The costs of changing national policy: lessons from malaria treatment policy guidelines in Tanzania

OBJECTIVE

To document the cost incurred by the Tanzanian government by changing the policy on first-line treatment of malaria, from chloroquine to sulfadoxine-pyrimethamine.

METHODS

Costs were analysed from the perspective of the Ministry of Health and included all sources of funding. Costs external to the public health sector (e.g. private and community costs) were not included. The base case analysis adopted an incremental rather than a full cost approach, assuming that an organizational infrastructure was already in place. However, specific attention was paid to the burden placed on National Malaria Control Program staff. We also costed activities planned but not implemented to estimate the total expense for an 'ideal' process.

RESULTS

Total costs were Tsh 795 million (USD 813,743), with the largest proportion accounted for by training. Costs of the policy change process were equivalent to about 4% of annual government and donor expenditure on malaria and to about 1% of overall public expenditure on health. A number of planned activities were not implemented; including these would bring the total cost to Ts 880 million (USD 896,130).

CONCLUSION

On top of extra costs for the drugs themselves, a change in treatment policy requires time, resources and substantial management capacity at national and local level. A better understanding of these issues and the costs involved benefits countries planning and implementing policy change.

Production of the antimalarial drug precursor artemisinic acid in engineered yeast

Malaria is a global health problem that threatens 300-500 million people and kills more than one million people annually. Disease control is hampered by the occurrence of multi-drug-resistant strains of the malaria parasite Plasmodium falciparum. Synthetic antimalarial drugs and malarial vaccines are currently being developed, but their efficacy against malaria awaits rigorous clinical testing. Artemisinin, a sesquiterpene lactone endoperoxide extracted from Artemisia annua L (family Asteraceae; commonly known as sweet wormwood), is highly effective against multi-drug-resistant Plasmodium spp., but is in short supply and unaffordable to most malaria sufferers. Although total synthesis of artemisinin is difficult and costly, the semi-synthesis of artemisinin or any derivative from microbially sourced artemisinic acid, its immediate precursor, could be a cost-effective, environmentally friendly, high-quality and reliable source of artemisinin. Here we report the engineering of Saccharomyces cerevisiae to produce high titres (up to 100 mg l(-1)) of artemisinic acid using an engineered mevalonate pathway, amorphadiene synthase, and a novel cytochrome P450 monooxygenase (CYP71AV1) from A. annua that performs a three-step oxidation of amorpha-4,11-diene to artemisinic acid. The synthesized artemisinic acid is transported out and retained on the outside of the engineered yeast, meaning that a simple and inexpensive purification process can be used to obtain the desired product. Although the engineered yeast is already capable of producing artemisinic acid at a significantly higher specific productivity than A. annua, yield optimization and industrial scale-up will be required to raise artemisinic acid production to a level high enough to reduce artemisinin combination therapies to significantly below their current prices.

Fever treatment and household wealth: the challenge posed for rolling out combination therapy for malaria

OBJECTIVE

To investigate the variation in malaria parasitaemia, reported fever, care seeking, antimalarials obtained and household expenditure by socio-economic status (SES), and to assess the implications for ensuring equitable and appropriate use of antimalarial combination therapy.

METHODS

A total of 2,500 households were surveyed in three rural districts in southern Tanzania in mid-2001. Blood samples and data on SES were collected from all households. Half the households completed a detailed questionnaire on care seeking and treatment costs. Households were categorised into SES thirds based on an index of household wealth derived using principal components analysis.

RESULTS

Of individuals completing the detailed survey, 16% reported a fever episode in the previous 2 weeks. People from the better-off stratum were significantly less likely to be parasitaemic, and significantly more likely to obtain antimalarials than those in the middle or poor stratum. The better treatment obtained by the better off led them to spend two to three times more than the middle and poor third spent. This reflected greater use of non-governmental organisation (NGO) facilities, which were the most expensive source of care, and higher expenditure at NGO facilities and drug stores.

