Economic Impact of Malaria in Peru

1. THE ECONOMIC IMPACT OF MALARIA IN PERU

3. Original Title: This work was carried out with the participation of: El impacto económico de la malaria en el Perú. Design and Supervision Dr. César Bueno-Cuadra (MOH) © MINSA-Perú, 1999. Dr. César Cabezas-Sanchez (MOH) Dr. Jaime Chang-Neyra (USAID) Dr. Walter Mendoza-De Souza (MOH) Dr. Salomón Durand-Velasco (MOH) Dr. Luis Seminario-Carrasco (USAID) Dr. Víctor Zamora-Mesía (MOH)

The reference terms for the study were made by: María Antonia Remenyi-Díaz (Economist)

Translation: Roxana Lescano Translation reviewer: Dr. Fernando Llanos-Zavalaga

Research Team: APOYO Institute: Lorena Alcázar-Valdivia, Ph.D. in Economy (Project Director) Rosa Ana Balcázar-Suárez (economist) (Project Director) Pedro Francke-Ballve (economist) (Technical specialist in charge) Dr. Manuel Quimper-Herrera (epidemiologist) Augusto Portocarrero-Grados (economist) Javier Paulini-Sanchez (economist) Claudia Barrios-Paucar (sociologist) This publication was made with financial support from the Vigia Project “Addressing the Threats of Emerging and Re-Emerging Diseases ” (Cooperative Agreement between the Ministry of Health of Peru and the U.S. Agency for International Development (USAID).

Correspondence: Proyecto Vigia (MINSA-USAID) Camilo Carrillo 402, Jesus María, Lima Telephones: 51 (1) 332-3482, 51 (1) 332-3458 http: //www.minsa.gob.pe/pvigia [email protected]

This document can be freely used and reproduced, as a whole or in part, as long as its procedence is mentioned and there is no commercial use.

ISBN: 9972-820-15-7 Depósito Legal N° 1501012000-4490 DEDICATION

To the families in rural areas of the northern coast and jungle of our country who suffer the effects of malaria and fight collectively against the disease.

To the health workers.

THE ECONOMIC IMPACT OF MALARIA IN PERU

MINISTRY OF HEALTH

Dr. Alejandro Aguinaga-Recuenco Minister of Health

Dr. Víctor Zamora-Mesía National Director of the Vigia Project

ACKNOWLEDGEMENTS

To the families of those sick with malaria who opened their doors to us for the survey.

To the Ministry of Health workers who work in health facilities and in the Regional Health Offices of Loreto, Piura and Tumbes for their valuable and speedy collaboration in the collection and correction of regional data.

To the Director’s Offices from the ESSALUD Hospitals of Piura and Iquitos.

To the organizations that provided information: Proyecto Vichayal III, Bosque del Norte, ADEC, Villa Nazaret, Ideas, CIPCA, Médicos del Mundo and the Red Cross Loreto.

To the Transitory Council Boards of Regional Administration in Piura, Tumbes and Loreto.

To the Provincial Municipalities of Piura, Tumbes and Maynas

To the Basic Health and Nutrition Project, coordination headworkers of Piura.

To Dr. Marie-Andree Diouf-Romisch, representative of the Pan American Health Organization Mission in Peru

INDEX

INDEX p. 11 PROLOGUE p. 13 EXECUTIVE SUMMARY p. 15 INTRODUCTION p. 17

1. Malaria in Peru and in the world p. 21 1.1. General aspects p. 21 1.2 Malaria in the world p. 21 1.3 Malaria in Peru p. 22 1.3.1 Historical evolution p. 23 1.3.2 Current status p. 25 1.3.3 Characteristics of the main malaria transmission areas in Peru p. 28 1.4 Prevention and control strategies p. 29

2. Cost estimation in the health reform framework p. 33 2.1 A global view of the health sector in the reform process p. 33 2.2 The economic theory, costs and health economics p. 34 2.3 The study of the economic costs of malaria and its implications in the health reform p. 35

3. Aspects considered in cost estimation p. 39 3.1 Economic costs and effects of the health status p. 39 3.2 Concepts of the economic costs p. 40 3.2.1 Direct costs p. 40 3.2.2 Indirect costs p. 41 3.2.3 Other indirect costs produced by the effects on the behavior of economic agents p. 42

4. Methodology used in the economic costs estimation of malaria p. 43 4.1 Methodological techniques and tools considered p. 43 4.1.1 Calculation of the MOH direct institutional costs p. 44 4.1.2 Costs of other institutions: ESSALUD, NGOs, and others p. 47 4.1.3 Direct and indirect costs borne by patients and their families p. 47 a) Contents of the house survey p. 48 b) Sampling for the house survey p. 49 c) Application of the survey p. 52 d) Value of time p. 53 e) Value of life p. 55 f) Value of suffering p. 55 4.1.4 Calculation of the costs by loss of tourism p. 56 4.2 Possible bias and deficiencies of the methodology used p. 56

5. The economic cost of malaria in Peru p. 59 5.1 The cost of malaria in Peru in 1998 p. 59 5.1.1 The total cost of malaria in Peru p. 59 5.1.2 The Ministry of Health costs p. 60 5.1.3 Costs of other institutions p. 68 5.1.4 Total costs for families in prevention p. 69 5.1.5 Total cost for families for treatment p. 70 5.1.6 Mortality costs p. 73 5.1.7 Costs for loss of tourism p. 73 5.1.8 The fiscal costs of malaria p. 74 5.1.9 Malaria costs in regard to the GDP and by economic activity. p. 75 5.2 The cost of malaria for families p. 77

6. Final comments p. 83

BIBLIOGRAPHY P. 87

ANNEX 1

The economic impact of malaria in Peru Socio-economic Profile of the areas in the study p. 93

ANNEX 2 Profile of for health services user p. 117

INDEX OF ANNEXES NOT INCLUDED p. 127

12. PROLOGUE

Malaria has re-emerged alarmingly in the epidemiological maps of the world and has turned into a serious threat, not only for individual and collective health but for the sustainable economic development of the societies struck by it.

Social, economic, biological and environmental phenomena explain its re-emergence. The dramatic change suffered by the environment –which determines earth warming and thus, the modification of climatic patterns–; the expansion of agricultural borders; overpopulation and uninterrupted migration; constant changes in the biology and behavior of the vector and parasite involved in the transmission of the disease; increased resistance to medications and insecticides used to fight it; as well as the limited interest in developing new technologies and procedures for its control (since it is a disease centered around countries of limited economic development, therefore, not very attractive for the commercialization of new drugs and vaccines) are the underlying factors of this threat, which pose an enormous challenge for the health systems.

The threat this problem poses to the whole world, as well as its extreme complexity, has lead the World Health Organization to develop a special program to fight it. This is the “Roll Back Malaria Initiative” whose main development scene is the African continent where this disease has reached unusual levels of morbidity and mortality. The last World Assembly of the World Health Organization, after extensive discussion on the magnitude and implications of malaria, was able to persuade the main international cooperation agencies of the need to carry out an additional effort to fight it, assigning special funds for malaria research, prevention and control.

In our country, upon the boundless advance of malaria, the Ministry of Health has made huge efforts to try to control the phenomenon. However, the multiple factors conditioning the disease and the complexity of the control measures that overflow the health borders, have stopped the malaria prevention and control results from being optimum.

The study entitled “Economic Impact of Malaria in Peru” is a Ministry of Health initiative, its purpose is to contribute to improve the knowledge of some elements that make up the complex malaria problem and its repercussions in the health and economy of the Peru- vian population. This effort has been accompanied and financed by the U.S. Agency for International Development (USAID) through the Vigia Project.

13. The results obtained in this study evidence the loss the country has and continues to have due to the persistent factors conditioning the magnitude of the disease, as well as the need for a multisectorial approach that guarantees the necessary resources to control a problem that seriously threatens the sustainable development and national security.

We hope this study becomes a powerful management and awareness tool that commits institutions and society as a whole in the prevention and control of malaria in Peru.

Dr. Alejandro Aguinaga-Recuenco Minister of Health The economic impact of malaria in Peru

14. Executive summary

EXECUTIVE SUMMARY

The Ministry of Health and USAID, through the Vigia Project, contracted for the performance of this study. The objective was to estimate the cost of malaria, not only for the government, but also for the familes affected by the disease, and to find out about the other effects the disease has on the economic activity in an indirect manner. The study is framed within the sector reform context because the control of malaria implies prioritizing collective health and reducing the inequities in health.

The study has considered the estimation of direct costs which are the economic resources directly spent because of the disease; and the indirect costs that do not imply a cash disbursement of money but represent a loss of opportunities to produce or to work.

The methodology used involved: a survey of 364 houses of the areas affected by malaria (Loreto, Piura, Tumbes) to determine the time lost and other costs faced by families affected by the disease; a survey of health services to identify the total costs of the health centers, including personnel costs and general services; and the data collection from the Ministry of Health units and others that assign resources to the fight against malaria.

The main results and conclusions of the study are the following:

1. Malaria represents a high cost to the Peruvian economy. The estimated total cost is 37,9 million of US dollars. This figure represents 3% of the animal rearing industry GDP for the departments of Loreto, Piura and Tumbes, where its incidence concen- trates. Also, in regard to the total expenditure in health, the total cost of malaria represents 1,5% .

2. The cost for the Government (originated by the efforts carried out for its control) is 9,3 million US dollars, part of which comes from the resources allocated to it by the National program and other health units oriented to this goal. The amount includes time dedicated by professionals and health workers and the cost of the infrastructure involved. The government spending oriented to malaria is only 1% of the public expenditure in health.

3. Malaria represents an important cost for the families who live in endemic areas because it is as high as 26,6 million US dollars. For these families, mostly poor, the average cost by the disease is 475 US dollars. Although one malaria case costs yearly an average of 95 dollars to the families, the families experience an average of five

15. cases. For the rural families in the jungle, 70% of them are poor, this cost can equal to one third of their yearly earnings.

4. Mortality caused by malaria, in spite of its being low –43 deaths in 1998 in 77,000 cases of falciparum malaria, that is 0,5 per one thousand– represents an important economic cost. As for this measure, however, the limitations of appraising human lives must be highlighted.

5. Economic effects are generated in an indirect manner through the decreased tourism. This could explain the significant loss of between 700,000 and 3,5 million US dollars. In an extreme case, the cost would be meaningful in regard to the other costs identified.

6. The main malaria costs are those generated on the families or more indirectly on the economic activity and these are not adequately perceived by society. This adds to undervaluing the importance of the disease. That is, releasing the real cost to society may turn into a strategy that promotes more active participation of the civil society in the fight against malaria.

7. In the field work, a strategy was found to modify the watering system for rice crops in Piura that could be promising in the reduction of the presence of mosquitoes carrying the Plasmodium without generating a negative effect on the agricultural production. This system consists of alternating six days of watering with nine dry days. In the experimental testing, it reduces the presence of larvae in the fields without reducing their productivity. This system could presumably be generalized to other areas, after its replicability is tested through trials in the field. The economic impact of malaria in Peru

16. Introduction

INTRODUCTION

Malaria is a re-emerging infectious disease in Peru and in the world, with a significant increase on incidence in the last 20 years after great progress in its control achieved in the 1960s. Currently, if diseases were ordered on the health loss they cause, malaria would be the eleventh in the world and the seventh in the developing world.

In Peru, malaria has re-emerged as an important infectious disease due to its increased incidence and geographic distribution. In 1998, more than 200,000 malaria cases were reported, centered around the jungle and northern coastal area of the country. The Ministry of Health (MOH), as part of its mission, has been performing malaria prevention and control measures, including the development of research that allows for better knowledge of the disease and the most efficacious control methods.

The MOH within this context, through the Vigia Project carried out within a cooperative agreement with the U.S. Agency for International Development (USAID) decided to carry out a study on the economic impact of malaria in Peru. The objective was to estimate the cost of malaria, not only for the government but also for the families affected and to find out about the other effects generated by the disease on the economic activity in an indirect manner. Additionally, it was considered that the field work required to carry out this study provided an opportunity to analyze two additional aspects: the use of health services by the population and the socio-economic profile of the population affected.

It must be noted that many of the economic costs that malaria involves go unnoticed because they befall on a rural, poor and disperse population whose work days and resources are not usually accounted for. Identifying them allows us to highlight the real importance of malaria and improve the level of public opinion information about it, which is essential to the development of active strategies to fight it, not only on behalf of the government but on behalf of the population affected. On the other hand learning about the economic costs is an essential requirement for the application of economic tools such as the cost-benefit analysis or cost-effectiveness, used in health to guide the policy toward more efficient methods.

Once the reference terms for the study were established –made by María Antonia Remenyi, an economist, in collaboration with Dr. Jaime Chang and Dr. Víctor Zamora–, a public bid was called and the Apoyo Institute was awarded the contract.

17. The central team in charge of the project’s execution is made by Lorena Alcazar, Ph.D. in Economy and Rosa Ana Balcazar, economist, both responsible for the management of the project; by Pedro Francke, economist and principal investigator; Dr. Manuel Quimper, specialist in Epidemiology and Augusto Portocarrrero, economist. The team was completed by Claudia Barrios, sociologist and Javier Paulini, economist. The study was carried out in the course of three months and a half.

The methodology included a survey of 364 homes in the departments of Loreto, Piura and Tumbes, areas with the highest malaria prevalence (70 percent of the cases in the national territory). It also involved collection of data by means of forms, pre- established in coordination with the various central level organisms of the Ministry of Health, as well as with other national and international organizations that finance malaria control.

In order to complete the demographic and health information, we also visited the Regional Health Offices (Direcciones Regionales de Salud, DISAs), regional institutions and health facilities of the areas selected.

Coordination with the Vigia Project and collaboration with officials from various units within the Ministry of Health and Regional Health Offices have facilitated the access to information about the sector. Collaboration of officials from public and private entities, which allowed us to gather most of the information requested, has also been essential to the successful ending of this task.

This publication is the product of processing the information obtained on the economic cost of malaria. It starts with a chapter of general interest that places the malaria problem in context, in Peru and worldwide, and a concise description of the particular characteristics of this disease.

The economic impact of malaria in Peru The second chapter is also an introductory section that informs on the objectives of the reform of the health sector; a brief presentation of the concepts linking the health field and economic theory is provided; and a description of the tight relationship existing between malaria control activities on behalf of the government and the ongo- ing reform process. The following two chapters include the theoretical framework ad the methodology used as the basis for this study of the impact.

18. The results from the calculation and analysis of the economic costs of malaria are presented in detail in the fifth chapter. It includes a description of the direct and indirect costs malaria generates not only for the government but for various public and private institutions involved in its control as well as for the families affected by the disease. The sixth and last chapter presents some final comments related to the field work carried and the results obtained in the study.

The publication also includes other sections of interest, such as an executive summary (in the first pages) and two annexes: the socio-economic profile of the population affected by malaria and a study on the use of health services by individuals sick with malaria and on the interaction between the population and the institutions to apply control strategies.

19. The economic impact of malaria in Peru

20. Malaria in Peru and in the world

Malaria in Peru and in the world 1.

1.1 General aspects

Malaria belongs to the group of re-emerging infectious diseases because though it is an old disease, with a downward period at around the middle of this century and that has acquired great magnitude throughout the globe in the last few years.

Malaria is caused by a unicellular parasite of the genus Plasmodium. Four are the species affecting man: Plasmodium vivax, falciparum, malariae and ovale. The first one is identified with benign forms of the disease whereas the second one causes severe disease, occassionally leading to death and that is why it is also called “malignant malaria”. The third one is somewhat rare in our country; and the last form is not present here.

Transmission of the disease from one sick person to a healthy person takes place by a mosquito bite. This mosquito vector belongs to the genus Anopheles and there are over 40 species of this genus identified in Peru. The main ones are A. pseudopunctipennis, A. albimanus, A. benarrochi and A. darlingi (Calderón, 1995).

The mosquitoes that transmit malaria reproduce by laying their eggs in different bodies of water containing organic substrates. These rearing sites can be natural, such as puddles, swamps, aguaje farms, etc., or they can also be artificial, such as overflooded rice crops, fish farms, swimming pools, dams, canals, etc. The biological birth process of the larvae (infantile forms of the vector) from eggs, through growth and mature stage toward the adult forms requires special temperature and humidity conditions that are found in tropical climates, either valleys or jungle, and in swamp temperate areas. Thus, countries with an ecosystem such as that described above are generally malaria endemic.

1.2 Malaria in the world

This disease that had been eliminated or suppressed effectively in many parts of the world is now experiencing such a resurgence that today, it is a public health problem in more than 90 countries inhabited by 2,400 million people, that is 40% of the world population.

It is estimated to cause 500 million clinical cases and over one million deaths a year, half of them in children under 15 years old. Every 30 seconds, a child victim of malaria dies somewhere (Malaria Foundation International, 1998).

21. Malaria is considered a disease of poverty because its impact is much greater among poor people. The morbidity burden caused by this disease in the world is calculated at 39 million DALY1 (WHO,1999a).

Although Africa is the most severely punished region, South America and the Carib- bean have seen considerable increase in Malaria cases since 1980, adding up to 900,000 cases in 1997. Around 4,000 individuals out of these cases died. In 1997, Brazil presented with more than twice the number of cases than in 1980 and, in this same period of time, the number of cases have had a five fold increase for the Andean area. The areas affected are mainly the Amazon Basin and the Pacific coastal area near the Equatorial line (PAHO, 1998).

A particularly alarming aspect is the re-introduction of malignant malaria (caused by Plasmodium falciparum) in areas that were free of this severe form of the disease until short time ago.

This reality has led the new director of the World Health Organization (WHO) to launch a new control initiative called “Roll Back Malaria – A Global Partnership” shortly after taking over her position as the WHO Director in 1998. This initiative aims at associ- ating the poorest countries and those endemically struck by malaria, with international organisms of the United Nations, such as UNICEF, UNDP, the World Bank and the WHO, cooperation and bilateral development agencies, NGOs, the private sector, etc., in each country (WHO,1999b).

1.3 Malaria in Peru

In the public health scope of Peru, malaria holds a position of high importance due to its increased incidence and geographic coverage. In the last few years, the increased number of cases has turned Peru into the country with the second highest incidence in South America.

In 1998, 212,590 malaria cases occurred in Peru. Fortunately, although there were 43 fatal cases, in general, the mortality rate reported in our territory is way under that

The economic impact of malaria in Peru observed in other American countries and quite far from the rates reported in Africa (MOH-General Office of Epidemiology [OGE] 1999).

1 The calculation of DALY (disability adjusted life years) is used to measure the burden of morbidity.

22. Malaria in Peru and in the world

1.3.1 Historical evolution

There are historical references of the presence of malaria in Peru, mainly of the colonial period. A famous story by Ricardo Palma, by year 1631, tells about the “miraculous” cure experienced by the Countess of Chinchon, wife of the viceroy who suffering from “tertian fever” was treated by a Jesuit priest with powder from the quina bark; plant whose secrets had been revealed by the indigenous population. It is precisely in the National Peruvian Emblem that the quina tree appears, as a symbol of the contribution of our autochtonous culture to the health of humanity.

Since then, the chronicles have recorded innumerable malaria epidemics in various parts of our country, in the coast, Andean region and jungle.

At the beginning of this century, malaria was the most important public health problem in Peru. In the first half of the century, the first preventive measures of antivectorial fight, such as draining puddles, destruction of insects and larvae, and petrolization of puddles (currently not in practice), etc.

The historical tendency of the disease, registered since 1939 shows a clear downward trend in the 40s, particularly from 1945 on. However, a clear and sustained increase has been observed since 1990 (See Figure Nº1).

Figure N° 1 Evolution of malaria in Peru, 1939-1999 period. Curve of thousands of cases per years

250

200200

150

100100

00 1939 1944 1949 1954 1959 1964 1969 1974 1979 1984 1989 1994 1999

Source: MOH-General Office of Epidemiology (OGE) 1999.

23. In 1957, the National Malaria Erradication Service was created. It implemmented a series of actions based on the use of insecticides and mainly aimed at vector control and by the middle of the following decade, this institution had visible decreased malaria down to a level that led to the belief that erradication was not that far away. In 1965, only 1,500 cases were reported throughout the year.

These malaria control levels were maintained until the beginning of the 70s when a progressive increase in the number of cases became evident. Follow- ing this tendency, the malaria incidence in this decade has increased exces- sively reaching the highest peak of incidence of the last 60 years in 1998.

The appearance of important figures of Plasmodium falciparum malaria is added to this. By the end of the 80s and beginning of the 90s, P. falciparum malaria occurrence was limited to basically small outbreaks from imported cases that were relatively easily controlled through focal interventions. After 1993, a marked increase is seen and it continues to date, reporting thousands of cases monthly: 60 945 cases in 1999 (See Figure N° 2).

