TDR Final Report Series No. 37 (2001)

1. Social, Economic and Behavioural (SEB) Research Report Series No. 1 (2002) TDR Final Report Series No. 37 (2001)

2. Cost-performance analysis of malaria control in Henan Province, China TDR Project ID 950109 & 930413 (1994-1998) Professor Xi-Li Liu Principal Investigator Australian Collaborators: Dr Sukhan Jackson (Health Economics), Dr Adrian Sleigh (Epidemiology and Trop Med)

3. Malaria in Henan • worst province in 1970 (10.2 million cases) • 1971-1984: 280 million treatments, 1.8 billion anti-relapse courses, 2 billion prophylaxis courses • 1981-1992: active case detection, DDT spraying and (later) impregnated bednets • 1993: ‘basic elimination’ (<1 case/10,000 pop/yr), vivax persists in 4 poor counties in the south

4. Objectives 1) Measure costs for each malaria control component in Henan who incurred what costs? 2) Evaluate case-management performance what was purchased? 3) Assess balance and quality of investment in the control program what can improve?

5. Malaria study counties (shaded areas) Source: Sleigh et al. 1998 Bull WHO

6. Methods • cost all government inputs (fixed and variable) • cost all community inputs (direct and indirect) • evaluate and cost sample of case-management • least studied aspect in economic appraisals of malaria (epidemiologically important for control outcomes)1,2 • 1Mills A. The economics of malaria. Proc. of MIM African Malaria Conference, Durban, Sth Africa, March 1999: 92-109 • 2Mills A. The economics of malaria control. In Targett GAT (ed) Malaria: waiting for the vaccine. Chichester, John Wiley and Sons 1991: 141-168

7. Province, County and Township government costs measured for 2 years Village “Barefoot doctor” (VD) management, patient-carer costs 2-year study of 12,325 VD-managed suspected malaria cases (fever, typical sx, no other cause, all reviewed by Liu XL - all vivax based on sx and blood surveillance)

8. Costs of malaria control Government- invests US$99,970/yr, protects 3.4 million people in transmission zone at $0.03 per head population blood surveys (surveillance) - 25% vector surveillance (strategic knowledge) - 12% case-management (disease-transmission control) - 60% Community US$4.18 cost per illness - cases incur 83% of cost (=10 days income; 1/3rd fordrugs, >1/3rd due to lost income). Govt pays 17% of cost per illness and creates treatment system and case-management standards

9. Case-management performance • quick access to care, confidence in VDs • VDs slow to treat after diagnosis (40% wait 3-4 days) • most cases get schizonticide, CQ is available • treat duration too short (only 1-2 days for 62%) • many non-malarial drugs (moral hazards) • primaquine (8 day) course rarely finished

10. Conclusions Government stewardship good - maintains system for citizens to purchase care (drug supply, trained village doctors, standards, 17% of case management cost) and Maintains surveillance and strategic knowledge but Must maintain investment (boost a little?) - or risk resurgence and far greater costs later Need to improve case-management - a ‘poor buy’ at present - not value for money – poses an epidemiologic risk Need to resolve primaquine question - justified use?

11. Indicator (costs in US $) Community Government Total Annual cost* (1994-1995) (US$) 99,790 Population protected >3.4 million Cost per person protected (US$) 0.03 Cost per case treated (US$) 3.48 (83%) 0.70 (17%) 4.18 (100%) Government expenditure Vector control 12% Blood surveillance 25% Case-management 60% Contingencies/special projects 4% Cost per case prevented** 0.58 0.10 0.68 Cost per DALY saved** 30.27 6.09 36.36 Benefit: Cost Ratio** 3.4 to 1

12. Overall Reflections • Cost-performance method came from managerial economics – broader than CEA, CUA, CBA • Fits WHO’s focus on health system performance • Timely in China with partial defunding of many public health programs in the 1990s, like malaria • Our health system managers and policy makers now know what they are buying for malaria control • We can advocate evidence-based improvements (case-management) and continued productive investment (beneficial malaria control)

13. Malaria reflections • China had largest Asian malaria burden – now much reduced, has avoided resurgence • vivax problem typical of the malaria burden in many areas outside of Africa • We can invest in malaria control more efficiently – improving case-management • Need information like ours – one of the first such cost-performance studies, and almost the first economic appraisal of malaria case-management

14. Some project publications • Liu X, Jackson S, Song J & Sleigh A 1996 Malaria control and fever manage-ment in Henan Province. Tropical Medicine and International Health, 1: 112-116. • Jackson S, Liu XL & Song JD 1996 Socio-economic reforms in China's rural health sector: economic behaviour and incentives of village doctors. International Journal of Social Economics, 23: 409-419. • Sleigh AC, Liu XL, Jackson S, Li P & Shang LY. 1998 Resurgence of vivax malaria in Henan province, China. Bull of WHO, 76: 265-270

15. Some project publications (cont) • Zhuang J, Jackson S, Li P, Sleigh AC and Liu X. 1999 Knowledge, attitudes and practices for malaria and its control among residents of an endemic area in Henan, China. Henan Medical Research [Henan Yixue Yanjiu], 8: 267-269 (in Chinese) • Liu XL, Jackson S and Sleigh AC. 2001 Cost and Performance Analysis for Malaria Control in Henan Province. 2001 Final Report for Projects 930413 and 950109. TDR News (and web site) (In Press) • Jackson S, Sleigh AC and Liu XL. 2002 Economics of malaria control in China: cost, performance and effectiveness of Henan’s consolidation programme TDR Research Report Publication Series (monograph) (In Press)