MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

CHAPTER 3: FINANCIAL FEASIBILITY
INTRODUCTION
The previous chapters have shown that malaria elimination in
Zanzibar is technically feasible, though significant operational
challenges will need to be overcome for malaria-free status to be
achieved and sustained. However, the government of Zanzibar
and its donors are also fundamentally interested in whether
pursuing elimination will be financially feasible before they
invest in this new strategy. There is no doubt that if funding
were limitless, elimination would be worth pursuing. But in an
environment of funding constraints, competing priorities, and
uncertain future financing, the question of how much elimination
will cost relative to alternatives, notably the maintenance of
interventions and disease burden at roughly current levels
(“sustained control”), is critical to decision-making. This chapter
examines that question, first analyzing the estimated cost of
different elimination scenarios and then exploring the challenges
and potential solutions to sustainably financing an elimination or
sustained control program.
In most cases elimination will be more costly than sustained
control in the short- to medium-term. Surveillance activities
will be intensive and vector control activities will need to reach
nearly universal coverage to ensure a path to zero prevalence.
Both of these activities are manpower and commodity intensive,
requiring significant resources. The question of financial
feasibility therefore revolves around the magnitude of that initial
increase and the degree to which costs will later fall, particularly
after elimination is achieved. While it is likely that some activities
could be scaled back, many interventions (e.g., surveillance,
diagnosis and treatment, etc.) will need to continue for decades
to ensure that malaria is not reintroduced. Estimating these
ongoing costs of preventing reintroduction, while challenging,
is thus central to determining whether and the degree to which
elimination will be cost-saving.
In order to determine if elimination is cost-saving in the medium-
to long-term, the cost analysis extends over a 25-year period
beginning in 2009. However, due to challenges in predicting key
inputs such as changes in malaria transmission on the mainland
and urbanization, which affect vulnerability and receptivity
respectively, programmatic costs beyond 5-7 years in the future
are more imprecise estimates. As such, this analysis should be
considered a decision-making tool, providing general projections
of cost trends between different programmatic scenarios, and not
used as a basis for detailed planning or budgeting.
The core methodology employed for this analysis is to compare
the cost of interventions for an elimination program with
those for a sustained control program. Zanzibar has recently
conducted several in-depth analyses of the costs of its current
program, including a five-year needs assessment supported by
the Roll Back Malaria Partnership and a comprehensive proposal
submitted to the Global Fund in Round 8. As these analyses take
into account the total needs of the program to achieve its control
targets, they are used as the sustained control baseline. The costs
of an elimination program are then estimated using the outputs
of the models and other analysis in the technical and operational
feasibility sections. Due to the imprecision of the estimates, the
core output of this analysis is not the absolute amounts that
sustained control and elimination will cost, but rather the change
in costs over time as shifts in interventions occur.
This costing approach has substantial limitations that should be
taken into account when interpreting this analysis. The optimal
information to provide to policymakers to guide their decisions
would be robust comparative cost-effectiveness or cost-benefit
analyses between elimination and sustained control. It was not
possible, however, to conduct those analyses for this exercise.
The benefits of malaria elimination beyond its direct effect on
morbidity and mortality are poorly understood and quantified.
It is likely that eliminating malaria will have positive effects
on tourism, education, workforce productivity, health system
performance and foreign investment, but none of these effects
have been quantified reliably and thus cannot be compared to
the cost of elimination.
A traditional cost-effectiveness analysis, while possible, is not
an appropriate metric for assessing this decision. Standard costeffectiveness
measures such as cost per marginal case disability-
adjusted life year averted will trend toward infinity as malaria
prevalence approaches zero in an elimination program. If
elimination is achieved, the malaria program costs will not
be contributing to a further direct reduction in morbidity or
mortality, but it will be preventing an increase in morbidity
and mortality resulting from the resurgence of malaria. Since
this effect will not be captured, a traditional cost-effectiveness
analysis is not a good decision-making tool for elimination. The
lack of benefits is important to bear in mind when interpreting
and acting on this analysis. If elimination is marginally more
expensive than sustained control it does not necessarily mean
that it is a bad investment especially in the light of recent reports
on resistance to first-line treatment (Dondorp et al., 2009)
and insecticides (Nwane et al., 2009). In the absence of a clear
quantification of benefits, the MOHSW will have to weigh the
magnitude of costs shown here against its own understanding
of the potential benefits of elimination. It is also clear that
developing a framework for assessing the benefits of elimination
should be a priority for the global Malaria Elimination Group
to assist Zanzibar and other countries in overcoming this
challenge. After analyzing the costs of eliminating malaria on
Zanzibar, this chapter examines the challenges and solutions
to financing a potential elimination program. Since Zanzibar’s
malaria program is heavily donor-dependent, a choice to pursue
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