Figure N° 2 Cases of Plasmodium falciparum malaria

90 000

80 000 77 056

70 000 60 945

60 000 52 719

50 000 38 738 40 000

30 000

20 000 The economic impact of malaria in Peru 6 575 10 003 10 000 725 00 000 1992 1993 1994 1995 1996 1997 1998 1999

Source: MOH-General Office of Epidemiology (OGE) 1999.

24. Malaria in Peru and in the world

1.3.2. Current status

It can be stated that malaria re-emergence in Peru involves at least two aspects:

a) Geographical dissemination: The disease has disseminated geographically and spread to various regions, mainly of the northern coast and the jungle. The Annual Parasite Index (API)2 reveals that in our country, over 8 million people live in areas with high and medium risk to malaria (See Figure Nº 3).

Figure N° 3 Epidemiological stratification of malaria by provinces according to the Annual Parasite Index. Peru - 1998

High risk Medium risk Low risk No risk

Source: MOH-General Office of Epidemiology (OGE) 1999.

2 The API is the number of confirmed autochtonous cases per one thousand inhabitants. The Ministry of Health also considers cases reported. According to this indicator, areas are classified as high risk when the API is 10 or more, medium risk when the API is between 1 and less than 10, and low risk when the API is under 1 and without risk when the API is 0.

25. On the other hand, malignant malaria has also expanded geographically, reaching various sub-regions in the country and concentrating on the same areas where vivax malaria is located. (See Figure Nº 4).

Figure N° 4 P. falciparum malaria, most affected sub-regions, 1997-1999

14 418 PIURA 25 941 3 390

10 713 LORETO 22 316 3 161

17 259 L. CASTILLA 14 253 6 120

14 505 TUMBES 6 726 4 696

1 983 LAMBAYEQUE 3 529 16

693 JAEN 2 787 290

276 SAN MARTIN 662 88

429 CAJAMARCA 333 101

280 BAGUA 28 116 1997 1998 1999

81 UCAYALI 22 11

0 5 000 10 000 15 000 20 000 25 000 30 000 The economic impact of malaria in Peru Source: MOH-General Office of Epidemiology (OGE) 1999.

b) The change in the ratio of parasite species. For decades P. vivax was the most predominant causative agent of malaria. However, in the last few years, a progressive increase in the ratio of P. falciparum has been observed (Figure N° 5) in regard to the predominant species.

26. Malaria in Peru and in the world

Figure N° 5 Percentage distribution of the malaria cases by P. vivax and P. falciparum

1992 1994 99% 99 92%

8% 1%1

1996 1998 78% 64%

22% 36%

P. vivax P. falciparum

Source: MOH- National Malaria Central Program and OGE

Among the factors for this epidemiological behavior, can be mentioned:

Appearance in some areas of cloroquine resistant strains of P. falciparum according to some Ministry of Health reports and an official investigation (MOH, 1999). Cloroquine is the principal medication used against malaria.

Climatic Factors: At global level, earth warming. At national level: the consequences of the El Niño Phenomenon, which caused accumulation of vector rearing sites, especially along the northern coastal area.

Changes in the model of agricultural development: the increased rice crops, which increase the presence of rearing sites of the vector. (Chang, 1995).

27. The introduction of a highly efficient vector in malaria transmission into Loreto as is Anopheles darlingi (Aramburú, 1999); and the progressive advance of A. albimanus in the northern coast.

Appearance of vector resistance to insecticides.

Increased mobility of individuals and vehicles due to commercial exchange along the borders, not only in Tumbes but also in Loreto and migration which favors the inadvertent transportation of the vector or that allows for the individuals carrying the parasite to arrive at an area where the vector is present and thus, facilitate the spread of the disease.

1.3.3 Characteristics of the main malaria transmission areas of Peru

It has been quite evident in the last few years that the principal malaria transmission areas present with characteristics that are so different from each other that it is possible to distinguish two malaria epidemic patterns in Peru: the “Northern Coast” epidemic pattern and the “Jungle” epidemic pattern. The factors conditioning and determining the presence of the disease in each epidemic pattern are clearly different and thus need to be addressed in a different manner for their adequate control (Químper, 1998).

The “Northern Coast” epidemic pattern established in the poorest provinces of the Piura department (where one of the three residual malaria foci of Peru existed by 1970) is characterized by the existence of areas receptive to the vector in the coastal valleys and the migration of people from a residual and never extinguished focus in the Alto Piura area, attracted by handlabor-intense agricultural activities developed in the medium and lower Piura river. The status of neighboring Ecuador and the fact that they share the same vector (Anopheles albimanus), that is capable and competent to transmit Plasmodium falciparum, have also favored the appearance of malignant malaria cases where there was only P. vivax, though in a lesser proportion than in the jungle.

The most affected population in the northern coastal area resides in precarious

The economic impact of malaria in Peru housing of the outskirts and is dedicated to agricultural tasks in the rice crops. This situation reveals that the rice producing activities prepare and maintain the place where the mosquito vector lives and reproduces.

In the “Jungle” epidemic pattern, it is the jungle itself that provides the mosquito with the ideal environmental conditions for its reproduction instead of the modification of man’s activities (with the exception of the recently introduced fish

28. Malaria in Peru and in the world

farms that represent an additional rearing site when they are not managed adequately). Because of this, malaria is endemic in the jungle, especially among native groups and it is unlikely to be erradicated. The countries sharing the Amazon Basin with Peru have malignant malaria by P. falciparum as one of their most serious health problems.

For reasons still unclear, the most important malaria transmissor in the jungle, Anopheles darlingi (which has great affinity with Plasmodium falciparum, causative agent of malignant malaria) had not been identified in our territory for a long period of time and this kept us free from the malignant form of malaria, thus being the exception among the Amazon peoples. However, a few years ago, this vector was found in the outskirts of Iquitos and in some localities throughout the provinces of Loreto, near the corridors leading to the different border areas.

Fortunately, knowledge of the elements that make the epidemiological chain of malaria (vector, parasite, host) allows us to confront the disease with better control possibilities than in other endemic diseases. Thus, we have learned that malaria vectors differ in their feeding times and in their preference of various types of Plasmodium related to benign or malignant forms of malaria, which allows for the design of various strategies of the fight against the vector in its larvae or adult stage, according to the peculiar biology of the vector and the predominant parasite, with different success perspectives.

1.4 Prevention and control strategies

The malaria problem represents a most singular challenge because as a disease that spreads through mosquito vectors, it requires a varied set of measures to attain its adequate control. These measures refer not only to care for people and their individual and collective behavior, including life styles, occupational risks, migratory movements, etc.; but also attention to the environment involving climatic variations, effects of productive activities on the environment and characteristics of housing and basic services.

The Ministry of Health has considered malaria to be one of its priority health problems (MOH, 1995). In this regard, the execution of prevention and control measures for the disease is deserving of the utmost attention. The National Malaria Control Program of the Ministry of Health increased its health service coverage guaranteeing diagnosis and treatment completely free of charge to patients. Investment in infrastructure and

29. equipment of the services as the product of the government’s stronger effort with international cooperation has contributed to improve the national capabilities for the deployment of actions against the disease. Also, malaria control requires detailed knowledge on the biology of the vector and on the different parasites that cause the disease.

Following is the set of measures are being conducted for malaria control:

1) Epidemiological Surveillance, that is notification and systematic investigation of cases and data analysis, directed by General Office of Epidemiology (OGE).

2) Entomological Surveillance, that is the study of the vector habits by geographic areas based on its transmission and insecticide resistance capabilities. This has led to the demonstration of the recent introduction of Anopheles darlingi, a much more efficient vector in its capabilities to attack human beings (Calderón, 1995).

3) Medical care for people, it involves reinforcement of individual and collective health services alike, taking into consideration the diagnosis, early detection and case treatment. The parasitological diagnosis has allowed us to verify the re-introduction of P. falciparum in various places of our territory. It also involves sanitary education, aspects on life styles and occupational risks, emphasizing personal protection measures (use of repellents and mosquito nets). Among these measures of preventive education, it has been detected that, for example, mosquitoes bite late at night, thus, it is possible to place mesh or mosquito nets as protection and control elements. The protective effect of these mosquito nets can be improved if they are impregnated or sprayed with insecticides (Aramburú et al, 1999).

4) Environmental Control, which involves fighting the vector through the following means:

a) Physical control, such as drainage of rearing sites, weeding borders and others. The economic impact of malaria in Peru b) Chemical control, not only of the vector larvae through larvicides, but of the adult forms as well, through home spraying with long-term action insecticides and spatial fumigation during epidemics. In Loreto, some measures have been tested to fight the larvae stage of the vector, taking advantage of the prolonged jungle summer caused by El Niño to get to the places where transmission foci had been identified before. (DISA Loreto, 1998).

30. Malaria in Peru and in the world

c) Biological control in some pilot areas. From 1990 to date, biological control has been tested in the northern region by means of a bacteria that attacks the larvae stage (Bacillus thuringiensis var. israelii), whose management in the hands of the community has been particularly well accepted (Ventosilla, 1993 a, b)

Maintaining strict surveillance is extremely important because the moving of people over uncontrolled routes may re-introduce the vector or its larvae into peri-urban areas of high populational density with the consequent risk of epidemics.

Community participation is particularly relevant in malaria control activities. This happens through individual activities carried out by health promoters who, in remote areas, take samples for diagnosis and treatment administration. This is also reflected in the work carried out by the community to eliminate rearing sites.

The development of better agricultural techniques and house building would allow for the achievement of adequate disease control as the population, now a malaria victim, adds the new techniques, as inferred by some community experiences developed in the northern region.

We can conclude that the fight against malaria requires coordinated participation from various governmental entities, local and regional authorities from the various departments in the coastal and jungle area and of the population –particularly from the native communities– and, even from the border countries because vectors do not recognize borders.

31. The economic impact of malaria in Peru

32. Cost estimation in the health reform Cost estimation in the health reform framework 2.

2.1 A global view of the health sector in the reform process

The reform of the health sector is a process for its transformation that has been taking place for some years worldwide and aims at generating ostensible changes in the functions and relations among the various institutions and agents operating in the sector in order to decrease the inequality of the health of the population health, increase the efficiency and efficacy of the systems and health services and satisfy the needs of the majorities through the provision of quality health services.

With that intent in mind, the following concrete objectives have been set forth for the health reform in Peru:

In the institutional aspect: Establish a clear separation of the three basic functions, as follows:

The Government function: Exercised by the Ministry of Health in the fulfillment of its role as regulator, assignor of public financing and warrantor of the supply of services. These functions include strategic planning based on the analysis and projections of the health status, control and fiscalization to ensure the fulfillment of sanitary regulations, regulating the provision of services by public and private providers, following-up and supervision of the contributing system of the social security in health and modulation in the field of preparation and licensing health professionals and technicians.

The function of Administrating the public resources destined to financing health services for the target population of the government (poor, extreme poor and population at risk), based on the logics of the purchase of services from public or private providers according to price, opportunity and quality.

The Service Production function exercised by the Ministry of Health and Peruvian social security-ESSALUD facilities, as well as the main institutions in the sector, not only from the private sector but also from the public sector as well. The latter is organized in service networks for basic health care and in national and regional hospitals, as well as specialized institutes to tend to more complex interventions. For more flexibility in the use of resources, it is proposed that the networks of institutions and the hospitals and specialized institutes under the Government jurisdiction will be subject to an autonomous regime regulated through management agreements and monitoring and control of results.

33. For these functions to be adequately fulfilled and thus, achieve the development proposed in the institutional field, we need to establish the organization of the services and generate the following capabilities:

In the Financial aspect.- The aim is to apply new forms of assigning and delivering public resources to health providers in order to promote equity and efficiency. To do this, we propose to rechannel the public health funds toward collective and individual health of a high social value toward more cost-effective interventions, to adequately regulate fee charges and promote new insurance schemes and establish payment mechanisms that promote the efficient production of priority services.

In the Service Providing aspect.- We propose to develop new models for health care that integrate basic health services and bring them closer to the users, adapting them to cultural and social realities of each region and establish a culture of quality and warmth in the service. Also, for the adequate organization of the services, it is required to put the offer in order, to establish adequate reference and counter-reference systems among the basic and more complex health services, as well as to professionalize the management of networks and hospitals by providing them with modern management tools.

These efforts were first exposed to public opinion at the end of 1995 with the presentation of the document entitled “Hacia un sector salud con equidad, eficiencia y calidad. Lineamientos de política de salud 1995-2000” (Towards a health sector with equity, efficiency and quality. Health Policy Guidelines 1995-2000) (MOH, 1995). The main guidelines for the Health Sector Reform were set forth in it, as well as a proposed general model for the reform that aims at being comprehensive and whole.

2.2 The economic theory, costs and health economics The economic impact of malaria in Peru

Health economics is the logic framework to improve decision making in the sector, mainly those decisions that refer to the use of resources, including such topics as financing health systems, balancing supply and demand, health appraisal, the relationship between health and the socio-economic environment and micro-economic evaluation of interventions.

34. Cost estimation in the health reform framework

The economic theory awards great importance to the issue of costs. It considers that maximizing benefits and minimizing costs allows for the optimal use of resources under determined hypotheses (perfect competition and prices that reflect all the relevant social effects). (Mc Guire et al., 1994)

However, the theory has various problems on its application in health, particularly because prices do not collect all the relevant social effects when there are problems in the configuration of the demand or in the external issues of the consumption. In the first case, health demand occurs within a context of incomplete information because the user does not know what services he/she requires or their quality. As for the externalities, they refer to the services that, in addition to providing a benefit to the individual, generate benefits for third parties, as well. A typical case of this is the transmissible diseases, in which curing an ill person tends to reduce the spread of the disease to others.

According to Abel Smith (1989), health economists have offered more than is possible because there are difficulties with the cost data and the epidemiological data. Measuring the benefits is also problematic. Reaffirming his statement, Abel-Smith cites Mills (1985), who states that “there are still few studies of economic evaluation that are capable of offering practical advise to governments.”

Hammer (1993) indicates that there is a large difference between the theory that proposes election among alternatives based on complete information and reality. In theory, what must be done is to compare the marginal costs of the various interventions with its benefits or marginal effects and choosing the optimal combination to achieve the most benefits at the lowest cost. This, however, does not happen in practice. To demonstrate this, the author presents several highly illustrative examples about the mistakes made when priority is assigned to other factors such as the importance of the disease or when the analysis is restricted only to the average cost of the treatment.

2.3 The study of the economic cost of malaria and its implications in the health reform

There are many aspects linking the study of the economic cost of malaria with the actual reform process of the health sector.

The first aspect refers to the need, outlined by the reform, to give priority to the intervention on collective health (MOH, 1995). Economic theory teaches that the

35. benefits provided by the public goods, like the various malaria prevention activities on vector control are distributed throughout the society as a whole and thus, they do not justify the cost incurred privately. At the same time, due to their trait of non- excludable and non-rivalry goods, it is not possible to establish mechanisms to charge for the access to benefits of public goods. Another factor to be considered is the positive externalities derived from curing a person ill with malaria; that is, the benefits for third parties that are indirectly embedded in treating one individual. These benefits result from the fact that transmission levels are lower when there are less individuals infected with the Plasmodium parasite.

A second aspect that coincides with the interventions in collective health proposed by the health reform is the need for them to have an integral and inter-sectorial nature. In the case of malaria, the need is evident given the fact that the vector development is closely associated to environmental conditions, which could be favorably or unfavorably impacted by actions carried out for economic development, such as road building or rice crops. This study of the economic impact of malaria highlights the importance of the disease for other sectors (Ministry of Economy and Finances, Ministry of Agriculture, Ministry of Industries), although the tendency in these sectors has been not to pay much attention to it.

A third aspect relates to health equity. This is one of the great principles of the health reform and is of particular importance in Peru where there is a large degree of inequality and even different epidemiological patterns among different strata of the society. Although in our country, no detailed studies have been performed in this regard, international studies show that in a large majority of the cases, transmissible diseases affect the poor in a much larger rate (given their living conditions) and that, because of this, the fight against these diseases is also justified from an equity point of view. The socioeconomic profile of those affected by the disease included in this study also provides information in the same direction.

A last aspect that relates the health sector reform with the present study is the optimization of the use of available financial resources. The aim is to achieve a

The economic impact of malaria in Peru greater impact in the health of the population for every dollar invested through more efficiency and efficacy. This greater rationality of the expenses is usually considered in health by means of cost-effectiveness and cost-benefit indicators. The first indicators refer to the impact achieved in the health status whereas the second ones establish a link between the economic cost and the economic profit obtained from improving health.

36. Cost estimation in the health reform framework

This study represents a contribution in both directions. On one hand, it allows for the calculation of the total direct cost to fight malaria, which is a requirement to perform estimations of cost-effectiveness3. On the other hand, it provides the possibility of making estimates of how larger costs funded directly by the State may reduce the costs borne by those affected families, thus leading to a net benefit for society.

3 Strictly speaking, a estimation of cost-effectiveness should deal with marginal costs and impact and not on average costs, but that is usually hard to estimate, and presumably requires from the knowledge of the average costs.

37. The economic impact of malaria in Peru

38. Aspects considered in cost estimation

Aspects considered in cost estimation 3

3.1 Economic costs and effects on the health status

Can be said that in the case of diseases, the main cost is almost always not the economic cost, measured through income lost, but it is the cost in terms of health status which takes into consideration the suffering of the individuals and the life years lost. In the field of social politics, one usually looses sight of the fact that the income is only one means for people to achieve a higher level of well-being, and there are other means and ways to achieve the same objective. Thus, aspects such as the health status and life expectancy are some of the final objectives in this search for well- being.

From this perspective and also considering the difficulty on ethical and technical terms, of measuring the value of a human life, many assessments of efficacy and impact in health are performed not in function of the economic cost but in function of the final goal of improving the health status. To achieve this, the following indicators are commonly used: years of potential life lost (YPLL), disability adjusted life years (DALY), and also healthy life years (HLY), all these indicators allow us to compare the different health strategies or interventions. Thus, the estimations of YPLL and DALYs upon measuring premature death or discapacity produced by non fatal morbidity may lead to the knowledge of the cost-effectiveness levels of the various interventions, which would help an efficient resource allocation.

However, the analysis of economic costs is also relevant. From the estimation of direct and indirect costs, we can obtain indicators such as the cost-benefit ones that establish how profitable an expense in health is from the point of view of its own monetary recovery. Notwithstanding, it must be noted that this type of cost-benefit analysis has problems such as measuring the value of the added life years or days without disease achieved in terms of the enrollment of individuals, thus establishing differences in the value of health for different people. These limitations are better appreciated when extreme cases are observed since, theoretically, diseases that decrease life of the old people (who, generally do not have paid jobs) would not cause indirect costs. Better said, if nothing were spent curing the elderly, there would be no costs.

Based on the study performed, the theoretical development set forth in this report focuses on the economic cost of malaria, including an appraisal of the effects over health.

39. 3.2 Concepts of the economic costs

According to MOH-UNICEF-PAHO/WHO (1996), the economic costs are the “opportunity cost of all the resources used”; that is, what is not bought or done when using the resources. The Centers for Disease Control and Prevention (CDC, 1995) proposes that costs should at least consider the resources spent on the health intervention and the costs saved by the treatment, though they add that it should also include the effects on the productivity and those called “intangible” effects, that is the costs caused by suffering. However, the Basicc method used by CDC does not take them into account.

Drummond et al (1987) classify costs into three types: the health system or direct costs; the costs borne by patients or families that involve payments made, loss in productivity and psychological or cost of suffering; as well as the external costs.

CDC (1995) and Drummond consider that the benefits generated must be discounted from the costs. For Mills (1989), on the other hand, discounting the benefits is optional.

3.2.1 Direct Costs

Direct costs are, on one hand, the costs of surveillance, prevention, diagnosis and cure, including those incurred by the Ministry of Health and ESSALUD; and on the other hand, those incurred by the patient.

MOH and ESSALUD costs (and those of other government buildings), municipalities, non-government organizations (NGOs) and various institutions that subsidize the fight against malaria, all the costs, that is: supplies, personnel who intervene directly, administrative costs and the costs generated by infrastructure (depreciation and financial costs) as well as general services (cleanliness, electricity, etc.)

In regard to the surveillance costs, it must be noted that due to the system’s characteristics, it is not possible to distinguish between the costs for malaria surveillance and the costs for the surveillance of other diseases, or to tell apart

The economic impact of malaria in Peru those elements that correspond to surveillance from those of diagnosis. However, it is possible to recognize costs associated to disease prevalence because if this did not exist, personnel time and equipment of the surveillance system could be less.

