MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
CHAPTER 3: F<strong>IN</strong>ANCIAL FEASIBILITY<br />
<strong>IN</strong>TRODUCTION<br />
The previous chapters have shown that malaria elimination in<br />
Zanzibar is technically feasible, though significant operational<br />
challenges will need to be overcome for malaria-free status to be<br />
achieved and sustained. However, the government of Zanzibar<br />
and its donors are also fundamentally interested in whether<br />
pursuing elimination will be financially feasible before they<br />
invest in this new strategy. There is no doubt that if funding<br />
were limitless, elimination would be worth pursuing. But in an<br />
environment of funding constraints, competing priorities, and<br />
uncertain future financing, the question of how much elimination<br />
will cost relative to alternatives, notably the maintenance of<br />
interventions and disease burden at roughly current levels<br />
(“sustained control”), is critical to decision-making. This chapter<br />
examines that question, first analyzing the estimated cost of<br />
different elimination scenarios and then exploring the challenges<br />
and potential solutions to sustainably financing an elimination or<br />
sustained control program.<br />
In most cases elimination will be more costly than sustained<br />
control in the short- to medium-term. Surveillance activities<br />
will be intensive and vector control activities will need to reach<br />
nearly universal coverage to ensure a path to zero prevalence.<br />
Both of these activities are manpower and commodity intensive,<br />
requiring significant resources. The question of financial<br />
feasibility therefore revolves around the magnitude of that initial<br />
increase and the degree to which costs will later fall, particularly<br />
after elimination is achieved. While it is likely that some activities<br />
could be scaled back, many interventions (e.g., surveillance,<br />
diagnosis and treatment, etc.) will need to continue for decades<br />
to ensure that malaria is not reintroduced. Estimating these<br />
ongoing costs of preventing reintroduction, while challenging,<br />
is thus central to determining whether and the degree to which<br />
elimination will be cost-saving.<br />
In order to determine if elimination is cost-saving in the medium-<br />
to long-term, the cost analysis extends over a 25-year period<br />
beginning in 2009. However, due to challenges in predicting key<br />
inputs such as changes in malaria transmission on the mainland<br />
and urbanization, which affect vulnerability and receptivity<br />
respectively, programmatic costs beyond 5-7 years in the future<br />
are more imprecise estimates. As such, this analysis should be<br />
considered a decision-making tool, providing general projections<br />
of cost trends between different programmatic scenarios, and not<br />
used as a basis for detailed planning or budgeting.<br />
The core methodology employed for this analysis is to compare<br />
the cost of interventions for an elimination program with<br />
those for a sustained control program. Zanzibar has recently<br />
conducted several in-depth analyses of the costs of its current<br />
program, including a five-year needs assessment supported by<br />
the Roll Back Malaria Partnership and a comprehensive proposal<br />
submitted to the Global Fund in Round 8. As these analyses take<br />
into account the total needs of the program to achieve its control<br />
targets, they are used as the sustained control baseline. The costs<br />
of an elimination program are then estimated using the outputs<br />
of the models and other analysis in the technical and operational<br />
feasibility sections. Due to the imprecision of the estimates, the<br />
core output of this analysis is not the absolute amounts that<br />
sustained control and elimination will cost, but rather the change<br />
in costs over time as shifts in interventions occur.<br />
This costing approach has substantial limitations that should be<br />
taken into account when interpreting this analysis. The optimal<br />
information to provide to policymakers to guide their decisions<br />
would be robust comparative cost-effectiveness or cost-benefit<br />
analyses between elimination and sustained control. It was not<br />
possible, however, to conduct those analyses for this exercise.<br />
The benefits of malaria elimination beyond its direct effect on<br />
morbidity and mortality are poorly understood and quantified.<br />
It is likely that eliminating malaria will have positive effects<br />
on tourism, education, workforce productivity, health system<br />
performance and foreign investment, but none of these effects<br />
have been quantified reliably and thus cannot be compared to<br />
the cost of elimination.<br />
A traditional cost-effectiveness analysis, while possible, is not<br />
an appropriate metric for assessing this decision. Standard costeffectiveness<br />
measures such as cost per marginal case disability-<br />
adjusted life year averted will trend toward infinity as malaria<br />
prevalence approaches zero in an elimination program. If<br />
elimination is achieved, the malaria program costs will not<br />
be contributing to a further direct reduction in morbidity or<br />
mortality, but it will be preventing an increase in morbidity<br />
and mortality resulting from the resurgence of malaria. Since<br />
this effect will not be captured, a traditional cost-effectiveness<br />
analysis is not a good decision-making tool for elimination. The<br />
lack of benefits is important to bear in mind when interpreting<br />
and acting on this analysis. If elimination is marginally more<br />
expensive than sustained control it does not necessarily mean<br />
that it is a bad investment especially in the light of recent reports<br />
on resistance to first-line treatment (Dondorp et al., 2009)<br />
and insecticides (Nwane et al., 2009). In the absence of a clear<br />
quantification of benefits, the MOHSW will have to weigh the<br />
magnitude of costs shown here against its own understanding<br />
of the potential benefits of elimination. It is also clear that<br />
developing a framework for assessing the benefits of elimination<br />
should be a priority for the global Malaria Elimination Group<br />
to assist Zanzibar and other countries in overcoming this<br />
challenge. After analyzing the costs of eliminating malaria on<br />
Zanzibar, this chapter examines the challenges and solutions<br />
to financing a potential elimination program. Since Zanzibar’s<br />
malaria program is heavily donor-dependent, a choice to pursue<br />
67