# Bringing malaria diagnosis and treatment closer to the people: economic rationale for expanding malaria community case management to all ages in a rural district in Madagascar

## TL;DR

Expanding malaria treatment to all ages in Madagascar's rural communities is shown to be cost-effective and improves healthcare access.

## Contribution

The study provides new economic evidence supporting age-expansion of malaria community case management in resource-limited settings.

## Key findings

- Age-expanded mCCM averted 99.6 deaths and 3,721.7 DALYs annually.
- The intervention was cost-saving with net economic benefits of $1,172,283.
- Sensitivity analyses confirmed the cost-effectiveness of the program.

## Abstract

Expanding malaria community case management (mCCM) to all ages could shift the point-of-care to the community leading to improved healthcare access in underserved populations. This study assesses the economic viability of such an expansion in Farafangana district, Madagascar.

A cluster-randomized trial was conducted across 30 health centres and the 502 community health workers (CHW) in their catchment areas, with the intervention arm implementing the age-expanded mCCM intervention. CHWs across both arms received training, supplies, and supervision to manage malaria. An economic evaluation assessed cost-effectiveness from health sector and societal perspectives, measuring outcomes in disability-adjusted life years (DALYs) averted. The impact of CHW compensation and economic risks were evaluated using sensitivity analyses.

Without CHW compensation, annual costs were $794,000, primarily for antimalarials and diagnostic tests. Incremental cost-effectiveness ratios (ICERs) per DALY averted ranged from -$21.86 to $212.42. From a societal perspective, the ICER was -$135.64, and -$243.29 including mortality benefits, meaning the intervention was cost-saving. The programme could avert 99.6 deaths and 3,721.7 DALYs annually, yielding $1,172,283 in net economic benefits. Sensitivity analyses supported these findings.

Age-expanded mCCM is highly cost-effective and can enhance malaria treatment access in resource-limited settings.

The online version contains supplementary material available at 10.1186/s12936-025-05381-y.