TDR Final Report

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Social, Economic and Behavioural (SEB) Research
Report Series No. 1 (2002)
TDR Final Report Series No. 37 (2001)
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Cost-performance analysis of malaria control in
Henan Province, China
TDR Project ID 950109 930413
(1994-1998) Professor Xi-Li Liu Principal
Investigator Australian Collaborators Dr
Sukhan Jackson (Health Economics), Dr Adrian
Sleigh (Epidemiology and Trop Med)
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• Malaria in Henan
• worst province in 1970 (10.2 million cases)
• 1971-1984 280 million treatments, 1.8 billion
  anti-relapse courses, 2 billion prophylaxis
  courses
• 1981-1992 active case detection, DDT spraying
  and (later) impregnated bednets
• 1993 basic elimination (lt1 case/10,000
  pop/yr), vivax persists in 4 poor counties in the
  south

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Objectives 1) Measure costs for each malaria
control component in Henan who incurred what
costs? 2) Evaluate case-management
performance what was purchased? 3) Assess
balance and quality of investment in the control
program what can improve?
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Malaria study counties (shaded areas)
Source Sleigh et al. 1998 Bull WHO
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• Methods
• cost all government inputs (fixed and variable)
• cost all community inputs (direct and indirect)
• evaluate and cost sample of case-management
• least studied aspect in economic appraisals of
  malaria (epidemiologically important for control
  outcomes)1,2
• 1Mills A. The economics of malaria. Proc. of
  MIM African Malaria Conference, Durban, Sth
  Africa, March 1999 92-109
• 2Mills A. The economics of malaria control. In
  Targett GAT (ed) Malaria waiting for the
  vaccine. Chichester, John Wiley and Sons 1991
  141-168

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Province, County and Township government costs
measured for 2 years
Village Barefoot doctor (VD) management,
patient-carer costs
2-year study of 12,325 VD-managed suspected
malaria cases (fever, typical sx, no other cause,
all reviewed by Liu XL - all vivax based on sx
and blood surveillance)
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Costs of malaria control Government - invests
US99,970/yr, protects 3.4 million people in
transmission zone at 0.03 per head population
blood surveys (surveillance) - 25 vector
surveillance (strategic knowledge) - 12
case-management (disease-transmission control) -
60 Community US4.18 cost per illness - cases
incur 83 of cost (10 days income 1/3rd for
drugs, gt1/3rd due to lost income). Govt pays 17
of cost per illness and creates treatment system
and case-management standards
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• Case-management performance
• quick access to care, confidence in VDs
• VDs slow to treat after diagnosis (40 wait 3-4
  days)
• most cases get schizonticide, CQ is available
• treat duration too short (only 1-2 days for
  62)
• many non-malarial drugs (moral hazards)
• primaquine (8 day) course rarely finished

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Conclusions Government stewardship good -
maintains system for citizens to purchase care
(drug supply, trained village doctors, standards,
17 of case management cost) and Maintains
surveillance and strategic knowledge but Must
maintain investment (boost a little?) - or risk
resurgence and far greater costs later Need to
improve case-management - a poor buy at present
- not value for money poses an epidemiologic
risk Need to resolve primaquine question -
justified use?
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Overall Reflections

• Cost-performance method came from managerial
  economics broader than CEA, CUA, CBA
• Fits WHOs focus on health system performance
• Timely in China with partial defunding of many
  public health programs in the 1990s, like malaria
• Our health system managers and policy makers now
  know what they are buying for malaria control
• We can advocate evidence-based improvements
  (case-management) and continued productive
  investment (beneficial malaria control)

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Malaria reflections

• China had largest Asian malaria burden now much
  reduced, has avoided resurgence
• vivax problem typical of the malaria burden in
  many areas outside of Africa
• We can invest in malaria control more efficiently
  improving case-management
• Need information like ours one of the first
  such cost-performance studies, and almost the
  first economic appraisal of malaria
  case-management

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Some project publications

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• Liu X, Jackson S, Song J Sleigh A 1996
  Malaria control and fever manage-ment in Henan
  Province. Tropical Medicine and International
  Health, 1 112-116.
• Jackson S, Liu XL Song JD 1996 Socio-economic
  reforms in China's rural health sector economic
  behaviour and incentives of village doctors.
  International Journal of Social Economics, 23
  409-419.
• Sleigh AC, Liu XL, Jackson S, Li P Shang LY.
  1998 Resurgence of vivax malaria in Henan
  province, China. Bull of WHO, 76 265-270

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Some project publications (cont)

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• Zhuang J, Jackson S, Li P, Sleigh AC and Liu X.
  1999 Knowledge, attitudes and practices for
  malaria and its control among residents of an
  endemic area in Henan, China. Henan Medical
  Research Henan Yixue Yanjiu, 8 267-269 (in
  Chinese)
• Liu XL, Jackson S and Sleigh AC. 2001 Cost and
  Performance Analysis for Malaria Control in Henan
  Province. 2001 Final Report for Projects 930413
  and 950109. TDR News (and web site) (In Press)
• Jackson S, Sleigh AC and Liu XL. 2002 Economics
  of malaria control in China cost, performance
  and effectiveness of Henans consolidation
  programme TDR Research Report Publication
  Series (monograph) (In Press) 
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