Addressing child health inequity through case management of under-five malaria in Nigeria: A model-based extended cost-effectiveness analysis

Background Under-five malaria in Nigeria remains one of the biggest threats to global child health, accounting for 95,000 annual child deaths. Despite having the highest GDP in Africa, Nigeria's current health financing system has not succeeded in reducing high out-of-pocket medical expenditure, which discourages care-seeking and use of effective antimalarials in the poorest households. Resultingly, Nigeria has some of the worst indicators of child health equity among low and middle-income countries, stressing the need to evaluate how the benefits of health interventions are distributed across socioeconomic lines. Methods We developed a decision tree model for case management of under-five malaria in Nigeria and conducted an extended cost-effectiveness analysis of subsidies covering the direct and indirect costs of treatment. We estimated the number of under-five malaria deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. Findings Fully subsidizing direct medical costs plus a voucher system to cover non-medical and indirect costs with pro-poor increase in treatment coverage would annually avert over 19,000 under-five deaths, US$205.2 million in OOP spending, and 8,600 cases of CHE. Per US$1 million invested, this corresponds to 76 under-five deaths averted, 34 cases of CHE averted, and over US$800,000 in OOP expenditure averted. Due to low current treatment coverage and high disease burden, the health and financial-risk protection benefits would be pro-poor, with the poorest 40$1 million invested than broad, non-targeted interventions. Conclusion Subsidizing case management of under-five malaria for the poorest and most vulnerable children would significantly reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources.