Costs and financial feasibility of malaria elimination

Abstract

The marginal costs and benefits of converting malaria programmes from a control to an elimination goal are central to strategic decisions, but empirical evidence is scarce. We present a conceptual framework to assess the economics of elimination and analyse a central component of that framework-potential short-term to medium-term financial savings. After a review that showed a dearth of existing evidence, the net present value of elimination in five sites was calculated and compared with effective control. The probability that elimination would be cost-saving over 50 years ranged from 0% to 42%, with only one site achieving cost-savings in the base case. These findings show that financial savings should not be a primary rationale for elimination, but that elimination might still be a worthy investment if total benefits are sufficient to outweigh marginal costs. Robust research into these elimination benefits is urgently needed.

Figure 1

Comparison of the average yearly cost of elimination with controlled low-endemic malaria per head at risk in five case studies, with sensitivity analysis Red triangles represent the most likely cost for elimination and controlled low-endemic malaria (CLM), assuming elimination needs 10 years (8 years in Mauritius) and costs are not discounted. Red lines extend vertically to the minimum and maximum costs obtained from sensitivity analysis of elimination costs and horizontally to those for controlled low-endemic malaria, such that all points within the blue box represent potential financial comparisons between the two strategies. The shaded square represents costs that fall within 95% CIs derived from probabilistic simulation. The 45° dotted line shows equal costs for elimination and controlled low-endemic malaria, so that points above that line indicate elimination costs greater than controlled low-endemic malaria and points below indicate elimination costs less than controlled low-endemic malaria. If the entirety of the blue box is above the dotted line, elimination was not identified as less expensive than control in sensitivity analysis.

Figure 2

Comparison of average yearly cost of prevention of reintroduction with controlled low-endemic malaria per head at risk in five case studies, with sensitivity analysis Red triangles represent the most likely cost for prevention of reintroduction (POR) and controlled low-endemic malaria (CLM), assuming prevention of reintroduction is maintained for 10 years and costs are not discounted. Red lines extend vertically to the minimum and maximum costs obtained from sensitivity analysis of prevention-of-reintroduction costs and horizontally to those for controlled low-endemic malaria, such that all points within the blue box represent potential financial comparisons between the two strategies. The shaded square represents costs that fall within 95% CIs derived from probabilistic simulation. The 45° dotted line shows equal costs for prevention of reintroduction and controlled low-endemic malaria, so that points above that line indicate prevention-of-reintroduction costs greater than controlled low-endemic malaria and points below indicate prevention-of-reintroduction costs less than controlled low-endemic malaria. If a blue box crosses the dotted line, prevention of reintroduction was less expensive than controlled low-endemic malaria under certain combinations of assumptions.

Figure 3

Comparison of present value of elimination with controlled low-endemic malaria per head at a risk over 25 years (A) and 50 years (B) in five case studies, with sensitivity analysis Red triangles represent the most likely cost for elimination and controlled low-endemic malaria (CLM), assuming a 3% discount rate. Red lines extend vertically to the minimum and maximum costs obtained from sensitivity analysis of elimination costs and horizontally to those for controlled low-endemic malaria, such that all points within the blue box represent potential financial comparisons between the two strategies. The shaded square represents costs that fall within 95% CIs derived from probabilistic simulation. The 45° dotted line shows equal costs for elimination and controlled low-endemic malaria, so that points above that line indicate elimination costs greater than controlled low-endemic malaria and points below indicate elimination costs less than controlled low-endemic malaria. If a blue box crosses the dotted line, elimination was cumulatively less expensive than controlled low-endemic malaria under specific combinations of assumptions.