Costing malaria interventions from pilots to elimination programmes

Abstract

Background Malaria programmes in countries with low transmission levels require evidence to optimize deployment of current and new tools to reach elimination with limited resources. Recent pilots of elimination strategies in Ethiopia, Senegal, and Zambia produced evidence of their epidemiological impacts and costs. There is a need to generalize these findings to different epidemiological and health systems contexts. Methods Drawing on experience of implementing partners, operational documents and costing studies from these pilots, reference scenarios were defined for rapid reporting (RR), reactive case detection (RACD), mass drug administration (MDA), and in-door residual spraying (IRS). These generalized interventions from their trial implementation to one typical of programmatic delivery. In doing so, resource use due to interventions was isolated from research activities and was related to the pilot setting. Costing models developed around this reference implementation, standardized the scope of resources costed, the valuation of resource use, and the setting in which interventions were evaluated. Sensitivity analyses were used to inform generalizability of the estimates and model assumptions. Results Populated with local prices and resource use from the pilots, the models yielded an average annual economic cost per capita of $0.18 for RR, $0.75 for RACD, $4.28 for MDA (two rounds), and $1.79 for IRS (one round, 50% households). Intervention design and resource use at service delivery were key drivers of variation in costs of RR, MDA, and RACD. Scale was the most important parameter for IRS. Overall price level was a minor contributor, except for MDA where drugs accounted for 70% of the cost. The analyses showed that at implementation scales comparable to health facility catchment area, systematic correlations between model inputs characterizing implementation and setting produce large gradients in costs. Conclusions Prospective costing models are powerful tools to explore resource and cost implications of policy alternatives. By formalizing translation of operational data into an estimate of intervention cost, these models provide the methodological infrastructure to strengthen capacity gap for economic evaluation in endemic countries. The value of this approach for decision-making is enhanced when primary cost data collection is designed to enable analysis of the efficiency of operational inputs in relation to features of the trial or the setting, thus facilitating transferability.

Mass Drug Administration: Contextual Factor Considerations

“…The cost of MDA varied from ∼$1.04 to $19.40 USD per person per round; one study estimated that drugs accounted for 70% of the cost of MDA. 49 On the lower end, Gabaldon and Guerrero 50 estimated a cost of $0.11 to $0.21 USD per person per visit, depending on distance between houses, (approximately $1.04 to $1.99 in 2021 USD). Cirera et al.…”

“…Galactionova et al. 49 estimated an initial cost of $2.35 USD per person treated per round in the first year, dropping to $2.19 USD per person per round if implemented annually for 5 years, and that MDA would be more expensive than other interventions such as rapid reporting, reactive case detection, or indoor residual spraying. This same study also noted that aspects such as sensitization and training may overlap between programs such as MDA and reactive case detection and that co-implementation might provide overall improvements in cost-effectiveness.…”

Health system readiness and the implementation of rectal artesunate for severe malaria in sub-Saharan Africa: an analysis of real-world costs and constraints

“…HSS costs per child were $230, $143, and $354 in Uganda, Nigeria, and DR Congo, while rectal artesunate-specific costs were $92, $76, and $110, respectively. We present absolute variation in startup, annually recurring, and total costs per child at risk and per child treated in table 2 (gross total costs and per-child costs by programme component are shown in appendix 2 pp 20-21; sensitivity analysis is presented in appendix 2 pp [22][23]. Costs per child younger than 5 years are substantially higher in DR Congo than in Uganda or Nigeria due to the large financing requirements for monitoring and evaluation.…”

“…Several other studies have encouraged the integration of health system constraints into costing as a crucial step towards realistic budgeting and cost-effectiveness analyses, across a range of diseases. [19][20][21][22][23] Due to CARAMAL's focus on severe disease and the health system constraints at different levels of the system, comparing our estimates with costs of other malaria interventions might be misleading. A review of the costs of CHW programmes in low-income and middle-income countries found only seven studies reporting these on malaria, with large heterogeneity in methods and scope.…”

Cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in the low endemic setting of Namibia: an analysis alongside a 2×2 factorial design cluster randomised controlled trial

“…Finally, we limited our assessment to the test interventions used in the trial, and used RACD and/or no RAVC as a comparison. It is possible that comparisons with other approaches, including non-targeted interventions, and/or use of a different control (eg, no RACD), would also be cost effective 41…”