Elsevier

Social Science & Medicine

Volume 49, Issue 10, November 1999, Pages 1385-1399
Social Science & Medicine

Cost-effective malaria control in Brazil: Cost-effectiveness of a Malaria Control Program in the Amazon Basin of Brazil, 1988–1996

https://doi.org/10.1016/S0277-9536(99)00214-2Get rights and content

Abstract

Malaria transmission was controlled elsewhere in Brazil by 1980, but in the Amazon Basin cases increased steadily until 1989, to almost half a million a year and the coefficient of mortality quadrupled in 1977–1988. The government's malaria control program almost collapsed financially in 1987–1989 and underwent a turbulent reorganization in 1991–1993. A World Bank project supported the program from late 1989 to mid-1996, and in 1992–1993, with help from the Pan American Health Organization, facilitated a change toward earlier and more aggressive case treatment and more concentrated vector control. The epidemic stopped expanding in 1990–1991 and reversed in 1992–1996. The total cost of the program from 1989 through mid-1996 was US$616 million: US$526 million for prevention and US$90 million for treatment. Compared to what would have happened in the absence of the program, nearly two million cases of malaria and 231,000 deaths were prevented; the lives saved were due almost equally to preventing infection and to case treatment. Converting the savings in lives and in morbidity into Disability-Adjusted Life Years yields almost nine million DALYs, 5.1 million from treatment and 3.9 million from prevention. Nearly all the gain came from controlling deaths and therefore from controlling falciparum. The overall cost-effectiveness was US$2672 per life saved or US$69 per DALY, which is low compared to most previous estimates and compares favorably to many other disease control interventions. Contrary to much previous experience, case treatment appears more cost-effective than vector control, particularly where falciparum is prevalent and unfocussed insecticide spraying is relatively ineffective. Halting the epidemic by better targeted vector control and emphasizing treatment paid off in much reduced mortality from malaria and in significantly lower costs per life saved.

Introduction

Although the Malaria Eradication Program of the Ministry of Health in Brazil had succeeded by the late 1970s in freeing the majority of the country from malaria transmission, it was unable to contain the rapid spread of the disease in the Amazon Basin. By June 1984, that region, including nine of the country's 26 states, accounted for 97% of all reported malaria cases, with high fatality rates. Between 1977 and 1988 the coefficient of mortality (deaths per 100,000 population) in the Amazon more than quadrupled. The enormous extent of the region, the substantial and hard-to-trace migration into and within it, and the existence of numerous transient and dispersed settlements, rendered ineffective the traditional eradication strategy based on active case detection for treatment and eliminating the vector through widespread use of insecticides. At the end of 1983, there were 280,000 reported cases of the disease, but with the number of people infected rising by 40,000 every year, incidence reached almost half a million four years later.

In 1986 the Government of Brazil requested World Bank technical and financial assistance to develop an Amazon Basin Malaria Control Project (known as PCMAM from its Portuguese title) to support the national program. The project was expected initially to be conducted over four years and cost US$200 million; it became effective in September 1989 and closed in June 1996, with a final cost of US$133.7 million, of which US$72.9 million was financed by a Bank loan (The World Bank, 1996). The project was originally aimed at getting the malaria outbreak in the Amazon Basin under control, preventing the spread into uninfected areas and strengthening institutional capacity. Like the program which it supported, the project consisted of vector control (application of insecticides in dwellings and fogging of high-risk communities), entomological surveillance, reduction of sources of mosquitoes (drainage and regulation of water flows), epidemiological surveillance, treatment, special efforts for disease control in indigenous areas and information, education and communication (IEC).

This paper provides an evaluation of the project during the interval of almost seven years corresponding to the World Bank loan. (There is no distinction between the Bank project and the pre-existing government program, so this is not an evaluation of the marginal contribution of the Bank-financed project.) A first estimate of the results of the project is provided by an extensive evaluation by one of the authors (Akhavan, 1996); some of these initial findings have been published in a World Bank evaluation (The World Bank, 1996) as well as in a government summary publicizing the results of this and a parallel project for the control of three other endemic diseases in northeastern Brazil (National Health Foundation, 1996). A more detailed state-by-state analysis was conducted later (Akhavan, 1997). The present study provides projections of three key variables in the absence of the project, the incidence, severity (proportion of falciparum) and lethality (case fatality rate) from malaria in the Amazon Basin during the period 1989–1996, and summarizes the estimated savings in lives, morbidity (cases) and disability-adjusted life years (DALYs) from malaria control.

Section snippets

Old and new strategies for fighting malaria

Prior to 1991, malaria control was the responsibility of a semi-autonomous federal agency, the Superintendency for Public Health Campaigns (Superintendência para Campanhas de Saúde Pública, SUCAM), which carried out nation-wide malaria and endemic disease control campaigns through a workforce of 40,000. The agency was noted for its strong staff and line organization and had an excellent record in sustaining endemic disease control programs in remote areas, under very difficult conditions.

Directly observed results: malaria cases, severity and program expenditures

Fig. 1 shows how the malaria epidemic began to come under control. The upper panel relates the total number of blood slides positive for malaria to the total expenditure on malaria control by SUCAM and subsequently by NHF; the lower panel shows the same information, but for P. falciparum only. These are all directly observed variables, involving no estimations or assumptions. The numbers in Fig. 1 differ slightly from those used to estimate the total health benefits and the total costs of the

Methods: estimating illness, lives and disability-adjusted life years saved

The malaria control program produced health gains partly by preventing cases, some of which would have ended in death while the rest produced only short-term morbidity and partly by treating cases, particularly by preventing deaths from P. falciparum infection. The estimate of health benefits from vector control begins with the projected incidence of cases of malaria and proceeds through the expected severity (share of falciparum in total cases) and lethality (case fatality rate) to derive the

Estimating program costs and cost-effectiveness

The estimated health gains just described were derived from both prevention and treatment, so the costs attributable to malaria control include both kinds of expenditures. Spending on prevention (vector control) was partly through the World Bank project (PCMAM), all of which occurred in the Amazon Basin, and partly through the NHF malaria control program, which operated in the whole country; it is estimated that 92% of those expenditures occurred in the Amazon. Capital investment and non-salary

Discussion

Since the project helped to introduce a major change in malaria control strategy halfway through the period analyzed, Table 5 presents the cost-effectiveness results separately for 1989–1992 and for 1993–1996, considering only lives saved by preventing or treating cases of falciparum. The same assumptions about incidence are used as for the analysis of the whole period 1989–1996, because the control efforts in 1989–1992 do not appear to have had much effect on incidence. The cost of saving a

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