CONCLUSION

The coverage of appropriate malaria treatment was low in all SES groups, but the two poorer groups were particularly disadvantaged. As countries switch to antimalarial combination therapy, distribution must be targeted to ensure that the poorest groups fully benefit from these new and highly effective medicines.

Reaching the Abuja target for intermittent preventive treatment of malaria in pregnancy in African women: a review of progress and operational challenges

OBJECTIVE

To review progress with the implementation of intermittent preventive treatment (IPT) for the control of malaria in pregnancy in sub-Saharan Africa (SSA), in order to identify facilitating factors and operational challenges for scaling up IPT delivery.

METHODS

Information on the status of IPT policy, programme and coverage indicators was extracted from published sources. Information on country experiences from both published and unpublished literature was supplemented with semi-structured interviews with malaria programme managers.

RESULTS

Whilst countries in SSA have made important progress with IPT implementation, coverage levels remain low. High antenatal clinic (ANC) attendance alone is not sufficient to ensure high IPT coverage. Staff shortages, poor drug supply, poor ANC access and poor health worker practices are some of the operational challenges in delivering IPT.

CONCLUSION

Country experiences show that IPT can be introduced and scaled up relatively quickly and effectively where there is political will, effective integration between malaria and reproductive health programmes, adequate funding and drug supply, high ANC attendance and community receptiveness. There is however urgent need to better document best practices and lessons as a basis for developing simplified guidelines for dissemination to countries embarking on IPT implementation.

Cost effectiveness analysis of strategies to combat malaria in developing countries

OBJECTIVE

To determine the cost effectiveness of selected malaria control interventions in the context of reaching the millennium development goals for malaria.

DESIGN

Generalised cost effectiveness analysis.

DATA SOURCES

Efficacy data came from the literature and authors' calculations supported by expert opinion. Quantities for resource inputs came from the literature and from expert opinion; prices came from the WHO-CHOICE database.

METHODS

Costs were assessed in year 2000 international dollars, and effects were assessed as disability adjusted life years averted by a 10 year implementation programme. Analysis was restricted to sub-Saharan regions where the most deadly form of malaria, Plasmodium falciparum, is most prevalent. The impact on population health for various interventions, and their combinations, was evaluated at selected coverage levels by using a state-transition model. Sensitivity analysis was done for age weights and discounting.

RESULTS

High coverage with artemisinin based combination treatments was found to be the most cost effective strategy for control of malaria in most countries in sub-Saharan Africa.

CONCLUSIONS

A much larger infusion of resources than those currently available is needed to make headway in the fight to roll back malaria. On cost effectiveness grounds, in most areas in sub-Saharan Africa greater coverage with highly effective combination treatments should be the cornerstone of malaria control. However, treatment alone can achieve less than half the total benefit obtainable through a combination of interventions-scaling up the use of impregnated mosquito nets or indoor spraying with insecticides is also critical. Intermittent presumptive treatment of pregnant women can bring a small but important additional health gain at relatively low cost.

Economic evaluation of a policy change from single-agent treatment for suspected malaria to artesunate-amodiaquine for microscopically confirmed uncomplicated falciparum malaria in the Oussouye District of south-western Senegal

Senegal is changing policy for case management of uncomplicated falciparum malaria, which hitherto is diagnosed clinically and treated with chloroquine or intramuscular quinine. The WHO recommends artemisinin-based combinations for treating falciparum malaria, preferably based on a parasitological diagnosis. There are no economic projections if such a policy were introduced in Senegal. We have conducted a preliminary economic assessment of such a policy change. The study took place in the chloroquine-resistant district of Oussouye in south-western Senegal. We reviewed clinic registers of the district health posts (n=5) from 1996 to 2001, and piloted artesunate combined with amodiaquine (at 4 and 10 mg/kg/day x 3 days respectively) (AS--AQ) for treating slide-proven falciparum malaria during two rainy seasons (2000 and 2001) at one health centre. These data were used to calculate current direct patient costs (clinic visit, diagnosis, drugs) of malaria treatment and project future costs for the district. The robustness of the model was tested by allowing for different drug failure rates and costs of diagnosis. During 1996--2001, the mean number of primary treatments per year was 7654 for a mean, direct cost of 17,452 US dollars to the community. Clinical diagnosis resulted in over-treatment: 56% and 66% in the wet and dry seasons respectively. Current policy leads to substantial drug wastage and excess direct costs for the community. The direct costs of implementing AS-AQ for slide-proven malaria would be 8,150 US dollars (53% less expensive). Studies examining the public health effect and economics of deploying AS--AQ on a wider scale are underway in Senegal.

