Article Text

Global investment targets for malaria control and elimination between 2016 and 2030
1. Edith Patouillard1,2,3,
2. Jamie Griffin4,
3. Samir Bhatt5,
4. Azra Ghani5,
5. Richard Cibulskis1
1. 1Global Malaria Programme, World Health Organization, Geneva, Switzerland
2. 2Swiss Tropical and Public Health Institute, Basel, Switzerland
3. 3Universität Basel, Basel, Switzerland
4. 4School of Mathematical Sciences, Queen Mary University of London, Mile End Road, London, UK
5. 5Medical Research Council Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
1. Correspondence to Dr Edith Patouillard; patouillarde{at}who.int

Abstract

Background Access to malaria control interventions falls short of universal health coverage. The Global Technical Strategy for malaria targets at least 90% reduction in case incidence and mortality rates, and elimination in 35 countries by 2030. The potential to reach these targets will be determined in part by investments in malaria. This study estimates the financing required for malaria control and elimination over the 2016–2030 period.

Methods A mathematical transmission model was used to explore the impact of increasing intervention coverage on burden and costs. The cost analysis took a public provider perspective covering all 97 malaria endemic countries and territories in 2015. All control interventions currently recommended by the WHO were considered. Cost data were sourced from procurement databases, the peer-reviewed literature, national malaria strategic plans, the WHO-CHOICE project and key informant interviews.

Results Annual investments of $6.4 billion (95% uncertainty interval (UI$4.5–$9.0 billion)) by 2020,$7.7 billion (95% UI $5.4–$10.9 billion) by 2025 and $8.7 billion (95% UI$6.0–$12.3 billion) by 2030 will be required to reach the targets set in the Global Technical Strategy. These are equivalent to annual investment per person at risk of malaria of US$3.90 by 2020, US$4.30 by 2025 and US$4.40 by 2030, compared with US$2.30 if interventions were sustained at current coverage levels. The 20 countries with the highest burden in 2015 will require 88% of the total investment. Conclusions Given the challenges in increasing domestic and international funding, the efficient use of currently available resources should be a priority. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/ View Full Text Statistics from Altmetric.com Key questions What is already known about this topic? • Extending malaria control measures to universal health coverage targets is a key challenge. Insufficient investment contributes to the current intervention coverage gaps and malaria burden. • New global targets for malaria control and elimination have been adopted for the 2016–2030 period. A methodology to estimate the cost of accelerating progress towards reaching these targets is required in order to monitor funding progress and identify shortfalls over the next 15 years. • Previous estimates of global resource needs for malaria control and elimination have not considered malaria transmission dynamics and the effectiveness of combinations of interventions. What are the new findings? • Under the Global Technical Strategy for malaria 2016–2030, annual investment targets per person at risk of malaria are estimated at US$3.90 by 2020, US$4.30 by 2025 and US$4.40 by 2030.

• The total investment need for malaria control and elimination is not expected to decrease before 2030, reflecting in part population growth in currently high burden countries and the costs of surveillance in countries near elimination.

Estimating investment targets

The average unit cost of implementing an intervention can vary with the scale at which the intervention is delivered and with the range of other interventions implemented alongside it. (Dis)economies of scale or scope describe a situation where average unit costs (increase) decrease with increasing programme reach or scope. At very high levels of intervention coverage, average unit costs rise with the increasing cost of reaching the last few populations. Managing the process of intensifying malaria control interventions when scaling up several interventions at the same time could also produce diseconomies of scope if current infrastructures are overwhelmed, or economies of scope by piggybacking on underused capacity.40 Malaria control interventions are likely to be expanded in settings with different levels of infrastructure, a situation that would affect the incremental costs of increasing intervention coverage. Scaling-up processes are also likely to use different pathways that would most likely impact costs and cost structures.41 However, reliable evidence on how cost and cost structure vary with coverage levels and across different settings in low-income and middle-income countries is extremely limited, notably for malaria control interventions.20 In this context, we chose not to impose cost functions in this global analysis42 and conducted extensive uncertainty analysis to capture potential variations in unit costs during our investment target estimation.

