 2015 Equatorial Guinea Health system All age OP 42 ( 17 ) 2022 Benin Household All age Both 43 ( 18 ) 2022 Burundi Health system and Household Under five Both Small study effect test (Assessment of publication bias) Publication bias or small study effect was evaluated using both visual inspection of a funnel plot and statistical testing via Egger’s regression test. The funnel plot (Fig. 2 ) demonstrated a relatively symmetric distribution of effect sizes around the pooled estimate, suggesting the absence of publication bias. Furthermore, the result of Egger’s test did indicate statistical evidence of small study effects, with a p-value of < 0.001 (Fig. 3 ). The findings collectively suggest that the systematic review results are not substantially influenced by bias from smaller studies or selective publication. Household Malaria Cost The cost estimates derived from the literature were converted to 2023 cost rates. Most studies (34/43) which assessed the cost of malaria from the household perspective assessed the treatment costs. From the household perspective, the treatment cost of malaria was analysed with each of the cost categories and level of severity for malaria. The mean cost of illness per outpatient household, uncomplicated episode of malaria, across sub-Saharan Africa countries was $ 23.03 (range $ 17.64– $ 28.42). The highest household outpatient cost was in Ethiopia( 42 ) $ 49 and Nigeria( 7 ) $ 48.60 and the lowest was in the Gambia( 46 ) $ 3.78. There was also difference in outpatient cost within a country. ( Fig. 4 ). Moreover, for inpatient care of sever malaria, the average cost per episode from the studies was approximately $ 90.79 (range $ 64.93– $ 116.65). The average total household inpatient cost was four times the average household outpatient cost in the region. The observed variation in cost estimates was large across different health care service type for severe malaria treatments such as inpatient hospitalization, medication and laboratory test. The highest household inpatient patient cost was in Ghana ( 39 ) $ 312.46 and Gabon ( 34 ) $ 244.64 and the lowest was in Kenya ( 24 ) $ 12.52 and Burkina Faso ( 48 ) $ 7.13 (Fig. 5 ). Health System Malaria Cost Almost half of the studies assessed the cost of malaria from the health system perspective and analysed the cost for diagnosis, and treatment of malaria. The cost for malaria diagnosis was mainly for RDT. The average outpatient cost uncomplicated malaria from the health system perspective from the studies was $ 20.58 (range $ 5.88 to $ 35.29). When we compare the cost among countries, the cost was the highest in Nigeria ( 33 ) which was $ 122.50 whereas the lowest was in Uganda( 21 ) $ 1.72 (Fig. 6 ). The average inpatient cost of severe malaria, from the health system perspective was $ 94.18 (range $ 55.22 to $ 133.15). Comparing the cost among countries, the cost in Nigeria( 7 ) was $ 186.80 whereas in Uganda ( 21 )the cost was $ 11.29 ( Fig. 7 ). Discussion This review presented the result of synthesized evidence from forty- three studies on the costs of malaria published since 2007 in SSA. The analysis indicated that, the pooled mean household malaria treatment cost for outpatient (uncomplicated) per case from studies was approximately USD $ 23.03 (range: $ 17.64– $ 28.42) and USD $ 90.79 (Range: $ 64.93– $ 116.65) per episodes of sever malaria. Regarding health system costs, pooled estimates from studies on malaria treatment showed the average outpatient cost at approximately $ 20.58 (range: $ 5.88– $ 35.29), while the average inpatient costs was $ 94.18 (range: $ 55.22– $ 133.15). There was variation in outpatient malaria cost for household and health system costs among the countries involved in the studies. The difference might be due to varying costing methods or malaria treatment guidelines used across studies countries. Studies reveal additional factors driving variations in outpatient malaria costs between households and health systems across countries. These include limited health insurance coverage (37,53), distance from healthcare facilities ( 35 , 36 , 41 ), treatment facility type (e.g., health centres vs. primary hospitals) ( 35 , 41 ), and economic disparities both within and between countries (36,38,54). Similarly, the presence of comorbidities, facility type for inpatient treatment, and duration of hospital stay were all significant drivers of household and health system costs ( 23 , 25 , 39 ). Moreover, there was considerable heterogeneity in estimates in the literature based on settings from which costing data were gathered and the health facilities in which care for malaria was sough. The cost of treatment could vary within and between countries based on the capabilities, and resources available for treatment in those settings leading to some heterogeneity in reported costs. This review differs from earlier analyses of malaria costs [Ref], which focused primarily on treatment expenses and included studies only up to the year 2000. In contrast, this review incorporates studies published between 2007 and 2024, evaluating malaria costs from various angles, including both health system and household perspectives. It also considers outpatient and inpatient costs reported in the selected studies. Additionally, the review specifically targets research on malaria costs within sub-Saharan Africa. We acknowledge several limitations of this study. First, for the methodological limitations, there was substantial heterogeneity among the individual studies regarding study setting and facilities type. We did not do subgroup analysis to understand the individual influence of these factors on the cost, we could not account for all of these factors simultaneously due to data scarcity. Therefore, our estimates of malaria management cost should be interpreted as a crude median cost. Second, due to data gaps, we could not estimate the cost of malaria management according to aetiology, particularly for falciparum or vivax. This suggests that economic evaluation, such as cost-effectiveness analysis, might consider using the cost of malaria management as an alternative to the pathogen-specific cost data. As a result, the reported cost of this analysis was underestimated. Conclusions The study provides an overview of outpatient and inpatient cost of malaria management from household and health system perspectives in SSA. It also indicated that malaria constitute the high burden for household and health system in the region. Our findings provide important evidence for the prioritizing healthcare policy and intervention to reduce malaria burden. I also optimise resource allocation and healthcare strategies for malaria in SSA. While some of the knowledge gaps are addressed by this study, the substantial remaining data gaps are worth highlighting, including the lack of cost data by region, pathogen, and comorbidities. Addressing these data gaps would further support health economic evaluation analysis to quantify the net benefits of interventions against malaria treatment. Declarations Funding · The authors declare no funding source for this study. Contributions · All authors made a significant contribution to the work reported. YSB and LFA contribute on conception, study design, analysis and write up. YAB contributed on editing and reviewing of the manuscript. Competing interest: · Author declare no competing interest Availability of data and materials · The article is a systematic literature review that relies only on previously published studies and does not present any new data from the authors; all original sources are properly cited. Consent for publication · Not applicable. 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BMJ Open. 2021;11(12):1–8. Devine A, Pasaribu AP, Teferi T, Pham HT, Awab GR, Contantia F, et al. Provider and household costs of Plasmodium vivax malaria episodes: A multicountry comparative analysis of primary trial data. Bull World Health Organ. 2019;97(12):828–36. Gunda R, Shamu S, Chimbari MJ, Mukaratirwa S. Economic burden of malaria on rural households in Gwanda district, Zimbabwe. Afr J Prim Health Care Fam Med. 2017;9(1):1–6. Broekhuizen H, Fehr A, Nieto-Sanchez C, Muela J, Peeters-Grietens K, Smekens T, et al. Costs and barriers faced by households seeking malaria treatment in the Upper River Region, The Gambia. Malar J [Internet]. 2021;20(1):1–8. Available from: https://doi.org/10.1186/s12936-021-03898-6 Koné I, Marschall P, Flessa S. Costing of Malaria treatment in a rural district hospital. Health N Hav. 2010;02(07):759–68. Castellani J, Mihaylova B, Siribié M, Gansane Z, Ouedraogo AZ, Fouque F, et al. Household costs and time to treatment for children with severe febrile illness in rural Burkina Faso: The role of rectal artesunate. Malar J [Internet]. 2018;17(1):1–12. Available from: https://doi.org/10.1186/s12936-018-2526-8 Maccario R, Rouhani S, Drake T, Nagy A, Bamadio M, Diarra S, et al. Cost analysis of a school-based comprehensive malaria program in primary schools in Sikasso region, Mali. BMC Public Health. 2017;17(1):1–11. Traore S, Haidara A, Samake Y. Estimation of the Average Direct Cost of Treating Severe Malaria in Infants 0-59 Months Old in the CSRef of Fana , Mali. 2025;14(1):1–4. ٢٠٠٧ ،٦ ﺩﺪﻌﻟﺍ ،ﺮﺸﻋ ﺚﻟﺎﺜﻟﺍ ﺪﻠﺠﳌﺍ ،ﺔﻴﳌﺎﻌﻟﺍ ﺔﺤﺼﻟﺍ ﺔﻤﻈﻨﻣ ،ﻂﺳﻮﺘﳌﺍ ﻕﺮﺸﻟ ﺔﻴﺤﺼﻟﺍ ﺔﻠﺠﳌﺍ. 2004; Romay-Barja M, Jarrin I, Ncogo P, Nseng G, Sagrado MJ, Santana-Morales MA, et al. Rural-urban differences in household treatment-seeking behaviour for suspected malaria in children at Bata District, Equatorial Guinea. PLoS One. 2015;10(8):1–16. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8858635","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595158603,"identity":"acf36b61-e200-4c8f-985f-2d4e5197a038","order_by":0,"name":"Yirgalem 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University","correspondingAuthor":false,"prefix":"","firstName":"Yihalem","middleName":"","lastName":"Belay","suffix":""},{"id":595158605,"identity":"ed1cdc03-552a-484b-9a6c-cc2c82e2ea29","order_by":2,"name":"Lelisa Assebe","email":"","orcid":"","institution":"Success healthecon consultancy plc","correspondingAuthor":false,"prefix":"","firstName":"Lelisa","middleName":"","lastName":"Assebe","suffix":""}],"badges":[],"createdAt":"2026-02-12 07:08:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8858635/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8858635/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103345682,"identity":"1c84e730-fe3e-4904-a47b-7e004ffcd305","added_by":"auto","created_at":"2026-02-24 16:13:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":36910,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study selection process\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/07fe4c9a599f837acde03221.png"},{"id":103506383,"identity":"61693a49-fbf8-4152-b520-95f5402c32fe","added_by":"auto","created_at":"2026-02-26 13:35:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":30436,"visible":true,"origin":"","legend":"\u003cp\u003eFunnel plot of the 43 studies included in the systematic review assessing the pooled estimate of household and health system cost in SSA.