Determining cost-effectiveness and cost component of three malaria diagnostic models being used in remote non-microscope areas.

This cross-sectional experimental study developed a methodology to analyze the cost-effectiveness of three malaria diagnostic models: microscopy; on-site OptiMAL; and on-site Immunochromatographic Test (on-site ICT), used in remote non-microscope areas in Thailand, from both a public provider and patient perspective. The study covered six areas in two highly malaria-endemic areas of provinces located along the Thai-Myanmar border. The study was conducted between April and October 2000, by purposively recruiting 436 malaria suspected cases attending mobile malaria clinics. Each patient was randomly selected to receive service via the three diagnostic models; their accuracy was 95.17%, 94.48% and 89.04%, respectively. In addition, their true positive rates for all malaria species were 76.19%, 82.61% and 73.83%; for falciparum malaria 85.71%, 80.95% and 80.00%, and for vivax malaria 57.14%, 100% and 50%, respectively, with the parasitemia ranging from 80 to 58,240 microl of blood. Consequently, their costs were determined by dividing into provider and consumer costs, which were consequently classified into internal and external costs. The internal costs were the costs of the public providers, whereas the external costs were those incurred by the patients. The aggregate costs of these three models were 58,500.35, 36,685.91, and 40,714.01 Baht, respectively, or 339.53, 234.39, and 243.93, in terms of unit costs per actual case. In the case of microscopy, if all suspected malaria cases incurred forgone opportunity costs of waiting for treatment, the aggregate cost and unit cost per actual case were up to 188,110.89 and 944.03 Baht, respectively. Accordingly, the cost-effectiveness for all malaria species, using their true positive rates as the effectiveness indicator, was 446.75, 282.40, and 343.56 respectively, whereas for falciparum malaria it was 394.80, 289.37 and 304.91, and for vivax malaria 595.67, 234.39 and 487.86, respectively. This study revealed that the on-site OptiMAL was the most cost-effective. It could be used to supplement or even replace microscopy for this criteria in general. This study would be of benefit to malaria control program policy makers to consider using RDT technology to supplement microscopy in remote non-microscope areas.

Cost-effectiveness analysis of lambdacyhalothrin-treated nets for malaria control: the patients' perspective.

The present study was undertaken to evaluate the cost-effectiveness of lambdacyhalothrin-treated nets in comparison with conventional DDT-spraying as a method of malaria control according to the patients' perspective among migrant populations in a high-risk area along the Thai-Myanmar border in Thailand. Ten hamlets comprising 243 houses with 948 inhabitants were given only treated nets. Twelve hamlets comprising 294 houses and 1,315 inhabitants represented the DDT-treated area and another six hamlets with 171 houses and 695 inhabitants served as controls. Information as to consumer costs was obtained by interviewing 3,214 patients seeking care at all levels of the health care system in the study area. Analysis showed that the impregnated-net program was more cost-effective than the DDT-spraying program or surveillance alone (US$ 0.59 vs US$ 0.74 vs US$ 0.79 per 1 case of prevented malaria). We conclude that in a high-risk area such as along the Thai-Myanmar border in western Thailand, integrating the use of impregnated nets with large-scale primary health care programs is likely to constitute the most cost-effective method for controlling malaria according to the patients' perspective.

Cost and performance of malaria sector: a case study at Malaria Sector 11, Tak Province, Thailand.

The objective of this study was to assess the cost and performance of each operational unit at the malaria sector level and to calculate the unit cost of each activity accordingly. Data were collected at Malaria Sector No.11 situated at the western border of Thailand with Myanmar during the fiscal year of 1995. The unit cost was calculated by dividing the total cost of each activity by its output using appropriate units of analysis. The result showed that 67% of the total cost of malaria sector was labor cost and 45% of the total cost was allocated to diagnosis and treatment activities. Unit cost in terms of cost/visit, cost/case found, cost/case of falciparum malaria treated, cost/case of vivax malaria treated, cost/house spray and cost/impregnated net were US$1.85, 8.21, 10.07, 8.46, 2.24 and 1.54 respectively. The results of this study will provide important information as to the best use of limited available resources to determine which activities should be stopped, continued, increased or decreased at the malaria sector level.

Application of geographical information systems to co-analysis of disease and economic resources: dengue and malaria in Thailand.

Two vector-borne communicable diseases, malaria and dengue, are among a number of diseases of particular importance in relation to economic development in Southeast Asia and thus need to be assessed in relation to economic parameters in the region. Geographical Information Systems (GIS) provide one means of comparing disease and resource data versus time and place, to facilitate rapid visualization by planners and administrators. Given that Thailand is a global epicenter of multidrug resistant falciparum malaria and of dengue hemorrhagic fever, both of which are mosquito-borne, application of GIS methods to these two diseases gives opportunity for comparison of resource needs and allocation in relation to disease epidemiologic patterns. This study examined per capita gross provincial product (GPPpc) and health care resources in relation to geographic distribution of malaria and dengue in Thailand. The two diseases vary greatly in overall seasonal patterns and in relation to provincial economic status, and present differing demands on resource utilization: planned integration of control of malaria and dengue could utilize such analyses in relation to resource sharing and consideration of allocative efficiency. The concentration of malaria (and to a lesser extent dengue) along international border areas underscores the desirability of multi-country coordination of disease management and control programs. Because socio-economic and disease data are collected by quite different means and in different time frames, there are some limitations to the dynamic interpolation of these two broad data sets, but useful inferences can be drawn from this approach for application to overall planning, at both national and multi-country levels.

