Part II: The Global Strategy
2. Control: Overcoming Malaria
5. Costs and Benefits of Investment in Malaria Control, Elimination, and R&D
- The total cost of the global strategy (including both country implementation and R&D costs) is estimated to average US$ 5.9 billion per year from 2011 to 2020.
- Country implementation will cost approximately US$ 5.3 billion in 2009, US$ 6.2 billion in 2010 and average US$ 5.1 billion annually from 2011 to 2020.
- R&D will cost approximately US$ 750 - 900 million per year through 2018 for new tools (vector control, drug, vaccine, and diagnostic technologies)
- The Global Strategy requires a long-term commitment: continued funding is essential in both country implementation and R&D to prevent a re-emergence of malaria.
- However, the investment is worthwhile.
- Malaria control is cost effective, saving more lives per dollar spent than interventions for most other diseases.
- R&D investment today in new and improved interventions can help countries eliminate malaria faster and reduce the need for longer-term R&D costs.
Investment in country implementation and R&D saves lives today and prevents deaths tomorrow. It is highly cost effective and results in lower treatment costs, lower R&D investment needs, and positive economic benefits in the future. This section describes:
- The cost of country implementation of malaria control and elimination strategies;
- The cost of R&D to develop new tools for these strategies; and
- The benefits of investing in malaria control, elimination and R&D
These estimates are based on the best understanding of costs and benefits today, but will be continuously revised as part of ongoing activities of the RBM Partnership.
Cost of Country Implementation of Malaria Control and Elimination Strategies
We have estimated the full implementation costs for all 109 malarious countries to scale-up, sustain control, and eliminate malaria. Developed in consultation with experts from the RBM Resources Working Group and the London School of Hygiene and Tropical Medicine as well as experts from many other institutions, the costing model and estimates apply the most recent data and best approaches currently available.
Preliminary estimatesAll estimates are nominal based on 2008 dollars. For projections based on potential inflation rates, please see Appendix 3.
Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source shown in Figure II.14 below indicate that
- Approximately US$ 5.3 billion and US$ 6.2 billion are needed in 2009 and 2010, respectively.
- From 2011-2020, an average of US$ 5.1 billion is needed annually.
- From 2021-2030, average annual costs of US$ 3.3 billion are expected.
- From 2031-2040, average annual costs of US$ 1.5 billion are expected.
Figure II.14: Global cost for malaria control and elimination
Source: GMAP costing model
Implementation costs include the costs of prevention, treatment and control programs. Estimates represent the fully loaded costs of preventive tools (LLINs, IRS, and IPTp)Although important, the costs of environmental management were not included due to insufficient information. and curative interventions (anti-malarial drugs, diagnostics, and severe case management), as well as malaria control program costs, for all 109 malaria endemic countries. Fully-loaded costs represent intervention costs plus distribution, warehousing and other delivery expenses based on published or expert sources. See Appendix 4: Assumptions behind Country Implementation Cost Estimates for more information relating to assumptions for the cost estimates. For more information on current funding from national and international sources, please see Part I – Chapter 4: Funding for Malaria Today.
Cost of prevention: LLINs, IRS and IPTp. The most substantial costs in malaria control are those of preventive interventions. This is because prevention will need to be sustained to prevent re-emergence of malaria in many areas even when burden declines. Prevention costs hover around 70% of total costs over time, creeping up slightly as countries sustain control after scale-up.
Covering the 3.3 billion people at risk globally with the appropriate preventive interventions will cost approximately US$ 3.7 billion in 2009 and US$ 3.9 billion 2010 (see Figure II.15). IRS represents 55%, LLINs represent almost 45%, and IPTp comprises less than 1% of total prevention costs. (See Part II – Chapter 2: Controlling Malaria for recommendations on coverage). From 2011 to 2020, preventive costs will average US$ 3.6 billion annually due to the need to sustain control and to population increases.
Vaccines. The baseline projections and charts do not consider new interventions, including vaccines. Preliminary assumptions show that a 2013 launch and subsequent 2-year scale-up of a partially effective vaccine covering 80% of all children in Africa under 1 year of age would cost an additional ~US$ 533 million per year.