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/6fd364a2a848f832cc8dffb3.png"},{"id":103345683,"identity":"c2294801-f5a1-4dc7-bca0-a4877e9a2c51","added_by":"auto","created_at":"2026-02-24 16:13:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87475,"visible":true,"origin":"","legend":"\u003cp\u003eEgger’s test plot for the 43 studies included in the systematic review assessing the pooled estimate of household and health system cost in SSA.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/758e4fde0691941374ffaf54.png"},{"id":103345684,"identity":"df260c4f-83d9-4658-b665-14eb950622c1","added_by":"auto","created_at":"2026-02-24 16:13:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":337346,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing the pooled household outpatient malaria cost\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/cee4cec08eb235558ee16f8b.png"},{"id":103506507,"identity":"885cef55-27b1-48be-be5a-38e502a72218","added_by":"auto","created_at":"2026-02-26 13:37:09","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":278505,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing the pooled Household malaria inpatient cost\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/cc68a072bc73c729c033d599.png"},{"id":103345686,"identity":"e698d547-a6ad-4510-a2a9-a79f0a4ede79","added_by":"auto","created_at":"2026-02-24 16:13:42","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":170859,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing the pooled Health system outpatient malaria cost\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/a659f692a188b9d300b293cc.png"},{"id":103506342,"identity":"f0114d53-269e-414f-9708-d0b0bb3fe596","added_by":"auto","created_at":"2026-02-26 13:35:27","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":204616,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot showing the pooled Health system inpatients malaria cost\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/81973a8bf13305f2976119c0.png"},{"id":103512792,"identity":"1157647d-fbe3-4ffe-81bc-163a513d5cf6","added_by":"auto","created_at":"2026-02-26 14:15:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1736889,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8858635/v1/f79fe949-fec2-42d2-bf11-eda22db501a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Household and Health System Cost of malaria in Sub Sahara Africa: Systematic review analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDeaths and illnesses caused by malaria remain unacceptably high (1). It remains as a significant global health concern with substantial impacts on human health, social well-being, and economic development (WHO). Globally, an estimated 263 million cases and 597 000deaths were reported in 2023 (2). Nearly half of all cases worldwide were reported from four countries in Sub-Saharan Africa (SSA) - Nigeria (30.9%), the Democratic Republic of the Congo (11.3%), Niger (5.9%) and Tanzania (4.3%) (2). According to US Centers for Disease Control and Prevention, malaria disproportionately affects vulnerable populations, including young children and pregnant women. The disease not only leads to acute illness and mortality but also contributes to long-term health complications and disabilities. Malaria-related anaemia, cognitive impairment in children, and adverse pregnancy outcomes are some of the consequences that hinder individual and societal well-being (3).\u003c/p\u003e\n\u003cp\u003eThe economic impact of malaria on individuals and households in SSA is profound and far-reaching according to WHO. The SSA is plagued by malaria not merely as a disease, but as a persistent public health crisis. The burden of malaria in endemic regions not only results in high prevention and treatment costs and lost wages, but it also changes social and economic behaviour, which can further worsen economic consequences (4) Firstly, malaria imposes a significant financial burden on individuals and households (5). The direct costs of seeking treatment, including medical consultations, diagnostic tests, and antimalarial medications, become quickly accumulate, resulting in families struggling to make ends meet. These expenses can push them further into poverty or force them to make difficult choices, such as forgoing other essential needs like food or education (6). Malaria has a considerable impact on household productivity and economic development. It leads to lost workdays and decreased productivity, as affected individuals cannot fulfil their work responsibilities, resulting in income losses for affected individuals and their households (7). Moreover, malaria-related absenteeism from schools can disrupt children's education and hinder their future economic prospects. Lastly, the economic impact of malaria extends beyond individual households. It affects communities and national economies by reducing workforce productivity, increasing healthcare expenditures, and hindering economic growth (8). The high prevalence of malaria in SSA undermines efforts to improve agricultural productivity, as farmers and laborers are frequently incapacitated by the disease. This not only affects their income but also leads to food insecurity and economic instability (9).\u003c/p\u003e\n\u003cp\u003eAddressing the economic impact of malaria requires comprehensive strategies that focus on prevention, treatment, and strengthening health systems. Investing in effective preventive measures, such as insecticide-treated bed nets and indoor residual spraying, can reduce the incidence of malaria and its associated economic burden. Accessible and affordable diagnosis and treatment services are crucial to ensure prompt and appropriate care for affected individuals. \u0026nbsp;Therefore, reducing the economic impact of malaria in SSA countries can create healthier and more economically prosperous communities.