The global distribution of clinical episodes of Plasmodium falciparum malaria

Interest in mapping the global distribution of malaria is motivated by a need to define populations at risk for appropriate resource allocation and to provide a robust framework for evaluating its global economic impact. Comparison of older and more recent malaria maps shows how the disease has been geographically restricted, but it remains entrenched in poor areas of the world with climates suitable for transmission. Here we provide an empirical approach to estimating the number of clinical events caused by Plasmodium falciparum worldwide, by using a combination of epidemiological, geographical and demographic data. We estimate that there were 515 (range 300-660) million episodes of clinical P. falciparum malaria in 2002. These global estimates are up to 50% higher than those reported by the World Health Organization (WHO) and 200% higher for areas outside Africa, reflecting the WHO's reliance upon passive national reporting for these countries. Without an informed understanding of the cartography of malaria risk, the global extent of clinical disease caused by P. falciparum will continue to be underestimated.

The clinical spectrum of severe malaria in children in the east provincial hospital of Bertoua, Cameroon

Severe malaria claims 1.5 to 2.7 million lives annually most of which are young children in rural areas in sub-Saharan Africa. We retrospectively reviewed the files of 387 patients, admitted and treated for severe malaria according to WHO guidelines, in the Bertoua provincial hospital, a peripheral health center in East Cameroon from 1st October 1998 to 30h October 2000. Our main objective was to study the epidemiological aspects, clinical presentation and outcome. The mean age was 2.7 years (range 2 months - 15 years) among them 214 males and 173 females giving a sex ratio of 1.2. Transmission was observed all year round at variable frequencies with peaks in the rainy seasons. Major symptoms were fever in 202 patients (52.2%), convulsions in 150 (38.8%), prostration in 79 (20.4%) and persistent vomiting in 78 patients (20.2%). Major clinical findings were severe pallor in 196 patients (50.6%) and splenomegaly in 75 patients (19.4%). The average time between onset of symptoms and consultation was 4.4 days (range 1 - 21 days). Blood smears were positive for Plasmodium falciparum in 288 patients (74.4%) and negative in 99 (25.6%). Concerning outcome, recovery was observed in 317 patients (81.9%), interruption of treatment (because of financial constraints) in 58 (15%) and 12 deaths (3.8%). Among the 317 patients who recovered, neurological sequelae were observed in six patients, blindness in four patients and deafness in three patients were the most frequent. We conclude that severe malaria constitutes a major challenge of early diagnosis together with implementation of appropriate treatment especially in rural areas. The use of WHO guidelines in the management of this disease and the recommended preventive measures of vector control have yielded good results in patients managed and followed up in our hospital.

The process of changing national malaria treatment policy: lessons from country-level studies

Widespread resistance of Plasmodium falciparum parasites to commonly used antimalarials, such as chloroquine, has resulted in many endemic countries considering changing their malaria treatment policy. Identifying and understanding the key influences that affect decision-making, and factors that facilitate or undermine policy implementation, is critical for improving the policy process and guiding resource allocation during this process. A historical review of archival documents from Malaŵi and data obtained from in-depth policy studies in four countries (Tanzania, South Africa, Kenya and Peru) that have changed malaria treatment policy provides important lessons about decision-making, the policy cycle and complex policy environment, while specifically identifying strategies successfully employed to facilitate policy-making and implementation. Findings from these country-level studies indicate that the process of malaria drug policy review should be institutionalized in endemic countries and based on systematically collected data. Key stakeholders need to be identified early and engaged in the process, while improved communication is needed on all levels. Although malaria drug policy change is often perceived to be a daunting task, using these and other proven strategies should assist endemic countries to tackle this challenge in a systematic fashion that ensures the development and implementation of the rational malaria drug policy.