Also considered are the costs of prevention (spraying with insecticides, impregnated mosquito nets, etc.), costs of diagnosis (diagnostic consultation, labora-

40. Aspects considered in cost estimation

tory tests, etc.), costs of cure (consultation, medications, hospitalization, etc.) and costs of recovery.

An element not considered in the cost estimation due to difficulties estimating medium and long term consequences of malaria on the health status, such as more predisposition to other diseases and discapacity.

As for the direct costs corresponding to patients, these involve medications, consultations, tests, as well as the cost of traveling (tickets and food, not only for the patient but also for an accompanying family member if required). As for the medications, consultations and tests, we evaluated the possibility of double accounting of costs since they could be considered as patient costs and also as MOH costs. However, this possibility has been discarded since the Ministry of Health gives the required malaria medications free of charge. In these conditions, the expense on medications incurred by families seen by the the MOH would be for analgesics and other medications not specifically required on malaria treatment.

3.2.2 Indirect costs

Indirect costs refer, in general to the opportunity costs, that is, the costs that, even though they do not imply a disbursement of cash, represent a loss of opportunities for production or work, and even the idle time measured in terms of the opportunity cost had they used that time in productive work. In the specific case of malaria, this varies according to the time of the year because the economic effect is higher if the disease affects the working capability in critical times like harvest season.

Indirect costs can be classified according to the reasons why families lose chances of income due to the disease. The first loss of income opportunities is the time ill individuals dedicate to obtain cure. This can be analyzed in terms of duration of the trip to the health center, time spent waiting for consultation, time dedicated by the accompanying person, etc. The family costs for their participation in preventive activities carried out by the community can also be included.

A second loss of income is the days and hours during which the ill individual cannot work or works with less productivity. These days include not only the period of disease but the convalescence because the malaria infected individual recovers gradually. Also considered is the income lost due to death of the individual.

41. 3.2.3 Other indirect costs produced by the effects on the behavior of economic agents

Finally, there are costs caused by the effect produced on other economic agents and that have a repercussion on the economy as a whole. One evident cost, though hard to measure, is the one on tourism because as potential tourists perceive the area as a risk area, the demand for tourist services will decrease. However, some of these people may also change their tourist destination to another area of Peru, in which case, the economic cost would be for the region but none for the country as a whole.

Another cost identified relates to the dynamics of the economic activity. Any time the disease risk is internalized by the economic agents and there is mobility of factors, they will tend to demand higher salaries to make up for the cost the disease has on them. Such behavior applies not only to the hand labor (in this regard, testimonies from the beginning of the century shows that the malaria presence in the coastal ranches generated resistance to work there on behalf of Andean workers (Cueto, 1997), like investments, that due to a higher price for hand labor, confront lower rentability margins. The economic impact of malaria in Peru

42. Methodology used in the economic costs estimation Methodology used in the economic costs estimation of malaria 4.

4.1 Methodological techniques and tools considered

The methodology used combines different tools according to the components of the economic estimation. The chart below is a summary that will be detailed in the following pages.

Chart 1 Methodology to estimate the various components of costs

Costs to Source of Scope of Methods for Possible estimate information Application national estimation bias

DIRECT FROM THE MOH

Supplies Direct collection of Central organisms Directly obtained None information

Personnel at the pri- Survey at health fa- Selected health Unit cost by number Higher cost in low mary health care level cilities facilities of cases prevalence areas

General services at Survey of the health Selected health Unit cost by number Higher cost in low the primary health facilities and data from facilities of cases. prevalence areas care level. the Costs and Income System at Morropon

Hospitalization Direct interview and Piura and Loreto Number of cases in Unregistered cases fees ESSALUD Hospitals the regions by unit in other regions cost

DIRECT FROM OTHER INSTITUTIONS WITH A NATIONAL AND INTERNATIONAL SCOPE

Total cost Direct collection of Central organisms Directly obtained None information

Total cost Direct collection of Organisms identified Directly obtained Possible omission of information in each region organisms in other areas

OF FAMILIES

Treatment Household survey Districts with higher Unit cost per variety Different costs in malaria prevalence by number of cases other areas

Prevention Household survey Districts with higher Unit cost per family Number of families malaria prevalence by number of who perform families in the prevention is regions selected unknown

BY TOURISM

Total Interviews to National and Loreto Total income for Percentage of companies and tourism by estimated loss tourist leaders percentage of estimated loss

Made by: APOYO Institute.

43. 4.1.1 Estimation of the MOH direct institutional costs

The estimation of the direct health service costs provided by the State presents various problems. For Prescott and Warford (1993), these are due to the fact that in the health field, subsidies many times distort or cloud the recognition of the service prices. On the contrary, Drummond et al., (1987) puts the stress on other known problems for cost estimation, such as the need to prorate the shared costs among various services because they think that there are no clear responses, for example, for prorating costs such as general and administrative services.

According to Drummond et al., (1987), there are three methods for the appraisal of health services; identify each supply and factor utilized in each procedure, which becomes highly costly; observe the total costs and divide them between the total number of cases or the procedures; or combine both methods, considering the supplies specifically used and prorating the other costs. The capital costs involve the financial costs or the opportunity to use the money and the depreciation of equipment or infrastructure.

Cohn (1973) adds that supplies must be appraised according to the shadow exchange rate without tariffs and the work must be appraised according to marginal productivity, which would be its shadow price and not according to salaries. In economy, shadow price means the price that would prevail if there were no distortions in the functioning of the free market and would reflect, according to the well-being theory, the social cost for the economy. However, it must be noted that the utilization of shadow prices for the exchange rate or salaries, although theoretically correct from the point of view of the project’s social efficiency, has presented with serious methodological difficulties.

In his study of cost-effectiveness of malaria control programs in the Brazilian Amazon region, Ahkavan (1997) only considers the direct costs, appraising the personnel costs according to their salaries, treatment and hospitalization ac-

The economic impact of malaria in Peru cording to fee for service, in a sensitivity analysis two fees were considered: the fee set forth by the government and the fee established by the physician organization.

This study has distinguished the Ministry of Health costs into supplies, personnel and other general and intermediate services.

44. Methodology used in the economic costs estimation of malaria

As for the cost of supplies directly used in malaria surveillance, prevention, diagnosis and treatment, we compiled data on the expenses of the Basic Health for All Program (PSBT) –that funds the National Malaria Control Pro- gram–, the Basic Health and Nutrition Project (PSNB), the General Office of Epidemiology (OGE), the General Office for Environmental Health, the National Defense Office of the Ministry of Health and the National Institute of Health (INS), who directly buy and send these supplies to the regions where this disease prevails. This information was obtained from central organisms and for the national level.

As for the costs confronted by the primary health facilities with other resources (basically personnel costs, costs for general and intermediate services and infrastructure), the following method was used for the estimation: through field work, we estimated the average time used by physicians and health personnel, as well as the basic services used. The time was broken down according to:

Surveillance: entomological surveillance, surveillance of contacts, record- ing and transmission of information4 among the various institutions performing the surveillance;

Prevention: talks and Information, Education and Communication in general, provision of mosquito nets, setting biological controllers (Bacillus thuringiensis reared in coconut water, larvivores fish), search for patients, spraying with insecticides, drying out reservoirs;

Diagnosis and treatment: consultations, house visits, laboratory tests.

Field work was based on in-depth interviews with the heads of the health facilities, physicians and health personnel, carried out directly by the members of the work team in meetings organized by the regional director’s offices between the May 14th and 17th in Piura and Tumbes, and May 20th and 22nd in Loreto. In these meetings, they also gathered information on other organizations, like municipalities and NGOs that may have expenses in malaria or in looking for alternative control methods based on changes of the environment management to obtain qualitative information on the patterns of service use.

4 Surveillance of cases and treatment resistance would be collected by laboratory test as part of diagnostic testing.

45. Chart 2 Installations taken as samples for service costs

Piura Tumbes Loreto

Hospital De Apoyo III de Sullana H. de Apoyo

Health Centers CLAS Tambo Grande Aguas Verdes San Juan

Querocotillo Zorritos Santo Tomas

Marcavelica Corrales Moronacocha

CLAS Ignacio Escudero Belen

Sta. Teresita 6 de Octubre

CLAS La Huaca

Suyo

La Unión

Salitral

Morropón

Catacaos

Health Posts Mallaritos La Curva Santa Clara

El Obrero Malval

Paccha

Made by: APOYO Institute.

The costs of general and intermediate services, as well as infrastructure costs have been estimated applying ratios obtained for services within the same generic category (consultations, laboratory tests) from the System of Costs and Income (SICI) data base applied in the Morropon service network in Piura (MOH-PSNB, 1999).

The economic impact of malaria in Peru Later, the data was projected at national level under the supposition that the unit cost recorded for the surveyed areas is the same as the ones in the other areas (also included are estimation assuming suppositions through a sensitivity analysis).

Additionally, hospitalization costs have been considered for those cases where the disease worsens. It must be noted that in this case, there is one poten-

46. Methodology used in the economic costs estimation of malaria

tially higher cost since currently, treatment for these cases is rather limited given the little funding available for hospitals and given the conditions of the patients, most patients are poor and have no medical insurance. For the estimation, we opted to multiply the number of hospitalized patients times the average number of days in which the malaria patients are hospitalized in a ward and in the Intensive Care Unit (ICU) and times the value of these services. The number of patients was directly obtained from the Piura and Loreto hospitals, as well as the estimate of the average number of days the patients remain in the ward and in the ICU. In order to appraise these services, ESSALUD fees have been used since its installations are in the same level of complexity and they come closest to the unit cost of this service.

4.1.2 Costs of other institutions: ESSALUD, NGOs and others

There are other institutions that carry out efforts for the control of malaria. Information was also collected from WHO/PAHO and ESSALUD. As for WHO/ PAHO, these are expenses used for this disease. As for ESSALUD, their fee system was used. It establishes budget amounts for the department management offices and hospitals according to the number of cases treated and a reference fee based on cost studies.

In regard to other institutions of local scope, we opted for identifying them in the regional visits. In the northern coastal area, information was gathered about the following NGOs and projects: Vichayal III, Bosque del Norte, Asociación de Desarrollo Comunal (ADEC), Villa Nazaret, IDEAS, CIPCA and PRISMA, as well as about the Provincial municipality of Piura and CTARs Piura and Tumbes. In Loreto, information was gathered about Medicos del Mundo and the Red Cross, as well as about INADE – National Institute for Development. Other institutions like the Provincial municipality of Maynas were investigated without any findings of significant expenses made in relation to malaria.

4.1.3 Direct and indirect costs borne by patients and their families

In order to estimate the costs borne by malaria patients, directly and indirectly, data provided by the affected families was gathered by means of a survey.

47. a) Contents of the house survey

The main information compiled at this level for the economic costs estimation were:

Variety of malaria, number of episodes.

Number of consultations, including up to two alternative sites for consultation.

Length of time for the trip and cost of transportation fare to these two alternative sites of consultation.

If the consultation was made when the ill person was disabled or represented additional time lost.

Persons accompanying the patient to the consultation.

Total time spent in the health facility, including waiting time, consultation, payments, sample taking and collecting medications.

Expenses incurred for the consultations, laboratory tests, and medications.

Days during which the patient was totally and partially disabled.

If during the days of disability, the patient lost a special opportunity to carry out a business and obtain income.

Days and hours dedicated to caring for the patient by the caregiver who cared for him, and if this stopped that person from performing other activities.

Other expenses and time dedicated to prevent the disease, not only in The economic impact of malaria in Peru community but in family activities as well, such as mosquito nets, screens, insecticides and biological controllers, among others.

Additionally, information was gathered to determine the socio-economic profile of the families and patients in the areas selected, in order to break down the costs according to various categories, such as:

48. Methodology used in the economic costs estimation of malaria

Age.

Sex.

Education level.

Mother tongue.

Main occupation of the members.

Housing conditions (water, sewage, electricity, telephone, floors, roofs, walls, number of rooms). b) Sampling for the house survey

According to the background of malaria in Peru, the provinces included in this study have different behaviors in regard to the seasons, high risk places for the transmission of this disease, age distribution and type of Plasmodium in the cases reported. These differences occur, essentially, at regional level, that is between the northern coastal area and the jungle. Since, we originally expected to find similar behaviors between Piura and Tumbes, we opted to consider two strata of research: “Northern Coastal Area” made by Piura and Tumbes and “Jungle” represented by Loreto.

Given the nature of the research, a probabilistic sampling system was used, divided into two stages: 1) selection by cluster criterion (Foci); (2) search for homes with at least one member who had malaria in the last 12 months.

There is some argument in the specialized literature as to whether the use of a house survey is methodologically adequate or not, given the possibility that the disease may not have been identified in the houses. However, Vosti (1990) believes that in spite of the fact that part of the population is migrant and may have less knowledge of the disease, malaria is well identified. For the survey, most of those who suffered from the disease were detected with the aid of the health center or port and the records they keep. The pilot test and the definitive survey found that the homes and the sick individuals do recognize the disease adequately, although under different names; only a small number of individuals was not able to identify the variety of disease they had.

49. Choosing the sample for the application of the house survey was performed in coordination with the VIGIA Project and with the individuals in charge of the Malaria Control Program at departmental level. The departments of Loreto, Piura and Tumbes were designated for the study. The following criteria was used for the selection of the provinces to be evaluated:

Level of Annual Parasite Index (API), defined according to the Ministry of Health as the number of cases reported among the total population.

Evolution of the disease in regard to the year before. Priority was given to the places that showed a higher incidence during the first trimester of 1999.

Socio-economic characteristics of the areas, in order to obtain a sample from places according to the various economic activities, ethnic group (native communities) and access to basic services.

Accessibility to the area.

Inside each district, the selection of localities was carried out in coordination with the health center to identify the most affected areas.

The universe of the study was made up by the houses where at least one of the members had contracted malaria in the last 12 months, period considered as acceptable given the severity of the disease. The key informer was the mother or individual most directly involved in the care of the patient.

Work was carried out in 12 districts that belonged to 9 provinces, performing approximately 30 interviews per locality, with a total of 360 surveys. The economic impact of malaria in Peru

50. Methodology used in the economic costs estimation of malaria

Chart 3 Surveys conducted Department Province District Locality Number Individuals of families registered for surveyed the survey

TambograndeMalingas, El Car- 30 213 bón, Cruzeta

CuramoriNuevo Sta. Rosa, 30 221 Piura Chato Grande, Pozo de los Ra- Piura mos

La Arena13 de Abril, Yapa- 30 177 tera, La Victoria

Sullana BellavistaTupac Amaru 30 208

Morropon SalitralCarrasquillo 32 187

Maynas IquitosSamito 31 189

Alto NanaySanta Maria De 30 190 Nanay

Peruanito, SJ de Loreto TrompeterosTrompeteros, Pu- 30 204 cacuro, Santa Ele- Loreto na, Palmeras

Nueva Esperan- Mariscal Caballocochaza, Sanchez Ce- 30 182 Castilla rro, San Fco de Marichin, San Pe- dro

Alto YurimaguasPampa Hermosa 30 182 Amazonas

Tumbes Tumbes CorralesCorrales, La Gari- 31 198 ta, Malval

Zarumilla Aguas VerdesAguas Verdes, La 30 181 Curva

TOTAL 364 2 332

Source: Survey of malaria affected homes. Made by: APOYO Institute.

51. c) Application of the survey

The questionnaire was validated in a pilot test carried out in 42 families of the three departments and covered the following districts:

Chart 4 Places of application pilot test

Department Province District

Piura Sullana Bellavista Paita Tamarindo Tumbes Zarumilla Aguas Verdes Tumbes La Cruz Loreto Maynas Mazan Iquitos

Made by: APOYO Institute

Emphasis was placed on the assessment of questions that are generally hard to manage, such as income, length of time waiting for medical consultation, appraisal of the prevention mechanisms of the disease. Changes suggested to the initial house questionnaire were made as a consequence of the results obtained.

Surveyors, not only for the pilot test but also for the final field work, were selected in the city of Lima, under the criteria of quality control of the information obtained.

Considering the particular characteristics of the survey, there were surveyors of two levels of specialization:

Surveyors for social projects Professionals with a background in sociology, anthropology and economy, as well as experience in the application of methodological tools in rural areas, specifi- The economic impact of malaria in Peru cally in the malaria study area.

7th year-medical students of the Universidad Peruana Cayetano Heredia With experience in methodological design, systematization of epidemiological information and health administration programs. This preparation makes them qualified to carry out supervision tasks and collection of qualitative information through the application of observation guides.

52. Methodology used in the economic costs estimation of malaria

In regard to the application of the survey, the following activities were also performed:

Systematization of the qualitative information gathered through observation guides in meetings with all the evaluation team to compare results by areas and prepare preliminary conclusions.

Quality control of the information collected. Considering the type of information gathered by the survey, once the field work was finished, they proceeded to clean out and review the surveys. This process was performed with the physical presence of the surveyors.

In order to guarantee the quality of the information, work was carried out in coordination with field supervisors, which allowed for a strict quality control of the data collected. Additionally, an exhaustive desk was performed and it helped to overcome some minor problems in the coding of options on behalf of the evaluators.

Also, an analysis of the data collected by the survey was performed by means of a program especially designed that allowed crossings and pertinent corre- lations. d) Value of time

The methods found by Mills (1989) to appraise the lost days are varied: salaries, average agricultural productivity, elasticity of the product to the work offer, marginal productivity calculated from a Cobb-Douglas production function, income per capita, income per capita adjusted by differences in sex and age, salaries differenced by sex, salaries for employees, 50% of the salaries for those under- employed and zero for unemployed individuals.

This study, due to the rural condition of most of the families affected and the difficulty in collecting information, estimated the cost of lost man-hours utilizing information from Living Standards Measurement Survey (LSMS) (Cuanto S.A., 1997) for similar areas (rural jungle and rural coast) and, according to the age and gender profile. To do this, a estimation of the personal income was performed processing the LSMS database, considering not only the basic income but the complementary income as well and the principal and secondary jobs.

53. Consideration of work and time that are not negotiated in the market, like domestic work and leisure time, is common in specialized literature. McGuire et al, indicate that most of the cost-benefit studies consider the female time according to the extra product the woman would obtain if she worked, valued at market prices and considering it as the opportunity costs. Drummond et al. (1987) propose that leisure time can be valued at price zero, at the price of a similar salary in the market or at the price of the salary for overtime, but that the most common way starts out at zero and performs a sensitivity analysis. This involves carrying out additional estimations, changing the critical parameters within a reasonable margin in which they can change. Bonilla et al., (1991) value all the time, even the time spent at home and on leisure, according to the average productivity of individuals of similar characteristics (income by worker).

The study used the cost by person-hour, even for children, women and other individuals who do not work since this time has a value, estimated according to that cost as a shadow price. An alternative estimation was performed for a sensitivity analysis in which only half of the market salary was considered for this market.

On the other hand is the problem of replacing the sick person’s work by a family member. Najera et al. (1991) indicate that the redistribution of time within the home can be considered in two ways: as an effect that reduces the costs of the disease or simply as a redistribution of the costs. In the study, this aspect has been considered as part of the second case, that is, as a redistribution inside home that does not reduce the costs for it.

Finally, there is the problem of how to add cost variations to the possible estimations of the disease. This occurs when the demand for hand labor and the salaries or shadow prices of the hand labor are higher or lower due to seasonal reasons, such as harvest, planting or others. Konradsen et al., (1997) in a study for Sri Lanka, considered the salary with the higher values in periods of high work demand; the loss of work days is higher during important agricultural seasons and the total annual cost is between 6% and 18% of

The economic impact of malaria in Peru their annual income.

In the study, we opted to consider these effects according to the answers of the patients themselves about whether they had lost an economic opportunity or if they had to face special costs due to these reasons. These losses were valued with a co-efficient of 10%, located within the class found by Konradesen et al., for Sri Lanka.

54. Methodology used in the economic costs estimation of malaria

e) Value of life

As for the costs caused by mortality, we calculated the years of useful productive life lost by mortality on the basis of a maximum productive age of 65 years old and they were valued according to the profile of income by ages obtained from the LSMS. The possible loss due to mortality by other causes was discounted, utilizing the mortality rates for ages in effect from the CELADE- INEI study for 1995-2000. Given the low mortality rate associated to this disease, the surveys do not have enough representativity to show reliable results, opting for the use of the surveillance system records that presumably carry a registry of the deaths by this disease.

