Ir et al. MWJ 2020, 11:2 OPEN ACCESS Cost-effectiveness of malaria elimination in Sampov Loun Operational District, Cambodia Ir Por1, Siv Sovannaroth2, Alexander Moran3, Lek Dysoley2, Sokomar Nguon4, Om Bunthy5, May Sak Meas5, Lawrence Barat6, Rida Slot6, Sharon Thangadurai4, Bryan K. Kapella6, Saad El-Din Hassan6, Ly Po2, Sen Sam An4, John E. Gimnig6, Mary McDowell6, Michael Thigpen6, Jennifer Armistead6, Hala Jassim AlMossawi3, Soy Ty Kheang1,4, Neeraj Kak3* 1 National Institute of Public Health, Phnom Penh, Cambodia; 2 National Malaria Control Program, Phnom Penh, Cambodia; 3 Universi- ty Research Co., LLC (URC), Chevy Chase, MD, USA; 4 PMI/USAID Cambodia Malaria Elimination Project, Phnom Penh, Cambodia; 5 Sampov Loun Operational District, Battambang Province, Cambodia; 6 US President’s Malaria Initiative, United States Agency for In- ternational Development,Washington DC, USA. *email: [email protected] Background. Over the past decade, Cambodia has seen a significant decline in its malaria burden. The gov- ernment has established the goal of eliminating malaria in the country by 2025. With PMI/USAID support, Cambodia is implementing a package of interventions as part of its efforts. This assessment aimed to describe the cost of malaria elimination activities in Sampov Loun Operational District (OD) between July 2015 and March 2018, to describe the cost per malaria case detected under PMI programming, and to estimate the in- cremental cost-effectiveness of the elimination programme per Plasmodium falciparum (Pf) or P. vivax (Pv)/Pf mixed case averted under the Cambodia Malaria Elimination Programme (CMEP) and the U.S. President’s Malaria Initiative. Opportunity costs of government workers were also assessed to understand the theoretical cost of sustaining this programme through government efforts alone. Materials and Methods. We conducted an empirical micro-costing analysis based on elimination activities alone using CMEP internal project implementation data and corresponding epidemiologic data from July 2015 to March 2018 and empirical findings from implementation to date. We then constructed a cost model in Mi- crosoft Excel using empirical data and used a cost-effectiveness decision tree to describe programme effective- ness in the first three years of implementation and to estimate efficacy for the subsequent year. Results. The total cost of malaria elimination activities in Sampov Loun OD from July 2015 to March 2018 was $883,096. The cost per case of malaria detected in 2017 was $1,304. Including opportunity costs for government staff from July 2015 to March 2018, the total cost was $926,000. Under continued CMEP implementation, the projected future total cost of the program would be about $110,000 per year, or $0.64 per Sampov Loun resi- dent. The incremental cost-effectiveness of the elimination programme was $28 for every additional Pf or Pv/Pf mix malaria case averted, compared to the no-CMEP proxy. Conclusion. CMEP activities are cost effective compared to the no-CMEP proxy, as shown through an incre- mental cost-effectiveness of $28 for every additional Pf or Pv/Pf mix malaria case averted. The total cost of the project is 0.93% of the total per capita spending on health in Cambodia and about 5% of all government health expenditure. Continuing investments in malaria will be needed at national level for stewardship and gover- nance and at local level for ensuring programme readiness in case of malaria outbreaks. INTRODUCTION dissemination and replication for malaria elimina- tion in Cambodia. PMI-funded malaria elimination The US President’s Malaria Initiative (PMI) Control activities began in July 2015 in Sampov Loun Oper- and Prevention of Malaria (CAP-Malaria; 2011- ational District (SPL OD), Battambang Province. 2016) and CMEP (2016-2021) support the Cambo- In Cambodia, there has been a decline in con- dian National Center for Malaria Control, Para- firmed malaria cases from 8/1,000 people in 2006 to sitology and Entomology’s (CNM) goal of nation- 1/1,000 people in 2016 [1]. This decrease can be wide malaria elimination by 2025. PMI-funded attributed to widespread use of effective arte- malaria elimination activities, including CAP- misinin-based combination therapies (ACT), in- Malaria and CMEP, seek to develop a scalable, evi- creased access to long-lasting insecticide-treated dence-based elimination model in Sampov Loun nets (LLINs), and early diagnosis and appropriate (SPL) operational district (OD) and to support its treatment (EDAT). Additionally, behaviour change MalariaWorld Journal | ISSN 2214-4374 1 April 2020, Vol. 11, No. 2 Ir et al. MWJ 2020, 11:2 communication (BCC) services, particularly tiveness of additional Pf and Pv/Pf mix malaria cas- through the network of village malaria workers es averted under CMEP implementation compared (VMWs), established in 2004 under the auspices of to a no-CMEP proxy. CNM [2], and huge effort made by public health facilities (HFs), operational districts (ODs) and MATERIALS AND METHODS provincial health departments (PHDs) have con- tributed to this decrease. Building on the Malaria PMI-funded