MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

FIGURE 30: AVERAGE COST PER YEAR FOR THE DIFFERENT STAGES OF AN
ELIMINATION PROGRAM WITH LLINS KEPT AT > 75% EFFECTIVE COVER-
AGE COMPARED TO SUSTAINED CONTROL
FIGURE 31: AVERAGE COST PER YEAR FOR THE DIFFERENT PHASES OF
AN ELIMINATION PROGRAM WITH NO LLINS AFTER 2030, COMPARED TO
SUSTAINED CONTROL
The annual cost of the second elimination scenario (including
border screening) is modestly above that of sustained control
by the end of the period considered in this analysis. If the least
expensive scenario is assumed (no border screening), the cost of
an elimination program will fall below that of a sustained control
program, indicating that, in the long-run, elimination may be
intrinsically cost saving if conditions on the mainland enable
LLINs to be withdrawn. However, given the initial increased
expenditure and relatively modest (20%) annual savings, the
MOHSW would not yield savings from elimination on a
cumulative basis until well after 2050.
The authors do not believe that such long-term estimates are
valuable beyond providing broad indications. The approach to
and cost of border screening is too uncertain to make concrete
estimates of cost savings. Moreover, there are many other
uncertainties in the long-run that could fundamentally affect
costs, including changes in transmission risk (i.e., R 0 ) that could
enable relaxation of interventions, development of insecticide
and drug resistance, introduction of new technologies, and basic
economic and demographic changes, among others. It is also
important to note that the cost estimates provided here are not
discounted and therefore do not take into account the time value
of money–greater expenditure now followed by reductions later
has a higher opportunity cost than smoother costs because those
funds could be used for other priorities in the short-term (e.g.,
another disease control program).
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In conclusion, this analysis suggests that an elimination program
on Zanzibar will not be cost saving in the medium-term. In the
most optimistic feasible scenario, the annual cost of preventing
reintroduction will be modestly lower than sustained control.
However, these annual savings would only be realized after many
years of substantially higher expenditure so the cumulative cost
of an elimination program would remain well above those for
sustained control over the period analyzed. This conclusion does
not preclude the Ministry of Health from deciding to pursue
elimination for other reasons. The average additional cost of
elimination would be $1.3–1.9 million per year, which the
MOHSW may decide is a worthy cost for the expected benefits
from elimination. Those benefits, which are not examined or
quantified in this assessment, could range from the reduced
burden on the health system, increased tourism and/or foreign
investment, the national pride associated with having eliminated
malaria, and of course the end of morbidity and mortality from
a largely preventable disease. If the MOHSW is not comfortable
making this decision without a more concrete estimation of those
benefits, an in-depth follow up research project could address
these questions while recognizing the significant technical
challenges involved.
FINANCING SUSTAINED CONTROL AND
ELIMINATION
Regardless of whether or not the Zanzibar MOHSW decides to
pursue malaria elimination or to maintain a high level of control,
consistent financing for the malaria program will need to be secured
for many years to come. As discussed in the Technical Feasibility
Chapter, a resurgence of malaria in Zanzibar is nearly assured if
control and surveillance measures are scaled back considerably.
Because the Zanzibar government has accomplished such a great
reduction in malaria exposure, acquired immunity to malaria has
most likely declined, and the mortality and morbidity impact of
resurgence may be quite substantial. Perhaps the most important
component in preventing resurgence is a plan for steady, longterm
financing for the malaria program.
CHALLENGES
Aid Dependence
Financing malaria control or elimination will be particularly
challenging in Zanzibar for a number of reasons. Most of
Zanzibar’s health programs, including malaria control, are very
donor dependent. This means that ZMCP’s ability to continue
investing in malaria will be highly contingent upon the ability
to secure substantial foreign aid. Zanzibar has been successful
at attracting substantial funding for its malaria program over
the past five years, but securing such a high level of funding is
likely to become increasingly difficult for reasons outlined below.
Should Zanzibar decide to pursue elimination, such a high level
of financing will most likely not be required in the long term.
We discussed above various conditions under which it may be
possible to reduce costs significantly, for example through the
scaling back of vector control programs. However, a steady level
of financing will be required over the long term to maintain