\u003c/p\u003e\n\u003cp\u003eThe previous review assesses the patient cost of inpatient and outpatient management of malaria in SSA. These reviews focused on presenting minimum and maximum treatment costs from household, health system, and societal perspectives but did not estimate average costs for inpatient and outpatient household and health system malaria treatment (10,11). In addition, there is limited evidence on the pooled estimates of patients’ and health systems’ malaria-related costs across the region, hindering prioritization of efforts to alleviate the malaria burden. The rationale for conducting this systematic review is to assess the pooled estimate of costs incurred by household and health system for malaria treatment in SSA. Such knowledge is essential for prioritizing healthcare policy and intervention to reduce the economic burden of malaria in SSA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e3.1\u0026nbsp;Data Sources and Search Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive search was conducted in the following electronic databases: PubMed, Scopus, Embase, Web of Science, and google scholar. Using the PECO framework (Population, Exposure, Comparator, and Out comes), both simple and advanced search was conducted in each of the databases using a combination of keywords related to malaria, patient costs, economic burden, SSA, as well as Medical Subject Headings (MeSH) terms. The search terms were adapted according to the specific requirements of each database by incorporating appropriate Boolean operators (AND, OR) and truncation symbols. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe search strategy also included citation tracking of relevant articles and a manual search of the reference lists of included studies to identify additional potentially relevant studies. Grey literature sources, such as government reports, conference abstracts, and dissertations, were searched to minimize publication bias. The search strategy used in PubMed is shown in\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Data Extraction\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were extracted using a Microsoft Excel extraction sheet intended for this purpose. The data extraction included study characteristics (author, publication year, study design), participant characteristics (demographics, socioeconomic status), intervention details (if applicable), outcome measures (direct costs). The data extraction process was conducted independently by two reviewers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Eligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative studies, including cross-sectional, cohort, case-control, and randomized controlled trials (RCTs) were eligible for inclusion. Qualitative studies were also considered if they provide relevant information on the experiences and perspectives of malaria patients and their caregivers regarding costs incurred. Studies focusing on individuals of any age group, gender, or socioeconomic background who have been diagnosed with malaria in SSA were eligible for inclusion. By encompassing a broad population range, the review aimed to capture the diverse experiences and costs incurred by different demographic groups. Studies that assessed the direct and indirect costs incurred by malaria patients or their caregivers were included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Study Selection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo independent reviewers (LF, and YB) screened the identified studies based on predefined inclusion and exclusion criteria. All retrieved records were imported to EndNote version 20 software and duplicates were removed. All authors screened the titles and abstracts of retrieved studies. Then, the full texts of included studies were reviewed against the eligibility criteria. Disagreements between two screeners were resolved through discussion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4. Quality Assessment and risk of bias\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality assessment was performed using appropriate tools based on the study design. Ottowa’s critical Appraisal of Cross-Sectional Studies, NIH’s Quality assessment tool for observational cohort and cross-sectional studies, were used to assess the quality the studies. These checklists consist of items related to study design, sample size calculation, data collection methods, statistical analysis, and interpretation of results. Each item was evaluated for its presence and adequacy in the included studies. For qualitative studies, the Critical Appraisal Skills Programme (CASP) qualitative checklist was used to assess the methodological rigor, credibility, and relevance of the studies. The CASP checklist includes items related to research design, data collection methods, data analysis, interpretation of findings, and consideration of ethical aspects. For mixed-methods studies, a combination of appropriate tools was used to assess both qualitative and quantitative components, ensuring a comprehensive evaluation of the study quality.\u003c/p\u003e\n\u003cp\u003eThe risk of bias assessment was conducted to identify potential sources of bias that may impact the validity of the included studies. The assessment was performed using appropriate tools specific to the study design. For randomized controlled trials (RCTs), the Cochrane Collaboration's tool for assessing the risk of bias was employed. This tool evaluates several domains of bias, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other potential sources of bias. Each domain was assessed for the risk of bias as low, high, or unclear.