Handling uncertainty

We conducted probabilistic uncertainty analysis using Monte Carlo simulations to determine a 95% uncertainty range for the investment need estimates. Cost parameters were assigned a γ probability distribution informed by median cost estimates and IQRs from the literature, except for outpatient and inpatient CHOICE cost range estimates, for which a uniform distribution was used (table 3). Cost parameters were varied simultaneously to obtain 1000 costs simultaneously combined with 50 stochastic realisations of case incidence projections from the mathematical model of P. falciparum transmission.6 The mean unit costs and uncertainty intervals (UI) across the 1000 cost estimations for core malaria control interventions are reported in the online supplementary file.

Results

Reducing malaria case incidence and mortality risk by 90% globally by 2030 is estimated to require annual investments of $6.4 billion (95% UI$4.5–$9.0 billion) by 2020,$7.7 billion (95% UI $5.4–$10.9 billion) by 2025 and $8.7 billion (95% UI$6.0–$12.3 billion) by 2030 (figure 1). This translates to an investment need of US$101.8 billion (95% UI $72.6–$142.0 billion) over 15 years, equivalent to a 40% increase in investments compared with sustaining coverage (US$60.1 billion, 95% UI$49.2–$74.7 billion). In the initial 5 years, the required costs increase most rapidly as levels of coverage are scaled up from current levels to 80%. In addition, the substantial projected population growth in the affected countries further increases the need. From 2020 onwards, the lower linear increase is due to increasing coverage from 80% to 90%. Figure 1 Global annual investment targets for malaria control and elimination under sustain and accelerate scenarios with 95% uncertainty intervals (constant 2014 US$).

We estimated that 88% of the total investment will be required by the 20 countries with the highest burden in 2015. The majority of the total cost was estimated in Africa (63.1%) where malaria transmission is most intense, with the remaining in the Asia and Pacific regions (30.3%), Europe and the Middle East (5.3%) and Central and South America (1.4%).

Overall, the annual investment target per person at risk amounts to US$3.90 by 2020, US$4.30 by 2025 and US$4.40 by 2030, compared with, on average, US$2.30 if interventions were to be sustained at their current coverage levels over the 15 years. Reaching these investment targets are expected to avert an additional 171 million cases and 646 100 deaths by 2020.6

We predict that the majority of investments will be required for prevention activities, notably vector control (55%, 95% UI 44%–64%) and chemoprevention (5.6%, 95% UI 1.4%–10.7%). Substantial investments will also be required for diagnosis of NMFs (20%, 95% UI 9%–32%), malaria case management (15%, 95% UI 10%–23%) and surveillance (5%, 95% UI 3%–6%; figure 2). These proportions are, however, expected to change over the 15-year period as the impact of increasing intervention coverage reduces the malaria burden (figure 3A–C). Specifically, the costs of malaria treatment are predicted to decline from 2020 onwards, representing a decrease in the absolute malaria burden and a proportionate decrease that outweighs the underlying population growth (figure 3B). Savings in case management costs are expected from 2025 onwards, with the greatest savings in the current highest burden countries. In contrast, surveillance costs are projected to increase as more countries progress towards elimination (figure 3C). In addition, we project an increase in the costs associated with testing NMFs as an increasing proportion of tests confirm a negative malaria diagnosis (figure 3C).

Figure 2

Per cent of global annual investment targets for malaria control and elimination under the accelerate scenario, by intervention (constant 2014 US$). Figure 3 (A) Per cent of global annual investment targets for vector control interventions under sustain and accelerate scenarios (constant 2014 US$). (B) Global annual investment targets for diagnostics and treatment of malaria cases in the public sector (health facility and community levels) under sustain and accelerate scenarios (constant 2014 US$). (C) Global annual investment targets for surveillance activities (including diagnostics of non-malaria fevers) under sustain and accelerate scenarios (constant 2014 US$).

