Background
Methods
Model overview
Programme description
-
Arm 1: simple subsidy of RDTs for sale at 100 Kyat (approximately $0.12) to retailers with a support visit every month
-
Arm 2: RDT subsidy with financial incentive: one free RDT for every five purchased with a support visit every month
-
Arm 3: RDT subsidy with support visits every two weeks.
Data input values
Parameter
|
Input value
|
Source
| |
---|---|---|---|
Epidemiology
| |||
Percentage of P. falciparum (P.f.)/P. vivax (P.v.) malaria | 65% P.f./35% P.v.
| Published data [23], PSI Myanmar stock audit data | |
Proportion of febrile cases in population that are malaria | 8% | PSI Myanmar MIS data (Sun Primary Health) | |
Average number of febrile patients that visit one private provider per month | 20 | PSI Myanmar MIS data (Sun Primary Health) | |
Health outcomes
| |||
Case fatality rates for P. falciparum malaria | Given ACT | 0.01% | Very low probability |
Given chloroquine or quinine | 0.7% | Published data on falciparum drug resistance [24] | |
Given no anti-malarial | 3% | ||
Case fatality rates for P. vivax
| Given ACT | 0.01% | Very low probability |
Given chloroquine or quinine | 0.01% | Published P. vivax treatment rates with chloroquine in Papua [27] | |
Given no anti-malarial | 1% | Extrapolated from published materials from Papua [28] | |
Case fatality rate for non-malarial febrile illnesses | Given ACT or other anti-malarial | 0.2% | Published data from Bago, Myanmar [25] triangulated with PSI MIS data |
Given no anti-malarial | 0.16% | ||
Average duration of malaria illness without effective treatment | 1 week | Published data on hospital records in Myanmar [31] | |
Average duration of non-malarial febrile illness | 1 week | Assumption | |
DALY weight of malaria | 0.2 | Published data [21] | |
DALY weight of non-malarial fever | 0.18 | Estimated from published data [22] | |
Mean life expectancy in Myanmar | 62 years | ||
Average age of malaria-induced death in intervention townships | 25 years | PSI Myanmar MIS data | |
Average age of non-malarial febrile death in Myanmar | 30 years | PSI Myanmar MIS data | |
Discount rate | 3% | Standard rate | |
Diagnostic test characteristics
| |||
RDT sensitivity and specificity |
P. falciparum sensitivity | 100% | Published RDT performance [35] |
P. falciparum specificity | 97% | Published RDT performance [35] | |
Pan plasmodium sensitivity | 92% | Published RDT performance [35] | |
Pan plasmodium specificity | 98% | Published RDT performance [35] |
Provider behaviour
|
No intervention
|
Arm 1
|
Arm 2
|
Arm 3
| |
---|---|---|---|---|---|
Probability of clinical diagnosis | 0.98 | 0.98 | 0.98 | 0.92 | |
Probability of using RDT | 0.02 | 0.02 | 0.02 | 0.08 | |
Diagnosis | Medicine prescribed | ||||
Clinical Diagnosis | ACT | 0.05 | 0.12 | 0.12 | 0.19 |
Other anti-malarial | 0.03 | 0.07 | 0.07 | 0.07 | |
No anti-malarial | 0.92 | 0.81 | 0.81 | 0.74 | |
RDT Pan + falciparum + | ACT | 0.75 | 0.78 | 0.84 | 0.87 |
Other anti-malarial | 0.05 | 0.05 | 0.05 | 0.05 | |
No anti-malarial | 0.2 | 0.17 | 0.11 | 0.08 | |
RDT Pan + falciparum - | ACT | 0.5 | 0.10 | 0.10 | 0.10 |
