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1: Lancet. 1999 Jul 31;354(9176):378-85.
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Comment in:
Cost-effectiveness of malaria control in sub-Saharan Africa.

Goodman CA, Coleman PG, Mills AJ.

Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK. c.goodman@lshtm.ac.uk

BACKGROUND: Information on the cost-effectiveness of malaria control is needed for the WHO Roll Back Malaria campaign, but is sparse. We used mathematical models to calculate cost-effectiveness ratios for the main prevention and treatment interventions in sub-Saharan Africa. METHODS: We analysed interventions to prevent malaria in childhood (insecticide-treated nets, residual spraying of houses, and chemoprophylaxis) and pregnancy (chloroquine chemoprophylaxis and sulfadoxine-pyrimethamine intermittent treatment), and to improve malaria treatment (improved compliance, improved availability of second-line and third-line drugs, and changes in first-line drug). We developed models that included probabilistic sensitivity analysis to calculate ranges for the cost per disability-adjusted life year (DALY) averted for each intervention in three economic strata. Data were obtained from published and unpublished sources, and consultations with researchers and programme managers. FINDINGS: In a very-low-income country, for insecticide treatment of existing nets, the cost-effectiveness range was US$4-10 per DALY averted; for provision of nets and insecticide treatment $19-85; for residual spraying (two rounds per year) $32-58; for chemoprophylaxis for children $3-12 (assuming an existing delivery system); for intermittent treatment of pregnant women $4-29; and for improvement in case management $1-8. Although some interventions are inexpensive, achieving high coverage with an intervention to prevent childhood malaria would use a high proportion of current health-care expenditure. INTERPRETATION: Cost-effective interventions are available. A package of interventions to decrease the bulk of the malaria burden is not, however, affordable in very-low-income countries. Coverage of the most vulnerable groups in Africa will require substantial assistance from external donors.

PIP: This paper examines the cost-effectiveness of malaria control using an innovative modeling approach based on probabilistic sensitivity analysis in sub-Saharan Africa. The variables included in the study were interventions for preventing malaria in childhood (insecticide-treated nets, residual spraying of houses and chemoprophylaxis), preventing malaria in pregnancy (chloroquine chemoprophylaxis and sulfadoxine-pyrimethamine intermittent treatment), and improving treatment for uncomplicated malaria (better compliance, improved availability of second- and third-line drugs, and changes in first-line drugs). Effectiveness was calculated in terms of disability-adjusted life years (DALY) formula. The cost data were obtained through published and unpublished literature, program budgets, price catalogues, and consultation with researchers and program managers. Results showed that in a very-low-income country, the cost-effectiveness range of insecticide-treated nets was US$19-85. If only insecticide treatment was required, the range would be decreased to US$4-10 per DALY averted. Cost effectiveness was $32-58 for residual spraying (two rounds per year), $3-12 for children's chemoprophylaxis, $4-29 for intermittent treatment of pregnant women, and $1-8 for improvement in case management. Cost-effectiveness analysis helped identify interventions that would result in the effective use of resources, but information on total costs was also needed in order to assess affordability. Furthermore, coverage of the most vulnerable groups in Africa would require substantial assistance from external donors.

Publication Types:
PMID: 10437867 [PubMed - indexed for MEDLINE]