Figure II.15: Preventive intervention costs
Source: GMAP costing model
Cost of case management: RDTs, ACTs, Chloroquine, Primaquine and Severe case management. Case management costs, which include ACTs (for P. falciparum), RDTs, chloroquine and primaquine (for P. vivax) and severe case management are approximately 20% of total costs during the initial scale-up and early sustained control periods (see Figure II.16). RDTs comprise the bulk of costs due to the assumption that half of all fevers suspected of malaria are diagnosed with an RDT (the other half are assumed to be diagnosed via microscopy). Upon reaching a peak cost of about US$ 1.4 billion in 2011, treatment costs decline significantly (to less than 10% of total costs) due to the impact of scaled-up preventive interventions on incidence throughout the sustained control period. In elimination, treatment will eventually decline to approximately 1% of total costs.
While in reality, there is often overuse of treatment, the baseline estimate takes an aspirational approach assuming wide-spread diagnosis and treatment of confirmed cases (plus an additional 25% to account for some over-treatment). However, a sensitivity analysis was conducted for Africa showing a 75% lower usage of RDTs than the baseline “aspirational” scenario and subsequent treatment of all fever cases. In this case, overall case management costs are ~40% higher. This makes a powerful argument for scaling up diagnostics, provided patients do not still seek anti-malarial treatment regardless of the diagnosis.
Figure II.16: Case management costs
Source: GMAP costing model
Cost of Malaria Programs: M&E, Operational Research, Training, Human Resources and Infrastructure. Program costs are country-level costs, and include local operational research, monitoring and evaluation, health infrastructure, training and community health workers, using country-specific estimates and methodology described by Kiszewski and Johns et alKiszewski A, Johns B, et al. Estimated global resources needed to attain international malaria control goals. Bulletin of the World Health Organization, 2007, 85:623-630.
Click for source (see Figure II.17). These estimates do not include global costs such as R&D, operational research or monitoring and evaluation (M&E) at an international level.The model uses country estimates when available for costs, target interventions and coverage, etc., and global or regional assumptions when country-specific information was not available. Country-costs increased at the rate at which the country’s population was projected to grow from 2005 to 2050. Other than this annual adjustment, no changes were made to reflect currency adjustments in the baseline. For estimates based on projected inflation rates, see Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source Specific components of each of the four categories of costs are described in Appendix 4: Assumptions behind Country Implementation Cost Estimates.
Program costs are initially approximately 14-19% percent of the overall annual costs, and make up a greater relative percent as treatment and preventive intervention costs decline. During elimination, programs costs, except for surveillance, are slightly lower than during sustained control, as malaria control is integrated into broader, multi-disease control programs. Although declines in incidence may suggest even lower costs, intensive surveillance and vigilance require continued investment.
Figure II.17: Malaria program costs
Source: GMAP costing model
When estimating delivery and program costs for malaria, there is a potential to over-estimate the shared delivery costs and/or the health systems costs which could be attributed to multiple diseases. While care was taken to minimize potential overlap by validating with experts and cross-referencing with multiple sources, some duplication may still exist due to the difficulty of differentiating malaria-specific costs, particularly in resource-constrained environments and across 109 countries. This highlights the need to understand better (and take advantage of) the synergies in malaria program costs with other disease programs.
Cost differences per stage. Annual costs decline as countries progress from scaling up to sustaining control to eliminating malaria. Estimates are based on differing assumptions and durations for each stage (which are detailed in Appendix 4: Assumptions behind Country Implementation Cost Estimates). The initial years between 2009 and 2011 will be the most expensive as most countries are scaling up malaria control. This stage requires significant investments across all intervention types. However, the short duration of the scale-up period means that in total this stage will be the least expensive relative to the others.
Annual costs begin to decline as countries focus on sustaining control over time since use of preventive interventions decreases the amount of treatment needed. However, while treatment costs decline, there is still significant expense required in maintaining preventive coverage. Hence sustaining control is expected to cost an average of US$ 5.1 billion annually from 2011-20. Countries are assumed to stay within the sustained control stage between 5-20 years depending on natural-state transmission levels.
In the elimination stage, annual costs, while still significant, are expected to decline further. Country by country, all costs will vary depending on each country’s natural transmission level. During the time periods where more and more countries are expected to enter into elimination campaigns, preliminary estimates show costs could average US$ 3.3 billion annually from 2021 to 2030, US$ 1.5 billion annually from 2031-2040 and US$ 550 million annually from 2041-2050. There is, of course, a likelihood that elimination will extend beyond 2050, which will extend the costs further.
