Cost-effectiveness of malaria control in sub-Saharan Africa

Summary

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 Data were obtained from published and unpublished sources, and consultations with researchers and programme managers.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.

Introduction

One of the main initiatives of Gro Harlem Brundtland, the new Director General of WHO, was to launch the Roll Back Malaria campaign, which aims to generate a substantial expansion in effective malaria prevention and treatment.1, 2 The initial focus is on sub-Saharan Africa, where malaria is the most important infectious disease in childhood. Policy makers need information on the costs and effectiveness of interventions. The existing knowledge base on cost-effectiveness is, however, sparse, and is limited to a few studies that are hard to compare, generalise, or relate to operational situations. Although more studies are required, results will not be available to inform urgent decisions on resource allocation.

To address this gap in available data, we estimated cost-effectiveness ratios for the main prevention and treatment interventions in sub-Saharan Africa. We used an innovative modelling approach based on probabilistic sensitivity analysis, which we believe provides policy makers with robust conclusions, despite the imperfect data available.