We assessed the sensitivity of our base-case estimates by considering alternative scenarios for the resource need as malaria elimination is approached. Investment targets were, as expected, most sensitive to variations in the assumed need for vector control once local elimination has been achieved, with an estimated reduction of 23% in annual investments by 2030 (US$6.4 billion, 95% UI 4.5–9.0 billion, or US$3.30, 95% UI $2.28–$4.56, per person at risk) if vector control is removed 3 years following local elimination. Reducing universal malaria testing of NMFs to a target of 10% of NMFs after local elimination is projected to further reduce needs to US$6.1 billion (95% UI 4.3–8.6 billion), or US$3.10 ($2.20–$4.36) per person at risk by 2030. Other approaches marginally decreased funding requirements (figure 4).

Figure 4

Sensitivity of estimated global annual investment targets to four stratification approaches under the accelerate scenario (constant 2014 US$). Discussion Investments in malaria control and elimination activities were estimated at around$2.9 billion in 2015.1 To accelerate transmission reductions and consequently further reduce malaria-associated morbidity and mortality, we estimate that global annual investments in malaria will need to increase to $6.4 billion (95% UI$4.5–$9.0 billion) by 2020,$7.7 billion (95% UI $5.4–$10.9 billion) by 2025 and $8.7 billion (95% UI$6.0–$12.3 billion) by 2030. This translates to an annual cost of intensifying malaria control globally ranging between US$3.90 and US$4.40 per person at risk depending on the level of intervention coverage achieved. This falls within the broad range of per capita estimates published previously.43 Despite the large sums required to achieve the goals set out in the GTS, the intervention mix remains highly cost-effective. Under the strategy costed here, Griffin et al6 estimate, on average, that an additional 220 million cases will be averted annually. With this estimated to cost nearly$102 billion over the 15 years compared with $60 billion to sustain interventions at their current level, this translates to a cost per additional case averted of around$12. Furthermore, as many countries move towards elimination and subsequently progressively discontinue prevention interventions, the global costs are predicted to plateau towards the end of this 15-year period. Thus, accelerating progress towards elimination will see a move towards reducing the financial burden of malaria globally.

The costing approach developed here provides a methodology to monitor progress over the next 15 years and to identify shortfalls in the funding required to achieve the goals set out in the GTS. Our approach to estimate a global price tag for the global malaria strategy uses dynamic modelling to underpin forward projections of impact. A key benefit of this approach is that our investment targets account for malaria transmission dynamics and the effectiveness of combinations of interventions rather than of interventions implemented in silos.

We assume a slower but more realistic rate of increase in intervention coverage compared with previous studies, which projected reaching UHC within 2 years of intense scale-up.7 ,44 We predict increasing investment needs throughout the 15-year period compared with contemporary studies that assume decreasing needs from 2025 as large geographical areas achieve elimination.45 ,46 This difference is in part due to the substantial population growth projected over the next 15 years in high burden countries, such that, in our modelling, the reduced cost associated with elimination in a number of countries is counterbalanced at the global level by the increasing population size in those countries remaining endemic. The only scenario in which we estimate a reduction in global needs is if universal vector control coverage is scaled back once local elimination occurs. However, scaling back vector control in areas where local transmission has been interrupted is not recommended without a thorough evaluation of the epidemiological characteristics and capacities of health systems to detect and respond to potential reintroduction and resurgence,47 which in themselves may introduce other costs.