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5. Data Synthesis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA narrative synthesis was conducted to summarize the findings of the included studies. This was involving a systematic review and summary of the characteristics and results of individual studies, including the outpatient and inpatient costs incurred by malaria patients and health system in SSA. The findings were also quantitatively pooled based on systematic review principles. This involved the quantitative pooling and analysis of the direct and indirect outpatient and inpatient mean costs incurred by malaria patients and health system in SSA. Due to heterogeneity among the studies, random-effects models of the Dersimonia_Laird method using Stata version 16 software was used to calculate summary estimates of household and health system cost, along with their corresponding 95% confidence intervals. Heterogeneity among the studies was assessed using statistical tests (e.g., I^2 statistic), and meta regression. The results of both the narrative synthesis were interpreted collectively to provide a comprehensive overview of the economic impact associated with malaria in SSA. \u0026nbsp;To assess publication bias, both visual and statistical methods were used. A funnel plot was generated, and Egger’s regression test was performed, with statistical significance set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eCost estimates extracted from the included studies were converted and presented in 2023 cost rate. To get the country specific value of the cost with 2023 rate, cost estimates in the source literature were first collected, then multiplies with country-specific consumer pricing index rates of 2023. Consumer pricing index data series were obtained from the World Bank’s World Development Indicators database (12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6. Ethical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince the systematic review was only use published data, no ethical approval required. The study was adhered to relevant guidelines for systematic reviews and ensure the confidentiality, privacy and respect the original authors work and extracted data.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch results from review of the studies\u003c/h2\u003e \u003cp\u003eWe identified 1,640 studies through our database search. Upon excluding duplicate records, we screened 1,082 studies for relevance of which only 46 were eligible for full text review. Forty-three of the studies met the inclusion criteria and were included in the final systematic review (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCharacteristics of the Studies\u003c/h3\u003e\n\u003cp\u003eAbout 23% of the studies reported both the health system and household costs. Most studies (36/43, 83.7%) reported using either household or Heath system perspectives. Nineteen articles were focuses on both inpatients and outpatient cost of household and health system costs. The remaining articles reported costs to either the health system or households in inpatient or outpatient settings. Approximately half of the articles studied populations across all age groups. Half of the research articles were published between 2016 and 2023, with six studies appearing between 2022 and 2023(\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the included in the systematic review Pooled estimate of household and health system cost of malaria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArticle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCost perspective\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStudy population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStudy focus\u003c/p\u003e \u003cp\u003e[Inpatient (IP) /Outpatient\u003c/p\u003e \u003cp\u003e(OP)/Both]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda, Mozambique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUganda, Burkina Faso Ghana, Nigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold and Health System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMozambique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold and Health System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMozambique, South Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold and Health System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCameroon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChildren age\u0026thinsp;\u0026lt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCameroon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCameroon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold and Health System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZambia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDR Congo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDR Congo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChildren age\u0026thinsp;\u0026lt;\u0026thinsp;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDR Congo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth System\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDR Congo, Madagascar, Mozambique, Nigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system and Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNigeria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGabon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMalawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGhana\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGhana. Tanzania, Kenya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system and Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTanzanians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRwanda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEthiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system and Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGambia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGambia, Burkina Faso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBurkina Faso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBurkina Faso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSudan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGuinea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEquatorial Guinea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBenin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHousehold\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBurundi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHealth system and Household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnder five\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eSmall study effect test (Assessment of publication bias)\u003c/h3\u003e\n\u003cp\u003ePublication bias or small study effect was evaluated using both visual inspection of a funnel plot and statistical testing via Egger\u0026rsquo;s regression test. The funnel plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) demonstrated a relatively symmetric distribution of effect sizes around the pooled estimate, suggesting the absence of publication bias. Furthermore, the result of Egger\u0026rsquo;s test did indicate statistical evidence of small study effects, with a p-value of \u0026lt;\u0026thinsp;0.001 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The findings collectively suggest that the systematic review results are not substantially influenced by bias from smaller studies or selective publication.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eHousehold Malaria Cost\u003c/h3\u003e\n\u003cp\u003eThe cost estimates derived from the literature were converted to 2023 cost rates. Most studies (34/43) which assessed the cost of malaria from the household perspective assessed the treatment costs. From the household perspective, the treatment cost of malaria was analysed with each of the cost categories and level of severity for malaria. The mean cost of illness per outpatient household, uncomplicated episode of malaria, across sub-Saharan Africa countries was \u003cspan\u003e$\u003c/span\u003e23.03 (range \u003cspan\u003e$\u003c/span\u003e17.64\u0026ndash; \u003cspan\u003e$\u003c/span\u003e28.42). The highest household outpatient cost was in Ethiopia(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 49 and Nigeria(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 48.60 and the lowest was in the Gambia(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 3.78. There was also difference in outpatient cost within a country. ( Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMoreover, for inpatient care of sever malaria, the average cost per episode from the studies was approximately \u003cspan\u003e$\u003c/span\u003e90.79 (range \u003cspan\u003e$\u003c/span\u003e64.93\u0026ndash; \u003cspan\u003e$\u003c/span\u003e116.65). The average total household inpatient cost was four times the average household outpatient cost in the region. The observed variation in cost estimates was large across different health care service type for severe malaria treatments such as inpatient hospitalization, medication and laboratory test. The highest household inpatient patient cost was in Ghana (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 312.46 and Gabon (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 244.64 and the lowest was in Kenya (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e 12.52 and Burkina Faso (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e7.13 (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eHealth System Malaria Cost\u003c/h3\u003e\n\u003cp\u003eAlmost half of the studies assessed the cost of malaria from the health system perspective and analysed the cost for diagnosis, and treatment of malaria. The cost for malaria diagnosis was mainly for RDT. The average outpatient cost uncomplicated malaria from the health system perspective from the studies was \u003cspan\u003e$\u003c/span\u003e 20.58 (range \u003cspan\u003e$\u003c/span\u003e 5.88 to \u003cspan\u003e$\u003c/span\u003e 35.29). When we compare the cost among countries, the cost was the highest in Nigeria (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) which was \u003cspan\u003e$\u003c/span\u003e 122.50 whereas the lowest was in Uganda(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) \u003cspan\u003e$\u003c/span\u003e1.72 (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The average inpatient cost of severe malaria, from the health system perspective was \u003cspan\u003e$\u003c/span\u003e 94.18 (range \u003cspan\u003e$\u003c/span\u003e 55.22 to \u003cspan\u003e$\u003c/span\u003e 133.15). Comparing the cost among countries, the cost in Nigeria(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) was \u003cspan\u003e$\u003c/span\u003e 186.80 whereas in Uganda (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)the cost was \u003cspan\u003e$\u003c/span\u003e11.29 ( Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review presented the result of synthesized evidence from forty- three studies on the costs of malaria published since 2007 in SSA. The analysis indicated that, the pooled mean household malaria treatment cost for outpatient (uncomplicated) per case from studies was approximately USD \u003cspan\u003e$\u003c/span\u003e23.03 (range: \u003cspan\u003e$\u003c/span\u003e17.64\u0026ndash; \u003cspan\u003e$\u003c/span\u003e28.42) and USD \u003cspan\u003e$\u003c/span\u003e90.79 (Range: \u003cspan\u003e$\u003c/span\u003e64.93\u0026ndash; \u003cspan\u003e$\u003c/span\u003e116.65) per episodes of sever malaria. Regarding health system costs, pooled estimates from studies on malaria treatment showed the average outpatient cost at approximately \u003cspan\u003e$\u003c/span\u003e20.58 (range: \u003cspan\u003e$\u003c/span\u003e5.88\u0026ndash;\u003cspan\u003e$\u003c/span\u003e35.29), while the average inpatient costs was \u003cspan\u003e$\u003c/span\u003e94.18 (range: \u003cspan\u003e$\u003c/span\u003e55.22\u0026ndash;\u003cspan\u003e$\u003c/span\u003e133.15).