Financial Implications and Strategies for Prevention

Exploring the Impact of Malaria on Global Health: Financial Implications and Strategies for Prevention

1. Introduction

Malaria, an infectious disease caused by Plasmodium parasites transmitted through the bites of infected mosquitoes, has plagued humanity for centuries. Its symptoms include fever, headache, chills, and vomiting, which can progress to severe illness and death if left untreated. Despite advancements in treatment and prevention, malaria remains a major global health issue, particularly in sub-Saharan Africa. The purpose of this paper is to explore the impact of malaria on global health, specifically focusing on the financial implications and strategies for prevention.

Malaria poses a significant risk to global health, particularly in low- and middle-income countries where it is endemic. The disease is disproportionately high and causes high morbidity and mortality among the most vulnerable groups, including children and pregnant women. In 2021 alone, there were an estimated 247 million cases of malaria and 619,000 malaria deaths worldwide. The emergence of drug-resistant parasites and insecticide-resistant mosquitoes has exacerbated the problem, threatening to reverse progress made in recent years. The impact of malaria on global health is not just limited to illness and death but extends to the economy as well. Malaria is associated with significant economic costs due to loss of productivity, reduced income, and increased healthcare spending. The disease is estimated to cost African countries billions of dollars in lost economic growth each year. Insecticide-treated mosquito nets (ITNs) are one of the most cost-effective interventions for preventing malaria, particularly among vulnerable populations. ITNs reduce malaria transmission rates and provide protection against other mosquito-borne diseases. The use of ITNs has increased significantly in recent years, with millions of nets distributed in endemic countries. However, the continued effectiveness of ITNs is threatened by insecticide resistance. (Andrade et al.2022)

2. Epidemiology of Malaria

Malaria ranks among the top five causes of morbidity and mortality in many tropical countries. Approximately one third of the world’s population lives in areas at risk for malaria transmission, and an estimated 300 million cases with more than one million deaths occur annually, with most of the mortality occurring among children aged less than five years. This burden of disease falls disproportionately in Africa, where the life-threatening form of malaria, caused by Plasmodium falciparum, is endemic. Control, even with aggressive deployment of current vector control interventions, would only partially reduce the burden of this disease, but even this reduced burden would benefit those 300 million people living at risk. (Garrido-Cardenas et al.2023)

Malaria, a disease caused by infection with the protozoan parasite of the genus Plasmodium, is transmitted by the bite of the female Anopheles mosquito. It ranks high among infectious diseases in terms of morbidity and mortality. Plasmodium species are responsible for malaria in man. Although there are five species that can infect humans, it is P. falciparum that is responsible for the vast majority of deaths.

The distribution of malaria is unequal worldwide: it mainly occurs in tropical and subtropical regions, with a few pockets of transmission in temperate regions. The distribution is changing due to global climatic change and social changes such as increased rates of urbanization. Using epidemiological data, it is possible to refine the general epidemiological distribution of malaria in order to assess control requirements and to model the potential benefits of newly developed or deployed control measures. (Lana et al.2021)

Malaria is an ancient disease that may have been present in early hominids. Its gradual spread among human populations is postulated to have paralleled the evolution of the Anopheles mosquito vectors that are now responsible for its transmission to man. It was one of the first infectious diseases to be widely recognized by the great ancient civilizations. However, the causal agents could not be identified until the late 19th century. The first description of the clinical features of malaria is attributed to Hippocrates (460-377 BC), although it is possible that malaria was recognized well before this. The term malaria was derived in the late 17th century from the Italian “mala aria” meaning bad air, referring to the noxious vapors generated by swampy and marshy land that were thought to cause the disease. (Sharp et al.2020)

2.1. Global Burden of Disease

Malaria, transmitted through the bite of infected female Anopheles mosquitoes, represents one of the most severe health challenges in the world today. The World Health Organization (WHO) estimates that in 2020 there were 241 million cases globally, a significant increase from 227 million cases in 2019. While malaria is absent in many parts of the world, it placed a huge burden of illness and death in 2020 in 29 countries in sub-Saharan Africa, India, and a few areas in Oceania and Southeast Asia. Despite significant progress in prevention and treatment over the past 20 years, there were an estimated 627,000 deaths from malaria worldwide, with 96% of these occurring in Africa. About two-thirds of those infected with malaria are children under age 5. (Patel et al.2024)