The costs of mortality must be temporarily discounted although there is a debate in regard to which rate is applicable for the discount. CDC (1995) uses a 3% discount rate, making sensitivity analysis changing it between 0 and 8%. In a sensitivity analysis, Cohn (1973) uses a discount rate between 6 and 18%, suggesting that the most relevant range is between 10 and 15%. Akhavan (1997) also uses a discount rate of 3% annually. Following international sources in this regard, the future income was discounted according to different rates that range from 1% to 10%, using a rate of 3% as the basis because it is the most widely accepted one. f) Value of suffering

It is proposed that the most adequate appraisal of the cost of disease for the families should be the willingness-to-pay, which is the price the individual or the family would be willing to pay to get rid of the disease (Hammer 1993, McGuire et al 1994 and Prescott and Warford 1993). This data seems more exact than that of the effective cost for families as it involves other disease costs, such as the cost of suffering for the families and it also adds those cases where the families do not spend because they prefer to have the disease instead of spending money. From that point of view, the cost effectively incurred by the families would be a minimum value of the total real cost. A similar estimate that could be the upper limit is the willingness-to-accept (Hammer 1993), also called compensatory variation (McGuire et al), which would be the price a person would charge to agree to having the disease, if he/she could so choose.

In the pilot survey, a question was introduced aimed at capturing this willingness to pay. However, it was found that individuals did not have an adequate response, due to the habit of having free treatment and the difficulty of understand-

55. ing and responding to a hypothetical situation as “if there were an immediate cure…”. Because of this, this type of appraisal had to be left aside.

4.1.4 Estimation of the costs by loss of tourism

In regards to the effects of malaria on other economic activities, Mills (1989) stated that they are left aside by most of the research studies because they are considered untreatable. Mills (1989) only found two studies that explore this topic: one of them uses a macro-economic model through which the disease affects the demographic behavior and this affects the income per capita; and the other study investigates the use of the land, but in his opinion, has little solid evidence.

The study looked for information related to tourism. Interviews with seven tourist companies in Lima and Iquitos were carried out, giving more privilege to the leading companies and to those that sell tourist packages abroad to come to the jungle area. Also, interviews with leaders of the various fields of the sector were performed.

Additionally, official information was obtained on the number of tourists that visited the study sites, as well as on the average amount spent by each tourist in Peru. This last piece of information was obtained from a survey annually performed by the Banco Central de Reserva (BCR) to estimate the income by tourism and that is used as the bases for estimates in this item in the Balance of Payments.

Starting out from this information, we estimated the loss for tourism multiplying the percentage of tourists lost due to this disease times the total number of tourists visiting the site times the average amount spent per tourist, figure that was estimated by the Ministry of Industry and Tourism (MITINCI) and/ or the BCR. Since the first parameter was hard to identify, the results must be inter- preted as proxies, that is simple magnitude orders of what this cost could be achieving. The economic impact of malaria in Peru 4.2 Possible bias and deficiencies in the methodology used

It is necessary to point out that the methodology inevitably has weaknesses and imperfections that need to be evaluated to find out the possible bias the information may have.

56. Methodology used in the economic costs estimation of malaria

The main bias and deficiencies may be associated to the following considerations:

The estimated cost is an approximation to the cost the country actually had in 1998 and does not take into account approximations of the counter-factual type, that is, of how much the cost would be if no malaria control actions had been performed.

Stated above, the survey of houses and search for information in other public and private institutions was performed in the areas with the highest malaria incidence and with this baseline, we estimated the total economic costs in these areas and also an average unit cost per case. With these data, we extrapolated the cost of malaria at national level over the basis of the total number of existing cases. However, it is possible that elements such as the severity of the disease and use of services may not be similar in the areas with the highest incidence and those with less number of cases. Presumably, in areas with extensive malaria presence, the population has higher levels of immunization and deeper knowledge of the disease, which probably reduces its costs.

Unit costs for personnel and health care services were estimated based on the health facilities in those regions most severely affected by malaria. Other regions are likely to have higher costs due to the lower prevalence and displacement of the population. It must be highlighted that this bias is opposite to the one before, which may decrease the total bias.

It was not possible to quantify other possible economic effects of the disease over productive activities due to the difficulty in the estimation. We measured the direct effects of malaria on the group of productive activities due to man- hours lost. However, issues such as the possible reduction of investment or effects on transportation and commerce caused by changes on the behavior of the economic agents (investors decide not to go ahead with their investment because of malaria or commerce does not happen and thus, affects other activities) require too much information that is hard to correct and quantify, thus not making a reliable estimation.

It is possible for a malaria consequence to increase the probability of having other diseases in later years, even when the patient has been cured of malaria. This would, in turn, have direct and indirect costs not taken into consideration by the study.

One must take into consideration that we made a estimation of the cost the disease actually has, but it is possible for there to be an important degree of

57. uncovered needs due to the deficiency of the supply side, particularly in regard to complex care. This is a “hidden” cost of the disease that must appear as the perception of the need by the ill people increase and as the availability of the offer increases in regard to these health problems.

The possible effects of the confluence of the disease seasonality and the seasonality of the requirements for hand labor for agricultural production and other activities are approximate figures supposing coefficients of higher loss given the difficulty to estimate different shadow salaries in different periods of the agricultural productive process. The economic impact of malaria in Peru

58. The economic cost of malaria in Peru

The economic cost of malaria in Peru 5

5.1 The cost of malaria in Peru in 1998

5.1.1 The total cost of malaria in Peru

The total cost of malaria in Peru for 1998 has been estimated at 37,85 US million dollars. Chart 5 Summary of the Malaria costs (in US dollars)

Concept Unit of Total Composition Source information dollars

MINISTRY OF HEALTH 9,254,199 24% Supplies National 5,068,325 13% Personnel in the first level Case 2,620,196 7 % Text General services in the first level Ratio 1/ 1,248,735, 3% Hospitalization National 221,562 1 % Chart 9 Administrative expenses at DISAs National 95,379 0 % Chart 10 OTHER INSTITUTIONS National 1,188,980 3 % Chart 11 FAMILIES 26,731,174, 71% For Prevention House 5,775,560 15% Chart 12 For Treatment Case 20,100,371 53% Chart 13 For Mortality Total 855,242 2 % TOURISM National 682,055,74 2 % Text TOTAL AMOUNT National 37,856,409,57

Source: All the sources consulted to make the study. Made by: APOYO Institute

The total cost for the Ministry of Health is 9,25 million dollars, which represents 24% of the total national cost. Other institutions (ESSALUD, CTARs,* etc.) provide an additional 1,19 million dollars, thus making a total of 10,45 million dollars for institutional costs. Most of the national cost, however, comes from the families for whom the cost of malaria is as high as 26,73 million dollars, 71% of the total.5 A relatively small cost has been estimated from the effects on tourism, and it is 0,68 million dollars.

5 Given the great importance of this component, it will be analyzed in detail in Chapter 5.2 of this report. * CTAR: Consejo Transitorio de Administración Regional (Transitory Council Boards of Regional Administration).

59. As observed, the relationship between the institutional spending and the expense for society is quite uneven. The State and in lesser degree, some other organizations of the civil society, spend close to one third of what malaria costs the rest of the society, the individuals and families and the economic activity. Unable to establish a concluding causality in this regard, this would suggest a weakness on behalf of these organizations in adequately perceiving the interests of society. This is a problem of the public good identified in the economic theory; if there is no market mechanism to channel the demand, this must be expressed through collective forms that have a cost of organization. There is also the problem of the free rider, there are no incentives to the individual participation because this has costs whereas the benefits are public, that is not excluding. In the case of malaria, these problems, probably worsen due to the isolation and dispersion of the principal individuals affected, as well as to their lack of knowledge of the existing possibilities to reinforce the struggle to control the disease.

5.1.2 The Ministry of Health Costs

The study has established differences in the Ministry of Health costs between supplies (goods and services) and transferences sent from the central level specifically for malaria, personnel expenses and other expenses for general and intermediate services, as well as administration.

As for the resources specifically sent for malaria control from the central level, information was gathered about expenses made by the various programs and projects, which added to 5,07 million dollars for 1998. (See Chart 6). The economic impact of malaria in Peru

60. The economic cost of malaria in Peru

Chart 6 Resources sent from Lima for the struggle against malaria 1998 (in US dollars)

PIURA TUMBES \1 LORETO NO DISTRI- TOTAL COMPO- BUTABLE SITION

MOH 1,455,752,20 487,221,09 1,695,006,60 1,372,803,60 5,010,783,30 99% Malaria Program 710,598,03 218,987,96 1,242,742,70 2,172,360,40 43% Malaria Program \2 0037,531,52 37,531,52 1 % PSNB 2,092,81 2,092,81 0 % OGE \3 277,237,56 52,413,68 178,905,92 508,557,17 10% DIGESA 21,843,52 1,240,871,70 1,262,715,20 25% NIH 14,317,07 17,308,20 32,366,49 131,931,89 195,923,66 4 % National Defense 451,506,49 176,667,72 203,459,93 831,634,14 16% OTHERS 0 0 0 57,541,97 57,541,97 1% PAHO 29,699,08 29,699,08 0,5% WHO 27,842,89 27 842,89 0,5%

TOTAL 1 455 752,20 487 221,09 1 695 006,60 1 430 345,50 5 068 325,30 100%

COMPOSITION 4/ 000

1\ According to the report from the DISA Tumbes, funding from the National Source: MOH and PAHO. Defense was 376,526,13 dollars; the datum consignated was supplied by Made by: APOYO Institute the Office of National Defense in Lima. 2\ Donation from the European Community. 3\ The expenses of OGE for Piura & Loreto have been estimated. 4\ Excluding the non distributable.

The main sources of these resources are the Program for the Control of malaria and Other Arthropod Borne Diseases, the General Office of Epidemiology (OGE), the General Direction of Environmental Health (DIGESA) and the Office of Na- tional Defense of MOH. These four organisms account for 94% of the funding destined from the central level for the fight against malaria.

The support of external financing sources through the MOH is quite limited. Infor- mation was obtained from PAHO-WHO and Basic Health and Nutrition Project, (PSNB) the latter financed principally6 by the World Bank. Both organisms to- gether do not even reach 2% of the funding for malaria control, adding to fewer than 57,000 US dollars.

6 Not exclusively since it has a counter fund from the National Treasury.

61. According to the information obtained, these resources were practically intended for Loreto and the northern coast (Piura y Tumbes) in equal amounts, although during 1998, there was a higher incidence of malaria in the northern coastal area (93,000 cases versus 54,000 in Loreto), particularly of the malignant variety or falciparum of severe consequences to the health (47,000 versus 22,000 cases in Loreto). Since the evolution of the malaria epidemic in 1998 in these areas depends as much on natural environmental conditions (especially the El Niño phenomenon) as on the control actions carried out, it is not possible to conclude that there is an incorrect or unequal distribution of resources as it is possible that the lesser incidence of malaria in Loreto is due to the transference of funding.

On the other hand, the difference in the resources sent to Piura and Tumbes may be revealing the greater importance awarded by the authorities to the malignant variety of malaria. In fact, almost four times the amount of funding sent to Tumbes was sent to Piura, in spite of the total number of malaria cases which is only 58% higher. However, the concentration of cases of malignant malaria is indeed much higher in Piura than in Tumbes (almost six times more cases).

The various activities where malaria control funding can be assigned have been identified for two thirds of this funding (See Chart 7). Of this, a little less than 20% is dedicated to surveillance and almost one third to prevention. The rest (49%) is oriented at detection and treatment of cases. Surveillance and prevention are assigned relatively more funding in the northern coastal area than in Loreto.

On the other hand is the cost faced by primary health facilities for personnel and services funded with other resources, mainly the regional budgets and the Basic Health for All Program (PSBT). In this regard, the costs for personnel and general and intermediate services have been estimated without taken into consideration the costs of capital (infrastructure and equipment) given the difficulties met in their estimation. The economic impact of malaria in Peru

62. The economic cost of malaria in Peru

Chart 7 Resources sent from Lima for the struggle against malaria 1998 (in US dollars)

INVESTIGATION PREVEN- DETECTION TREAT- NON TOTAL AND TION MENT DISTRI- SURVEILLANCE BUTABLE

PIURA

MOH 331,876,78 436,000,95 360,619,25 61,012,67 266,242,63 1,455,752,20 Malaria Program \1 88,835,92 360,480,20 58,919,86 202,362,36 710,598,03 Malaria Program \2 PSNB 2,092,81 2,092,81 OGE \3 277,237,56 277,237,56 DIGESA INS 14,178,02 139,06 14,317,07 National Defense 40,461,19 347,165,03 63,880,27 451,506,49 OTHERS PAHO WHO

TOTAL 331 876,78 436 000,95 360 619,25 61 012,67 266 242,63 1 455 752,20

TUMBES

MOH 82,404,18 193,350,01 115,138,73 4,184,99 92,143,17 487,221,09 Malaria Program \1 50,936,33 112,008,55 4,184,99 51,858,09 218,987,96 Malaria Program \2 PSNB OGE 52,413,68 52,413,68 DIGESA 21,843,52 21,843,52 INS 14.178,02 3,130,19 17,308,20 National Defense 15,812,48 142,413,68 18,441,56 176,667,72 OTHERS PAHO WHO

TOTAL 82 404,18 193 350,01 115 138,73 4 184,99 92 143,17 487 221,09

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63. Continue from page 63

INVESTIGATION PREVEN- DETECTION TREAT- NON TOTAL AND TION MENT DISTRI- SURVEILLANCE BUTABLE

LORETO

MOH 215,934,74 309,413,05 595,264,17 352,051,31 222,343,68 1,695,006,90 Malaria Program \1 134,028,82 584,164,39 352,051,31 172,498,25 1,242,742,70 Malaria Program \2 37,531,52 37,531,52 PSNB OGE \3 178,905,92 178,905,92 DIGESA INS 21,267,03 11,099,78 32,366,80 National Defense 15,761,80 137,852,70 49,845,42 203,459,93 OTHERS PAHO WHO

TOTAL 215 934,74 309 413,05 595 264,17 352 051,31 222 343,68 1 695 006,90

NON DISTRIBUTABLE BY DEPARTMENTS

MOH 131,931,26 1,240,871,70 1,372,802,90 Malaria Program \1 Malaria Program \2 PSNB OGE DIGESA 1,240,871,70 1,240,871,70 INS 131,931,26 131,931,26 National Defense OTHERS 57,541,97 58,916,69

The economic impact of malaria in Peru PAHO 29,699,08 30,408,62 WHO 27,842,89 28,508,08

TOTAL 57 541,97 1 431 719,60

Continue in page 65

64. The economic cost of malaria in Peru

Continue from page 64

INVESTIGATION PREVEN- DETECTION TREAT- NON TOTAL AND TION MENT DISTRI- SURVEILLANCE BUTABLE

TOTAL

MOH 630,215,71 938,764,01 1,202,953,40 417,248,97 1,821,601,20 5,010,783,30 Malaria Program \1 273,801,07 1,056,653,10 415,156,16 426,718,72 2,172,329,10 Malaria Program \2 37,531,52 37,531,52 PSNB 2,092,81 2,092,81 OGE \3 508,557,17 508,557,17 DIGESA 1,262,715,20 1,262.752,20 INS 49,623,06 146,300,28 195,923,66 National Defense 72,035,48 627,431,42 132,167,24 831,449,78 OTHERS 57,541,97 57,541,97 PAHO 29,699,08 29,699,08 WHO 27,842,89 27,842,89

TOTAL 630 215,71 996 305,98 1 202 953,40 417 248,97 1 821 601,20 5 068 325,30

PERCENTAGES

M O H 12 19 24 8 36 99 Malaria Program \1 5218843 Malaria Program \2 11 PSNB 0 0 OGE \3 10 10 DIGESA 25 25 INS 1 3 4 National Defense 1 12 3 16 OTHERS 1 1 PAHO 1 1 WHO 1 1

TOTAL 12 20 24 8 36 100

1\ The financial resources appearing as non distributable are Source: MOH and PAHO units. intended not only to prevention actions (fumigation and others) but also for transportation for the house visits). Made by: APOYO Institute. 2\ Donation from the European Community. 3\ OGE expenses for Piura and Loreto have been estimated.

65. The personnel cost has been found to be an average of 12,35 dollars per case of malaria (See Chart 8). Unit costs seem lower in Loreto than in the northern coast due to a different composition of the personnel, since in the jungle, sanitary technicians and nurses are predominant, whereas in the northern coast, there is a larger proportion of physicians. The larger coverage of health facilities in the northern coastal area also plays a role in this regard.

Chart 8 Costs for services per case of malaria (in US dollars)

Personnel Cost Cases Unit cost

Piura I 265 453,91 14 587 18,05 Tumbes 71 304,09 9 310 7,60 Loreto 95 853,66 11 203 8,55 TOTAL 432 611,65 35 100 12,35

SICI-Chulucanas Personnel 21 529,93 4 819 4,43 Services 10 260,69 Total 31 790,62 4 819 6,65 Ratio 48%

Source: Survey of the Heads of facilities. Made by: APOYO Institute.

At national level, the personnel costs would represent 2,63 million dollars. Also inferred are the costs for general and intermediate services from the information in the System of Costs and Income (SICI) applied to a network of primary installations in the Morropon-Chulucanas network. The average ratio between the cost of these services and the personnel cost for malaria care was obtained

The economic impact of malaria in Peru and this allowed us to calculate that this cost went up to almost 1,27 million dollars in 1998.

Additionally, there are hospitalization costs for those who developed complications of the disease. A total of 241 hospitalizations were found in the hospitals in Piura and Iquitos during 1998, estimating a cost of 180,000 dollars. Since these departments concentrate 82% of the falciparum malaria cases at national

66. The economic cost of malaria in Peru

level that is the type of malaria that tends to generate complications and risk of death, the projected cost of hospitalizations due to malaria at national level is close to 221 562,24 dollars in 1998.

Chart 9 Costs of hospitalization due to malaria (in US dollars)

PIURA LORETO AMOUNT NATIONAL

NORMAL 13 769,40 15 561,61 29 331,01 N° of cases 63 178 241 297 Days of hospitalization 5 2 Cost by day 43,71 43,71

HOSPITALIZATION IN INTENSIVE CARE UNITS 24 652,28 121 758,31 146 383,59 N° of cases 63 178 241 Days of hospitalization 2 4 Cost per day 195,44 195,44

HOSPITALIZATION IN THE EMERGENCY WARD 4 198,29 - 4 198,29 N° of cases 141 - 141 Cost per emergency 29,7

TOTAL COST 42 592,97 137 319,92 179 912,89 221 562,24

Memo: Falciparum cases 40 216 22 355 62 571 77 056

Source: Interview to hospitals. Made by: APOYO Institute

Finally, the figure calculated for the cost of administration directly related to malaria, figure which is handled by the National Malaria Control Program in the health regions and offices of epidemiology is 95,026 dollars yearly.

As a total, 5 out of the 9,25 million dollars that malaria costs the Ministry of Health are financed in a specific form by the central level and an additional 4,18 million dollars are financed through production factors oriented at the general functioning of the health services. This is relevant because these 4,18 millions of personnel costs and services are generally “hidden” and do not appear in the budget formulations and in the economic analyses carried out in that regard.

67. Chart 10 Administrative expenses of the regional health offices in the fight against malaria (in US dollars)

Malaria General Office of Epidemiology Control Expenses of Malaria Other Percentage Estimated Program and the Epidemio- notifica- notifica- of malaria amount spent OEM logy Offices tions tions notifications on malaria

Piura 60 749,45 42 539,12 57 492 5 073 92% 39 089,96 Tumbes 6 477,04 10 940,45 36 325 1 244 97% 10 578,08 Loreto 16 980,36 17 815,01 54 315 3 309 94% 16 791,89 TOTAL 84 206,84 71 294,58 148 132 9 626 94% 66 459,93 NATIONAL 212 590 95 379,47

Source: Regional Health Offices their own estimates. Made by: APOYO Institute

5.1.3 Costs of other institutions

In the departments of Tumbes, Piura and Loreto, we identified various institutions that supplied resources for the fight against malaria. The total contribution of these institutions for 1998 was 1,19 million dollars, most of which (57%) was dedicated to prevention and the rest to surveillance and treatment. (See Chart 11).

