Cost-effective malaria control in Brazil - Cost-effectiveness of a MalariaControl Program in the Amazon Basin of Brazil, 1988-1996

Malaria transmission was controlled elsewhere in Brazil by 1980, but in the Amazon Basin cases increased steadily until 1989, to almost half a million a year and the coefficient of mortality quadrupled in 1977-1988. The gover nment's malaria control program almost collapsed financially in 1987-1989 a nd underwent a turbulent reorganization in 1991-1993. A World Bank project supported the program from late 1989 to mid-1996, and in 1992-1993, with he lp from the Pan American Health Organization, facilitated a change toward e arlier and more aggressive case treatment and more concentrated vector cont rol. The epidemic stopped expanding in 1990-1991 and reversed in 1992-1996. The total cost of the program from 1989 through mid-1996 was US$616 millio n: US$526 million for prevention and US$90 million for treatment. Compared to what would have happened in the absence of the program, nearly two milli on cases of malaria and 231,000 deaths were prevented: the lives saved were due almost equally to preventing infection and to case treatment. Converti ng the savings in lives and in morbidity into Disability-Adjusted Life Year s yields almost nine million DALYs, 5.1 million from treatment and 3.9 mill ion from prevention. Nearly all the gain came from controlling deaths and t herefore from controlling falciparum. The overall cost-effectiveness was US $2672 per life saved or US$69 per DALY, which is low compared to most previ ous estimates and compares favorably to many other disease control interven tions, Contrary to much previous experience, case treatment appears more co st-effective than vector control, particularly where falciparum is prevalen t and unfocussed insecticide spraying is relatively ineffective, Halting th e epidemic by better targeted vector control and emphasizing treatment paid off in much reduced mortality from malaria and in significantly lower cost s per life saved. (C) 1999 Elsevier Science Ltd. All rights reserved.