The cost of dengue hemorrhagic fever in Thailand.

The economic burden of DHF patients and of the Thai government in providing treatment and prevention and control of dengue hemorrhagic fever were assessed. Patient burden was reported by caretakers who stayed with the patients when they were admitted to three hospitals: Children's Hospital in Bangkok; Suphan Buri Provincial Hospital and Don Chedi Community Hospital, Don Chedi District in Suphan Buri Province. The hospital costs--medicine and laboratory costs--were collected from the treatment forms and the routine service cost was estimated by the staff of the hospitals. Cost of prevention and control were compiled from the budget report of Departments of the Ministry of Public Health and the Ministry of Interior. Based on 184 DHF patients admitted at the three hospitals, the direct patient costs--treatment cost and the costs of travel, food and lodging--was 66.99 US$ and 61.02 US$ per patient for one episode of DHF in Bangkok and Suphan Buri, respectively. The total patient costs--direct patient costs and opportunity costs were 118.29 US$ for a child patient and 161.49 US$ for an adult patient in Bangkok, 102.82 US$ for a child patient and 138.02 US$ for an adult patient in Suphan Buri. The net hospital cost in providing treatment for each DHF patient was 54.6 US$ and 38.65 US$ in Bangkok and Suphan Buri, respectively. The total cost of prevention and control of DHF in Thailand from government agencies in 1994 was 4.8724 million US$. Based on these findings, the whole expenditure of Thailand for DHF in 1994, would be at least 12.596 million US$, of which 54.8% was from the government budget, the rest, 45.2%, was the expenses paid by 51,688 patients and their families. The study concluded that in recording the economic-loss of DHF both the expenditures of the government and also the patient costs--direct and indirect--should be taken into account.

Screening for thalassemia: an economics viewpoint.

Thalassemia presents individual, social and economic burdens: a key question is whether medical and economic viewpoints converge or not. Using precise molecular probes, prenatal diagnosis of the various thalassemia genotypes is available in the case of parents who are known carriers, so identified because of a previous affected child or a positive family genetic history. However, the ideal option of prevention of the birth of a first affected child requires community screening. The only practical approach thereto is prenatal screening of women in early pregnancy at ante-natal clinics (ANC). The initial steps (OF, DCIP) are simple, cheap and easily coupled with standard prenatal procedures. In the second phase, spouse screening, compliance is suboptimal and involves non-routine opportunity costs. Subsequent steps (secondary screening of positive pairs, genotyping of positives, and fetal diagnosis [PND]) represent greater costs to provider and consumer, and, as they are relatively expensive, reduced compliance at each step if the major part of the economic burden (direct and indirect costs) is to be borne by the consumer. Thus, only a proportion of cases is likely to face the final decision to terminate pregnancy or not. Some broad estimates of costs of each phase (ANC-->PND) have been made for comparison with the estimated costs of case management of the several thalassemia disease classes for their projected lifetimes, while several more detailed studies are in progress to fine tune the real costs (direct and indirect) of diagnosis. In a purely economic sense the situation presents opportunity to consider trade-offs between PND and disease case management, in terms of benefit:cost ratio. Viewed from a health systems vantage point this ratio depends substantially on compliance, as the system must consider the cost of caring for all thalassemia cases, including those births which could have been avoided by optimal compliance. In ideal circumstances the rough estimates indicate a probable benefit:cost ratio > 1, supporting the notion of community-based screening. Such a result, however, compares procedures in a short, finite time frame (diagnosis) with a less predictable, longer life-time (case management), requiring bureaucratic flexibility (if the public provider is to pay) or family emotional/fiscal investment (if the consumer is to pay) or both (cost-sharing): either way there is an inescapable element of long term investment planning that requires squaring off of the emotional, social and fiscal ingredients in the equation. In this sense the thalassemia syndromes represent an example of decision-making pathways involved in assessing and handling chronic disease burdens at family, community and national levels: at the latter level regional incidence varies considerably, a geopolitical factor which may require differential demographic planning.

Assessing the economic impact of a rapid on-site malaria diagnostic test.

A set of three models has been developed for assessing the economic impact of existing and new malaria diagnostic technology, specifically microscopy of blood slides and rapid on-site diagnostic tests (RDT). The models allow for phased introduction of the new technology in targeted areas. The derived computer software program facilitates evaluation of costs to the supplier, to the consumer and aggregate costs, with comparison among the three models to give relative costs of progressive transition from blood slides to RDT technology. The models and the related software program can assist planners in the health sector in determining costs of current programs and assessing the potential economic impact of introducing rapid on-site diagnosis. Details of the models and the operational software program are available on request.