Among these institutions, the participation of the Municipality of Piura needs to be highlighted. Last year, this institution provided half of the funding dedicated by institutions other than the MOH for the fight against malaria. The economic impact of malaria in Peru

68. The economic cost of malaria in Peru

Chart 11 Expenses of other institutions to fight malaria in Piura, Tumbes y Loreto, 1998 (in US dollars)

Surveillance Prevention Detection Treatment Total

PIURA 200 242,31 609 613,24 3 680,71 245 045,29 1 058 581,50 ESSALUD 42 592,97 42 592,97 CTAR 158 378,20 158 378,20 NGOs 41 864,11 13 921,44 3 680,71 4 176,12 63 642,38 Municipal gov. 595 691,79 595 691,79 Community 198 276,21 198 276,21

TUMBES 0 19 490,02 2 850,81 5 796,64 28 137,47 ESSALUD 2 850,81 5 796,64 8 647,45 CTAR 19 490,02 19 490,02 Municipal gov. 0

LORETO 0 81 980,99 10 361,10 9 918,91 102 261,00 ESSALUD 334,49 10 361,10 9 918,91 20 614,51 CTAR 0 NGOs 0 INADE 63 469,75 63 469,75 Red Cross 18 176,75 18 176,75 Municipal gov. 0

TOTAL 200 242,31 711 084,25 16 892,62 260 760,84 1 188 980,00

Source: Interviews to institutions identified by the DISAs. Made by: APOYO Institute.

5.1.4 Total costs for families in prevention

The survey demonstrated that there is a relatively important cost for families for malaria prevention, particularly in the Department of Piura. It must be noted that this cost includes not only the monetary expenses incurred by the families but the appraisal of time spent on these prevention activities.

Families spend an average of 48 dollars yearly in prevention. This figure includes community activities such as drying out puddles and family activities, such as placing mosquito nets. This cost ranges from 77,4 dollars per home in Piura and 8,7 dollars per home in Tumbes (See Chart 12).

69. In all, it has been estimated that these malaria prevention activities cost families about 5.7 million dollars yearly.

Chart 12 Malaria cost for families in prevention (in US dollars)

Average cost Rural Individuals Number of Total per home population per home homes Cost

Loreto 14,56 333 348 6,3 53 153 773 974,02 Piura 77,40 425 290 6,6 64 259 4 973 385,80 Tumbes 8,69 20 173 6,2 3 247 28 200,82 TOTAL 47,86 778 811 120 658 5 775 560,60

Source: Survey of homes. Made by: APOYO Institute

5.1.5 Total cost for families for treatment

The survey found that an average of 94,55 dollars is spent by the families per malaria case (See Chart 13). This cost ranges from 84,19 dollars per case of vivax malaria to 112,77 dollars per case of falciparum malaria. As indicated above, this figure includes not only expenses, such as time lost due to incapability or due to attendance to consultations by the patient and accompanying party. Projecting these values toward the whole of Peru according to the number of cases reported in 1998 which is 212,590, the total cost estimated by families at national level is 19,95 million dollars. The economic impact of malaria in Peru

70. The economic cost of malaria in Peru

Chart 13 Malaria costs for families in treatment (in US dollars)

Cost per case Number of cases Total Cost

CALCULATIONS BY VARIETY Vivax 84,19 135 534 11 411 129,87 Falciparum 112,77 77 056 8 689 241,68 National 94,55 212 590 20 100 371,56

CALCULATIONS BY DEPARTMENT Loreto 98,57 54 315 5 354 079,19 Piura 88,03 57 492 5 060 825,78 Tumbes 96,01 36 325 3 487 522,33 3 Departments 93,85 148 132 13 902 426,99 National 93,85 212 590 19 951 914,48

Source: Survey of homes. Made by: APOYO Institute.

Some factors that could influence these estimations are, first, the regional differences. The average cost for families for each malaria episode is highly similar in the surveyed regions: 98,57 dollars in Loreto, 88,03 in Piura and 96,01 in Tumbes. The estimations performed with these department average values instead of the average cost by malaria variety yields total values that are very similar.

In the second place is the estimation due to “mild disability”. This study has appraised that loss, considering that the person works at half his/her capacity. This factor represents an average cost of 13,62 dollars per case, equivalent to 14,5% of the cost for families. If we alternatively suppose that, when the person has a “mild incapacity”, he/she only loses one third of its productive capacity and keeps two thirds, the total average cost for the families would decrease from 94,39 to 89,96 dollars, and the national estimated cost would be 0,79 million dollars less. If, on the contrary, individuals are considered “slightly disabled”, they do not lose half but two thirds of their work capabilities, then, the national total cost due to malaria should be increased in 0,79 million dollars.

71. In regards to the appraisal of time of those who do not participate in the work market or in productive activities, the total cost for time lost is only 12,7% for children from 6 to 15 and individuals over 65 years old. The appraisal of time at half the market salary would reduce the cost in 6,3%, that is, in 1,27 million dollars.

For those who declared occupations that are not valued in the market, the study established a value for their time that was equivalent to the salary they would get in the market. Under this estimation, housewives contributed with 36% of the time lost, students contributed with 11% of this cost and the unemployed with 0,2%. An appraisal at half the market salary for these occupations would reduce the estimation of the malaria cost in 4,75 million dollars. How- ever, various studies have established that in the rural areas, even women who state they are housewives participate in productive tasks because there is no clear difference between production tasks and consumption tasks. Thus, the woman participates in animal care, in agricultural activity when more hand labor is required (times of planting and harvesting), in artisan craft activities and activities of transformation, among others. Supposing that those who declare to be housewives have a shadow hand labor cost of 75% of the market salary and the students and the unemployed only have half of the salary as the shadow price for their time, the cost of malaria would be less than the cost of 2,95 million dollars.

Finally, the estimation also includes an additional cost of 10% over the time lost for those individuals who indicated that the disease had represented the loss of a special opportunity to obtain income, for example, during harvest or planting times. However, that loss only represents 1,4% of the value of time lost for the families because of malaria (See Chart 17), in view of the fact that only 10% of the ill patients indicated that they had registered that type of problem. Given the scarce magnitude of this phenomenon, even if it were not included in the estimations or if it was assumed that the loss was a higher proportion than the lost salaries, results would not be substantially modified. The economic impact of malaria in Peru

72. The economic cost of malaria in Peru

5.1.6 Mortality costs

As indicated, the mortality cost was valued through the estimated future flow of income that these individuals would have, discounting the present value. In- come was calculated by the LSMS (Living Standards Measurement Survey) by region and age range, with a limit of productive age at 65 years old. It is not redundant to restate the limitations of this method to value life, according to which, life of the elderly and poor has a lower value. This is really a method that only considers the value of individuals as a production factor, and not like a value in itself, and conceives the production of goods as the final goal. However, other methods to appraise human life are quite complex and equally arguable and there are no estimates for Peru.

The possible deaths due to other causes have been discounted. In 1998, 43 deaths due to malaria were recorded and these deaths, by a rate of 3% of annual discount, yield a total value of 0,85 million dollars. That is, an average of 19,640 dollars per person. However, there are 8 deaths recorded in individuals older than 65 years of age, whose value has been set at zero. Not including this last group, the estimated unit value for life lost is 24,390 dollars. About two thirds (65%) of this value lost to mortality occurs in the jungle, where a higher mortality toll is recorded (34 out of the 43 general cases and 27 out of 35 who were not elderly individuals).

If a discount rate of 12% is used, the value of lives lost to malaria would be 0,38 millions; and if the discount rate used is 6%, the value would be 0,57 million dollars.

5.1.7 Costs for loss of tourism

The number of tourists arriving in Loreto, Piura and Tumbes was registered as 46,903; 5,712; and 4,126, respectively. The Central Reserve Bank calculates that foreign tourists spend an average of 1,400 dollars during their stay in Peru, figure that has been considered for the estimation of tourism in the study sites since there are no other estimates that are more accurate. From the above data, the total income by foreign tourism in the departments mentioned above is around 79 million dollars. It must be highlighted that, in general, the tour operators consider that the effect of malaria on international tourism is none.

73. In-depth interviews were carried out with various tour operators and represen- tatives of the various companies in that field and we identified that the first tourist destination where malaria is, (the jungle) is part of adventure tourism or done by individuals willing to take risks, independently of the disease. Also, we found out that the serious touristic agents are prepared with chemoprophy- laxis and mosquito repellents in general. However, we were not able to find out about the number of tourists who fail to come because of the disease since there is a potential, unregistered demand for tourism through various mechanisms of information (internet, direct versions, tour companies abroad, etc.) –through which these individuals find out about the disease and decide against coming to Peru– decisions that are not recorded.

However, supposing that the rate of tourists who decide against coming to Peru due to malaria is 1% of those who arrive in Loreto and 0,5% of the ones arriving at the northern coast, the resulting cost of malaria is 725,000 dollars for 1998. If the effect were five times higher, that is 5% in Loreto and 2,5% in the northern coast, the total cost would be 3,6 million dollars.

5.1.8 The fiscal costs of malaria

An approximation of the total fiscal cost of malaria was also performed. In this case, not only the requirements on the public budget for malaria control, but also the lower income received by the government due to the decreased economic activity, as a consequence of the disease.

In order to calculate the loss of tax income, we have considered that the families decrease their consumption due to the malaria cost and this affects the income through the Value Added Tax (VAT) in the proportion of goods and services subject to this rate. Also, for the case of tourism, a global rate of 10% over the net income has been considered and this includes not only VAT but income tax and other taxes.

Chart 14 presents the total estimated fiscal costs and these are 11,15 million dollars. Most of it (85%) is observed to be due to budget funding allocated to

The economic impact of malaria in Peru the disease and the cost of loss of tax collection is relatively low. This is due to the fact that the families where malaria prevails are rural and poor, whose highest consumption item is food and who do not pay taxes.

74. The economic cost of malaria in Peru

Chart 14 Fiscal cost of malaria (in US dollars)

Costs

EXPENSES 9 499 537 Ministry of Health 9 254 199 Other public institutions 1/ 241 338

INCOME 1 656 037 Less VAT due to economic loss by families 2/ 1 587 832 Less VAT and income from tourism 3/ 68 205

TOTAL 11 151 574

1/ Municipalities are not included Source: MOH facilities. 2/ VAT is assumed to apply to the family expenses, except for food and education Made by: APOYO Institute. 3/ A total rate of 10% is calculated over the sales for tourism

5.1.9 Malaria costs in regard to the Gross Domestic Product (GDP) and by economic activity

In regard to the national GDP, the total costs of malaria calculated are only 0,07 %. However, in regard to the GDP of the departments analyzed where malaria con- centrates, the rate is 0,6%.

Chart 15 shows an approximation to the economic activities affected and what is the proportion in which these activities have been affected. This chart only includes malaria costs for the patients’ lost time since the expenses of the Ministry of Health and other institutions do not reduce the GDP. Indeed, the estimation does not consider the time lost by students, housewives and non-economically active individuals either, whose value is not included in the GDP according to the United Nations methodology on domestic accounts.

75. Chart 15 Costs by economic activities and GDP (in millions of US dollars)

GROSS AGRICULT. FISHING MINING MANUFAC- CONS- COMMERCE, RENTING GOVERNM. OTHER DOMESTIC HUNTING TURE TRUCTION RESTAUR. HOMES SERVICE SERVI- PRODUCT & HOTELS PRODUCERS CES SILVICULT.

Loreto

Losses 5,70 4,43 0,63 0 0 0 0 0 0,32 0

GDP 1 917,64 101,36 7,92 202,09 169,78 438,07 294,90 6,65 132,72 853,66

Losses /GDP 0,3% 4,3% 9,9% 0,0% 0,0% 0,0% 0,0% 0,0% 0,3% 0,0%

Piura

Losses 4,75 3,48 0 0 0 0 0,63 0 0 0,32

GDP 2 044,03 179,28 108,33 137,16 466,27 291,42 520,75 5,70 147,93 348,43

Losses /GDP 0,2% 2,0% 0,0% 0,0% 0,0% 0,0% 0,1% 0,0% 0,1% 0,1%

Tumbes

Losses 2,53 0,63 0 0 0 0 0,95 0 0,32 0,32

GDP 206,21 11,09 17,42 0 23,76 17,10 46,88 0,32 22,81 82,67

Losses /GDP 1,3% 5,9% 0,3% 0,0% 0,0% 0,3% 2,1% 0,0% 2,0% 0,5%

TOTAL

Losses 12,99 8,55 0,95 0 0 0,32 1,58 0 0,95 0,95

GDP 4 167,88 291,73 133,67 339,25 659,80 746,59 862,53 12,67 303,14 1 284,76 Losses/GDP 0,3% 3,0% 0,6% 0,0% 0,0% 0,0% 0,2% 0,0% 0,3% 0,1%

Made by: APOYO Institute.

As shown by the Chart, two thirds of the losses for economic activities estimated are centered on agriculture. Although the effect on the whole GDP in these departments is not very large, there are economic activities such as

The economic impact of malaria in Peru agriculture that accumulate an average loss of 3% for the three departments, that becomes 4% for Loreto and 6% for Tumbes. The other economic activities affected, though in a lesser degree, are fishing, government services and commerce.

76. The economic cost of malaria in Peru

5.2 The cost of malaria for families

The economic cost of malaria has been analyzed from a macro-economic point of view, observing its effects on the internal revenue and on the economic activities. The effects on families are shown below.

In this regard, it is important to indicate that many families register more than one case. This happens because many people get sick or because those who got sick had several episodes. In the areas surveyed, the average was 2,6 sick individuals per house and the average number of episodes per sick individual was 1,9. These data reveal that the home confronts an average of almost five episodes of malaria a year, which increases to over 7 in Loreto. There are no major differences in the number of episodes who had vivax and those who had falciparum, though there were differences among the regions.

Chart 16 shows the information on the malaria cost for families. As observed, the annual average cost is 495,41 dollars per family, which in Loreto is as high as 742,79 dollars whereas in the North coast, it is approximately 316,76 dollars. These regional differences are mainly explained by the larger number of cases per family in the jungle, since as seen in the preceding pages, the costs per each episode are very similar in both areas.

77. Chart 16 Total cost of malaria for surveyed houses (in US dollars)

Department Data Total Percentage Per house

LORETO Total family expenditure in malaria 112 156,16 100% 742,79 Cost for prevention 2 198,61 2 % 14,57 Cost for loss of time 100 136,20 89% 663,29 Money spent in treatment 9 821,35 9 % 64,94

PIURA Total family expenditure in malaria 47 085,85 100% 309,79 Cost for prevention 11 764,02 25% 77,29 Cost for loss of time 32 953,44 70% 216,66 Money spent in treatment 2 368,39 5 % 15,52

TUMBES Total family expenditure in malaria 21 116,57 100% 346,21 Cost for prevention 529,62 3 % 8,55 Cost for loss of time 18 639,53 88% 305,67 Money spent in treatment 1 947,42 9 % 31,99

TOTAL Total family expenditure in malaria 180 358,57 100% 495,41 Cost for prevention 14 492,24 8 % 39,91 Cost for time lost 151 729,17 84% 416,85 Money spent in treatment 14 137,16 8 % 38,96

Source: APOYO Institute

In the rural jungle, close to 70% of the population is poor, which means that they have income under 2,375,67 dollars a year for an average family of 6 members. The average income for the whole rural jungle population is 1,932,21 dollars a year.7 This allows us to realize that in Loreto, malaria may represent a cost that equals one third of the total income. However, it is possible that given

The economic impact of malaria in Peru the familiarity of the disease in endemic areas and because most of the cost is due to time lost (which, in general, is supplied by other family members or by the ill individuals themselves once they heal), the magnitude of the expense is not completely perceived.

7 These reference data of the income of the rural population comes the LSMS. The same source is used for the rural coastal area in this section.

78. The economic cost of malaria in Peru

In the rural coast, the average income is slightly higher, around 2,597,40 dollars annually; thus, the effects of malaria represent 12% of the average income.

Eighty-four percent of the costs for families are due to time lost, 8% to payments made in regard to the malaria episode and another 8% for prevention. Differences are found in this regard, among the regions: in Piura, prevention activities made by the families and communities are more important for the cost, 25%, whereas the costs for loss of time are lower.

Within the cost for time lost, most of it is due to the cost due to incapacitation (52%) and care for the ill (42%), and the time spent in going to the health installation and being treated there only an average of 5% (See Chart 17).

As for the cost of incapacitation, 93% of the ill individuals stated having been completely incapacitated for some days; the average number was 7,2 days. However, it is interesting to highlight that 45% of the cases were completely incapacitated for 4 days or less, but an important 14% were incapacitated over 14 days in total. Those individuals of productive age, indicated that they were incapacitated for longer periods than the children or elderly. Additionally, 85% of the ill individuals indicated that they were slightly incapacitated for an average of 6,8 days, though this was also higher between 26 and 65 years of age. Less than 20% of those incapacitated and who had an economically productive activity was replaced by a family member. This replacement is more frequent in the jungle.

79. Chart 17 Cost for time lost for the families (in US dollars)

Department Data Total Percentage Per family

LORETO Total expenditure for time lost 100 135,88 100,0% 663,29 Time spent traveling 2 375,67 2,4% 15,84 Time spent waiting for and in medical care 1 857,78 1,9% 12,35 Time spent caring for the sick 50 974,34 50,9% 337,66 Time lost due to incapacitation 43 319,29 43,3% 286,98 Time lost due to incapacitation 1 608,49 1,6% 10,77

PIURA Total expenditure for time lost 32 953,12 100,0% 216,66 Time spent traveling 547,04 1,7% 3,48 Time spent waiting for and in medical care 1 685,46 5,1% 11,09 Time spent caring for the sick 5 074,75 15,4% 33,26 Time lost due to incapacitation 25 243,27 76,6% 165,98 Time lost due to incapacitation 402,60 1,2% 2,53

TUMBES Total expenditure for time lost 18 639,53 100,0% 305,67 Time spent traveling 159,33 0,9% 2,53 Time spent waiting for and in medical care 558,12 3,0% 9,19 Time spent caring for the sick 7 298,38 39,2% 119,73 Time lost due to incapacitation 10 467,53 56,2% 171,68 Time lost due to incapacitation 155,84 0,8% 2,53

TOTAL Total expenditure for time lost 151 728,53 100,0% 416,85 Time spent traveling 3 082,36 2,0% 8,55 Time spent waiting for and in medical care 4 101,68 2,7% 11,40 Time spent caring for the sick 63 347,48 41,8% 173,90 Time lost due to incapacitation 79 030,41 52,1% 216,98 Time lost due to incapacitation 2 166,93 1,4% 6,02

Source: APOYO Institute The economic impact of malaria in Peru Only 20% of the ill individuals stated having lost a special opportunity due to the disease and more than half of these cases, it was due to harvest or planting season. Also, approximately half of these cases indicated they had been unable to perform the activitiesy or having performed done them in an incomplete manner; the rest of the individuals put the activity off or were able to do it in spite of the illness.

80. The economic cost of malaria in Peru

As for the care of the sick, only 322 were reportedly caring for 956 ill individuals in 364 homes. This seems to indicate that home care is exclusively in the hands of one person who assumes this task in a specialized manner. Although, this function is predominantly performed by women, especially in the jungle, over one third of those cared for are men, mostly adults. There are more caregivers in the northern coast (208 caregivers for 213 homes) than in the jungle (114 for 151 homes). These caregivers dedicate an average of 13 days, with over 8 hours each, to care for the sick; although in the jungle, the time spent providing care is longer (18 days of an average of 13 hours each).

It must be noted that if the ill patient is incapacitated at the moment of going to the health installation, that time included in the time lost due to incapacity and not during the consultation time, this accounts for 28% of the cases. On the other hand, the time spent by the accompanying person, some 60% of the cases, although this person is not present in all the consultations (an average of three times in contrast to 4,5 consultations, as an average).

The average length of the trip is 15 minutes and the average bus fare is 13 cents. On the other hand, the time spent waiting for and receiving medical care is an average of one hour; although it is somewhat longer in the northern coast (one hour and 12 minutes).

The time lost due to disability is more important in the northern coast, as well as the waiting time, whereas the time spent caring for the ill and traveling is longer in the jungle. In the jungle, traveling time is longer (an average of 20 minutes in contrast to 12 minutes in the northern coast), as well as bus fare (16 cents in contrast to 10 cents).

It must be highlighted that 90% of the ill patients are aged between 6 and 65 years old, although an important 31% is between 6 and 15 when the economic effects are not so severe. In this sense, the northern coast tends to be more economically affected by the disease, whereas a higher percentage of ill patients is between 16 and 45, the age of the highest productive potential (5% in the northern coast in contrast to 37 % in Loreto).

Also, it is important to stress that some consultation costs are registered (14% average of the component of direct payments and 1% of the total cost per family). These are more important in the northern coast, and a very limited amount due to laboratory tests, mainly in Tumbes. However, these expenses are generally limited, in spite of the fact that the average number of consultations is 4,4 per malaria episode (about one million consultations if projected at national level), given the

81. fact that most of the consultations (88%) take place in health centers and posts or by their medical personnel who visit the houses of the patients. Paid consultations account for 14% of the cases and cost an average of 2,85 dollars. There is a great difference between the cost of consultation among the health centers and posts (an average of 2,41 dollars) and the private consultation (an average of 17,93 dollars, but only 0,5% of the ill individuals). As for the laboratory tests, only 3% of the ill individuals stated having paid for them, an average of 4,34 dollars. These cases are centered on the northern coast.