\u003c/p\u003e \u003cp\u003eThere was variation in outpatient malaria cost for household and health system costs among the countries involved in the studies. The difference might be due to varying costing methods or malaria treatment guidelines used across studies countries. Studies reveal additional factors driving variations in outpatient malaria costs between households and health systems across countries. These include limited health insurance coverage (37,53), distance from healthcare facilities (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), treatment facility type (e.g., health centres vs. primary hospitals) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), and economic disparities both within and between countries (36,38,54). Similarly, the presence of comorbidities, facility type for inpatient treatment, and duration of hospital stay were all significant drivers of household and health system costs (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, there was considerable heterogeneity in estimates in the literature based on settings from which costing data were gathered and the health facilities in which care for malaria was sough. The cost of treatment could vary within and between countries based on the capabilities, and resources available for treatment in those settings leading to some heterogeneity in reported costs.\u003c/p\u003e \u003cp\u003eThis review differs from earlier analyses of malaria costs [Ref], which focused primarily on treatment expenses and included studies only up to the year 2000. In contrast, this review incorporates studies published between 2007 and 2024, evaluating malaria costs from various angles, including both health system and household perspectives. It also considers outpatient and inpatient costs reported in the selected studies. Additionally, the review specifically targets research on malaria costs within sub-Saharan Africa.\u003c/p\u003e \u003cp\u003eWe acknowledge several limitations of this study. First, for the methodological limitations, there was substantial heterogeneity among the individual studies regarding study setting and facilities type. We did not do subgroup analysis to understand the individual influence of these factors on the cost, we could not account for all of these factors simultaneously due to data scarcity. Therefore, our estimates of malaria management cost should be interpreted as a crude median cost. Second, due to data gaps, we could not estimate the cost of malaria management according to aetiology, particularly for falciparum or vivax. This suggests that economic evaluation, such as cost-effectiveness analysis, might consider using the cost of malaria management as an alternative to the pathogen-specific cost data. As a result, the reported cost of this analysis was underestimated.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe study provides an overview of outpatient and inpatient cost of malaria management from household and health system perspectives in SSA. It also indicated that malaria constitute the high burden for household and health system in the region. Our findings provide important evidence for the prioritizing healthcare policy and intervention to reduce malaria burden. I also optimise resource allocation and healthcare strategies for malaria in SSA. While some of the knowledge gaps are addressed by this study, the substantial remaining data gaps are worth highlighting, including the lack of cost data by region, pathogen, and comorbidities. Addressing these data gaps would further support health economic evaluation analysis to quantify the net benefits of interventions against malaria treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot; The authors declare no funding source for this study.\u003c/p\u003e\n\u003cp\u003eContributions\u003c/p\u003e\n\u003cp\u003e\u0026middot; All authors made a significant contribution to the work reported. YSB and LFA contribute on conception, study design, analysis and write up. YAB contributed on editing and reviewing of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interest:\u003c/p\u003e\n\u003cp\u003e\u0026middot; Author declare no competing interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003e\u0026middot; The article is a systematic literature review that relies only on previously published studies and does not present any new data from the authors; all original sources are properly cited.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003e\u0026middot; Not applicable.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003e\u0026middot; Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. WHO Guidelines for malaria - [Internet]. 2023. Available from: http://apps.who.int/bookorders.\u003c/li\u003e\n\u003cli\u003eWHO. The malaria situation worldwide [Internet]. 2024. 