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Essays on the economic and social-behavioral effectiveness of large scale malaria control programs in three sub-saharan Africa countries

Njau, Joseph (2013)
Dissertation (198 pages)
Committee Chair / Thesis Adviser: McFarland, Deborah A
Committee Members: Howard, David H ; Stephenson, Robert ; Kachur, Stephen (CDC);
Research Fields: Health Sciences, Public Health; Economics, General
Keywords: Malaria Control; Socio-Economic Inequalities; Program Cost-effectiveness; Maternal Education; Childhood Infections; Free bed-net distributions
Program: Laney Graduate School, Health Services and Research Health Policy
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Increased global health funding has accelerated the rollout of effective malaria control packages. Little is known about the effectiveness of some of these interventions in terms of reducing socioeconomic inequalities, effective pathways for long-term and sustainable community engagements to malaria control efforts and also the cost- effectiveness of some interventions such as the universal malaria diagnostic testing in children under-five years of age.

We use Malaria Indicator Survey (MIS) data collected from three sub-Saharan Africa countries to explore the effectiveness of large scale malaria control implementation programs being undertaken in the region. Supplementary data are obtained from study countries' national malaria control programs, as well as published and unpublished study reports. Regression and decision tree models are used in the data analysis. Additionally, marginal effects and Blinder-Oaxaca decomposition techniques are employed to put the results in better perspective.

Targeted free bed-net distributions increased household overall ownership of bed-nets but the poorest households remained disproportionately underserved. Children in wealthier households were up to 12 percentage points less likely to test positive for malaria and were more likely to own and use bed-nets. Poorest households were significantly more likely to have children testing malaria positive. Meanwhile, maternal education was associated with a 4.7 percentage point reduction in childhood malaria infections. Adoption of malaria Rapid Diagnostic Test (mRDT) strategy was cost-effective across the three study countries relative to presumptive treatment strategy. The mRDT strategy exhibited higher probability to save children's lives relative to presumptive malaria treatment strategy.

Targeted free distribution of bed-nets did not achieve equitable bed-net access and use. Inequities were caused by factors other than financial constraints alone. Maternal education and choice of malaria control strategy are critical for successful and sustainable malaria control. Malaria control policies like adoption of mRDT strategy were variably cost-effective. Malaria control efforts should focus on tapping the current global momentum with coalition of diverse financing partners for effective and sustainable malaria control. Partners should be flexible enough when disbursing malaria control resources for countries to tailor control policies that reflect their epidemiological, social and economic needs.

Table of Contents

Table of Contents
List of Tables
List of Figures
Chapter 1
General Introduction
Global Malaria Burden
Historical Context of Global Malaria Funding and Control Efforts
Problem Statement
Study Objectives
Specific Objectives
Structure of the Thesis
Chapter 2
Literature Review
Malaria interventions and health inequalities
The role of Socio-behavioral factors in improving child health and malaria control programs
Cost-effectiveness of Malaria Interventions: The case of universal malaria rapid diagnostic tests (mRDT) in young children
Review Synthesis
Existing Malaria Policy Context
Chapter 3
Description of Study Sites, Data Source and Limitations
Description of study sites and malaria control initiatives
Data Sources
Description of MIS data collection process
Sample size and survey designs
MIS Questionnaires and Malaria testing
Analytical Framework
Data Limitations
Chapter 4
Exploring the impact of targeted distribution of free bed-nets in mediating the relationship between household socioeconomic disparities and a set of childhood malaria indicators
Description of Study Sites and malaria control efforts
Materials and Methods
Outcome variables
Empirical Analysis
Interaction terms
Policy Implications
Chapter 5
Exploring the linkages between maternal education and childhood malaria infections
Delineating the pathways
Data and Methods
Independent Variables
Other Control Variables
Estimation Strategy
Blinder - Oaxaca Decomposition
Chapter 6
A comparative study on cost-effectiveness analysis for adopting universal malaria rapid diagnostic tests (mRDT) for children under-five years of age: With Evidence from Malaria Indicator Survey Data in three sub-Sahara African Countries.
Study Area
Description of study design and data
Analytical Approach
Effectiveness Indicator and cost-effectiveness measure
Sensitivity Analysis
Results from the sensitivity analyses
Study limitations
Chapter 7
Discussions Policy Implications and Overall Conclusions
General Discussions
Policy Implications
Overall Study Limitations
Areas for further Research
Appendix 1: CEA Model Parameter Inputs and Data Sources
Appendix 2: Baseline Malaria Country Profiles
Appendix 3 Malaria Indicator Survey (MIS) Questionnaire Modules


application/pdf Dissertation 198 pages (958.2 KB) [Access copy of Dissertation]
Supplemental Files
application/pdf MIS Introduction and Overview.pdf 10 pages (150.1 KB) [supplemental file for Dissertation]
application/pdf MIS Household Questionnaire.pdf 4 pages (23.3 KB) [supplemental file for Dissertation]
application/pdf MIS Woman Questionnaire.pdf 12 pages (48.1 KB) [supplemental file for Dissertation]
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