The burden of malaria is not evenly spread across the globe. There are 87 countries and territories in the world where malaria is endemic, home to 3.4 billion people who are at risk of infection, 1.3 billion of whom are at high risk. Malaria transmission is closely related to climate, land use, and socio-political factors. Africa bears by far the heaviest burden of malaria. Of the estimated 627,000 deaths from malaria globally in 2020, 482,000 (77%) were in the WHO African Region. Africa is also home to 61% of the 241 million cases of malaria in 2020 and 80% of the estimated 228 million cases of malaria globally in 2019. (Kogan & Kogan2020)

Children aged less than 5 years account for the highest proportion of malaria deaths. In 2020, an estimated 234,000 children aged under 5 years died from malaria, representing about 37% of all malaria deaths globally. The WHO African Region accounted for most (95%) of these deaths. The number of deaths in this age group remained unchanged from 2019 to 2020. Outside Africa, malaria is endemic in parts of Central and South America, the Caribbean, the Middle East, Eastern Europe, Central and Southeast Asia, and the Pacific Islands.

3. Financial Cost of Malaria

The global burden of malaria is staggering. The World Health Organization estimates that there were 241 million cases of malaria worldwide in 2020, with up to 627,000 deaths. In addition to this horrendous toll on human life, malaria has a significant cost associated with its prevention, treatment, and mortality. Furthermore, countries that have higher malaria burdens also have the highest poverty levels. Overall, a clearer picture of malaria’s financial cost is critical to understanding its impact on global health and poverty. Cost studies can help policymakers prioritize interventions such as alternative methods of financing national control programs. (Liu et al., 2022)(Health Organization, 2022)

Direct costs include the costs associated with the treatment of malaria, including those incurred by the ill and their loved ones, as well as the costs incurred by health care providers and other organizations involved in malaria control and prevention (e.g., using bed nets or insecticides). Indirect costs include the lost productivity of sick people and their caretakers, deaths, and the consequent loss of knowledge and experience. Due to the wide variation in the way these costs are measured, it is difficult to come to an overall estimate. In Burkina Faso, one of the poorest countries in the world, the total direct and indirect cost of malaria was estimated to be about 39.4 billion CFA francs (about $75 million) in 1993, which made up about 11% of the national budget. More recent studies conducted at the village level in Madagascar suggested that an attack of malaria cost an average rural household of 8 persons about $66.53 on direct costs, while endorsing an attack on adults required an even higher sacrifice of $80.42 on average. (Product et al.)

In 1997 in Tanzania, the direct economic burden of malaria was estimated at $118 million, including $75 million worth of drugs and health services in the formal market and $43 million in informal expenditures. This represented about 21% of the health budget and about 8% of total domestic expenditures on health in Tanzania. In Gabon, the total cost of illness for an episode of malaria in 1987 was $2.95 for outpatients and $37.00 for inpatients. In The Gambia, the economic cost of malaria (direct and indirect cost of malaria over outbreaks in 1993-94 and its loss of crop production) was estimated at a staggering $80 million (in 1989 dollars). Further financial and economic analysis using cost-of-illness methodology are warranted to obtain a clearer picture of malaria’s cost to health and the economy. (Conteh et al.2021)

3.1. Direct Costs

There is a great disparity in the distribution of the world’s population in relation to the disease burden. As defined by the WHO, there are about 2.5 billion people who live in malarial areas of the world, mainly in the tropics. 300 to 600 million cases of malaria occur annually. The distribution of cost is unequal. Over 80 percent of the malaria burden is borne by Africa south of the Sahara, which has 46 percent of the world’s population at risk in the malaria-endemic zone. The cost of malaria to a country is either direct or indirect. The most important medical costs are of drug treatment and hospitalization.

The drug treatment costs that are examined focus only on the oral chloroquine treatment regimen, the most widely used antimalarial drug. The costing is on a simple level because many do not have access to sophisticated accounting. The costs to people are considered estimates more than precise predictions. In refugee communities, such as that along the Uganda-Kenya border, malaria is one of the primary causes of health care referrals. Drug treatment alone costs US$112,000 or US$24 per case, which compares with US $21,000 treatment costs for such a centre in Uganda. In African communities in general, chloroquine treatments per case range from US$1.82 to US$23 per year, the former based on a moderate-risk control site in Mali, the latter high community transmission sites in Tanzania. For Uganda, drug treatment annual costs for chloroquine treatment regimen, at 81 percent protection, are estimated at US$60 million / year in the 4 endemic zones. (Barber, 2023)

Hospitalization costs were uncovered only accidentally. One 14-month-old child at Kayunga Health Unit died after a stay of 21 days, costing the family US$180, excluding lost work time and funeral costs. As this poor family had used most of their meager savings for the child’s treatment, the economic impact of hospitalization is high. In Tanzania, average length of hospitalization for severe malaria is 6.6 days at a mean cost of US$440 per child enrolled in a study, accounting for 69 percent of family annual income. In rural Uganda, cost of in-patient treatment for well-documented severe cases of malaria was US$114. The direct cost of malaria hospitalization in developing countries is likely in the hundreds of dollars.