Other anti-malarial | 0.25 | 0.45 | 0.45 | 0.45 | |
No anti-malarial | 0.25 | 0.45 | 0.45 | 0.45 | |
RDT Pan - falciparum + | ACT | 0.75 | 0.78 | 0.84 | 0.87 |
Other anti-malarial | 0.05 | 0.05 | 0.05 | 0.05 | |
No anti-malarial | 0.2 | 0.17 | 0.11 | 0.08 | |
RDT Pan - falciparum - | ACT | 0.4 | 0.057 | 0.083 | 0.022 |
Other anti-malarial | 0.02 | 0.029 | 0.056 | 0.089 | |
No anti-malarial | 0.58 | 0.914 | 0.861 | 0.889 |
Annual direct programme first year costs (non-recurrent in italics)
| ||||
---|---|---|---|---|
Costs for RDT intervention, 600 providers
|
No intervention
|
Arm 1
|
Arm 2
|
Arm 3
|
Interpersonal communicators
| $0 |
$34,599
|
$34,599
|
$34,599
|
Jr Health Service Officers | $0 | $17,568 | $17,568 | $17,568 |
Product promoters | $0 | $31,374 | $31,374 | $62,748 |
Office personnel | $0 | $79,186 | $79,186 | $79,186 |
Incentives for providers
|
$0
|
$17,784
|
$17,784
|
$17,784
|
Commodities | $95,614 | $103,658 | $104,087 | $119,127 |
Materials for providers | $0 | $19,656 | $19,656 | $19,656 |
Materials for product promoters | $0 | $324 | $324 | $324 |
Field staff training
|
$6,951
|
$6,951
|
$6,951
| |
Field staff transport: monthly office visits | $0 | $30,834 | $30,834 | $53,028 |
Motorcycle taxi | $0 | $39,202 | $39,202 | $59,402 |
PSI Overhead | $0 | $5,329 | $5,329 | $5,329 |
Shipping logistics | $0 | $1,271 | $1,271 | $1,271 |
Total, year 1
|
$95,614
|
$387,735
|
$388,163
|
$476,973
|
Non-recurrent, year 1
|
$0
|
$59,334
|
$59,334
|
$59,334
|
Recurrent annual
|
$95,614
|
$328,401
|
$328,829
|
$417,639
|
Commodity cost per unit
| ||||
No intervention
|
Arm 1
|
Arm 2
|
Arm 3
| |
RDT societal cost (donor + patient) | $1.16 | $0.68 | $0.80 | $0.68 |
ACT | $1.65 | $1.65 | $1.65 | $1.65 |
Quinine and chloroquine | $0.55 | $0.55 | $0.55 | $0.55 |
‘No anti-malarial’ (70% antipyretics, 30% antibiotics) | $0.58 | $0.58 | $0.58 | $0.58 |
Patient and provider time and travel costs
| ||||
Costs for RDT intervention, 600 providers
|
No intervention
|
Arm 1
|
Arm 2
|
Arm 3
|
Patient and provider time costs | $0 | $53,366 | $53,366 | $64,498 |
Provider travel costs to restock RDTs | $0 | $79,344 | $79,344 | $79,344 |
Sensitivity analysis
Ethical considerations
Results
Costs
Scenario (societal)
|
Total cost
|
Drug and RDT costs (scaled to uptake)
|
Programmatic staff and non-commodity costs
|
Patient and provider time costs
*
|
Provider travel costs
**
| |
---|---|---|---|---|---|---|
Total
|
(RDT donor only)
| |||||
No intervention
| $96,996 | $95,614 |
$0
|
$0
| $1,382 | $0 |
Arm 1: simple subsidy
| $625,486 | $103,658 |
$1,037
|
$387,735
| $54,748 | $79,344 |
Arm 2: subsidy with financial incentive
| $626,342 | $104,087 |
$1,382
|
$388,163
| $54,748 | $79,344 |
Arm 3: subsidy with IEC
| $734,339 | $119,127 |
$4,147
|
$476,973
| $58,896 | $79,344 |
Health outcomes
Subsidy scheme
|
Total costs
|
Added costs
vs
prior strategy
|
Total DALYs incurred
|
DALYs averted
vs
prior strategy
|
Incremental cost per DALY averted
vs
prior strategy
|
Cost per DALY averted
vs
no intervention
|
---|---|---|---|---|---|---|
No intervention
| $96,996 | -- | 10,155 | -- | -- | -- |
