Abstract
BackgroundThe emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options.MethodsA decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs.ResultsICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0569-7) contains supplementary material, which is available to authorized users.
Highlights
The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts
The exploration of financial incentives vs IEC for subsidized malaria Rapid diagnostic test (RDT) use in the informal private sector is novel, and the World Health Organization (WHO) recommends that the cost-effectiveness of new interventions be established before strategies are recommended as policy [18]
Total commodity costs include all patient purchases: $0.32 per RDT, $0.53 per subsidized artemisinin-based combination therapy (ACT), $0.55 per course of ‘other anti-malarial’, and $0.58 per course of ‘no anti-malarial’
Summary
The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. An estimated 37.4 million people in Myanmar live in malaria-endemic areas, where 74% of malaria cases are P. falciparum infections and 26% are Plasmodium vivax infections [7]. There is a wide range of uncertainty in the incidence of malaria in Myanmar, as the large number of cases from migrants working in forests and agricultural areas are difficult to quantify. Recent estimates of the number of cases range between 500,000 cases (in 2011) to 4.2 million cases (in 2008), resulting in 9,100 deaths annually [9,10,11]
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