MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies
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MONITOR<strong>IN</strong>G & EVALUATION (M&E)<br />
As discussed in Chapter 2, current and planned methods for<br />
M&E would not be sufficient if Zanzibar were to embark on<br />
elimination, including due to inadequate sample sizes and<br />
inappropriate parasite detection methods. An additional<br />
serological prevalence survey, conducted bi-annually, is thus<br />
recommended with a sample size large enough to detect very<br />
low levels of parasite density. Based on the costs of typical<br />
malaria indicator surveys with a sample size of roughly 8,000<br />
and assuming that this sample size would need to at least double<br />
and that serological testing would be added at roughly $2 per<br />
slide, we estimate that these surveys would add $100,000 per<br />
year for M&E of an elimination program. In addition to these<br />
surveys, an elimination program will need to implement a<br />
range of other core M&E activities. It is assumed that these will<br />
represent a similar proportion of the overall budget as M&E does<br />
for sustained control in the latest Global Fund proposal (8%). 2<br />
As the surveys and other M&E activities will be consistently<br />
implemented throughout the program, we do not expect that<br />
this cost will decline over time.<br />
TOTAL COST IMPLICATIONS OF <strong>ELIM<strong>IN</strong>ATION</strong><br />
Figure 29 shows a comparison of the annual difference (%) in<br />
expenditure for two elimination scenarios compared to sustained<br />
control, over the course of the 25 year period analyzed. This figure<br />
presents a clear answer to the core question asked in this chapter:<br />
elimination will not be cost-saving in the short- or mediumterm<br />
in Zanzibar. The additional investment needed to move<br />
towards elimination initially results in an almost 85% increase<br />
in average annual expenditure compared with sustained control,<br />
with costs remaining 45-50% more expensive over the course<br />
of the remainder of the effort to reach elimination. Contrary to<br />
expectation, costs do not dramatically decline once elimination is<br />
achieved and the country enters the prevention of reintroduction<br />
phases: in the most likely scenario, costs in this phase are 5%<br />
higher than during the elimination period. This is because as<br />
long as importation risk remains at current or modestly reduced<br />
levels, interventions will need to remain constant in order to<br />
prevent rapid resurgence.<br />
For the purposes of comparison, the best possible elimination<br />
scenario is included in this costing although the authors believe<br />
it is unlikely the necessary reduction in importation risk will be<br />
possible. Under this scenario in which LL<strong>IN</strong>s are withdrawn<br />
entirely, annual costs during the prevention of reintroduction<br />
phase will decrease substantially. The degree of this reduction<br />
depends on the assumed implementation of border screening:<br />
if comprehensive screening is introduced in order to reduce<br />
importation risk to the necessary level, ongoing costs will be<br />
roughly equivalent to (4% higher than) sustained control, while<br />
if screening is less extensive or not conducted at all annual costs<br />
could fall as low as 20% below sustained control.<br />
2 This ratio is also in line with the requirement of most donors that 5-10% of<br />
total program budgets be spent on M&E.<br />
3 | Financial Feasibility<br />
FIGURE 29: ESTIMATED ANNUAL PERCENT DIFFERENCE <strong>IN</strong> EXPENDITURE<br />
BETWEEN <strong>ELIM<strong>IN</strong>ATION</strong> SCENARIOS AND SUSTA<strong>IN</strong>ED CONTROL<br />
100%<br />
80%<br />
60%<br />
40%<br />
20%<br />
0%<br />
-20%<br />
-40%<br />
SCENARIO 1: NETS > 75% EFFECTIVE COVERAGE, IMPORTATION RISK<br />
REDUCES FROM 2 TO 1/1000 <strong>IN</strong>HABITANTS PER YEAR<br />
SCENARIO 2A: NO NETS AFTER 2030, IMPORTATION RISK REDUCES FROM<br />
2 TO 0.4/1000 <strong>IN</strong>HABITANTS PER YEAR (<strong>IN</strong>CLUDES BORDER SCREEN<strong>IN</strong>G)<br />
SCENARIO 2B: WITHOUT BORDER SCREEN<strong>IN</strong>G<br />
SUSTA<strong>IN</strong>ED CONTROL<br />
2011<br />
2013<br />
2015<br />
2017<br />
2019<br />
2021<br />
2023<br />
As shown in Figures 30 and 31, the higher costs of both elimination<br />
and prevention of reintroduction are driven primarily by<br />
increased surveillance and diagnosis. This is particularly evident<br />
in the second elimination scenario where these activities combined<br />
comprise 47% and 65% of total costs in the elimination<br />
and prevention of reintroduction phases respectively compared<br />
to just 15% for sustained control. In the more likely scenario<br />
where universal LL<strong>IN</strong> coverage needs to be maintained, case<br />
management and surveillance represent 45% and 35% for the<br />
elimination and prevention of reintroduction phases respectively,<br />
which is in line with experiences from other countries.<br />
For example, Mauritius continues to spend $2.15 per capita to<br />
prevent the reintroduction of malaria, 39% of which is devoted<br />
to surveillance activities (Tatarsky, unpublished data). The<br />
estimated average per capita costs of prevention of reintroduction<br />
on Zanzibar varies between $1.73 and $2.27 depending<br />
on the elimination scenario, aligning closely with the benchmark<br />
provided by the Mauritius case. One of the only other<br />
available benchmarks is the report of the Eighth WHO Expert<br />
Committee on Malaria, which estimated in 1961 that the cost<br />
of prevention of reintroduction was roughly 65-75% of the<br />
“attack” (elimination) phase (WHO, 1961). Given that Zanzibar<br />
is facing higher transmission and importation risk than most of<br />
the countries considered at that time, the second elimination<br />
scenario, with the prevention of reintroduction phase between<br />
69% and 88% of the elimination phase, appears to be largely in<br />
line with this benchmark.<br />
2025<br />
2027<br />
2029<br />
2031<br />
2033<br />
73