Our approach has a number of limitations. First, we did not include any constraints in the capacity of countries to scale up to high levels of coverage across all interventions. In reality, in many resource-poor settings, the lack of human resources or/and their poor productivity48 are likely important determinants of the effect and costs of malaria control strategies. This may therefore limit the potential impact of interventions. Furthermore, we only included the direct costs to the health system, and thus while we captured additional personnel time, associated human capital and infrastructure spending needed to increase the capacity of health systems was not included. Equally, we did not capture the savings to health systems that could be obtained from reducing the burden of malaria and hence potentially freeing capacity to treat other conditions. Second, we did not include the costs of near-term innovations that would most likely be required before 2030 to reach the GTS goals because of the uncertainty around the nature of these innovations and their implementation costs. Third, we did not estimate the additional costs of research and development for malaria as these have been estimated elsewhere (an additional US$673 million per year (range US$524–US$822 million)).5 Finally, we focused on the Sustainable Development Goal period and did not attempt to provide estimates post-2030 because of the increasing uncertainty in the type, effectiveness and costs of interventions. Despite the substantial increase in financing towards malaria control and elimination over the past 15 years, we expect challenges in attaining the investment targets for 2016–2030. Relatively optimistic assumptions suggest that international and domestic contributions may increase to$3.8 billion by 2020,11 which implies a funding gap of \$2.6 billion in this year. Only through significant increases in domestic and international funding, and in particular through economic growth and greater commitment to internationally agreed targets, could the current gap in financing begin to be bridged.11 While economic growth generates additional resources which can contribute to increasing government expenditure for health,49 ,50 countries at the highest risk of malaria are often the most resource-constrained and international funding sources are likely to continue playing a significant role in funding malaria interventions in the 2016–2030 period. Interlinkages between progress towards malaria elimination and economic wealth also imply that as countries get wealthier, they face graduation from donors' funding while successful malaria elimination requires predictable sustained funding to reach and sustain malaria-free status. These factors indicate that global malaria control and elimination face major challenges in the Sustainable Development Goal financing landscape. Ensuring the efficient use of currently available resources to maximise value for money should therefore be a priority, with a focus on the most effective interventions targeted to the populations most in need.

Acknowledgments

The authors thank Andrea Bosman, Abraham Mnzava, Erin Shutes, Tessa Knox, Charlotte Rasmussen, Pascal Ringwald, Cristin Fergus, Graham Brown, Fabrizio Tediosi, Katya Galactionova, Silke Fernandes, Lesong Conteh, Tom McLean and Patrick Walker for their input into the costing methodology. The authors also thank members of the GTS Steering Committee, the Technical Expert Group on Surveillance Monitoring and Evaluation and the Malaria Policy Advisory Committee and participants in the GTS Regional Workshops for helpful comments on earlier drafts of this work.

EP and RC are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.

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Footnotes

• Handling editor Seye Abimbola.

• Contributors The study was designed by EP and RC with input from JG, AG and SB. EP and JG undertook the analysis. SB provided input data on the bed net distribution model. EP, AG and RC drafted the manuscript. All authors provided input on the manuscript.

• Funding EP and RC acknowledge support from the Bill and Melinda Gates Foundation. EP also acknowledges support from the Swiss Tropical and Public Health Institute, through a grant from the Swiss Development Cooperation. RC acknowledges support from the UK Department for International Development (DFID) and the US Agency for International Development (USAID). JG is an MRC Methodology Fellow (#G1002284) funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement. AG acknowledges research grant support from the Bill and Melinda Gates Foundation (#OPP1068440), and Centre support from the UK MRC and the UK DFID under the MRC/DFID Concordat agreement. SB acknowledges research grant support from the MRC and DFID under the MRC/DFID Concordat agreement and receives support from the Bill and Melinda Gates Foundation (#OPP1068048, #OPP1106023). Members of the Bill and Melinda Gates Foundation, UK Department for International Development and US Agency for International Development provided input into the development of the scenarios through their formal roles on the Global Technical Strategy scientific committees.

• Competing interests None declared.

• Provenance and peer review Not commissioned; externally peer reviewed.

• Data sharing statement No additional data are available.

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