Background: Malaria inflicts significant costs on households and on the economy of malaria endemic countries. There
is also evidence that the economic burden is higher among the poorest in a population, and that cost burdens differ
significantly between wet and dry seasons. What is not clear is whether, and how, the economic burden of malaria
differs by disease endemicity. The need to account for geographical and epidemiological differences in the estimation
of the social and economic burden of malaria is well recognized, but there is limited data, if any, to support this
argument. This study sought to contribute towards filling this gap by comparing malaria cost burdens in four Kenyan
districts of different endemicity.
Methods: A cross-sectional household survey was conducted during the peak malaria transmission season in the
poorest areas in four Kenyan districts with differing malaria transmission patterns (n = 179 households in Bondo; 205
Gucha; 184 Kwale; 141 Makueni).
Findings: There were significant differences in duration of fever, perception of fever severity and cost burdens. Fever
episodes among adults and children over five years in Gucha and Makueni districts (highland endemic and low acute
transmission districts respectively) lasted significantly longer than episodes reported in Bondo and Kwale districts (high
perennial transmission and seasonal, intense transmission, respectively). Perceptions of illness severity also differed
between districts: fevers reported among older children and adults in Gucha and Makueni districts were reported as
severe compared to those reported in the other districts. Indirect and total costs differed significantly between districts
but differences in direct costs were not significant. Total household costs were highest in Makueni (US$ 19.6 per
month) and lowest in Bondo (US$ 9.2 per month).
Conclusions: Cost burdens are the product of complex relationships between social, economic and epidemiological
factors. The cost data presented in this study reflect transmission patterns in the four districts, suggesting that a
relationship between costs burdens and the nature of transmission might exist, and that the same warrants more
attention from researchers and policy makers.