3.2. Indirect Costs

Malaria has severe economic consequences, which can be observed at the social and individual levels. However, only a little effort has been made to estimate the total economic cost of malaria. The idea was to develop an econometric model that has a direct impact on payroll. The modeled functions take into account direct and indirect costs, personal evaluation, and health spending per beneficiary to estimate productivity gains. Clarifications have been made regarding some impact indicators that are seldom included in studies exploring the costs of malaria. The indicators defined are proportion of days without and with malaria, total days absent in the population, yearly attendance, derivation of yearly attendance, payment for health services, and health spending per beneficiary. Nevertheless, poverty makes it difficult to access health services, and this restrains the consideration of costs. The results obtained from the stochastic model give insight about malaria and demonstrate the technical approach of development Econometrics. (Devine et al.2021)

The World Bank has classified countries according to the number of malaria infections per 1,000 inhabitants per year. In Southeast Asia, Cambodia, Laos, Myanmar, Thailand, and Vietnam suffer from unstable malaria. There are countries with stable malaria, such as Bangladesh, Bhutan, India, Maldives, Sri Lanka, and Nepal. There are some opportunities to reorient efforts towards discovering diseases of different natures, such as Other Filariases (Microfilaria in Lymphatic System), viral hepatitis ‘B’, undetermined ‘A’ viral hepatitis, Childhood Infections Not Elsewhere Classified, and Hydatid Disease. It is socially profitable to eradicate malaria from Southeast Asia, and this encourages the population to grasp the possibilities of interventions to overcome the disease. (Sahu et al., 2020)(Apeagyei et al.2024)

Though malaria causes severe loss in income capital, there is an incentive for intervention. Nevertheless, individual economic costs of malaria were not computed. Many of the studies concentrate on alternative economic loss measured by individual or social income loss. Malaria incidence among various groups was approximated and its association with income inequality was evaluated. The relationship between income disparities and malaria incidence in a community was examined through a field survey in Madagascar. Education and sinsemilla farming were found to be contributory to reduced parasitaemia and malaria prevalence respectively. It is important to understand the economic burden of disease properly as it is often used to advocate against modifiable behavioral factors. Sickle cell trait (HbAS) is evaluated as modifiable against malaria.

4. Strategies for Malaria Prevention

Malaria continues to be a significant public health challenge worldwide. The disease has claimed millions of lives, particularly in sub-Saharan Africa and other tropical regions. Although treatments of malaria continue to develop, prevention is a much cheaper way of ensuring individuals do not fall sick from malaria. Preventive measures that target mosquitoes can drastically lessen or even eliminate the possibility of getting the disease. Various strategies to prevent the spread of malaria are highlighted in the discussion that follows. (Oladipo et al.2022)

Vector control measures target the mosquitoes that transmit malaria from infected individuals to healthy individuals. Preventive measures that do not target mosquitoes but rather the infected sick individuals do exist, such as treatment of malaria in infected individuals, which would stop the parasites from being transmitted. However, such strategies are not extensively used as they are too costly, would require massive health infrastructure improvement, and are only effective if there is a high test rate of individuals with malaria. The vast majority of strategies to prevent the spread of malaria are vector control measures.

Chemoprevention is the method of using drugs to prevent illnesses or diseases. In malarial transmission, treatments such as the presumptive treatment of fever, intermittent preventive treatment of malaria, or seasonal malaria chemoprevention could be employed. Presumptive treatment of fever involves the treatment of any individual who presents with an elevated temperature regardless of whether or not they have the disease. This treatment could alleviate the immediate health burden of the sick individual, however it would only work if the fever is indeed caused by malaria. Furthermore, such treatment might increase drug-resistant strains of the parasite, especially in high-transmission areas, worsening the situation. For the intermittent preventive treatment of malaria (IPT), certain populations such as pregnant women or infants would be tested at certain times and would be treated regardless of whether or not they had malaria. While this treatment could considerably prevent the risk of the development of severe disease and even death, improvement of life conditions to avoid mosquito bites should still be the priority. Finally, seasonal malaria chemoprevention (SMC) would use malaria treatments to prevent malaria in only high-transmission areas during certain times of the year. Although this method of prevention could stop malaria infection in the short term, it cannot replace vector control measures, as drug-resistant strains would emerge due to the selective pressure of the treatment. (Plowe, 2022)(Greenwood et al.2021)

4.1. Vector Control Measures

A primary strategy for malaria prevention revolves around vector control measures. The goal is to either kill or repel the mosquitoes that transmit the malaria parasite or to reduce their population, resulting in a lower probability of malaria transmission. Vector control measures employed against malaria mosquitoes include the long-lasting insecticide-treated nets (LLINs), insecticide residual house spraying (IRS), and several other strategies under research development.

