Determining cost-effectiveness and cost component of three malaria diagnostic models being used in remote non-microscope areas.

This cross-sectional experimental study developed a methodology to analyze the cost-effectiveness of three malaria diagnostic models: microscopy; on-site OptiMAL; and on-site Immunochromatographic Test (on-site ICT), used in remote non-microscope areas in Thailand, from both a public provider and patient perspective. The study covered six areas in two highly malaria-endemic areas of provinces located along the Thai-Myanmar border. The study was conducted between April and October 2000, by purposively recruiting 436 malaria suspected cases attending mobile malaria clinics. Each patient was randomly selected to receive service via the three diagnostic models; their accuracy was 95.17%, 94.48% and 89.04%, respectively. In addition, their true positive rates for all malaria species were 76.19%, 82.61% and 73.83%; for falciparum malaria 85.71%, 80.95% and 80.00%, and for vivax malaria 57.14%, 100% and 50%, respectively, with the parasitemia ranging from 80 to 58,240 microl of blood. Consequently, their costs were determined by dividing into provider and consumer costs, which were consequently classified into internal and external costs. The internal costs were the costs of the public providers, whereas the external costs were those incurred by the patients. The aggregate costs of these three models were 58,500.35, 36,685.91, and 40,714.01 Baht, respectively, or 339.53, 234.39, and 243.93, in terms of unit costs per actual case. In the case of microscopy, if all suspected malaria cases incurred forgone opportunity costs of waiting for treatment, the aggregate cost and unit cost per actual case were up to 188,110.89 and 944.03 Baht, respectively. Accordingly, the cost-effectiveness for all malaria species, using their true positive rates as the effectiveness indicator, was 446.75, 282.40, and 343.56 respectively, whereas for falciparum malaria it was 394.80, 289.37 and 304.91, and for vivax malaria 595.67, 234.39 and 487.86, respectively. This study revealed that the on-site OptiMAL was the most cost-effective. It could be used to supplement or even replace microscopy for this criteria in general. This study would be of benefit to malaria control program policy makers to consider using RDT technology to supplement microscopy in remote non-microscope areas.

The malaria cauldron of Southeast Asia: conflicting strategies of contiguous nation states.

The past half-century or so has witnessed dramatic failures but also some successes in control of malaria in the world at large. South and Southeast Asia have had their share of both outcomes, a scenario that reflects many variables in control programs: technology, management strategy, human and financial resources. However, at least equally culpable have been major wars and minor conflicts, economic growth and stagnation, inequity of opportunity, urbanisation, deforestation, changing transport and communications. The history of malaria is thus an integral part of the broader political and economic evolution of the region, as well as the story of the wisdom and unwisdom of malaria specialists. In positive reflection on the latter, systematic organisational effort using standard tools of trade has seen the gradual elimination of major malaria foci from central plain regions of a number of nations in this large region, with residual foci at forested border areas. In many cases there is good evidence of sustainability of elimination in defined areas but the differing success stories reflect in part conflicting strategies in neighboring nation states. On the other hand, physical conflicts, population migration, inequitable economic change, border instability and many other socio-economic variables can be clearly seen to undermine the most ingenuous strategies. Undoubtedly the single most important negative ingredient is the rise and spread of multi-drug resistant falciparum malaria that has its epicenter in Southeast Asia, from which it threatens the world in insidious fashion. Containment of this phenomenon has been the focus of attention for 30 years, more particularly the past decade, and represents the greatest challenge at this time in predicting the continuing impact of malaria globally on human history. So too does the compelling necessity to link malaria control with macro and micro economic planning. This challenge impinges on the sovereignty of individual nations in this region, for they exist in contiguity, so that successful applications of technology require collaborative political determination.

Ecology, economics and political will: the vicissitudes of malaria strategies in Asia.

The documented history of malaria in parts of Asia goes back more than 2,000 years, during which the disease has been a major player on the socioeconomic stage in many nation states as they waxed and waned in power and prosperity. On a much shorter time scale, the last half century has seen in microcosm a history of large fluctuations in endemicity and impact of malaria across the spectrum of rice fields and rain forests, mountains and plains that reflect the vast ecological diversity inhabited by this majority aggregation of mankind. That period has seen some of the most dramatic changes in social and economic structure, in population size, density and mobility, and in political structure in history: all have played a part in the changing face of malaria in this extensive region of the world. While the majority of global malaria cases currently reside in Africa, greater numbers inhabited Asia earlier this century before malaria programs savored significant success, and now Asia harbors a global threat in the form of the epicenter of multidrug resistant Plasmodium falciparum which is gradually encompassing the tropical world. The latter reflects directly the vicissitudes of economic change over recent decades, particularly the mobility of populations in search of commerce, trade and personal fortunes, or caught in the misfortunes of physical conflicts. The period from the 1950s to the 1990s has witnessed near "eradication" followed by resurgence of malaria in Sri Lanka, control and resurgence in India, the influence of war and postwar instability on drug resistance in Cambodia, increase in severe and cerebral malaria in Myanmar during prolonged political turmoil, the essential disappearance of the disease from all but forested border areas of Thailand where it remains for the moment intractable, the basic elimination of vivax malaria from many provinces of central China. Both positive and negative experiences have lessons to teach in the debate between eradication and control as alternative strategies. China has for years held high the goal of "basic elimination", eradication by another name, in sensible semi-defiance of WHO dictates. The Chinese experience makes it clear that, given community organization, exhaustive attention to case detection, management and focus elimination, plus the political will at all levels of society, it is possible both to eliminate malaria from large areas of an expansive nation and to implement surveillance necessary to maintain something approaching eradication status in those areas. But China has not succeeded in the international border regions of the tropical south where unfettered population movement confounds the program. Thailand, Malaysia and to an extent Vietnam have also reached essential elimination in their rice field plains by vigorous vertical programs but fall short at their forested borders. Economics is central to the history of the rise and fall of nations, and to the history of disease in the people who constitute nations. The current love affair with free market economics as the main driving force for advance of national wealth puts severe limitations on the essential involvement of communities in malaria management. The task of malaria control or elimination needs to be clearly related to the basic macroeconomic process that preoccupies governments, not cloistered away in the health sector Historically malaria has had a severe, measurable, negative impact on the productivity of nations. Economic models need rehoning with political aplomb and integrating with technical and demographic strategies. Recent decades in Chinese malaria history carry some lessons that may be relevant in this context.

PIP: Malaria has been a major player in the socioeconomic stage of Asia. During the last half of the century, dramatic changes in the social, economic, and political condition, population size, density and mobility, played a role in changing the face of malaria in Asia. Even before programs to fight malaria savored significant success in Asia, a large number of people were already suffering from the disease earlier this century including the global threat of Plasmodium falciparum. This reflects the vicissitudes of economic change in this decade, particularly the mobility of populations in search of commerce, trade, and so on. Between 1950s and 1990s, there was a near eradication of malaria in Asia followed by its resurgence in Sri Lanka, India, Cambodia, Myanmar, Thailand, and China due to several precipitating events and conditions. Both the positive and negative experiences have lessons to teach in relation to malaria eradication and control strategies. For instance, the Chinese experience that given community organization, exhaustive attention to case detection, management and focus elimination, and political will at all levels of the society is possible for the elimination of malaria from large areas. Economics is central to the prosperity and deterioration of nations and the disease experienced by the population. Malaria control and elimination should therefore be related to the basic macroeconomic process of the government, and economic models should be developed with political aplomb, while integrating technical and demographic strategies.