Communities of practice
Higher costs for malaria elimination than control
3 Nov 2010
The last of four publications in the Lancet’s Malaria Elimination series  examines the economic costs of eliminating malaria, and highlights data indicating that “the cost of achieving malaria elimination will be substantially greater than the cost of control” . The authors conducted a review of published works and created and analysed datasets from present elimination programmes. Comparing the economic costs of malaria elimination versus malaria control in China, Mauritius, Swaziland and Tanzania, they concluded that elimination is not likely to produce a cost-saving benefit over control within 50 years.
Lead author Oliver Sabot of the Clinton Health Access Initiative concludes that, “We shouldn’t consider cost savings as a rationale for pursuing [malaria elimination]” because elimination “is not likely to be cost-saving” compared with controlling the disease. Sabot considers that, based on this new analysis, treating “elimination as an investment, as any good business would do, [would mean that] generally across the board countries would be in the red”.
Sabot does, however, emphasize that there may be other financial benefits to eliminating malaria that are not included in this analysis. Describing foreign direct investment and tourism as potential areas that may bring benefits, Sabot comments that these and other potential benefits remain speculations which have “never been robustly examined”. Sabot suggests “if [we] want to go for [elimination] there are other reasons, and we need to understand those reasons better”.
For Professor Geoff Targett, Emeritus Professor at the London School of Hygiene & Tropical Medicine (LSHTM) and member of the Malaria Elimination Group, the findings are sobering. Targett is encouraged that analyses of malaria elimination financial feasibility are being conducted, but considering the high permanent costs of malaria control as an alternative to elimination, he asks “if you settle for control – for how long?” Advising that there is “real opportunity to make progress towards eliminating malaria”, Targett urges individual countries to carry out feasibility studies that take into account technical, operational and financial issues associated with elimination. In the meantime, Sabot et al. suggest that their data can “serve as an interim guide” .
The financial costs will be substantial and Dr Lesong Conteh, Senior Lecturer in Health Economics at Imperial College, London, accepts that economic expenditure is centrally important to informing decisions about malaria elimination. However, Conteh considers that this should not be the main motivation. “Absolute health gains and ethical considerations are critical” she comments. “Costs should not be used as an excuse to put people off the goal, but rather to help manage the expectations”.
With a malaria vaccine in late stage trials, efficacious malaria interventions are anticipated in coming years. Conteh considers that economic evaluations should try to model the possible costs and benefits of new interventions over time, but also acknowledges the enormous difficulty in forecasting these in “long-time horizon” analyses.
“Yes, elimination is sexy” admits Sabot, but the current “quick win” malaria movement will not sustain elimination. “With the idea of a quick win,” he says “comes the idea that we can quickly declare victory and go home”; malaria elimination won’t succeed with this approach. It is likely that the “fundamental shift in the perception of malaria investment from a so-called quick win to a routine expenditure”  which the authors suggest, should be focused on regional, rather than single country, approaches as the best route to malaria elimination. This regional approach is encouraged by Targett, and also defined by the parasite. “Parasites are circulating in genetic groupings [that] fit with studies of migration patterns in Africa” advises Dr Cally Roper, Senior Lecturer at LSHTM.
For Professor Chris Whitty, Head of Research for the UK Department for International Development (DFID), while this “new, clear and useful” series of publications is welcome, it also uses data that is “far too weak” to inform firm conclusions. Whitty sees a “significant paradox” between shrinking the malaria map, so that fewer areas are malaria endemic, and stopping people dying of malaria. He also considers that malaria elimination is “most popular where it’s least attainable” and “most realistic in the countries that can attain it themselves”.
Whichever route, control or elimination, is taken to tackle malaria by specific malaria-endemic countries, the financial costs will be high; commitment and investment will need to be sustained both locally and globally. Malaria elimination, it seems, won’t cut the costs of malaria control in the short term. Choosing either route will mean a long and bumpy financial ride.
1. Various authors (2010). Malaria elimination (series). Lancet; Early online publication, 29 October 2010. Available online: http://www.thelancet.com/malaria-elimination.
2. Sabot O, Cohen JM, Hsiang MS, Kahn JG, Basu S et al. (2010). Costs and financial feasibility of malaria elimination. Lancet; Early online publication, 29 October 2010. Available online (abstract only): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61355-4/abstract
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