Many governments in affected countries have failed to introduce cost-effective approaches to tackle malaria. Researchers from the London School of Hygiene and Tropical Medicine reviewed the literature on malaria control and used economic analysis to assess demand for and supply of malaria control methods. The authors make recommendations for improving both the prevention and treatment of this major public health problem.

Governments need to play a role in ensuring access to cost-effective interventions for malaria treatment and prevention. Often such preventions are beyond the means of individuals, and the high costs of treating severe malaria can drive households into poverty. The poorest households cannot afford these effective interventions. In addition, private demand for some strategies will be low because they work at the population level rather than for individuals, or consumers lack information about their benefits.

Existing studies of malaria treatment reveal that quality is low in both public and private sectors, service delivery is inefficient and utilisation of adequate care is low. Demand is constrained by costs (including travel and time), income, lack of information and difficulty in assessing treatment quality.

Problems with the supply of treatment are linked to broader health service delivery issues, such as inadequate resources, poorly trained staff and inappropriate incentives for health workers. Health workers also lack information about appropriate treatments, especially in commercial outlets where vendors are untrained, or when drug policy changes.

To improve treatment, they recommend that policy-makers should aim to strengthen the health system as a whole by:

• increasing availability of effective anti-malarial drugs in public health facilities
• addressing problems of quality from the users’ perspective
• widening access to health services
• strengthening performance incentives for health workers
• improving surveillance and supply systems
• introducing measures to prevent rapid growth of resistance to new drugs.

In addition to system-wide strengthening, malaria-specific measures are also required, including:

• providing care seekers with better information about treatment
• modifying provider incentives to encourage appropriate drug use, follow-up and supervision
• involving private providers in the design and delivery of interventions
• simplifying the process of dispensing and using drugs, for example by pre-packaging.

Because the majority of malaria episodes are treated at home with drugs bought in the private sector, it is important to include private providers in these strategies.

Malaria prevention suffers from similar problems in terms of low utilisation and poor quality.  In addition, delivery of some effective preventive measures suffers from the specific problems of public goods and external effects. For example, indoor insecticide spraying, where those whose houses are not sprayed also benefit from the intervention, or insecticide-treated nets which, at high enough levels of coverage will also benefit those who do not sleep under nets.  In these circumstances, private markets will either not emerge, or will not produce high enough levels of coverage. Other interventions which suffer from these problems include:

• indoor insecticide spraying and treatment of bed-nets
• environmental management
• health education
• epidemic surveillance. 

Government action and community cooperation are particularly important to increase uptake of these interventions.

Governments have a crucial role in ensuring access to insecticide-treated nets for the poorest households through some form of subsidy.  If subsidising population-wide coverage is not feasible, governments should consider measures to encourage the development of commercial markets, such as tax and tariff reforms, regulation and large scale promotion, to allow targeting of subsidies.

Source(s):
‘The economics of malaria control interventions’, Global Forum for Health Research, WHO: Geneva, by K. Hanson et al, 2004 Full document.

Funded by: UK Department for International Development; Wellcome Trust, UK

id21 Research Highlight: 21 January 2005

Further Information:
Kara Hanson
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0) 20 7927 2267
Fax: +44 (0) 20 7637 5391
Contact the contributor: kara.hanson@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Other related links:
'Making insecticide treated nets available to the poorest households in Nigeria'

'Selling insecticide re-treatment of mosquito nets in Nigeria: at what price?'

'Household spraying against malaria in southern Africa: cost-effective?'

'Reducing malaria-related infant deaths: strategies for success?'

'Price of protection: affording mosquito nets in rural India'

'Rolling back reality: making malaria control accessible to all'

'Insecticide treatment of mosquito nets - the user’s view'