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Review
. 2011 Nov 3:10:337.
doi: 10.1186/1475-2875-10-337.

Costs and cost-effectiveness of malaria control interventions--a systematic review

Michael T White  1 , Lesong Conteh, Richard Cibulskis, Azra C Ghani
Affiliations
Review

Costs and cost-effectiveness of malaria control interventions--a systematic review

Michael T White et al. Malar J. .

Abstract

Background: The control and elimination of malaria requires expanded coverage of and access to effective malaria control interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment (IPT), diagnostic testing and appropriate treatment. Decisions on how to scale up the coverage of these interventions need to be based on evidence of programme effectiveness, equity and cost-effectiveness.

Methods: A systematic review of the published literature on the costs and cost-effectiveness of malaria interventions was undertaken. All costs and cost-effectiveness ratios were inflated to 2009 USD to allow comparison of the costs and benefits of several different interventions through various delivery channels, across different geographical regions and from varying costing perspectives.

Results: Fifty-five studies of the costs and forty three studies of the cost-effectiveness of malaria interventions were identified, 78% of which were undertaken in sub-Saharan Africa, 18% in Asia and 4% in South America. The median financial cost of protecting one person for one year was $2.20 (range $0.88-$9.54) for ITNs, $6.70 (range $2.22-$12.85) for IRS, $0.60 (range $0.48-$1.08) for IPT in infants, $4.03 (range $1.25-$11.80) for IPT in children, and $2.06 (range $0.47-$3.36) for IPT in pregnant women. The median financial cost of diagnosing a case of malaria was $4.32 (range $0.34-$9.34). The median financial cost of treating an episode of uncomplicated malaria was $5.84 (range $2.36-$23.65) and the median financial cost of treating an episode of severe malaria was $30.26 (range $15.64-$137.87). Economies of scale were observed in the implementation of ITNs, IRS and IPT, with lower unit costs reported in studies with larger numbers of beneficiaries. From a provider perspective, the median incremental cost effectiveness ratio per disability adjusted life year averted was $27 (range $8.15-$110) for ITNs, $143 (range $135-$150) for IRS, and $24 (range $1.08-$44.24) for IPT.

Conclusions: A transparent evidence base on the costs and cost-effectiveness of malaria control interventions is provided to inform rational resource allocation by donors and domestic health budgets and the selection of optimal packages of interventions by malaria control programmes.

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Figures

Figure 1
Figure 1
Information extracted from cost studies.
Figure 2
Figure 2
Search strategy for costing studies. The number of cost and cost-effectiveness studies identified in each category is shown (left-hand number is cost/right-hand number is cost-effectiveness (CE)).
Figure 3
Figure 3
Geographical location of costing and cost-effectiveness studies. A: Map of P. falciparum parasite prevalence in Africa estimated in 2007 from the Malaria Atlas Project [27]. B: Geographical location of African based studies of cost and cost-effectiveness. 78% of reviewed studies were located in Africa, 18% in Asia and 4% in South America.
Figure 4
Figure 4
Year of costing of cost and cost-effectiveness studies. The year refers to when the intervention was costed and not the publication year.
Figure 5
Figure 5
Unit financial costs of malaria control interventions broken down into components. A: Unit financial cost per ITN distributed. Data is taken from Additional file 2: Table S1. B: Unit financial cost per person protected by IRS. Data is taken from Additional file 3: Table S2. C: Unit financial cost per course of IPT. (i) indicates IPT in infants, (c) IPT in children, and (p) IPT in pregnant women. Data is taken from Additional file 4: Table S3. D: Financial cost of diagnosing a patient for malaria. Data is taken from Additional file 5: Table S4. E: Financial cost of diagnosis and treatment with ACT. Data is taken from Additional file 5: Table S4. F: Financial cost of treatment of either uncomplicated or severe malaria. (u) indicates uncomplicated malaria and (s) severe malaria. Data is taken from Additional file 6: Table S5. All studies were costed from a provider perspective except those marked * which were costed from a societal perspective. All costs are in 2009 USD.
Figure 6
Figure 6
Economies of scale for ITNs, IRS and IPT. Financial costs per beneficiary of malaria control interventions, as a function of the number of beneficiaries of the program or project evaluated. Dotted lines represent straight lines of best fit.
Figure 7
Figure 7
Cost-effectiveness of anti-malarial interventions against deaths averted, DALYs averted and cases of malaria averted. The ICERs for ITN, IRS and IPT are against a baseline of no widespread preventive interventions. The ICERs for ACT are calculated against a baseline of alternative treatment strategies, and hence care must be taken when comparing ICERs for preventive and treatment based interventions.
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