Chart 18 Cost by direct payment of the families for treatment (in US dollars)

Department Data Total Percentage Per family

LORETO Total Monetary Expenditure 9 821,44 100,0% 64,94 Payments for consultation 1 190,37 12,1% 7,92 Payments for laboratory tests 55,12 0,6% 0,32 Payments for bus fare 7 120,56 72,5% 47,20 Payment for medications 1 455,40 14,8% 9,50 PIURA Total Monetary Expenditure 2 368,39 100,0% 15,52 Payments for consultation 497,94 21,0% 3,17 Payments for laboratory tests 47,51 2,0% 0,32 Payments for bus fare 686,41 29,0% 4,43 Payment for medications 1 136,52 48,0% 7,60 TUMBES Total Monetary Expenditure 1 947,32 100,0% 31,99 Payments for consultation 353,22 18,1% 5,70 Payments for laboratory tests 177,70 9,1% 2,85 Payments for bus fare 211,59 10,9% 3,48 Payment for medications 1 204,81 61,9% 19,64 TOTAL Total Monetary Expenditure 14 137,16 100,0% 38,96 Payments for consultation 2 041,53 14,4% 5,70 Payments for laboratory tests 280,33 2,0% 0,63 Payments for bus fare 8 018,56 56,7% 22,17 Payment for medications 3 796,74 26,9% 10,45

Source: Survey of homes affected by malaria

The economic impact of malaria in Peru Made by: APOYO Institute

Loreto 69,5% Piura 16,8% Tumbes 13,8% Total 100,0%

Source and made by: APOYO Institute

82. Final comments

Final comments 6.

1. Malaria represents a high cost to the Peruvian economy. The estimated total cost is 37,85 millions of US dollars for 1998. Although this only represents 0,07% of the national GDP, it accounts for 3% of the cattle raising GDP for the departments of Loreto, Piura and Tumbes, where their incidence is centered. Also, in regard to the total expenditure in health, the total cost for malaria represents 1,5%.

2. One of the main costs originated by malaria is due to the efforts the government has undertaken for its control. This total cost adds up to 9,25 million dollars, a part of which comes from the resources assigned by the national program and other health entities oriented toward this goal. An important portion of the cost is originated in the time dedicated by the professionals and workers of the sector and by the cost of the infrastructure involved. The government expense in malaria is only 1% of the total public expenditures in health.

3. Malaria represents a significant cost for the families, most of them poor, that adds to 26,7 million dollars. For the families in endemic areas, the average cost per disease is 475 dollars. This is due to the fact that even one case of malaria costs an average of 95 dollars to the families; houses have an average of five cases per year. For the rural families in the jungle, 70% of which are considered poor, this cost could equal to one third of their yearly income. The effect of the severe malaria cases on families in extreme poverty conditions, or the effects of the concentration of non severe cases per family can undoubtedly be cata- strophic from the economic point of view. Thus, the importance of the study because malaria control would fit within the search for social equity and the fight against poverty.

4. This calculation of the economic cost has valued the time lost to the disease, but not the suffering caused by it. An attempt to come close to this measure through questions oriented toward determining the willingness-to-pay demonstrated its non-viability in the pilot survey.

5. Mortality caused by malaria, in spite of its being relatively low –43 deaths in 1998 in contrast to 77,000 falciparum malaria cases, that is 0,5 per one thousand– represents an important economic cost. Again, we must highlight the huge limitations of an appraisal of human lives based on the earnings they could acquire in their useful life.

83. 6. The study could not quantify with reasonable certainty the economic effects indirectly generated by malaria through the decrease in tourism. However, the most probable magnitude order seems to be within 700,000 and 3,5 million dollars. Only in the very extreme case, this would be meaningful in regard to the other costs identified by malaria in Peru.

7. The main malaria costs are those generated by the families or in an indirect manner on the economic activity. Given the fact that the families tend to recover these costs through a harder family effort and that effects such as those on tourism are not easily identifiable, these costs are not adequately perceived by society. These characteristics, in spite of the public good or with high externalities that the malaria control strategies have, favor the underestimation of the importance of the disease and the undersupplying of public resources for its control. This is why, the release of the real malaria costs for society may be efficacious within a strategy oriented toward the improvement of the relationship between the civil society and the government and bring it closer to the problems and demands of the population.

8. The study did not intend to perform cost-effectiveness or cost-benefit analyses in relation to the various malaria control activities. In that regard, studies of this type conducted in the Brazilian Amazon region (Musgrove et al 1999) indicate a cost between 64 y 69 dollars per DALY. However, this calculation is critically sup- ported by the supposition that falciparum cases would have achieved a lethality of 10% had they not been treated, in contrast to 0,15% in this country in 1996. This lower lethality rate responds for over 90% of DALY appropriated to the intervention conducted.

In Peru, there is a very low malaria lethality rate and there are no estimates on its lethality rate without treatment. In spite of that, the cost caused by malaria mortality is significant. This indicates that a strategy such as the one used in Brazil based on concentrating vector control programs in areas with high concentration of falciparum malaria deserves some attention. The economic impact of malaria in Peru

84. Final comments

9. In the field work, a strategy to change the watering system for rice crops in Piura has been found to be promising in the decrease of the presence of mosquitoes carrying Plasmodium without generating negative effects on the agricultural production (Programa de Salud de la Comunidad de San Juan de Catacaos, 1994- 1997). The system consists on alternating six watering days with nine dry days. In the experimental test, it brought down to zero the presence of larvaes in the rice crops without reducing productivity, although it required a slightly higher additional cost for hand labor in order to weed the fields. Presumably, this system could be generalized to Piura and Tumbes, as well as to the departments of San Martín and upper jungle. Field tests are obviously required to evaluate and ensure its replicability. Tumbes confronts the additional problem of mosquitoes rearing in shrimp farms. In Loreto and in the lower jungle, this system of rice crops cannot be applied.

85. The economic impact of malaria in Peru

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Ministry of Health, MOH (1997) Análisis del gasto público en salud. 2000 Project, Lima.

Ministry of Health, MOH (1998b) Desarrollo e implementación del SICI en el Hospital Víctor Ramos Guardia de Huaraz: análisis de resultados. 2000 Project, Lima.

Ministry of Health, MOH (1999) Resistencia del Plasmodium falciparum a medicamentos antimaláricos en el Perú. Lima.

Ministry of Health - Basic Health and Nutrition Project (PSNB) (1999) Plan de desarrollo e implementación del Sistema de Costos e Ingresos (SICI), Documento 5 A, Análisis de la producción, costos e ingresos de establecimientos seleccionados en la red de servicios de salud Morropón – Chulucanas (Piura).

Murray, Christopher (1993) “Quantifying the burden of disease: the technical basis for disability adjusted life years”, Bull World Health Organ 1994, 72: 419-445.

Najera, J, Liese, B y J. Hammer (1995)

The economic impact of malaria in Peru “Malaria”. In: Disease control priorities in developing countries, D. Jamison y W. Mosley eds, Oxford University Press for the World Bank.

PAHO, Pan American Health Organization (1996) Status of malaria programs in the Americas: XLIV Report, documento N° CD39/INF/2, Sep, Washing- ton, USA.

90. PAHO, Pan American Health Organization (1998) “Salud en las Américas 1998”, Boletín Epidemiológico, 19, 3: 1-10, September.

Parodi, Carlos (1997) Economía de las Políticas Sociales, CIUP, Lima

Pesse, K y Castro, C (1994) “Para que no pique la turula”. In: Control de la malaria en la comunidad campesina de Catacaos, Comunidad Campesina de San Juan de Catacaos, Piura

Ruz, W y K. Pesse (s/f) El impacto socioeconómico de la malaria.

Prescott, Nicholas (s/f) The economics of malaria, filariasis and human trypanosomiasis, documento TDR / SER (SC-1) / 80.4, World Health Organization, Ginebra.

Prescott, Nicholas y Jeremy Warford (1993) Evaluación económica del sector salud. MOH-PAHO (1993)

Programa de Salud de la Comunidad campesina San Juan de Catacaos (1994-1997) Riego intermitente de los cultivos de arroz y su efecto sobre la reproducción del mosquito vector de malaria. Piura.

Químper, M. (1998) Malaria en la Región Loreto, Study for Integrated Project of Malaria in Region of Loreto, CARE-Peru, july.

Romero, J. (1968) “Estimación del costo de un programa de erradicación del paludismo”, Bulletin of PAHO, february.

Ruebush, T, Porter, C y J. Stein (1997) Short-term consultation to the malaria control program, Loreto region, Peru, CDC, USA.

Smith, P.G. (1987) Evaluating interventions against tropical diseases, International Journal of Epidemiology 16, 2.

The Scientist (1997) “Malaria: a statistical index” http://www.the-scientist.library.upenn.Edu /yr1997/may/mack_p6a_970512.html

91. Ventosilla, P. (1993a) Control Vectorial de la Malaria mediante Bacillus thuringiensis var. Israeli (Bti) cultivado en agua de coco, en Piura, Peru, Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima.

Ventosilla, P. (1993b) Participación de la comunidad y los escolares en control biológico de la Malaria con Bti en Piura, Peru. Instituto de Medicina Tropical “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima.

Vosti, S (1990) “Malaria among gold miners in southern Pará, Brazil: estimates of determinants and individual costs”, Soc. Sci. Med, 30, 10.

WHO, World Health Organization (1999a) The World Health Report 1999, World Health Organization.

WHO, World Health Organization (1999b) “Roll Back Malaria”, http://www.who.int/rbm/about.html The economic impact of malaria in Peru

92. Annex 1: Socioeconomic profile Annex 1 Socioeconomic profile of the areas included in the study: Loreto, Tumbes and Piura

1. LORETO

1.1 Demographic and economic data

The department of Loreto has a population of approximately 819,037 inhabitants1, which increases at a rate of 2,5 % annually2. Throughout its six provinces and 47 districts, the province of Maynas presents with the fastest trend of population growth (3 % annually). In spite of that, the population density for the whole department is very low (2,22 inhabitants/ square km) when compared to the national average (18,96 inhabitants per square).

Chart 1 Loreto: Politics and demographic data.

Province Population Province Number of (Inhabit.) Capital districts

Maynas 465 817 Iquitos 10 Alto Amazonas 139 846 Yurimaguas 11 Ramón Castilla 39 973 Ramón Castilla 4 Loreto 60 102 Nauta 5 Requena 56 770 Requena 10 Ucayali 56 529 Contamana 6

Source: Instituto Nacional de Estadística e Informática, 1998 Made by: APOYO institute.

Among the main resources available in this department are the forest resources where lumbering, medicinal and oleaginous species are the most important sources of income for the population. The department also has livestock resources such as cattle, swine and poultry; as well as wild animals (deer, sajino, ronsoco and tapir) and river tortoises (charapas). Among the mineral resources are gold, oil, salt, gypsum, arcilloso iron and hot springs.

Agricultural activity is centered around crops of yucca, sugar cane, cocaine plants, tobacco, coffee, corn, rice, beans and fruits. The main industrial activities highlighted are oil refineries, lumbering mills, factories of buttons, soap, oil, cookies, rice mills, molasses and sugar cane alcohol, manufacture of cloth with chambira and tamshi fiber and shipyards.

1 Compendio de Estadísticas Departamentales 1997-1998. INEI 2 Compendio de Estadísticas Departamentales 1997-1998. INEI

93. As for its macroeconomic indicators, the Gross Domestic Product (GDP) per capita for Loreto in 1996 was 1,204,6 dollars, higher than that for the whole of Peru, which is 800,6 dollars. As for the GDP distribution by economic activities, the most important sector is mining which stands for almost 46% of the entire GDP because Loreto is the first oil producer in Peru. Also, commercial and tourist activities represent around 10% of the department’s GDP.

Figure 1 Loreto: GDP by main economic activities

MANUF. INDUSTRY CONSTRUCTION 3% COMMERCE/TOURISM 13% 9% 1% 2% HOUSE RENTING 10% GOVERN. SERV. PRODUC. OTHER SERVICES AGRIC. HUNT. FORES. 11% 47% FISHING 4% MINING

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute.

1.2 Social Aspects

a) Access to basic services: Water, sewage and electricity

In the department of Loreto, 70% of the homes have no access to drinking water. This figure is 17% higher than that for the national average. In the various provinces of the department, large differences are evident. Whereas in Maynas, the province where Iquitos, the capital city is located, access to this service comes up to 56% in households; in the more remote provinces, this figure increases considerably until

The economic impact of malaria in Peru it reaches an average of 90% of households that are deprived of this service. As for access to sewage services, less than 10% of the homes have this service in the provinces of Loreto, Requena and Castilla.

At a departmental level, access to electricity is most widespread (51,5% of the population). However, a wide gap of 45% is observed between the provinces with the least access (Loreto) and the one with the most access (Maynas).

94. Annex 1

Chart 2 Housing conditions (percentage of homes)

Without water Without sewage Without electricity Overcrowded

Loreto 70,7 71,1 51,5 37,1 Loreto 92,8 95,4 79,5 49,0 Maynas 56,5 55,7 36,3 31,6 Alto amazonas 85,9 87,3 72,1 38,7 Requena 90,1 94,1 71,5 50,5 Mariscal Castilla 94,6 96,2 74,2 54,1 Peru 53,3 60,0 45,1 17,8

Source: Foncodes Map of Poverty, INEI: Censo de Población y Vivienda, 1993 Made by: APOYO Institute

b) Rural population

In 1996, the rural population of Loreto accounted for 41% of the total population and important differences have been observed among the provinces. In Maynas, 26% of the population live in rural areas whereas in Mariscal Castilla, the rural population exceeds 75%. The level of access to basic services (water, sewage, electricity, education and health) is lower for these populations because they are much more costly and the delivery of the service is slow or not at all in these areas. .

Figure 2 Percentage of rural population in the provinces of Loreto 100,0

80,0 72,5 76,6

60,0 55,0 49,1 40,0 26,1 20,0

0,0 Loreto Maynas Alto Amazonas Requena Ramón Castilla

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute.

95. c) Education

As for education, the rate of illiteracy reveals large differences among provinces. Whereas Maynas and Requena are below the average illiteracy rate for Peru, the provinces of Castilla, Alto Amazonas and Loreto are 5% over the national illiteracy rate.

Chart 3 Education indicators

Illiteracy School Total Female Absenteeism

Loreto 10,8 14,9 17,6 Loreto 17,3 25,4 17,8 Maynas 7,4 10,0 15,7 Alto amazonas 20,2 28,9 22,2 Requena 10,9 15,9 19,5 Ramón Castilla 18,3 25,0 20,6 Peru 12,8 18,3 12,7

Source: INEI. Censo de Población y vivienda, 1993 Made by: APOYO Institute

1.3 Health

a) Resources from the Health Sector3

The department of Loreto has 07 hospitals, 43 health centers and 234 health posts. The per capita budget the Ministry of Health assigns to Loreto is 19,70 dollars4. When figures are compared for the various provinces, the hospital infrastructure in Maynas (province where the capital city is located) is approximately The economic impact of malaria in Peru 34% of the entire hospital infrastructure existing in the department.5

3 Second Infraestructure and Health Sector Resources Census. MOH- Statistics and Computing Office. 4 Ministry of Health. General Epidemiology Office. www.oge.sld.pe. Portocarrero Grados A. Analysis of the Health Regions and Sub- Regions Budget 1998. Page 5. 5 Compendio de Estadísticas Departamental 1997-1998. INEI.

96. Annex 1

b) Morbidity, mortality and nutritional status

The morbidity rate among children under 5 years of age due to acute diarrheal diseases (ADD)6 is 221,9 per every 100,000.7 This figure is higher than the national average of 148,7 per 100,000.

Among the diseases affecting all age groups alike8 (contagious diseases such as dengue, leishmaniasis, malaria, cholera, among others), Malaria is the disease with the highest incidence in the department, followed by tuberculosis with a morbidity rate of 133,9 per 100,000. This rate is higher than the national figure of 111,9 per 100,000, but lower than Lima (180 per 100,000). The incidence of cholera is 60.6 per 100,000, higher than the national average (18.8 per 100,000). Finally, leishmaniasis with a morbidity rate of 53,6 per 100,000 and the rate for classic dengue is 19,8 per 100,000. Both rates double the national average rate.

Among the main mortality causes of children under 1 are Acute Respiratory Infections (ARIs) in 22% of the cases and Acute Diarrheal Diseases in 9% of the cases, and the infantile9 mortality of 50 per 100,000 babies born alive.

On the other hand, the nutritional status10 of the children has a direct incidence in the levels of morbidity and mortality in the department. The index of chronic malnutrition in Loreto indicates that 36% of the children under 5 suffer from growth delay and 4% weigh less than the standard weight for their age (global malnutrition).

c) Malaria aspects in the area

Loreto is an endemic area for malaria and 25% of the cases reported in the national territory are centered on it. Higher rates of the disease occur in rural areas, especially in the farther away communities because their main economic activities, fishing, hunting, agriculture, are high risk activities.

6 The Morbidity Rate per ADDS is the number of cases per illness (in children younger than 5 years old) per each 100 000 children younger than 5 years that will be brief as cases per ten thousands. 7 The Information for each of te departments regarding ADDS was obtained at: Ministry of Health - Epidemiology General Office. www.oge.sld.pe. Diarrhoea and Cholera Illness Control Program. 8 The Information obtained for malaria, cholera, tuberculosis, uta and dengue comes from the Epidemiology General Office of the Ministry of Health. www.oge.sld.pe. 9 Encuesta Demográfica y de Salud Familiar (ENDES) 1996 (INEI, 1997). 10 Ibid.

97. Factors contributing to the expansion of the disease are forest plundering (consequence of mining explorations or lumbering) and the humid tropical weather of the jungle because they favor the movement of the vector toward new areas and the formation of puddles which create adequate conditions for the development of the vector.

However, in the last year, a decrease in the number of cases has been experi- mented (from 94,736 in 1997 to 54,315 cases in 1998). The epidemiological characteristics of individuals affected by Malaria in Loreto indicate that the disease has affected all age groups in a similar manner, no differences were observed between sexes or among native communities.

Figure 3 Loreto provinces classified according to API (Annual Parasitic Index)

50,0 43,72 42,35 40,0

30,0

20,0 16,37 11,66 8,60 10,0 0,45 0,0 Maynas Alto Loreto Ramón Requena Ucayali Amazonas Castilla

Source: Information presented in this section for all the departments is extracted from the Descriptive Reports. Made by: APOYO Institute. 1.4 Districts visited11

a) Iquitos (Samito Locality)

The economic impact of malaria in Peru In this locality, transportation is basically by the river and the main economic activities are wood extraction, fishing and agriculture. CARITAS plays an important support role for the farmers. This locality has a public telephone (the only one in the village). As for health infrastructure, the village has a health care place under the jurisdiction of the Santa Maria health post and is located at a borrowed

11 Information presented in this section for all the departments is extracted from the Descriptive Reports of Field Work done by the team of evaluators sent to these areas.

98. Annex 1

house. There is no medical or nursing personnel in charge of the center and three health technicians are currently working there.

The health post carries out important prevention campaigns for Malaria and Cholera. They promote prevention activities, such as the elimination of mosquito reservoirs and have also given away mosquito nets to almost all the houses. They also promote drying out puddles, among other things. In addition to this, they develop various programs sponsored by the Ministry of Health (ARI, Diarrheal diseases, health insurance for students, family planning, etc.).

There is no noteworthy participation of the community individuals as a unit, a sample of this is that the population expects the Institutions to take the initiative and this is difficult because the municipal government does not have its own headquarters and must follow guidelines set forth by Santa Maria. b) Alto Nanay (Santa María de Nanay locality)

The main economic activities of this locality are agriculture, wood extraction, manufacture of hirapai leave roofs and fishing. CARITAS actions are also important in this locality through their technical and economic support to the farmer, as well as for the Winai program, which provides food assistance to undernourished children.

Santa Maria has a health center where a physician, an obstetrician, a nurse and three technicians work. They have a well-equipped pharmacy for the treatment of malaria. This health center is responsible for various health centers in the area, Samito among them, and they constantly visit these other health centers for the study and control of malaria and to monitor the PANFAR program.

