Abstract
BACKGROUND: Chronic diseases such as sickle cell anaemia (SCA) often lead to catastrophic health expenditures, especially in malaria-endemic regions. There is limited evidence on the economic burden faced by households with children suffering from SCA. This study aimed to assess the household economic burden of SCA and the incidence of catastrophic health expenditures in Uganda and Malawi. METHODS: This prospective cohort study was nested in a clinical trial comparing malaria chemoprevention regimes: weekly dihydroartemisinin-piperaquine versus monthly sulfadoxine-pyrimethamine for children aged 6 months to 15 years in Uganda and Malawi. The economic burden was evaluated using the cost of illness approach by measuring and valuing direct and indirect costs. Quantile regression models were employed to identify factors associated with these costs. FINDINGS: The study included 723 children with an SCA (437 in Uganda and 286 in Malawi) with mean ages of 7.3 years (SD 3.9) and 8.0 years (SD 4.1), respectively. The annual median costs per household were $638.8 (IQR: $227-$2,693) in Uganda and $387.3 (IQR: $203-$694) in Malawi. The main contributors to the economic burden were direct costs in Uganda and indirect costs in Malawi. Factors such as malaria episodes, hospitalisation, hydroxyurea use, household wealth, children's age, and gender significantly influenced direct and indirect costs. The concentration indices (CI) revealed a pro-rich distribution with poorer households incurring higher direct costs in both Malawi, CI=-0.12 (SE = 0.00, P < 0.00), and Uganda, CI= -0.23 (SE = 0.02, P < 0.000). Most households in both countries experienced catastrophic health expenditures, with the highest incidence in the poorest quartile. CONCLUSION: Households with children with SCA incur high expenditures, which are catastrophic for a substantial proportion of them. Malaria episodes, hospitalisation and wealth status significantly increase the economic burden on households. Targeted interventions are needed to alleviate this financial strain, reduce disparities and improve outcomes for vulnerable households. Enhancing access to improved treatment strategies, such as effective malaria prevention measures and the consistent availability of hydroxyurea, could help reduce the number of sick episodes and, consequently, the economic burden on households and patients.