To examine relative cost per stage more closely, one of the lower populations at risk (PAR) countries that is currently scaling up was examined to determine specific average costs per stage. Relative costs are shown in Figure II.18. Evaluation of higher PAR countries show a slightly lower decline in relative annual costs across each stage, meaning the program from start to finish would cost more.
Figure II.18: Average annual costs decline per stage
Note: Decreases shown are relative. In reality, cost declines are gradual
Source: GMAP costing model
Costs vary substantially by regions. Regions with high incidence and large populations at risk, such as Africa and Asia-Pacific, account for the largest portion of global costs throughout the duration of the program (see Figure II.19). Between 2009-10, approximately 43% of the annual costs are for Africa, and an addition 50% of the costs are from Asia-Pacific. Other regions, which consist of many countries in elimination and later stages of sustained control, have significantly lower malaria control costs. From 2011-20, approximate average annual control costs for regions are: Africa: US$ 2.3 billion, Asia-Pacific: US$ 2.5 billion, the Americas: US$ 225 million, and Middle East and Eurasia (MEE): US$ 120 million. Please see Part III: Regional Strategies for information on current national and international funding available to regions.
Figure II.19: Annual costs by region
Source: GMAP costing model
Cost of Research and Development
Based on preliminary estimates outlined in Figure II.20, malaria research and development will cost approximately US$ 750 to US$ 900 million per year through 2018 for new tools. This represents a total cumulative investment of more than US$ 8.9 billion through 2018. Significant investment must be made into drugs, vaccines, vector control and diagnostics over the coming years to achieve the near-term goal of malaria control and prepare for elimination and eradication in the long-term. Of the US$ 8.9 billion, about US$ 1.2 billion is for vector control, US$ 3.5 billion for drugs, US$ 2.6 billion for vaccines, and US$ 140 million for diagnostics. In addition to the direct cost of interventions, about US$ 1.5 billion is needed for early research and for information needed to assess effectiveness and impact of new tools.
Figure II.20: Malaria research anddevelopment costs
Source: GMAP costing model
These costs, while high, will lead to the introduction of important new tools. The R&D costs are based on today’s thinking about the general classes of the preventive and therapeutic tools necessary to enable world-wide eradication. These tools were broadly discussed in the R&D section, but prescriptive estimates are necessary to model R&D cost projections.
Vaccines. With a sustained commitment to R&D, the world will have four different vaccines by 2028. Two vaccines will be developed for P. falciparum, however, the second vaccine will be more efficacious than the first. In addition, one P. vivax vaccine will be developed. One other vaccine that has the capability to target both P. vivax and P. falciparum simultaneously and/or block transmission and/or be used by pregnant women is anticipated.
Preventive and therapeutic drugs. By 2018, two IPT-specific drugs will be launched and four different types of therapeutic drugs will be developed: a next generation ACT for P. falciparum, a combination that targets P. vivax in the liver stage, and two therapeutics that separately block P. falciparum and P. vivax transmission. The transmission blocking drugs may also have the capability to treat the disease at the red blood cell stage. After launch of these drug products, it is estimated that two novel therapeutic drug combinations and one novel preventive treatment will be created every 10 years to avoid resistance build-up. In addition, new formulations for drugs will be created for pregnant women, children and infants, and different delivery modes will be created for severe malaria.
Vector control. For vector control, three new active ingredients and 15 formulations will be needed over the next 12 years to pre-empt pesticide resistance and integrate new paradigms such as larviciding and consumer products. Only one active ingredient and 10 formulations will be developed in subsequent decades for the same purposes.
Diagnostics. Reliable, robust and cost efficient microscopy and rapid diagnostic test technologies are necessary to enable malaria elimination. Over the next several decades, investments in microscopy, improvements in current diagnostic technology, developments of new monoclonal antibodies and innovative polymerase chain reaction (PCR) technology to increase diagnostic sensitivity, and inventions of non-invasive tests and broader diagnostic tools are necessary.
Timeframes and costs. These new tools require significant time and sustained investment. The cost to develop a vaccine ranges from US$ 600 million to US$ 1 billion and the project timeline is estimated to be 13 years. It takes approximately US$ 250 million and 10 years to develop a new active ingredient for drug therapies and between two and six years and US$ 25 million to launch a reformulation. For vector control, developing a new active ingredient requires a US$ 175 million investment and 12 years whereas a reformulation is only US$ 3 million over two to six years. Annual investments in developing new microscopic and diagnostic technologies range from approximately US$ 10 to US$ 15 million.