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Health N Hav. 2010;02(07):759\u0026ndash;68. \u003c/li\u003e\n\u003cli\u003eCastellani J, Mihaylova B, Siribi\u0026eacute; M, Gansane Z, Ouedraogo AZ, Fouque F, et al. Household costs and time to treatment for children with severe febrile illness in rural Burkina Faso: The role of rectal artesunate. Malar J [Internet]. 2018;17(1):1\u0026ndash;12. Available from: https://doi.org/10.1186/s12936-018-2526-8\u003c/li\u003e\n\u003cli\u003eMaccario R, Rouhani S, Drake T, Nagy A, Bamadio M, Diarra S, et al. Cost analysis of a school-based comprehensive malaria program in primary schools in Sikasso region, Mali. BMC Public Health. 2017;17(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eTraore S, Haidara A, Samake Y. Estimation of the Average Direct Cost of Treating Severe Malaria in Infants 0-59 Months Old in the CSRef of Fana , Mali. 2025;14(1):1\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003e٢٠٠٧ ،٦ ﺩﺪﻌﻟﺍ ،ﺮﺸﻋ ﺚﻟﺎﺜﻟﺍ ﺪﻠﺠﳌﺍ ،ﺔﻴﳌﺎﻌﻟﺍ ﺔﺤﺼﻟﺍ ﺔﻤﻈﻨﻣ ،ﻂﺳﻮﺘﳌﺍ ﻕﺮﺸﻟ ﺔﻴﺤﺼﻟﺍ ﺔﻠﺠﳌﺍ. 2004; \u003c/li\u003e\n\u003cli\u003eRomay-Barja M, Jarrin I, Ncogo P, Nseng G, Sagrado MJ, Santana-Morales MA, et al. Rural-urban differences in household treatment-seeking behaviour for suspected malaria in children at Bata District, Equatorial Guinea. PLoS One. 2015;10(8):1\u0026ndash;16. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cost, Health System, Household, Malaria, sub-Saharan Africa, Review","lastPublishedDoi":"10.21203/rs.3.rs-8858635/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8858635/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalaria is a significant public health problem in sub-Saharan Africa (SSA), causing a substantial burden on households and population. This systematic review aims to analyze the cost burden faced by malaria patients and health systems in sub-Saharan Africa (SSA)\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted the current review according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guideline. Studies reporting direct and indirect outpatient and inpatient costs incurred by malaria patients and the health system in SSA were included in the review. A pooled mean estimate for household and health system costs of malaria was conducted using random effects model of the Dersimonia_Laird method using Stata version 17 software.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe included 43 studies in the current analysis. Nearly a quarter of studies (21.74%) reported costs using both household and health system perspectives. The pooled outpatient household cost per episode of malaria was \u003cspan\u003e$\u003c/span\u003e23.03 (range \u003cspan\u003e$\u003c/span\u003e17.64\u0026ndash;\u003cspan\u003e$\u003c/span\u003e28.42). For inpatient care of severe malaria, the average household cost per episode from the studies was \u003cspan\u003e$\u003c/span\u003e90.79 (range \u003cspan\u003e$\u003c/span\u003e64.93\u0026ndash;\u003cspan\u003e$\u003c/span\u003e116.65). For health system costs, the average outpatient cost was \u003cspan\u003e$\u003c/span\u003e20.58 (range \u003cspan\u003e$\u003c/span\u003e5.88\u0026ndash;\u003cspan\u003e$\u003c/span\u003e35.29), and the average inpatient cost was \u003cspan\u003e$\u003c/span\u003e94.18 (range \u003cspan\u003e$\u003c/span\u003e55.22\u0026ndash;\u003cspan\u003e$\u003c/span\u003e133.15).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur study found that malaria had a significant economic burden to households and health systems in SSA. Our findings provide important evidence for the planning of malaria programs and health insurance policies to optimise resource allocation and healthcare strategies for malaria in SSA.\u003c/p\u003e","manuscriptTitle":"Household and Health System Cost of malaria in Sub Sahara Africa: Systematic review analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:13:37","doi":"10.21203/rs.3.rs-8858635/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-16T11:28:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T17:44:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T13:08:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T19:05:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1824661365274804352597104255137235385","date":"2026-02-24T19:13:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57755408422610967823781775886208858103","date":"2026-02-24T12:49:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15735021765983755350183584433864777018","date":"2026-02-24T05:53:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-23T15:55:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243318509874912960969235936245299102695","date":"2026-02-23T13:48:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258937808146904973047210971583582150089","date":"2026-02-23T10:18:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6740624927662022151085338348974552816","date":"2026-02-21T14:01:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261129911838990598093086982869871213704","date":"2026-02-19T14:45:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310433757718098161213931948158882799163","date":"2026-02-19T11:51:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T04:27:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-13T07:47:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-13T07:45:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2026-02-12T07:00:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa4ed314-2b14-4330-b3df-af33c6b019ba","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T09:56:41+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:13:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8858635","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8858635","identity":"rs-8858635","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}