Download Malaria

Social, Economic and
Behavioural (SEB) Research
Report Series No. 1 (2002)
TDR Final Report
Series No. 37 (2001)
Cost-performance analysis of malaria
control in Henan Province, China
TDR Project ID 950109 & 930413
(1994-1998)
Professor Xi-Li Liu Principal Investigator
Australian Collaborators:
Dr Sukhan Jackson (Health Economics),
Dr Adrian Sleigh (Epidemiology and Trop Med)
Malaria in Henan
•worst province in 1970 (10.2 million cases)
•1971-1984: 280 million treatments, 1.8 billion antirelapse courses, 2 billion prophylaxis courses
•1981-1992: active case detection, DDT spraying
and (later) impregnated bednets
•1993: ‘basic elimination’ (<1 case/10,000 pop/yr),
vivax persists in 4 poor counties in the south
Objectives
1) Measure costs for each malaria control
component in Henan
who incurred what costs?
2) Evaluate case-management performance
what was purchased?
3) Assess balance and quality of investment
in the control program
what can improve?
Malaria study
counties
(shaded areas)
Source: Sleigh et al.
1998 Bull WHO
Methods
•cost all government inputs (fixed and variable)
•cost all community inputs (direct and indirect)
•evaluate and cost sample of case-management
least studied aspect in economic appraisals of malaria
(epidemiologically important for control outcomes)1,2
1Mills A.
The economics of malaria. Proc. of MIM African Malaria Conference,
Durban, Sth Africa, March 1999: 92-109
2Mills A.
The economics of malaria control. In Targett GAT (ed) Malaria: waiting
for the vaccine. Chichester, John Wiley and Sons 1991: 141-168
Province, County and
Township government
costs measured for 2 years
Village “Barefoot doctor”
(VD) management,
patient-carer costs
2-year study of 12,325 VD-managed suspected malaria
cases (fever, typical sx, no other cause, all reviewed by
Liu XL - all vivax based on sx and blood surveillance)
Costs of malaria control
Government - invests US$99,970/yr, protects 3.4
million people in transmission zone at $0.03 per head
population blood surveys (surveillance) - 25%
vector surveillance (strategic knowledge) - 12%
case-management (disease-transmission control) - 60%
Community
US$4.18 cost per illness - cases incur 83% of cost (=10
days income; 1/3rd for drugs, >1/3rd due to lost income).
Govt pays 17% of cost per illness and creates treatment
system and case-management standards
Case-management performance
• quick access to care, confidence in VDs
• VDs slow to treat after diagnosis (40% wait 3-4 days)
• most cases get schizonticide, CQ is available
• treat duration too short (only 1-2 days for 62%)
• many non-malarial drugs (moral hazards)
• primaquine (8 day) course rarely finished
Conclusions
Government stewardship good - maintains system for
citizens to purchase care (drug supply, trained village
doctors, standards, 17% of case management cost)
and
Maintains surveillance and strategic knowledge
but
Must maintain investment (boost a little?) - or risk
resurgence and far greater costs later
Need to improve case-management - a ‘poor buy’ at
present - not value for money – poses an epidemiologic risk
Need to resolve primaquine question - justified use?
Indicator (costs in US $)
Community
Annual cost* (1994-1995) (US$)
Government
99,790
Population protected
>3.4
million
Cost per person protected (US$)
Cost per case treated (US$)
0.03
3.48 (83%)
0.70 (17%)
0.58
30.27
12%
25%
60%
4%
0.10
6.09
Government expenditure
Vector control
Blood surveillance
Case-management
Contingencies/special projects
Cost per case prevented**
Cost per DALY saved**
Benefit: Cost Ratio**
Total
4.18 (100%)
0.68
36.36
3.4 to 1
Overall Reflections
• Cost-performance method came from managerial
•
•
•
•
economics – broader than CEA, CUA, CBA
Fits WHO’s focus on health system performance
Timely in China with partial defunding of many
public health programs in the 1990s, like malaria
Our health system managers and policy makers now
know what they are buying for malaria control
We can advocate evidence-based improvements
(case-management) and continued productive
investment (beneficial malaria control)
Malaria reflections
• China had largest Asian malaria burden – now
•
•
•
much reduced, has avoided resurgence
vivax problem typical of the malaria burden in
many areas outside of Africa
We can invest in malaria control more efficiently
– improving case-management
Need information like ours – one of the first such
cost-performance studies, and almost the first
economic appraisal of malaria case-management
Some project publications
• Liu X, Jackson S, Song J & Sleigh A 1996 Malaria control
and fever manage-ment in Henan Province. Tropical
Medicine and International Health, 1: 112-116.
• Jackson S, Liu XL & Song JD 1996 Socio-economic
reforms in China's rural health sector: economic behaviour
and incentives of village doctors. International Journal of
Social Economics, 23: 409-419.
• Sleigh AC, Liu XL, Jackson S, Li P & Shang LY. 1998
Resurgence of vivax malaria in Henan province, China.
Bull of WHO, 76: 265-270
Some project publications (cont)
• Zhuang J, Jackson S, Li P, Sleigh AC and Liu X. 1999
Knowledge, attitudes and practices for malaria and its
control among residents of an endemic area in Henan, China.
Henan Medical Research [Henan Yixue Yanjiu], 8: 267-269
(in Chinese)
• Liu XL, Jackson S and Sleigh AC. 2001 Cost and
Performance Analysis for Malaria Control in Henan
Province. 2001 Final Report for Projects 930413 and
950109. TDR News (and web site) (In Press)
• Jackson S, Sleigh AC and Liu XL. 2002 Economics of
malaria control in China: cost, performance and
effectiveness of Henan’s consolidation programme TDR
Research Report Publication Series (monograph) (In Press)