The R&D forecasts are uncertain and timelines are conservative. Though the model assumptions were vetted through interviews with industry experts, there is inherent uncertainty in the types of tools that are needed and the timelines to develop them. When in question, the current timeline estimates err on the side of conservatism. For example, we are assuming it requires development of two drugs to block transmission of P. falciparum and P. vivax. However, efforts are underway to simultaneously block both parasites with one product which would ultimately reduce overall cost and time spent on R&D. As a result, it will be necessary to continuously update this model over time. See Appendix 5: Assumptions behind Research and Development Cost Estimates for more information about the model inputs and assumptions.
Benefits of Investing in Malaria Control, Elimination, and R&D
While the costs of fighting malaria are not low, the benefits are significant. There are several compelling reasons why malaria makes a good investment:
- Malaria control saves lives today and prevents deaths tomorrow;
- Malaria control is cost effective, especially when compared to interventions for other diseases;
- R&D investments save long-term control costs;
- Costs saved through rapid scale-up enable reinvestment in other health programs; and
- Lower burden yields positive economic benefits and can reduce poverty.
Malaria control saves lives today and prevents deaths tomorrow. Investing in rapid scale-up today and sustaining the achievements over the longer term will save several million lives. A consortium of organizations led by the Institute of International Programs at Johns Hopkins Bloomberg School of Public Health has developed an IMPACT model measuring child survival based on work by the Child Health Epidemiology Reference Group (CHERG) and using software developed by the Futures Institute. In Figure II.21, an indicative analysis of 20 high-burden African countriesCountries evaluated represent ~82% of global malaria mortality: Angola, Burkina Faso, Cameroon, Chad, the Democratic Republic of Congo, Cote d’Ivoire, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Mali, Mozambique, Niger, Nigeria, Senegal, Sudan, Tanzania, Uganda, Zambia. The model only looks at the impact on deaths due to P. falciparum. shows that if 2010 coverage goals are met, over 4.2 million cumulative lives will be saved between 2008 and 2015. If scale-up targets are not achieved until 2015, only 2.8 million lives will be saved over that same period. See Appendix 4. Assumptions behind Country Implementation Cost Estimates for cost implications of slower scale-up.
The model bases child survival rates on the current effectiveness levels of preventive and curative interventions. These gains will likely increase as operational effectiveness increases and new tools are developed, making the goal of near zero deaths possible. Already, some countries have seen even greater reductions in mortality.
Figure II.21: Impact of scale-up on malaria mortality in 20 high burden African countries
a) Countries evaluated represent ~82% of global malaria mortality
Source: CHERG Child Survival Model
Malaria control is highly cost effective. In addition to the impact on morbidity and mortality, interventions to prevent and cure malaria have been shown to be very cost effective with high benefit-cost ratios in a number of studies. In Table II.3, a recent analysis of sub-Saharan Africa shows a package of malaria preventive interventions (including nets, IRS, and IPTp) to be the second most cost effective intervention compared to those of multiple diseases and conditions including HIV/AIDS and tuberculosis.Based on chapters in Jamison D et al. Disease Control Priorities in Developing Countries, 2nd edition, 2006, as summarized in Laxminarayan et al., 2006.
Click for source At a cost of US$ 2-24 per DALY (disability-adjusted life year)DALYs for a disease are the sum of the years of life lost due to premature mortality in the population and the years lost due to disability for incident cases of the health condition. One DALY represents the loss of one year of equivalent full health. Murray CJL, Salomon JA, Mathers CD, Lopez AD (eds.). Summary measures of population health: concepts, ethics, measurement and applications. Geneva, World Health Organization, 2002. See http://www.who.int/healthinfo/boddaly/en/ for more information.
Click for source averted the only intervention with higher cost effectiveness was childhood immunization. Using the same data, malaria interventions (including nets and ACTs) ranked among the top 7 of 315 health interventions analyzed based on a combination of benefit-cost and burden addressed.Jamison D. Disease Control. In Lomborg B, eds. Solutions for the World's Biggest Problems: Costs and Benefits. Cambridge University Press, 2008.