malaria elimination activities began in Elimination Action Framework 2016-20 (MEAF), SPL OD in July 2015. The start-up period included approved by CNM on 20 May 2015 [3], Cambodia July-December 2015 with 80% coverage, and full committed to the goal of reducing malaria inci- implementation (100% coverage) began in January dence to less than one per 1,000 people at risk in 2016. PMI-funded malaria elimination activities use each OD in the country and eliminating Pf, includ- an OD-centered approach to build capacity for on- ing multidrug resistance, by 2020. going malaria control and elimination. The project Since March 2016, no locally transmitted cases team supported development, implementation, and of malaria have been detected in Sampov Loun OD. monitoring of OD annual operational plans, intro- The majority are among SPL residents who travel ducing data visualisation to support evidence- outside of SPL for short-term work in the forestry based decisions. Joint supervision at all levels were or agricultural sector with some cases among mi- used to improve the quality of care and routine re- grant workers coming into SPL OD for temporary porting. To increase inclusion of at-risk-popula- employment. Currently, most cases reported are tions, the project team worked with community among young males (15-49 years of age) who live networks for better access to and quality of early or work in forested areas or on private farms near diagnosis and treatment (EDAT). It also strength- forests. With PMI support, from 2015-2016, the ened passive and active surveillance systems, sup- number of malaria cases in supported areas de- ported distribution of LLINs, and implemented creased by 57 percent. In recent years, outbreaks behaviour change communication (BCC) activities have occurred in geographic areas with high migra- to promote prevention and treatment-seeking be- tion as people move due to land clearance for agri- haviours. cultural settling or other commercial purposes. In A specific example of these activities is the 1-3-7 addition, increasing artemisinin resistance, detect- approach to elimination. Briefly, this approach aims ed following the failure of artesunate-mefloquine to identify suspected malaria cases by VMWs or at combination therapy (ASMQ) in 2008, and then HFs. All suspected cases are tested via either RDTs rapid development of molecular signs of resistance or microscopy on day one. Patients with negative to Malarone (atovaquone-proguanil) in 2013 [4], results are advised to seek consultation at a public and rapid development of treatment failures to di- health facility, and patients with positive results are hydroartemisinin-piperaquine (DHA-PIP) reported immediately placed on a three-day directly ob- in 2016/17, have made the goal of achieving malar- served therapy (DOT) regimen with ASMQ or simi- ia elimination in Cambodia challenging. larly appropriate therapy for pregnant women or Since 2017, CMEP has worked closely with people with drug resistance. All confirmed malaria stakeholders to continue implementation of malaria cases are reported to OD health authorities within elimination activities in SPL OD, which were begun one day of diagnosis. Within three days, case inves- under the predecessor project CAP-M, and has tigations, which include interviews with index cas- supported introduction of malaria elimination ac- es and resultant case classification, are conducted tivities in four additional ODs: Battambang, Maung by village malaria workers and health facility staff. Russey, Thmar Kaul and Pailin. This study is an Finally, within seven days, targeted response mea- activity-based empirical micro-costing analysis us- sures are undertaken, although these often happen ing data reported by the CMEP Project team. We within three days in conjunction with case investi- examine the cost of USAID/PMI-funded malaria gation activities. These response measures included elimination activities in Sampov Loun OD, assess reactive case detection (initially testing of co-trav- government opportunity costs of implementing the ellers, household contacts and family members, program, and project the incremental cost effec- and surrounding households with suspected MalariaWorld Journal | ISSN 2214-4374 2 April 2020, Vol. 11, No. 2 Ir et al. MWJ 2020, 11:2 malaria cases, and later only testing of co-travellers ducted under the CAP-Malaria Project, which was and family members after no additional cases were extended to January 2017. Cost estimates were identified in other groups), and provision of health based on activities focused exclusively on malaria education and insecticide-treated nets. Additional- elimination and were defined based on the classifi- ly, 28-day follow up microscopy is conducted for all cations shown in Table 1. Financial data are report- confirmed Pf and Pf/Pv mix cases to assess treat- ed in inflation-adjusted 2018 $US based on the av- ment efficacy. erage inflation rate of 3% prevailing in Cambodia for the period [5]. Cost of malaria elimination activities in Sampov Project staff costs were estimated based on URC Loun OD accounting records.