Artemisinin-based combination therapy reduces expenditure on malaria treatment in KwaZulu Natal, South Africa

INTRODUCTION

There is growing international evidence that artemisinin-based combination therapy (ACT) is one of the few effective measures available to 'Roll Back Malaria'. However, concerns about the costs and affordability of ACT are obstacles to its widespread implementation. This paper explores some economic aspects of the implementation of artemether-lumefantrine (AL) to replace sulphadoxine-pyrimethamine (SP) in the KwaZulu Natal (KZN) province, South Africa.

METHODS

Recurrent and capital costs for malaria treatment were compared at baseline and post-intervention for nine clinics and a sentinel rural district hospital. Changes in the unit costs of, and total expenditure on, malaria services were calculated and the cost effectiveness of AL relative to SP was assessed.

RESULTS

The number of outpatient malaria cases and inpatient admissions both declined by 94% between 2000 and 2002. After accounting for the role of concurrent improvements in vector control, it was conservatively estimated that 36% of the decline in outpatient cases and 46% for inpatient admissions was attributable to changing the first-line drug to AL. Although AL is considerably more expensive than SP, its improved cure rate and reduced malaria transmission resulted in an estimated 201,065 US dollars cost saving in 2002 alone for the subdistrict studied.

DISCUSSION

In the context of effective vector control and low efficacy of existing monotherapy, ACT can reduce total expenditure on malaria services. However, the relevance of these findings requires careful consideration in countries with currently effective treatment policies and higher intensity malaria transmission.

[Post-transfusion malaria: is the risk irreconciliable with biological silence?]

Despite the relatively high frequency of imported malaria in metropolitan France, the transmission of malaria by transfusion is exceptional. The screening of donations to determine those at risk is performed by an interview, and by the testing of serology for defined groups of donors. However, the exclusion of a candidate 'at risk' as a blood donor, by a pre-donation interview, is not completely mastered and the discrimination by biological examination lacks sensitivity, as much for methodological reasons as for reasons linked to the complex parasitic pathogenic agent (Plasmodium ssp.), as for the specific host defence system. The risk of introducing an unsafe-potentially dangerous (transfusion-transmitted malaria is often lethal)-element into the transfusional circuit is not completely covered. Is serology testing the most adequate test to avoid the risk of infected donations, in particular by Plasmodium falciparum; what are the alternatives and what will be the eventual added-costs of the biological qualification of such donations? The transfusional risk linked to Plasmodium seems, however, to be reduced to a minimum, concerning the circulation of plasma, which could represent an alternative for donors at real risk (rare) and those with a supposed risk (relatively numerous).

Is combination therapy for malaria based on user-fees worthwhile and equitable to consumers? Assessment of costs and willingness to pay in Southeast Nigeria

OBJECTIVES

To examine the equity implications of the costs of an episode of malaria, the benefit/cost ratios of using two artemisinin-based combination therapy (CT) from the consumers' view and inequities in willingness to pay (WTP) for CT.

METHODS

A cross-sectional survey was conducted in Southeast Nigeria, where there is a moderate to high level of malaria resistance to chloroquine and sulfadoxine-pyrimethamine formulations. WTP was elicited from respondents using the bidding game (BG) and the structured haggling technique (SH). A socio-economic status (SES) index was used to examine the level of inequity in the key variables. In the benefit/cost ratios, the average cost of CT in Nigeria and price of Coartem were, respectively, used as the cost inputs while the mean WTP was the measure of benefit. Multiple regression analyses were used to determine the validity of the WTP estimates.