The health center carries out important campaigns for the prevention of malaria and cholera by providing mosquito nets to the families in the last year and paying visits for a house control. Other Ministry of Health sponsored programs (Acute Respiratory Infections, Acute Diarrheal Diseases, health insurance for students, Family Planning, etc.) are administered by the health center. It is important to mention the joint participation of CARITAS and the health personnel, which allows for more support to the population, especially in the more distant areas. c) Trompeteros

The main source of income for the families in this area is oil exploitation. Populations located near wells and camps have more services and better infrastructure, each

99. locality has a radio frequency and their main means of transportation are boats, canoes and long boats used for public transportation.

FONCODES is one of the institutions in the area and it has financed the construction of latrines and water wells. No work carried out by the municipality is identified and there are no NGOs.

The Ministry of Health has health centers and posts but with rather meager resources. There is a health center in Villa Trompeteros, 3 health posts located in Providencia, Nueva Jerusalen and Pampa Hermosa, each one of them has health technicians, one obstetrician and one nurse (in the Trompeteros health center).

All the populated areas have a Glass of Milk Comittee. Only Providencia, Villa Trompeteros and Pampa Hermosa have mothers’ association each. The leaders of these organizations rate the participation of the community as very low.

d) Caballococha

Most of the locality’s economy is centered on commerce, motivated by the merchandise traffic along the border with Colombia. It must be noted that one of the most important problems affecting the population in general is the increase in gas prices, caused by the regulation of its distribution determined by Iquitos authorities and due to Peruvian gas smuggling in the border area. This led to the increase in transportation prices, as well as the restriction in education and health services for the more remote locations. In the rural communities, the economic activity is agriculture and livestock raising, fishing and rearing of minor animals. The presence of the industry is centered on the Caballococha area and small brick factories as well as small private farms of agricultural-industrial products such as olive oil can be found.

The monthly income level of the urban area is estimated at around 126,70 to 221,73 dollars, contrasting sharply with the rural areas where the monthly income is set at approximately 31,68 dollars.

The locality is the center node of the Ramón Castilla health network, which The economic impact of malaria in Peru administers and supervises the preventive actions in various border districts. The health center has several health posts assigned to it: the Caballococha health post, Cuchillo Cocha, Chimbote, Isla del Tigre and San Antonio. However, at the time of the study, a high concentration of medical personnel was observed in Caballococha, the only two doctors were there, as well as 20 out of the 24 health technicians available in the area.

100. Annex 1

Access to the Caballococha district is either by river through boats (7 hours) or by air (one-hour trip for 40 dollars). Access from the district toward the localities in the interior is through small private boats. By land, one can only reach the nearby communities through an incomplete walk way, implemented by PRONAA.

The localities have baseline organizations (Popular Kitchens, Glass of Milk Committees, and Mothers’ Associations) and there is active participation in the community work (construction of walkways and cleanliness of wells) as well as frequent local assemblies.

e) Yurimaguas

The most important productive activity in the area is agriculture, with rice, banana and bean crops mainly. The annual agricultural cycle involves two stages: planting in January and February, called “the large campaign” by the population and harvesting in June and July. The second planting or “small campaign” occurs in August with harvest time in December.

The main communication means in the area is the Yurimaguas-Tarapoto road, a side road of the marginal road but the localities communicate among each other through dirt road shortcuts. The city has electricity (from 6:30 to 10:30 p.m.) and a radio central station, this is why they are implementing the fixed phone service.

In the health area, the jurisdiction of Pampa Hermosa has a health center cared by two physicians, three nurses, two nursing technicians and one administrative clerk. Communities that have their own health posts, have their own promoter. These communities are Grau, San Juan de Pamplona, Santo Tomás, Cotayacu, Puerto Perú, Nueva Alianza and San Francisco de Pampayacu.

2. TUMBES

2.1 Demographic and economic aspects

The department of Tumbes has a population of approximately 178,525 inhabitants12 and it grows at a rate of 2,8 per cent a year. The province of Zarumilla is the one with the highest population increase (4,3 per cent annually). Politically, it is divided into 3 provinces and 12 districts.

12 Compendio de Estadísticas Departamentales 1997-1998. INEI

101. Chart 4 Tumbes: Political and demographic data.

Province Population Capital of the No. districts (Inhabit.) Province

Tumbes 131 334 Tumbes 6 Contralmirante Villar 14 744 Zorritos 2 Zarumilla 32 447 Zarumilla 4

Source and made by: APOYO Institute

The gross domestic product per capita in Tumbes for 1996 was 565,8 dollars, a relatively low figure since the mean national average per capita is 800,6 dollars. The most important economic activity in the department is commerce (32 per cent of the departmental internal net product) due to the intense rhythm of exchange with Ecuador, followed by fishing, where the rearing of shrimp and sea food are highlighted. In the third place is the agricultural activity, with rice, cotton, soy and bananas as the most important crops. Among the mining resources are oil, gold and salt.

Figure 4 Tumbes: GDP by main economic activities.

COMMERCE. REST. HOTELS HOUSE RENTING 11% GOVERN. PROD. SERVI. 24% 12% OTHER SERVICES 0% AGRIC. HUNT. SILVI. FISHING 7% 8% MINING 2% 4% MANUFACTUR. INDUST.

The economic impact of malaria in Peru 32% CONSTRUCTION

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute.

102. Annex 1

2.2 Social Aspects

a) Access to basic services: water, sewage and electricity

In the Department of Tumbes, 58% of the homes have access to potable water. This is an important figure if one takes into consideration that in the national territory; the coverage of this service is 47%. In the provinces studied, no substantial differences are observed because Tumbes has only 3% less access to potable water than Zarumilla.

Chart 5 Access to basic housing services (percentage of homes)

Without Without Without Overcrowded water sewage electricity

Tumbes 42,4 59,9 30,4 14,7 Zarumilla 40,2 55,2 40,7 19,5 Tumbes 37,6 57,3 26,5 14,3

Source: Foncodes Map of Poverty; INEI: Censo de Población y vivienda, 1993 Made by: APOYO Institute

As for access to sewage services, 60% of the households in this department do not have this service. This figure is similar to the national average but much higher than Lima, where only 32% of the homes do not have sewage. This goes to show that the coverage for this service in the department is still very poor. No significant differences were observed among provinces.

As for electricity, large differences are found in the provinces. On one hand, the province of Tumbes has a high coverage since three fourths of the homes have access to this service, figure close to the Lima figure but higher than the national average in about 18%. In the province of Zarumilla, coverage is lower, reaching only 60% of the homes.

103. b) Rural population

The percentage of rural population in the department is 11%, with minor differences among provinces.

c) Education

The rate of illiteracy in the department of Tumbes is about 7%, which suggests a high coverage in primary education. This rate is lower than the national average which is 13% and slightly higher than the Lima indicator of only 4%. Female illiteracy is slightly higher, but still stays within the same relationship when compared to the national average and with Lima. There are no major differences among provinces. Figure 5 Percentage of rural population in the provinces of Tumbes 40,0

30,0

20,0 12,8 9,0 10,0

0,0 Zarumilla Tumbes

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute.

Chart 6 Education indicators (rate)

Illiteracy School Total Female Absenteeism

The economic impact of malaria in Peru Tumbes 6,6 8,0 10,2 Zarumilla 7,0 8,3 8,7 Tumbes 6,4 7,7 7,6 Perú 12,8 18,3 12,7 Lima 4,2 6,2 7,9

Source: Foncodes Map of Poverty. INEI (Censo de Población y vivienda, 1993) Made by: APOYO Institute

104. Annex 1

2.3 Health

a) Resources, access and coverage

This department has a total of 5 hospitals, 26 health centers and 30 health posts. The budget allocated to Tumbes by the Ministry of Health is 21,51 dollars per capita. This figure is slightly higher than the national average (19,58 dollars per person). There are 7 physicians for every 10,000 inhabitants (throughout the nation, there are 10,3 per 10,000)

b) Morbidity

The morbidity rate due to acute diarrheas and ARIs is 196 and 86 per every 100,000 children under 5. Another highlighted disease is dengue whose rate is 112,3 for every hundred thousand and when compared to the national average (11,8 per hundred thousand) becomes quite a high figure. It must be noted that the dengue cases in Tumbes represent 7% of the cases at national level.

c) Mortality

As for the general mortality data, the infantile mortality rate found for the department of Tumbes is 47 per one thousand children born alive. This figure is higher than the national average (43 per one thousand children born alive) and also higher than the Lima figure (26 per one thousand born alive). Same thing happens with the child mortality rate (under 5) in Tumbes, which is 64 per one thousand children born alive, higher than the national average (59 per one thousand children born alive)

d) Food and nutrition

The chronic malnutrition rate is 14,7%, which indicates that 15 out of every 100 children under 5 have low height for their age (25,8% is the national rate). As for the global malnutrition rate, 3% of children under 5 years old are

105. underweight for their age and this figure is significantly lower than the national level (7,8%).

e) Malaria aspects in the area

The number of cases increased from 293 in 199713 to 36,325 in 1998 and the most affected group was the males aged 15 to 49 years old.

The province with the highest API is Zarumilla (152,97)14 in the border with Ecuador, and it is also the area with the highest Annual Parasite Index of all the provinces included in this study. The type of malaria predominant in this department is caused by Plasmodium vivax, representing a little over 80% of the total number of cases. Comparisons carried out with the number of cases throughout the national territory in 1998 indicate that Tumbes reported 17% of the cases.

A risk factor linked to the behavior of the families is the little knowledge about the disease magnitude, which leads to scarce prevention activities.

Figure 6 Tumbes Provinces classified according to API (Annual Parasite Index)

200,00 152,98 150,00

100,00

50,00 26,76

00,00 The economic impact of malaria in Peru Zarumilla Tumbes

Source: MOH-Regional Health Office of Tumbes. Made by: Instituto APOYO.

13 Ministry of Health - General Office of Epidemiology (OGE) WWW.oge.sld.pe 14 Weekly notifications from the Regional Health Office – General Office of Epidemiology

106. Annex 1

2.4 Districts visited

a) Corrales

The main economic activities in the area are agriculture (60%), commercial activities (20%), temporary jobs in construction, transportation and handcrafts, etc. (20%).

The average monthly income per farmer is 158,38 dollars per hectare whereas an employee makes from 95,03 to 221,73 dollars and a business person makes 158,38 dollars a month.

The district of Corrales has three health centers: Corrales (head of the network), La Cruz and San Jacinto, where there are five physicians, four of them work in Corrales and the other one rotates among the six additional health posts in Vaquería, Oidor, Casa Blanqueada, Malval, San Isidro and Rica Playa. House visits and fumigation campaigns are carried out to discard malaria.

As for the community organizations operating in this locality, only the Mothers Associations remain active, operating a bakery industry downtown Corrales. The Church has a certain participation preparing groups of Catholic couples who receive informational talks about various topics, malaria prevention among them. However, the number of attending couples is small and those who do attend live in the center of the district.

b) Aguas Verdes

The main economic activities here are commerce and agriculture. This locality has a health center in Aguas Verdes (staffed by three physicians in the district), and also a health post in La Curva and another one in Zarumilla. One of the points to bear in mind is the medical care received in the health centers and posts because the individuals surveyed have stated that they run into difficulties at times due to the increased number of cases which makes the operational capability of the service hard.

As for the community organizations, the municipality works with Neighbor Committees, Glass of Milk Committees and Community Kitchens, known as Popular Kitchens.

107. 3. PIURA

3.1 Demographic and economic aspects

In 1997, this department reported population close to 1’487,030 inhabitants15. The rate of population growth here is 1,3 per cent annually and the province of Piura is the one with the fastest growth rate (1,9 per cent yearly16). The department is divided into 8 provinces and 64 districts.

Chart 7 Piura: Politics and demographic data.

Provinces Population (Inhab.) Capital City

Piura 547 641 Piura Ayabaca 135 475 Ayabaca Huancabamba 122 351 Huancabamba Morropon 172 596 Chulucanas Paita 83 058 Paita Sechura 246 055 Sechura Sullana 134 636 Sullana Talara 45 218 Talara

Source: Compendio de Estadísticas Departamentales 1997-1998. Made by: APOYO Institute

The main industrial activities are oil explorations, fishmeal industries, shrimping, aviculture and production of poultry feed, in addition to important work in the field of handcrafts made of ceramic, straw and wood. Agricultural activity centers mainly on rice, cotton, sugar cane and wheat crops. Piura is the main producer of sorghum and the second producer of rice in the country.

The GDP per capita for Piura in 1996 was 675,7 dollars. Analyzing the distribution by economic activities, mining is found to be the main sector due to the importance

The economic impact of malaria in Peru held by oil exploration, which represents 28% of the department’s GDP. The commercial, hotel and agricultural sector follow the above in level of importance, with 16%.

15 Compendio de Estadísticas Departamentales 1997-1998. INEI. 16 Ibid

108. Annex 1

Figure 7 Piura: GDP by main economic activities.

EXPLOT. MINING Y CANTER. INDUST. MANUFACTUR.

CONSTRUCTION 5% 7% 16% 3% COMMERCE REST. AND HOTELS 6% 16% HOUSE RENTING GOVERN. PROD. SERVI. OTHER SERVICES AGRIC. HUNT AND SILVI. 8% 28% 11% FISHING

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute.

The main means of road communication is the Northern Panamerican Highway. In addition the airport in the city of Piura has landing fields in Paita, Sullana and Talara, as well as in ports in the cities of Paita and Talara.

3.2 Social Aspects

a) Access to basic services: water, sewage and electricity.

Forty-seven percent of homes have access to potable water in the department of Piura. This figure is similar to the national average but relatively low if contrasted with the department of Lima (71% of the homes). A significant difference is observed among the coastal provinces of the department (Piura and Sullana) and the Andean provinces (Ayabaca, Morropon17 and Huancabamba). For the first group, access to this services covers almost 60% of the population, whereas for Ayabaca and Huancabamba, the coverage is only 8% of the homes. Morropón has an intermediate level access since 33% of the homes in this district have potable water. .

17 Morropón has some areas located on the coastal region and others in the Andean region.

109. Chart 8 Access to basic housing services (percentage of homes)

Without Without Without Overcrowded water sewage electricity

Piura 52,5 70,8 58,6 18,9

Sullana 39,6 59,4 51,2 17,5

Ayabaca 93,2 96,2 92,3 23,9

Huancabamba 92,5 95,9 92,2 31,8

Morropon 67,8 88,5 81,4 17,5

Piura 42,1 64,4 49,8 18,4

Source: Foncodes Map of Poverty; INEI: Censo de Población y vivienda, 1993 Made by: APOYO Institute

As for the level of access to sewage, this only reaches an average of 30% of the homes in the department and this is very low when compared to the national territory (68%). There are differences among the provinces, although these are less marked in the case of the water services. In the first group, the access level is approximately 39%, whereas in the second group, it does not even reach 5% of the homes. Morropon fits in an intermediate range where 11% of the population lacks this service.

The figures also indicate low levels of access to electrical service (41% average at department level), whereas in the national territory, this services covers 55% of the homes. Like the other services, there are large differences among the above mentioned province groups.

b) Rural population

The province of Ayabaca is basically rural (90% of its population), followed by The economic impact of malaria in Peru Huancabamba with 88% and finally Morropon with 44% of its inhabitants living in rural areas. Again, a drop in the figures is observed and the provinces of Sullana and Piura only present with 12% and 14%, respectively.

110. Annex 1

Figure 8 Percentage of rural population in the provinces of Piura

100,0 89,5 87,9 80,0

60,0 43,6 40,0

20,0 14,4 11,7 0,0 Sullana Ayabca Huancabamba Morropon Piura

Source: Compendio de estadísticas departamentales 1997-1998. Made by: APOYO Institute. c) Education

As for the rate of illiteracy, the difference is also noted among the provinces near the coastal area and those of the Andean area of Piura. Whereas Piura and Sullana have approximately 12% of their population in illiterate status, in Ayabaca and Huancabamba, it is 32% of the inhabitants and in Morropón around 22%. The figures for the first group are similar to the national average, but much higher than those for Lima, where only 4% cannot read or write.

Chart 9 Education indicators (rate)

Illiteracy School Total Female Absenteism

Piura 16,3 21,2 14,2 Sullana 12,2 14,4 10,8 Ayabaca 31,7 40,6 26,3 Huancabamba 34,0 47,1 20,3 Morropon 22,3 27,5 14,8 Piura 13,1 18,0 11,7 Peru 12,8 18,3 12,7

Source: Foncodes Map of Poverty. INEI (Censo de Población y vivienda, 1993) Made by: APOYO Institute

111. 3.3 Health

a) Resources, access and coverage

Piura has 6 hospitals, 66 Health Centers and 294 Health Posts and the budget allocated by the Ministry of Health is 12,70 dollars per capita. The medical personnel in the area is 6,4 physicians and 3,3 nurses per ten thousand inhabitants, both figures are considerably lower than those of Lima (18,9 physicians per ten thousand and 9,1 per ten thousand, respectively).

b) Morbidity

As for diseases characteristically affecting children, acute diarrheas and ARIs have relatively low rates for the department (91,2 and 70,6 per each one hundred thousand children, respectively) when compared to the national average (148,7 and 74,8 per one hundred thousand, respectively). However, it is important to observe that the morbidity rate for Acute Respiratory Infections (ARIs), though lower than the national average is much higher than the rate for Lima, set at 25,8 cases per ten thousand children.

c) Mortality

The infantile mortality rate is 56 per one thousand children born alive, higher figure than the national average (43 per one thousand). The child mortality rate (under 5) is 81 per one thousand children born alive, higher than 59 per one thousand which is the national figure. The percentage of children dying of acute diarrheas (11%) is almost half the percentage of deaths due to ARIs (26%). The mortality rate due to infectious diseases (193 per one hundred thousand children) is high if compared to the national figures (170 per one hundred thousand) and it is almost 3 times the Lima figure.

d) Food and nutrition

The chronic malnutrition index shows that in Piura, 28 out of every 100 children The economic impact of malaria in Peru under 5 years old present a delay in the growth corresponding to their age. The indicator of acute malnutrition shows that 0,4% of the children are underweight for their height and one out of every 10 children does not have the adequate weight for their age.

112. Annex 1

e) Malaria aspects in the area

An important increase in the number of malaria cases has been reported. In 1997, a total of 11,944 cases18 were reported, increasing to 57,492 cases in 1998.19 The malaria incidence in the department of Piura presents a certain relationship with the agricultural calendar, particularly in the rice and cotton crops, with a certain relationship between the times of planting and harvesting and a higher number of cases, particularly among males.

The obsolete irrigation channels are another risk factor, presenting filtrations that lead to the formation of flooding and puddles that serve as mosquito rearing sites. Also, in the last year, the number of flooded areas has increased considerably due to rains which could lead to the increase of malaria cases.

Social risk factors are added to the above, such as inadequate housing, lack of knowledge on the mechanisms to prevent the disease or economic incapability to implement or acquire these methods. Habits and ways of the area also play an important role, such as doing laundry in water drains or having the children bathe in them at the end of the afternoon.

Figure 9 Piura Provinces classified according to the API (Annual Parasite Index)

10,00 9,38 8,14 8,00

6,00

4,00 3,08

2,00

0,00 Sullana Ayabaca Piura

Source: MOH-Regional Health Office of Piura Made by: APOYO Institute

18 Ministry of Health – General Office of Epidemiology. WWW.oge.sld.pe. 19 Weekly reports from the Health Region – General Office of Epidemiology

113. Up until 1997, the most important variety of malaria was vivax, but in 1998, the falciparum cases increased in such a way that the ratio of falciparum malaria cases over the total number of malaria cases became 68% for Piura I and 73% for Piura II19. This year, Piura represented 27% of all national cases, figure that is even higher than the cases in Loreto.

3. 4 Districts visited 20

a) Tambo Grande (locality of Cruceta)

The main activity is agriculture, with rice and mango crops, destined to exports. A worker’s daily income is 3,17 dollars.

In Cruceta, there is one health post, however, the population does not acknowledge the existence of health promoters in the area nor do they mention the presence of any NGO. Among the institutions active in the locality is FONCODES and it has financed the building of latrines in one of the neighborhoods (AA.HH. Sanchez Cerro). No community organization is perceived and, on the contrary, a quite socially desintegrated population is observed.

b) Cura Mori

The main economic activity is rice and cotton crops. The farmers’ income depends on the sale price of mill rice.

Four sanitary areas have been formed (Chato Grande, Pozo de los Ramos, Santa Rosa and Cucungará), each one with its corresponding health post. The Cucungara village is the one with a Health Center. This locality has a public telephone and radio and TV can be tuned to signals. However, the percentage of the population with access to this service is limited.