LLINs are the most extensively used vector control measures and are recognized as one of the most effective methods for preventing malaria, saving millions of lives each year. The World Health Assembly resolution (2000) called on countries to protect those at risk of malaria with LLINs, proposing a target of universal access to LLINs at 80% by 2010. The vast majority of LLINs are made from polyethylene and impregnated with pyrethroid insecticides, the only class of insecticides approved by the World Health Organization (WHO) for use on insecticide-treated nets (ITNs/LLINs). The networks’ cost-effectiveness depends on improving LLIN availability, which has been hampered by synthetic pyrethroid resistance. Over the last several years, WHO has launched major initiatives to increase LLIN availability in malaria-endemic countries. (Mosha et al.2022)

Insecticide residual spraying is another simple approach for malaria prevention. The concept of IRS proposes the application of residual insecticides (mostly organochlorines or organophosphates or pyrethroids) to the interior walls and roofs of houses. This method entails the periodic spraying of different surfaces in regular intervals, usually once or twice in a year, covering the houses in a given village/human settlement. This method is relatively effective in tropical/subtropical regions where the climate remains hot throughout the year, and housing conditions are favorable. It is performed by trained professionals using commercially available insecticides, designed to safely target the malaria vector. The insecticide selection methodology, life expectancy, weather patterns, spraying techniques, and housing design all impact the success of IRS. Unfortunately, IRS has been shown to reduce malaria transmission partially due to the emergence of DD-IRS-resistant An. gambiae s.s across several African nations. Currently, IRS is practiced in many countries, but only a handful meet the required level of coverage.

Research and development of alternative vector control strategies are ongoing, with the most promising ones being the genetically modified (GM) mosquitoes and the environmentally safe bacteria/larvicidal agent L. sphaericus. However, there are several challenges with these strategies before they could be launched in the endemic countries. As of now, community engagement, awareness generation, and active participation in controlling breeding sites, surveillance of malaria-positive cases, and adequate and timely treatment with recommended anti-malarials remain critical. These measures need to be part of a multi-pronged and zero-tolerance strategy, adopted both at individual settlements and national levels. Global public health officials need to pay equal attention to the growing threat of mosquito-borne diseases.

5. Conclusion and Future Directions

Malaria is a disease that is largely but far from completely preventable and curable that has claimed the lives of innumerable people. Significant financial resources are required in an effort to understand, contain, and eventually eliminate the disease. The results of a study showing the raw number of deaths due to malaria, both worldwide and by region, are shown here. The total number of deaths is reported, and may be broken down into children aged 5 and under and adults at the author’s choice. Malaria was estimated to have caused about 627,000 deaths globally in 2012, and about 413,000 of these deaths were in African children aged 5 and under in 2010. The financial implications of such a disease that is anything but well contained are also examined. In particular, recent budget reports from the Global Fund and the President’s Malaria Initiative are analyzed. This analysis shows that many countries where malaria is endemic are making little progress towards financial sustainability, even as the needs are expected to far exceed the available resources. A model for increased financial investment into malaria control is presented. Under stated assumptions, an increase in financial investment will translate into increased resources directed towards malaria control, and funding should be made available for the necessary research and development. Finally, precautions that should be taken with increased funding for malaria control are outlined. Policymakers should be aware of the possibility of diversion of funding and of any unrealistic expectations for short-term miracles.

Previous models have provided perceptive insights into underinvestment in malaria. These insights and associated policy recommendations remain relevant, and all R&D for malaria should not necessarily be redirected into a single alternative path. However, they have flaws that may hinder their practical policy impact. One flaw is the neglect of the separate but equally important issue of underresourcing established malaria control measures. Financial support for established measures should be made available in parallel with more transformative innovations. A related flaw is the shadowing off of the more specific and urgent issue of continued polio transmission until eradication is achieved by a focus on the more vague and remote prospects of selective investment in transformative R&D. On the other hand, this focus could animatedly be justified by the larger sums of money involved, more generous time horizons, and clearer visions of success. It is possible that deliberate miscalculations of the discounted net present value of a successful polio eradication initiative compounded by the R&D failures of the last decades exacerbated policy inertia from Colombia to Kazakhstan.

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