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s to be withdrawn.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