The study took place in the Fana Health District Reference Health Centre in the pediatric unit. The Fana health district was established in 1999 in Koulikoro region (Mali republic). It covers the districts of Béléco, Mena and Fana, divided into 13 rural communes with an area of 7319 km². It is currently composed of twenty-two (22) functional health areas; 2 private clinics; 5 private medical practices. The target population estimated in 2020 was 328,801 inhabitants according to the revised General Census of Population and Housing (RGPH 2009 révisé) [7].

This was a cross-sectional, descriptive study with prospective data collection, which ran from July 2017 to June 2018.

The study concerned children aged 0 to 5 years hospitalized and treated for severe malaria in the pediatric unit of the Reference health center of Fana.

Were included in this study:

• Children aged 0 to 59 months hospitalized and treated for severe malaria;

• The full availability of justification of expense (consultation and hospitalization ticket, prescription, analysis sheets, restaurant subscription);

• The obtaining informed parental consent.

• Cases of evacuation, abandonment or death during care;

• A hospitalization period of less than 24 hours.

The sample size was determined by making a comprehensive sampling based on the inclusion and non-inclusion criteria.

An authorization has been submitted and approved by the health officials of the Fana Health District. A document in which the objectives, purpose and confidentiality of the study are narrated, was presented or explained verbally to each participant in order to obtain informed consent. The observation of anonymity in the dissemination of results guarantees professional secrecy.

Children from 0 to 5 years old are part of the vulnerable population to malaria. In this study, the results showed that out of a total of 944 hospitalized cases (SLIS Fana) [8], 109 cases were included of which the most affected age group was 25 - 36 months or 3 years (Figure 1). This result is similar to the results of the study conducted by KAWELE Bouzoum [6] which showed a high number in children aged 3 years. Precisely at this age, the child begins to be no longer dependent on his mother but is not able to protect himself against mosquito bites. Due to the inattention of the parents, the disease is detected late. Even if the reality of trans-placental infection of the newborn is admitted, linked to the passage of parasitized red blood cells from the placenta congenital malaria-disease is rare. It appears after a variable delay of 5 to 60 days and the constant clinical sign is fever (Pierre Aubry et al.) [2]. The boys were the most exposed with a sex ratio of 1.4 to girls. The same result was obtained in a study conducted in the pediatric department of the Befelatanana Hospital in Antananarivo among children under 5 years old (Raobijaona H. et al. and by KAWELE Bouzoum) [6] [9]. This would show a vulnerability of boys compared to girls. The main complications were severe anemia (46%), convulsion (32%) and severe sepsis (7%). The most frequent and serious complications of P. falciparum infection in children are neuromalaria, severe anemia, respiratory distress (acidosis) and hypoglycemia (WHO Practical Guide 2013) [10].

The results of the Malaria Indicator Survey [5] showed that the economic well-

being index in rural areas is only 4%. The peak of malaria is reached during the winter season and this coincides with the lean season in rural areas, complicating the economic situation of families. In order to standardize the management of malaria, the reference documents were the Malian policies, standards and procedures (PNP-Malaria) [11] and the WHO 3rd edition practical guide. The three protocols for the management of severe malaria are based on the treatment with injectable quinine, injectable artesunate and intra-muscular artéméther. Thus, it was agreed to respect the medical prescription as much as possible towards the essential drugs (INN), as well as the indication of paramedical analyses to the strict necessary. The results of the study (Table 5) showed that the average direct cost of treating severe malaria in the pediatric ward of the CSRéf of Fana was 25,324 Franc CFA (58.9558 US Dollars) [12]. The costs of the consultation, hospitalization and rapid diagnostic test (RDT) were covered by the health center, so the average direct cost borne by patients is 22,824 Franc CFA or 53 US Dollars. This cost was lower than that of KAWELE Bouzoum conducted in Togo in 2013, which found an average direct cost of 55,215 Franc CFA (99.7256 US Dollars). It should be noted that the costs of transportation and catering were not included in the latter. Also, the cost of medical consultation 1000 Franc CFA (1.8061 US Dollars) and hospitalization 1500 Franc CFA (2.7092 US Dollars) are paid only once per hospitalization at the Fana pediatric hospital. Studies conducted in Côte d’Ivoire by G.L.S Couitchéré et al. [13] and Oshwa B. Mbalabu in DRC [14] found an average direct cost of 20,251 Franc CFA (36.5760 US Dollars) and 21,713 Franc CFA (39.2165 US Dollars) respectively. These amounts were lower than those obtained in our study. This can be explained by the fact that the cost of restoration was not taken into account in the study by G.L.S Couitchéré et al. and the cost of transport and restoration in the study by Oshwa B. Mbalabu in DRC.

A study on the cost evaluation of the treatment of severe malaria by M. Mtalimanja et al. [15] in Zambia revealed that the cost of the cure with artesunate was 65.6 US Dollars. Also the cost-effectiveness study by Y. Lubell et al. [16] showed a similar result with 66.5 US Dollars for artesunate versus 61.4 US Dollars for quinine. The drugs used and the care provided differed between the protocols. For example, the treatment with injectable quinine requires the use of glucose serum, infusion set and other adjuvant drugs in addition to close care of 4 hours of follow-up and risks of death are related to the incorrect use of this molecule (one in four deaths) [17]. While artesunate does not require the use of other drugs or long-term care; it is simple to administer and reduces the risk of hypoglycemic episodes during treatment by 45%, making it an economical treatment and, therefore, its use in the management of severe malaria in children is considered to have greater monetary benefits [18]. Thus the costs differ even though we did not take this into account in the calculation of the average cost.

Estimating the economic cost of severe malaria management is very complex and the context of a sick relative in hospital makes it difficult to interview parents. The estimated average cost of management of severe malaria in this study is more than half of the minimum wages in Mali (40,000 Franc CFA as of 2016) [19]. The study took place in a rural community whose main economic activity is agriculture dependent on the rainy season. So this estimate gives us some idea of the burden of managing severe malaria in children aged 0 - 5 years on the economy of the family.