Is home management of fevers a cost-effective way of reducing under-five mortality in Africa? The case of a rural Ghanaian District

Objective To assess the cost-effectiveness of two strategies of home management of under-five fevers in Ghana - treatment using antimalarials only (artesunate-amodiaquine - AAQ) and combined treatment using antimalarials and antibiotics (artesunate-amodiaquine plus amoxicillin - AAQ+AMX). Methods We assessed the costs and cost-effectiveness of AAQ and AAQ+AMX compared with a control receiving standard care. Data were collected as part of a cluster randomised controlled trial with a step-wedged design. Approximately, 12000 children aged 2-59months in Dangme West District in southern Ghana were covered. Community health workers delivered the interventions. Costs were analysed from societal perspective, using anaemia cases averted, under-five deaths averted and disability-adjusted life years (DALYs) averted as effectiveness measures. Results Total economic costs for the interventions were US$ 204394.72 (AAQ) and US$ 260931.49 (AAQ+AMX). Recurrent costs constituted 89% and 90% of the total direct costs of AAQ and AAQ+AMX, respectively. Deaths averted were 79.1 (AAQ) and 79.9 (AAQ+AMX), with DALYs averted being 2264.79 (AAQ) and 2284.57 (AAQ+AMX). The results show that cost per anaemia case averted were US$ 150.18 (AAQ) and US$ 227.49 (AAQ + AMX) and cost per death averted was US$ 2585.58 for AAQ and US$ 3272.20 for AAQ+AMX. Cost per DALY averted were US$ 90.25 (AAQ) and US$ 114.21 (AAQ+AMX). Conclusion Both AAQ and AAQ+AMX approaches were cost-effective, each averting one DALY at less than the standard US$ 150 threshold recommended by the World Health Organisation. However, AAQ was more cost-effective. Home management of under-five fevers in rural settings is cost-effective in reducing under-five mortality.