Catherine Goodman

Cost-effectiveness of malaria control in sub-Saharan Africa

BACKGROUND Information on the cost-effectiveness of malaria control is needed for the WHO Roll Back Malaria campaign, but is sparse. We used mathematical models to calculate cost-effectiveness ratios for the main prevention and treatment interventions in sub-Saharan Africa. METHODS We analysed interventions to prevent malaria in childhood (insecticide-treated nets, residual spraying of houses, and chemoprophylaxis) and pregnancy (chloroquine chemoprophylaxis and sulfadoxine-pyrimethamine intermittent treatment), and to improve malaria treatment (improved compliance, improved availability of second-line and third-line drugs, and changes in first-line drug). We developed models that included probabilistic sensitivity analysis to calculate ranges for the cost per disability-adjusted life year (DALY) averted for each intervention in three economic strata. Data were obtained from published and unpublished sources, and consultations with researchers and programme managers. FINDINGS In a very-low-income country, for insecticide treatment of existing nets, the cost-effectiveness range was US

Cost-effectiveness of malaria diagnostic methods in sub-Saharan Africa in an era of combination therapy

4-10 per DALY averted; for provision of nets and insecticide treatment

Cost-Effectiveness in Low- and Middle-Income Countries: A Review of the Debates Surrounding Decision Rules

19-85; for residual spraying (two rounds per year)

Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature.

32-58; for chemoprophylaxis for children

Effect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data.

3-12 (assuming an existing delivery system); for intermittent treatment of pregnant women

Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries

4-29; and for improvement in case management

Monitoring fever treatment behaviour and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries

1-8. Although some interventions are inexpensive, achieving high coverage with an intervention to prevent childhood malaria would use a high proportion of current health-care expenditure. INTERPRETATION Cost-effective interventions are available. A package of interventions to decrease the bulk of the malaria burden is not, however, affordable in very-low-income countries. Coverage of the most vulnerable groups in Africa will require substantial assistance from external donors.

Attracting and retaining health workers in rural areas: investigating nurses' views on rural posts and policy interventions.

OBJECTIVE To evaluate the relative cost-effectiveness in different sub-Saharan African settings of presumptive treatment, field-standard microscopy and rapid diagnostic tests (RDTs) to diagnose malaria. METHODS We used a decision tree model and probabilistic sensitivity analysis applied to outpatients presenting at rural health facilities with suspected malaria. Costs and effects encompassed those for both patients positive on RDT (assuming artemisinin-based combination therapy) and febrile patients negative on RDT (assuming antibiotic treatment). Interventions were defined as cost-effective if they were less costly and more effective or had an incremental cost per disability-adjusted life year averted of less than US

A pharmacy too far? Equity and spatial distribution of outcomes in the delivery of subsidized artemisinin-based combination therapies through private drug shops.

150. Data were drawn from published and unpublished sources, supplemented with expert opinion. FINDINGS RDTs were cost-effective compared with presumptive treatment up to high prevalences of Plasmodium falciparum parasitaemia. Decision-makers can be at least 50% confident of this result below 81% malaria prevalence, and 95% confident below 62% prevalence, a level seldom exceeded in practice. RDTs were more than 50% likely to be cost-saving below 58% prevalence. Relative to microscopy, RDTs were more than 85% likely to be cost-effective across all prevalence levels, reflecting their expected better accuracy under real-life conditions. Results were robust to extensive sensitivity analysis. The cost-effectiveness of RDTs mainly reflected improved treatment and health outcomes for non-malarial febrile illness, plus savings in antimalarial drug costs. Results were dependent on the assumption that prescribers used test results to guide treatment decisions. CONCLUSION RDTs have the potential to be cost-effective in most parts of sub-Saharan Africa. Appropriate management of malaria and non-malarial febrile illnesses is required to reap the full benefits of these tests.

Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities.

Cost-effectiveness analysis (CEA) is increasingly important in public health decision making, including in low- and middle-income countries. The decision makers’ valuation of a unit of health gain, or ceiling ratio (λ), is important in CEA as the relative value against which acceptability is defined, although values are usually chosen arbitrarily in practice. Reference case estimates for λ are useful to promote consistency, facilitate new developments in decision analysis, compare estimates against benefit-cost ratios from other economic sectors, and explicitly inform decisions about equity in global health budgets.The aim of this article is to discuss values for λ used in practice, including derivation based on affordability expectations (such as