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 and sustainability of lambdacyhalothrin-treated mosquito nets in comparison to DDT spraying for malaria control in western Thailand.

The cost-effectiveness of lambdacyhalothrin-treated nets in comparison with conventional DDT spraying for malaria control among migrant populations was evaluated in a malaria hyperendemic area along the Thai-Myanmar border. Ten hamlets of 243 houses with 948 inhabitants were given only treated nets. Twelve hamlets of 294 houses and 1,315 population were in the DDT area, and another 6 hamlets with 171 houses and 695 inhabitants were in the non-DDT-treated area. The impregnated net program was most cost-effective (US$1.54 per 1 case of prevented malaria). Spraying with DDT was more cost-effective than malaria surveillance alone ($1.87 versus $2.50 per 1 case of prevented malaria). These data suggest that personal protection measures with insecticide-impregnated mosquito net are justified in their use to control malaria in highly malaria-endemic areas in western Thailand.

The malaria cauldron of Southeast Asia: conflicting strategies of contiguous nation states.

The past half-century or so has witnessed dramatic failures but also some successes in control of malaria in the world at large. South and Southeast Asia have had their share of both outcomes, a scenario that reflects many variables in control programs: technology, management strategy, human and financial resources. However, at least equally culpable have been major wars and minor conflicts, economic growth and stagnation, inequity of opportunity, urbanisation, deforestation, changing transport and communications. The history of malaria is thus an integral part of the broader political and economic evolution of the region, as well as the story of the wisdom and unwisdom of malaria specialists. In positive reflection on the latter, systematic organisational effort using standard tools of trade has seen the gradual elimination of major malaria foci from central plain regions of a number of nations in this large region, with residual foci at forested border areas. In many cases there is good evidence of sustainability of elimination in defined areas but the differing success stories reflect in part conflicting strategies in neighboring nation states. On the other hand, physical conflicts, population migration, inequitable economic change, border instability and many other socio-economic variables can be clearly seen to undermine the most ingenuous strategies. Undoubtedly the single most important negative ingredient is the rise and spread of multi-drug resistant falciparum malaria that has its epicenter in Southeast Asia, from which it threatens the world in insidious fashion. Containment of this phenomenon has been the focus of attention for 30 years, more particularly the past decade, and represents the greatest challenge at this time in predicting the continuing impact of malaria globally on human history. So too does the compelling necessity to link malaria control with macro and micro economic planning. This challenge impinges on the sovereignty of individual nations in this region, for they exist in contiguity, so that successful applications of technology require collaborative political determination.

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.

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.

Ecology, economics and political will: the vicissitudes of malaria strategies in Asia.

The documented history of malaria in parts of Asia goes back more than 2,000 years, during which the disease has been a major player on the socioeconomic stage in many nation states as they waxed and waned in power and prosperity. On a much shorter time scale, the last half century has seen in microcosm a history of large fluctuations in endemicity and impact of malaria across the spectrum of rice fields and rain forests, mountains and plains that reflect the vast ecological diversity inhabited by this majority aggregation of mankind. That period has seen some of the most dramatic changes in social and economic structure, in population size, density and mobility, and in political structure in history: all have played a part in the changing face of malaria in this extensive region of the world. While the majority of global malaria cases currently reside in Africa, greater numbers inhabited Asia earlier this century before malaria programs savored significant success, and now Asia harbors a global threat in the form of the epicenter of multidrug resistant Plasmodium falciparum which is gradually encompassing the tropical world. The latter reflects directly the vicissitudes of economic change over recent decades, particularly the mobility of populations in search of commerce, trade and personal fortunes, or caught in the misfortunes of physical conflicts. The period from the 1950s to the 1990s has witnessed near "eradication" followed by resurgence of malaria in Sri Lanka, control and resurgence in India, the influence of war and postwar instability on drug resistance in Cambodia, increase in severe and cerebral malaria in Myanmar during prolonged political turmoil, the essential disappearance of the disease from all but forested border areas of Thailand where it remains for the moment intractable, the basic elimination of vivax malaria from many provinces of central China. Both positive and negative experiences have lessons to teach in the debate between eradication and control as alternative strategies. China has for years held high the goal of "basic elimination", eradication by another name, in sensible semi-defiance of WHO dictates. The Chinese experience makes it clear that, given community organization, exhaustive attention to case detection, management and focus elimination, plus the political will at all levels of society, it is possible both to eliminate malaria from large areas of an expansive nation and to implement surveillance necessary to maintain something approaching eradication status in those areas. But China has not succeeded in the international border regions of the tropical south where unfettered population movement confounds the program. Thailand, Malaysia and to an extent Vietnam have also reached essential elimination in their rice field plains by vigorous vertical programs but fall short at their forested borders. Economics is central to the history of the rise and fall of nations, and to the history of disease in the people who constitute nations. The current love affair with free market economics as the main driving force for advance of national wealth puts severe limitations on the essential involvement of communities in malaria management. The task of malaria control or elimination needs to be clearly related to the basic macroeconomic process that preoccupies governments, not cloistered away in the health sector Historically malaria has had a severe, measurable, negative impact on the productivity of nations. Economic models need rehoning with political aplomb and integrating with technical and demographic strategies. Recent decades in Chinese malaria history carry some lessons that may be relevant in this context.

PIP: Malaria has been a major player in the socioeconomic stage of Asia. During the last half of the century, dramatic changes in the social, economic, and political condition, population size, density and mobility, played a role in changing the face of malaria in Asia. Even before programs to fight malaria savored significant success in Asia, a large number of people were already suffering from the disease earlier this century including the global threat of Plasmodium falciparum. This reflects the vicissitudes of economic change in this decade, particularly the mobility of populations in search of commerce, trade, and so on. Between 1950s and 1990s, there was a near eradication of malaria in Asia followed by its resurgence in Sri Lanka, India, Cambodia, Myanmar, Thailand, and China due to several precipitating events and conditions. Both the positive and negative experiences have lessons to teach in relation to malaria eradication and control strategies. For instance, the Chinese experience that given community organization, exhaustive attention to case detection, management and focus elimination, and political will at all levels of the society is possible for the elimination of malaria from large areas. Economics is central to the prosperity and deterioration of nations and the disease experienced by the population. Malaria control and elimination should therefore be related to the basic macroeconomic process of the government, and economic models should be developed with political aplomb, while integrating technical and demographic strategies.

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.

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.

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.

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.