Click for source
Table II.3: Cost-benefit ratios for major health care interventions
|Health care intervention||Cost per DALY averted ($)||Burden (in M of DALYs)|
|Childhood immunization||1 - 5||Not assessed|
|Malaria preventiona||2 - 24||35.4|
|Surgical services & emergency care||7 - 215||25 - 134.2|
|Childhood illnesses||9 - 218||9.6 - 45.1|
|Cardiovascular disease||9 - 273||4.6|
|HIV/AIDS (prevention)||6 - 377||56.8|
|Maternal / neonatal care||82 - 409||29.8 - 37.7|
|HIV/AIDS (treatment)||673 - 1,494||56.8|
|Tuberculosis (treatment)||4,129 - 5,506||8.1|
a) Includes insecticide treated bed nets, indoor residual spraying and IPTp in sub-Saharan Africa
Source: Mills A. and Shillcutt S. Copenhagen Consensus Challenge paper on Communicable Diseases, 2004
This confirms the findings of similar studies, including the 2004 Copenhagen Consensus, which showed that investments in ACTs and LLINs not only saved significant lives, but that the annualized net benefits and benefit-cost ratios are high compared to other diseases.Mills A and Shillcutt S. Copenhagen Consensus Challenge Paper on Communicable Diseases. 2004.
Click for source This means that a dollar spent for malaria interventions may potentially have a larger impact on health outcomes than the same money spent on interventions against other diseases.Kiszewski A, Johns B, et al. Estimated global resources needed to attain international malaria control goals. Bulletin of the World Health Organization, 2007, 85:623-630.
Click for source
R&D investments save long-term costs. From a global cost standpoint, significant R&D investment made over the next decade is expected to yield highly effective tools which will decrease the need for R&D funding and expensive control efforts in future decades. For example, the launch of a successful vaccine would reduce long-term investment in drugs and other interventions. Over time, R&D investment will also permit development of more cost effective interventions and will therefore reduce ongoing in-country implementation costs. Until the launch of an efficacious tool that will help eliminate malaria, the annual R&D costs are projected to range from US$ 750 million to US$ 900 million through 2018. Ensuring these investments are made is integral to achieving the ultimate goal of malaria eradication.
Costs saved enable reinvestment. According to the costing model, most countries in the midst of control programs have an annual malaria control cost averaging US$ 1.85 per person at risk, depending on several factors including regional differences, population size and density, number of interventions used simultaneously, etc. This expenditure will decline over time due to the savings generated through lower treatment needs.
When compared to the average annual health expenditure of these countries, the costs are relatively low. Average annual health expenditures per person in Africa are US$ 19, US$ 30.5 in Asia, and US$ 26.50 in the Americas. As malaria control expenditure decreases due to rapid declines in incidence, funding is freed up to fund other health initiatives.
Lower burden yields positive economic benefits and can reduce poverty. Malaria usually affects some of the poorest, most marginalized populations in the world. Minimizing the burden enables individuals to continue to go to work and school as well as lessens time away from work caring for the sick. This promotes economic growth and can diminish the cycle of poverty.
These investments in malaria control can have a significant positive impact on a region’s economy. Some analyses have estimated the annual economic burden of malaria to be at least US$ 12 billion per year of direct losses, plus many times more than that in lost economic growth. This means that if US$ 2.3 billion is needed annually to control malaria in Africa, then every US$ 1 invested into malaria control could enable more than a US$ 5 gainExtrapolated from loss of US$ 12 billion of direct costs compared to the cost of achieving control in SSA. Gallup JL and Sachs J. The economic burden of malaria. American Journal of Tropical Medicine and Hygiene, 2001, 64:85-96.
Click for source , taking only into account the US$ 12 billion mentioned above. There are likely to be similar benefits in other parts of the world. Further research is being planned to evaluate the economic impact of malaria as well as the positive return seen when adequate investment in malaria happens. This document will be updated as this information comes available.
Table II.4: Summary of annual global costs
|Cost (US$ millions)||2009||2010||2015||2020||2025|
|Chloroquine and primaquine||5||5||2||1||0|
|Severe case management||27||23||16||9||4|
|Case management cost||968||1,359||550||226||87|
|Community health workers||79||82||97||96||75|
|M&E and OR||207||242||245||251||298|
|Infrastructure / inst. strengthening||248||419||331||347||283|
|Global control and elimination cost||5,335||6,180||5,037||4,877||3,378|
|Vector control interventions||108||108||108||105||65|
|Research & Development cost||759||759||800||681||460|
Note: Diagnostic costs are covered both by RDTs in case management and by microscopy in infrastructure / institutional strengthening
Source(s): GMAP costing model; Johns B. and Kiszewski A. et al