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

Background Expanding malaria community case management (mCCM) to all ages could shift the point-ofcare 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.Methods 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. ResultsWithout 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 costsaving. 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.Conclusions Age-expanded mCCM is highly cost-effective and can enhance malaria treatment access in resourcelimited settings.