RESULTS

More than 90% of the respondents were willing to pay for CT. The mean WTP in the BG was 301.1 Naira while it was 438.0 Naira in the SH. People in the highest SES quartile (Q4) were more willing to pay for CT than the lowest SES quartile (Q1). In the regression models, the SES quartiles were significantly related to levels of WTP. The benefit/cost ratios were higher in the SH group, and the ratio was only more than 1 using Coartem in only the SH group. The Q1 groups had the least benefit cost-ratios but the trend of SES differentials in benefit/cost ratios were not statistically significant in the BG group but was in the SH group.

CONCLUSION

CT based on user-fees may not be worthwhile and equitable because there are economic and equity constraints to its wide-scale use. Benefit/cost ratios depend on the type of questions that were used to elicit WTP. Governments and donors should be willing to commit funds to make CT affordable to the poor consumers for the intervention to be used to significantly reduce the burden of malaria.

Averting a malaria disaster in Africa--where does the buck stop?

The serious threat posed by the spread of drug-resistant malaria in Africa has been widely acknowledged. Chloroquine resistance is now almost universal, and resistance to the successor drug, sulfadoxine-pyrimethamine (SP), is growing rapidly. Combination therapy has been suggested as being an available and potentially lasting solution to this impending crisis. However, the current cost of combination therapy, and especially that of artemisinin combination therapy (ACT), is potentially a serious drawback, even if a significant part of its cost is passed on to the end-user. If the question of cost is not successfully addressed this could lead to adverse results from the deployment of combination therapy as first-line treatment. These adverse effects range from an increase in potentially fatal delays in infected individuals presenting to medical services, to exclusion of the poorest malaria sufferers from receiving treatment altogether. Urgent steps are needed to reduce the cost of combination therapy to the end-user in a sustainable way if it is to be usable, and some possible approaches are discussed.

A cost-effectiveness analysis of three antimalarial treatments for acute, uncomplicated Plasmodium falciparum malaria in Mumbai, India

BACKGROUND

Malaria is a major public health problem representing 2.3% of the overall global disease burden. The cost of treatment of malaria continues to rise as older drugs and insecticides become less effective and are replaced by more effective, but also more expensive products.

METHODS

A post-hoc pharmacoeconomic analysis (direct and indirect costs only) of three antimalarials, chloroquine, mefloquine and co-artemether, was carried out to address the problem of switch to a more expensive first-line antimalarial in the face of growing chloroquine resistance.

RESULTS

From the perspective of a large public hospital, it was seen that in an area of high grade chloroquine resistance, the total expenditure on patients who fail chloroquine would exceed the excess expenditure on mefloquine when the RII + RIII resistance exceeded 9%.

CONCLUSIONS

Switch to a more expensive drug like mefloquine as a first-line option would be cost-effective when the moderate-severe chloroquine resistance exceeded 9%.

Malaria and property accumulation in rice production systems in the savannah zone of Côte d'Ivoire

Irrigation stabilizes agricultural production and hence improves farmers' living standards and conditions. The permanent presence of water may, however, increase the burden of water-related parasitic diseases and counter the economic benefits of irrigation by reducing farmers' health. The purpose of this study was to assess the impact of malaria on farm household property, beyond the health risk (studied elsewhere). The research question was: by weakening individuals, does malaria reduce productive capacities and income workers, and consequently limit their property accumulation? To test this hypothesis, we use data on property (farming equipment, livestock and durable consumer goods) and Plasmodium falciparum indicators generated by a study carried out in 1998 in the Ivorian savannah zone characterized by inland valley rice cultivation, with a sample of nearly 750 farming households. Property is influenced by many factors related to the size of the family, the area under cultivation and high parasite density infection rate of P. falciparum. A significant negative correlation between high-density infection rate and the property values confirms that by reducing the living standards of households, malaria is a limiting factor for property accumulation.