Variation in the quality and out-of-pocket cost of treatment for childhood malaria, diarrhoea, and pneumonia: Community and facility based care in rural Uganda

PLoS One. 2018 Nov 26;13(11):e0200543. doi: 10.1371/journal.pone.0200543. eCollection 2018.


Background: A key barrier to appropriate treatment for malaria, diarrhoea, and pneumonia (MDP) in children under 5 years of age in low income rural settings is the lack of access to quality health care. The WHO and UNICEF have therefore called for the scale-up of integrated community case management (iCCM) using community health workers (CHWs). The current study assessed access to treatment, out-of-pocket expenditure and the quality of treatment provided in the public and private sectors compared to national guidelines, using data collected in a large representative survey of caregivers of children in 205 villages with iCCM-trained CHWs in mid-Western Uganda.

Results: The prevalence of suspected malaria, diarrhoea and suspected pneumonia in the preceding two weeks in 6501 children in the study sample were 45%, 11% and 24% respectively. Twenty percent of children were first taken to a CHW, 56% to a health facility, 14% to other providers and no care was sought for 11%. The CHW was more likely to provide appropriate treatment compared to any other provider or to those not seeking care for children with MDP (RR 1.51, 95% CI 1.42-1.61, p<0.001). Seeking care from a CHW had the lowest cost outlay (median $0.00, IQR $0.00-$1.80), whilst seeking care to a private doctor or clinic the highest (median $2.80, IQR $1.20-$6.00). We modelled the expected increase in overall treatment coverage if children currently treated in the private sector or not seeking care were taken to the CHW instead. In this scenario, coverage of appropriate treatment for MDP could increase in total from the current rate of 47% up to 64%.

Conclusion: Scale-up of iCCM-trained CHW programmes is key to the provision of affordable, high quality treatment for sick children, and can thus significantly contribute to closing the gap in coverage of appropriate treatment.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Child
  • Child, Preschool
  • Community Health Services / economics
  • Community Health Workers / economics
  • Costs and Cost Analysis / economics
  • Diarrhea / economics
  • Diarrhea / epidemiology*
  • Diarrhea / therapy
  • Health Care Costs*
  • Humans
  • Malaria / economics
  • Malaria / epidemiology*
  • Malaria / therapy
  • Patient Acceptance of Health Care
  • Pneumonia / economics
  • Pneumonia / epidemiology*
  • Pneumonia / therapy
  • Prevalence
  • Quality of Health Care / economics
  • Rural Population
  • Uganda / epidemiology

Grants and funding

The study was funded by a Bill and Melinda Gates Foundation grant to the Malaria Consortium - number OPP1002407. Webpage: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.