FONCODES has financed the building of latrines in certain sectors of the districts near Cura Mori. Also, a NGO Plan Internacional has carried out some activities in this locality providing training to health promoters in the Oral Rehydration Units, The economic impact of malaria in Peru carrying out house fumigation campaigns and delivery mosquito nets. Another NGO working in Cruceta is PRISMA. Through the Cusi Ayllu program, it provides food assistance to the population of the poorest villages, in the way PRONAA does.

20 Statements and data presented in this section have been taken from the Evaluator Reports (Malaria survey).

114. Annex 1

As for community organizations, there are Mothers’ Associations and a Neighbors Board formed by the local political authority, the municipal agent, the lady president of the Popular Kitchen and the president of the Community Development Committee. c) La Arena

The inhabitants of this locality are dedicated to agriculture (rice, cotton, tomatoes and corn crops), cattle raising, and a group of them work as laborers for the local industry. However, most are temporary workers (66% of the population) obtaining an average income of 4,75 dollars daily per shift.

As for the health sector, the district of Arenas has six health posts (Las Malvinas, Monte Grande, Chatito, Casa Grande, Loma Negra and Río Viejo). The La Arena Health Center also offers non traditional services through consultation with healers, bone fixers, midwives and herb prescribers. The spatial location of the health services is adequate, with a proportionate distribution according to the number of inhabitants per jurisdiction.

Reproductive health and family planning programs are conducted by Plan Internacional and CARE, which also collaborates in the vaccination campaigns and in the equipment of the various health services. d) Bellavista

The most important economic activities in Bellavista are agriculture and commerce. The most widespread crops are rice, lemons, corn and asparragus and the dwellers of the land are not the owners of it. An important group of the population is employed as workers in the farms.

The health center provides care to six localities of this district, carrying out seasonal fumigation and spraying campaigns over potential mosquito rearing sites.

There is no active local organization and an example of this is that the presence of health promoters is ther by initiative of the health post and not of the population.

115. e) Salitral

The main economic activity in this region is agriculture with rice, corn, beans and fruits as the most important crops.

The district of Salitral is within the micro health network of the same name. The Salitral Health Center is located in this district, as well as the health posts of Hualcas, Serrán, Malacasi, La Alberca and Chignia Baja. The Salitral micro health network belongs to the Chulucanas – Morropon macro network and this one belongs to the Piura I Health Region. The Salitral health center has two physicians, one nurse, six technicians and thirty-six health promoters. Malcasi has one physician, one nurse, two technicians and around twenty promoters. La Alberca does not have a doctor but it has two technicians and twenty promotors. Finally, the Serran health post has one physician, one nurse, four technicians and around forty promoters.

FONCODES and an NGO called IDEAS have an important presence in the area. The latter carries out work in support of agriculture through the introduction of new varieties of fruits. The economic impact of malaria in Peru

116. Annex 2: Profile of the health service user Annex 2 Profile of the health service user

1. GENERALITIES

According to the information gathered through the application of a survey in homes visited at the study sites, clear differences are observed between the characteristics of the malaria incidence in the northern coastal area and those in the lower jungle area.

A total of 512 malaria cases were reported for the 1,385 individuals surveyed in Piura and Tumbes, which equals to 37% of the total population surveyed in this site; whereas 444 cases were reported in Loreto out of a total of 947 individuals (47%) .

Chart 1 Total number of individuals ill with malaria by region and sex, according to place of consultation

Place of Consultation Total Piura-Tumbes Loreto Total Males Females Total Males Females

TOTAL 956 512 278 234 444 229 215

Place of First Consultation Hospitals 27 6 2 4 21 11 10 Health Center/Post 809 422 233 189 387 206 181 ESSALUD 1 1 0 0 0 0 0 Pharmacies 4 4 3 1 0 0 0 Private Consultation 10 4 2 2 6 2 4 Healer 1 0 0 0 1 0 1 Health Promoter visited me 35 7 4 3 28 10 18 Sanitary worker enrolled me 42 42 22 20 0 0 0 Other 26 26 11 15 0 0 0 Does not know 1 0 0 0 1 0 1

Source: Survey of malaria affected homes Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by : APOYO Institute

This agrees with the information obtained from the official registries in those Health Regions included in the study which, for 1997, report a total of 158,115 cases diagnosed in Loreto (121,268 confirmed by a parasitological diagnosis by thick smear in slides and 36,864 treated as probable malaria due to the lack of laboratory diagnostic means or because they were negative to the test). For a population of 819,000 inhabitants, this reaches as much as 19,3% of those affected (almost 1 out of every 5 inhabitants).

117. For 1998, in Piura II (Sullana), a total of 24,961 cases were reported in a population of 659,459 inhabitants, which represents 3,78%. This is certainly a very high rate but undoubtedly far from that reported in Loreto the year before.

In Tumbes during 1998, a total of 32,932 cases were reported for a population of barely 183,609 inhabitants which represents almost 18%, a figure close to the Loreto figure in the year before and which, in a way, reflects the consequences of the El Niño phenomenon in the northern coastal area.

Also, the severity of the cases is evidenced by the rate of cases coming to the Hospital for the first consultation, these were only 1,2% in Piura and Tumbes whereas in Loreto, the figure approached 4,7%, in spite of the fact that not only the availability but the access to Hospitals is less in Loreto.

Chart 2 Total number of individuals ill with malaria by region and sex, according to place of consultation (%)

Place of Consultation Total Piura-Tumbes Loreto Total Males Females Total Males Females

TOTAL 100 100 100 100 100 100 100

Place of First Consultation Hospitals 2,8 1,2 0,7 1,7 4,7 4,8 4,7 Health Center/ Post 84,6 82,4 83,8 80,8 87,2 90,0 84,2 ESSALUD 0,1 0,2 0,4 0,0 0,0 0,0 0,0 Pharmacies 0,4 0,8 1,1 0,4 0,0 0,0 0,0 Private Cons, 1,0 0,8 0,7 0,9 1,4 0,9 1,9 Healer 0,1 0,0 0,0 0,0 0,2 0,0 0,5 Health Promoter visited me 3,7 1,4 1,4 1,3 6,3 4,4 8,4 Sanitary worker enrolled me 4,4 8,2 7,9 8,5 0,0 0,0 0,0 Other 2,7 5,1 4,0 6,4 0,0 0,0 0,0 Does not know 0,1 0,0 0,0 0,0 0,2 0,0 0,5 The economic impact of malaria in Peru Source: Survey of malaria affected homes. Basis: Total Number of Surveyed Individuals Ill with Malaria (956) Made by: APOYO Institute

118. Annex 2

2. EPIDEMIOLOGICAL CHARACTERISTICS OF MALARIA IN THE NORTHERN COAST AND IN THE LOWER JUNGLE REGION

2.1 Characteristics of the cases

a) Person

In Loreto, the male and female ratio is almost the same: 51,5% males and 48,4% females, whereas in Piura and Tumbes, a male predominance –though very small– is observed (54.3% versus 45,7% females).

The case distribution by age groups is also different. Thus, in Piura-Tumbes, 4.7% in children under 5 years old, almost the same figure (around 26%) for age groups 6 to 15, 16 to 25 and 26 to 45, with 14.4% for those older than 65. However, in Loreto, there were three times more children under 5 (12.4%) and also a higher rate for the immediate older group of 6-15 years old (37.4%). On the other hand, the group of 16-25 only had a rate of 15.3% and the 26- 45 years old had a rate of 22.1%, leaving 12.9% for those older than 65 years.

Chart 3 Total number of individuals ill with malaria by region and sex, according to age groups (%)

Age Groups Total Piura-Tumbes Loreto Total Males Females Total Males Females

TOTAL 100 100 100 100 100 100 100

AGE GROUPS 0 – 5 8,3 4,7 4,3 5,1 12,4 11,4 13,5 6 – 15 31,3 26,0 23,7 28,6 37,4 36,2 38,6 16 – 25 21,2 26,4 27,7 24,8 15,3 16,6 14,0 26 – 45 25,5 28,5 29,1 27,8 22,1 21,4 22,8 46 - 65 11,8 12,3 11,9 12,8 11,3 13,1 9,3 66 and older 1,9 2,1 3,2 0,9 1,6 1,3 1,9

Source: Survey of homes affected by malaria. Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by: APOYO Institute

119. Chart 4 Rate of Individuals ill with Malaria by region and sex, according to age groups

Age Groups Total Piura-Tumbes Loreto Total Males Females Total Males Females

TOTAL 41,0 37,0 40,5 33,5 46,9 45,6 48,3 0 - 5 25,2 14,5 15,2 14,0 37,2 35,1 39,2 6 - 15 39,7 32,4 34,9 30,3 48,4 48,5 48,3 16 - 25 43,2 42,3 46,1 38,2 45,0 40,4 52,6 26 - 45 46,7 46,2 53,3 39,6 47,3 44,5 50,5 46 - 65 49,6 43,8 42,3 45,5 59,5 65,2 52,6 66 and older 40,0 35,5 40,9 22,2 50,0 42,9 57,1

Source: Survey of homes affected by malaria. Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by: APOYO Institute

Malaria incidence rates for all age groups are higher in Loreto than in Piura and Tumbes, but they are more similar among each other for the 16 and 45 years old groups.

In spite of the noticeable decrease in the incidence of malignant malaria in Loreto observed in the second semester of 19971, there are still as many cases of this form as there are of the benign malaria due to P. vivax. At the time of the survey, the severe or malignant forms of malaria due to P. falciparum are still almost 50% in Loreto, whereas in Piura and Tumbes, these are currently the predominant forms (62% versus 35% by P. vivax). Chart 5 Total number of individuals ill with malaria by region and sex, according to type of Malaria (%)

Age Groups Total Piura-Tumbes Loreto Total Males Females Total Males Females

TOTAL 100 100 100 100 100 100 100 Malignant, falciparum 56,1 62,1 62,2 62,0 49,1 49,3 48,8

The economic impact of malaria in Peru Benign, mild, vivax 40,5 35,7 35,6 35,9 45,9 45,9 46,0 Both 1,8 1,0 0,7 1,3 2,7 2,6 2,8 Does not know 1,7 1,2 1,4 0,9 2,3 2,2 2,3

Source: Survey of homes affected by malaria. Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by: APOYO Institute

1 Malaria Reemergente en la Región Amazónica peruana, Aramburu G. Javier Ramal. EN: Emerging Infectious Diseases Vol. 5, No.209 –215, mar – April, 1999.

120. Annex 2 b) Transmission site

In Tumbes malaria affects not only those workers dedicated to shrimp larvae extraction but also the farmers dedicated to rice crops.

In Piura I and Piura II (Sullana), the individuals affected are particularly farmers dedicated to rice crops and there is no evidence of other cases within the same families which would allow for the suspicion that the infection is not happening in the intra domiciliary, but in the work fields.

Something similar is currently being observed in Santa Maria de Nanay in Loreto where no cases are found (nor vectors) in the houses, in spite of this being the area with the highest incidence. The infection seems to be taking place in the forest, upon extraction of palm tree leaves, which is the main economic activity of the population.

This occupational exposure may be playing an important role in Tumbes and Sullana, justifying the need to perform entomological studies, not only in the dwelling but also at the work place and during the hours workers are exposed.

The areas that are legally required to remain free from rice crops in the vicinity of the homes are not being respected; the vector control activities (larvae as well as adults) are regarded with apprehension by the farmers, for fear of hurting the shrimp extraction; and lastly, it is relevant to ask if malaria transmission occurs in the intra domiciliary or at the work place itself.

IPHN studies are carried out under traditional conditions but there is a concern to find out if mosquitoes also feed in the rice paddies or in the shrimp ponds. There is clearly an alteration of the environment caused by man’s economic activities and closely linked to the development of the vectors and the spread of disease.

c) Intensity of the attack and principal parasite species

The average number of episodes per person observed in Loreto was 2,5 where 45% had only one episode, whereas 32,2% had more than three episodes (14,4% had five or more).

121. Also, similarly to what was observed in Piura I and Piura II (Sullana), the predominant form is the Malignant Malaria caused by P. falciparum, which doubles the number of cases caused by P.vivax. However, most of the individuals surveyed (almost 60%) had only had one episode of malaria last year, thus the number of individuals who had between 1 and 2 episodes was as high as 81,5%. The average rate in Piura and Tumbes was 1.4% episodes.

Chart 6 Average number of malaria episodes by region and sex, by age group and type of malaria (Summary)

Age Groups and Total Piura-Tumbes Loreto type of malaria Total Males Females Total Males Females

Total 1,9 1,4 1,4 1,4 2,5 2,6 2,4 0 - 5 1,6 1,2 1,3 1,2 1,7 1,7 1,8 6 - 15 1,9 1,3 1,2 1,4 2,3 2,4 2,3 16 - 25 1,7 1,3 1,3 1,3 2,5 2,7 2,1 26 - 45 2,0 1,5 1,5 1,6 2,7 3,0 2,3 46 - 65 2,5 1,4 1,4 1,3 3,9 3,3 4,9 66 and older 1,6 1,2 1,2 1,0 2,1 2,0 2,3

Type of malaria

Malignant, severe, falciparum 1,9 1,4 1,4 1,5 2,6 2,8 2,5 Benign, mild, vivax 2,0 1,3 1,3 1,3 2,5 2,6 2,5 Both 2,1 2,0 2,5 1,7 2,1 2,0 2,2 Does not know 1,0 1,0 1,0 1,0 1,0 1,0 1,0

Source: Survey of homes affected by malaria. Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by : APOYO Institute The economic impact of malaria in Peru

122. Annex 2

Chart 7 Number of individuals ill with malaria by region and sex, according to the number of episodes and type of malaria

Number of episodes Total Piura-Tumbes Loreto and type of malaria Total Males Females Total Males Females

Total 956 512 278 234 444 229 215 Once 562 364 201 163 198 100 98 Twice 217 114 60 54 103 52 51 Between 3 and 4 111 32 16 16 79 37 42 Five or more 66 2 1 1 64 40 24 P. falciparum 536 318 173 145 218 113 105 Once 306 220 123 97 86 47 39 Twice 130 75 39 36 55 24 31 Between 3 and 4 64 21 10 11 43 21 22 Five or more 36 2 1 1 34 21 13 P. vivax 387 183 99 84 204 105 99 Once 234 137 74 63 97 45 52 Twice 80 36 20 16 44 26 18 Between 3 and 4 44 10 5 5 34 16 18 Five or more 29 0 0 0 29 18 11 Both 17 5 2 3 12 6 6 Once 6 1 0 1 5 3 2 Twice 7 3 1 2 4 2 2 Between 3 and 4 3 1 1 0 2 0 2 Five or more 1 0 0 0 1 1 0 Does not know 16 6 4 2 10 5 5 Once 16 6 4 2 10 5 5

Source: Survey of homes affected by malaria. Basis: Total Number of Surveyed Individuals ill with Malaria (956) Made by : APOYO Institute

123. 3. USE OF SERVICES

The average expense incurred by patients for medications was twice as much in Piura - Tumbes than in Loreto, not only at Hospitals but at Health Centers and Posts, and even at Private Consultations. The average time spent waiting and under medical care is longer in Piura-Tumbes than in Loreto. The fee charged for medical care at the Health Centers and Posts is higher in Loreto.

3.1 Place of medical care

It is noticeable that the majority of patients (85%) were seen at Health Centers and Posts in Tumbes-Piura, as well as in Loreto. In Piura and Tumbes, 10% of those seen at Health Centers and Posts were enrolled by the Sanitary technician and in Loreto, a similar percentage was visited by the Health Promoter.

3.2 Accessibility

The time it took to access the first consultation site is about 10 minutes in Piura-Tumbes and almost 20 minutes in Loreto.

3.3 Concentration

The average number of consultations in both regions is similar for all health providers (approximately 4 consultations at Hospitals and Health Centers and half for Private Consultations and Healers), except for Piura-Tumbes where 10 visits were reported for EsSalud and 2,5 to the Pharmacy, which is unparalleled in Loreto. Also, the cost of transportation is 5 times higher in Loreto than in Piura-Tumbes. The economic impact of malaria in Peru

124. Annex 2

Chart 8 Average money spent on medications by region and sex, according to place of consultation and age groups

Place of Consultation Total Piura-Tumbes Loreto and Age Groups Total Males Females Total Males Females

Total 11,6 15,5 15,6 15,4 7,1 6,7 7,5 Hospitals 11,7 50,0 20,0 57,5 1,6 2,2 0,8 Health Centers/Posts 11,2 14,6 14,8 14,3 7,5 6,8 8,3 ESSALUD 15,0 15,0 15,0 0,0 0,0 0,0 0,0 Pharmacies 13,0 13,0 14,0 10,0 0,0 0,0 0,0 Private Consultation 20,1 40,0 45,0 35,0 6,8 16,0 2,3 Healer 5,0 0,0 0,0 0,0 5,0 0,0 5,0 Health Promoter visited me 6,5 2,3 3,0 1,5 7,6 9,2 6,6 Sanitary technician enrolled me 11,7 11,7 12,1 11,1 0,0 0,0 0,0 Other 23,0 23,0 34,6 16,4 0,0 0,0 0,0 Does not know 3,0 0,0 0,0 0,0 3,0 0,0 3,0 Age Group 0 – 5 7,3 6,7 5,0 9,2 7,5 3,8 12,9 6 – 15 7,8 10,6 9,3 11,9 6,0 6,0 6,1 16 – 25 10,8 12,7 11,9 13,8 7,1 7,5 6,7 26 – 45 15,4 19,2 19,9 18,3 9,4 9,1 9,8 46 – 65 16,4 24,0 27,5 20,2 5,8 6,7 4,5 66 and older 5,2 6,6 8,0 3,0 2,7 3,4 0,4

Source: Survey of homes affected by malaria. Basis: Sick individuals who paid for medications (607 cases) Made by : APOYO Institute

As for the mortality, there is also a large difference. It is much higher in Loreto (85 deaths in 1997), although generally in Peru, mortality due to malignant Malaria has been fortunately low and on a downward trend from 1994 to 1997. The highest risk is concentrated around patients under 5 years old and older than 60.

In summary, in spite of the marked decrease observed in the number of malignant and benign malaria cases in Loreto, it is still evident that the Incidence Rate is higher in this region than in Piura-Tumbes, greater number of episodes per inhabitant and higher mortality.

125. 4. VECTOR CONTROL ACTIVITIES

In Loreto, the main response from the population has been the increased use of mosquito nets (sprayed or impregnated with pytethoids), taking advantage of the appearance of a vector with intra-domiciliary and night biting habits which include times when most people are asleep (Anopheles darlingi). The use of mosquito nets is part of an activity promoted and spread by the Regional Health Office, along with others destined to control new rearing sites, identified as the fish farm ponds and other ponds where Temephus-type larvicides were used.

The assessment of these interventions, which were applied particularly during the extended summer window period derived from the El Niño phenomenon in the Amazon area, shows that a dramatic decrease of the epidemic curve was attained. Although, some of their conclusions have not been yet confirmed due to deficiencies in the methodology, there are important indicators suggesting that intra domiciliary transmission was affected by this intervention, particularly those studies carried out in riverside communities along the Napo River.

It is important to tell an interesting experience conducted in Piura-Tumbes by the individuals in charge of a Community Project developed in some sample parcels of the San Juan de Catacaos Community.

The experience involved modifying the habitual watering scheme of continuous flooding of the rice crops, comparing it with three intermittent watering models which subjected the crops to 7 days of watering and 3, 6, or 9 dry days in each one of the three experimental models to be tested.

Later, an assessment was conducted of the presence of various stages of anopheline larvae in the puddles, as well as the presence of pupae stage and the output of the rice crops. In the model of watering plus 9 dry days, a clear decrease in all larvae stages and a total absence of pupae were observed, keeping the rice crop production unaltered.

This was tested for two years and, at present, they are attempting a larger scale test, trying to achieve a multiplying effect by imitation. An additional economic advantage (not quite evident at present because farmers do not pay for the water they use in watering) is a savings of 40% water with the new scheme of 7 and 9 days of watering/dry. INDEX OF ANNEXES OF MALARIA STUDIES NOT INCLUDED IN THIS EDITION

Survey sheet of MOH and other Institutions.

Format to collect information about direct cost.

Questionnaire for MOH and other Institutions.

Interview form for tourist operators.

Questionnaire of malaria survey.

Surveyor’s manual.

Summary chart of the tourist operators interviews.

If you want asking for any annexes from this list, please apply for it to Proyecto Vigía, located at Camilo Carrillo 402, Jesús María, Lima; or telephone 51 (1) 332-3482 51 (1) 332-3458; fax 51 (1) 332-3458; or via e-mail: [email protected] This book was was printed by Editorial Supergráfica E.I.R.L. Jr. Ica 344-346, Lima 1 Telephone: 51(1) 4266470