Cost-effective malaria control in Brazil: Cost-effectiveness of a Malaria Control Program in the Amazon Basin of Brazil, 1988–1996
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
References (25)
Análise de Custo-Efetividade do Programa de Controle da Malária na Bacia Amazônica (PCMAM), relatório final, 18 de novembro
(1996)Cost-Effectiveness Analysis of Malaria Control and Treatment in the Brazilian Amazon: lessons in Strategy
(1997)Manual para el Control de las Enfermedades Transmisibles
(1997)Análise do Modelo Gerencial do PCDEN
(1996)Gestão de Polı́ticas Públicas: O Projeto de Controle da Malária na Bacia Amazônica (PCMAM)
(1996)- Campbell, C., 1997. Personal communication. Department of Public Health, Faculty of Medicine, University of Arizona,...
- Collins, W., 1997. Personal communication. Malaria Unit, Centers for Disease Control, Atlanta,...
Main Malaria Situations in the Brazilian Amazon
(1988)- et al.
Estudo sobre sub-registro de mortalidade por malária em Rondônia, Brasil
- Hoffman, S., 1997. Personal communication. Director, Malaria Program, US Navy, Washington,...
An Overview
Cited by (52)
Wrong place, wrong time: The long-run effects of in-utero exposure to malaria on educational attainment
2022, Economics and Human BiologyCitation Excerpt :Indoor DDT spraying and the distribution of antimalarial drugs among the population were the main actions taken by CEM at the prevention and treatment of malaria. Although numbers related to the cost and benefits of the nationwide campaign are scarce, Akhavan et al. (1999) find that, for a program targeting to control malaria in the Amazon basin, the overall cost-effectiveness was around US$69 per Disability-Adjusted Life Years, whereby case treatment seems to be the most-cost effective way to tackle malaria compared to vector-control. Fig. 1 displays the distribution of malaria cases across states in Brazil in 1959, the first year in which the Ministry of Health began providing state-level malaria burden reports).
Malaria burden and control in Bangladesh and prospects for elimination: An epidemiological and economic assessment
2014, The Lancet Global HealthCitation Excerpt :Monitoring of the potential spread of resistance of artemisinin-based combination therapies should be a high priority in Bangladesh. In addition to providing relatively expensive LLINs, the NMCP also supported cheaper insecticide treatment of nets,15 thus Bangladesh maintained highly cost-effective insecticide-treated net coverage compared with other malaria-endemic countries.29–32 The average international donor support for malaria control worldwide to malaria-endemic countries was US$1·86 per person per year.47
Morbidity and mortality disparities among colonist and indigenous populations in the Ecuadorian Amazon
2010, Social Science and MedicineCitation Excerpt :However, DHS data have been criticized for often not being representative of rural areas and possibly exhibiting reporting bias (Manesh, Sheldon, Pickett, & Carr-Hill, 2008). A number of focused epidemiological studies have been conducted in the Amazon that provide invaluable information pertaining to health burden, such as gastrointestinal illnesses and malnutrition, elevated blood-mercury levels, tuberculosis, and vector-borne and zoonotic diseases (e.g., Akhavan, Musgrove, Abrantes, & Gusmão, 1999; Basta et al., 2006; Carvalho-Costa et al., 2007; Passos et al., 2008). An unfortunate shortcoming of these studies is the (usually) inherent focus on a few key health outcomes due to study design and objectives that exclude the wider array of ailments that affect inhabitants and potentially overstating the impact of a particular disease for a region.
Why Brazil needs its Legal Reserves
2019, Perspectives in Ecology and ConservationWhy Brazil needs its Legal Reserves
2019, Perspectives in Ecology and ConservationCitation Excerpt :Also, in the Brazilian Amazon forest, deforestation increases the risks and incidence of malaria (Chaves et al., 2018; Terrazas et al., 2015; Olson et al. 2010): for each square kilometer of deforested land, 27 new malaria cases are produced (Chaves et al., 2018). Each person infected with malaria costs to public health more than 22 US dollars, considering ambulatory visits, blood tests, hospitalization and treatment (Akhavan et al., 1999). This does not take into account the costs of control programs, which represents 85% of government total costs with malaria (Akhavan et al., 1999).