Arm 1: Simple subsidy
| $625,486 | $528,490 | 9,703 | 452 | $1,169 | $1,169 |
Arm 2: Subsidy with financial incentive
| $626,342 | $857 | 9,698 | 5 | $185 | $1,159 |
Arm 3: Subsidy with IEC
| $734,339 | $107,997 | 9,158 | 540 | $200 | $639 |
Incremental cost-effectiveness ratios
Sensitivity analysis
Parameter
|
Value (Low, high of range)
|
Order**
|
ICERs ($/DALY averted)
| ||
---|---|---|---|---|---|
Low, high of range
| |||||
2
nd
vs
1
st
|
3
rd
vs
2
nd
|
4
th
vs
3
rd
| |||
Inputs that affect costs and health outcomes
| |||||
Base case | N/A | C, 1, 2, 3 | $1,169 | $185 | $200 |
Probability of using RDT in arm 1 (base case 0.02)
|
0.00
|
C, 1, 2, 3
|
$1,389
|
$53
|
$200
|
0.65
|
C, 2, 1, 3
|
1,159
|
$45
|
Dominated (DOM)
| |
Probability of using RDT in arm 2 (base case 0.02)
|
0.00
|
C, 2, 1, 3
|
$1,390
|
$39
|
$200
|
0.65
|
C, 1, 3, 2
|
$1,169
|
$3
|
$2
| |
Probability of using RDT in arm 3 (base case 0.08) | 0.02 | C, 1, 2, 3 | $1,169 | $185 | $317 |
0.65 | C, 1, 2, 3 | $1,169 | $185 | $72 | |
Number of febrile patients seeking care per private sector provider per month (base case 40) | 1 | C, 1, 2, 3 | $23,046 | $1,939 | $3,323 |
40 | C, 1, 2, 3 | $594 | $139 | $118 | |
Probability of ‘no anti-malarial’ administration for clinical diagnosis, arm 1 (base case 0.81)**
|
0.5
|
C, 2, 1, 3
|
$1,159
|
$34
|
DOM
|
0.93
|
C, 1, 2, 3
|
DOM
|
$1,159
|
$200
| |
Probability of ‘no anti-malarial’ administration for clinical diagnosis, arm 2 (base case 0.81)***
|
0.5
|
C, 1, 2, 3
|
$1,169
|
$35
|
DOM
|
0.93
|
C, 2, 1, 3
|
DOM
|
$1,169
|
$200
| |
Probability of ‘no anti-malarial’ administration for clinical diagnosis, arm 3 (base case 0.74)*** | 0.5 | C, 1, 2, 3 | $1,169 | $185 | $93 |
0.93 | C, 1, 2, 3 | $1,169 | $185 | DOM | |
Probability of ACT administration for clinical diagnosis, no intervention (base case 0.05)*** | 0.05 | C, 1, 2, 3 | $1,169 | $185 | $200 |
0.4 | C, 1, 2, 3 | DOM | $200 | $200 | |
Inputs that affect costs only
| |||||
Programme costs per febrile individual (base case $0 for C, $3.61 for arms 1 and 2, and $4.23 for arm 3) | $2 | C, 1, 2, 3 | $655 | $92 | $36 |
$10 | C, 1, 2, 3 | $3,204 | $92 | $36 | |
Cost of ‘no anti-malarial’ (base case $0.58) | $0.30 | C, 1, 2, 3 | $1,178 | $194 | $205 |
$1.00 | C, 1, 2, 3 | $1,156 | $272 | $193 | |
Cost of ACT, same across all arms (base case $1.65) | $0.50 | C, 2, 1, 3 | $1,148 | $179 | $99 |
$2.50 | C, 1, 2, 3 | $1,186 | $199 | $214 | |
Probability of using RDT for no intervention (base case 0.02) | 0.02 | C, 1, 2, 3 | $1,169 | $185 | $200 |
0.11 | C, 1, 2, 3 | $4,183 | $185 | $200 | |
Cost of other anti-malarial, same across all arms (base case $0.55) | $0.18 | C, 1, 2, 3 | $1,165 | $179 | $200 |
$1.65 | C, 1, 2, 3 | $1,183 | $201 | $201 | |
Inputs that affect health outcomes only
| |||||
Probability of death for non-malarial fever given no anti-malarial (base case 0.0016) | 0.001 | C, 1, 2, 3 | $1,873 | $297 | $247 |
0.05 | C, 1, 2, 3 | $37 | $6 | $12 | |
Probability of death for non-malarial fever given ACT (base case 0.002) | 0.001 | C, 1, 2, 3 | $846 | $140 | $153 |
0.05 | C, 1, 2, 3 | DOM | DOM | DOM | |
Percentage of febrile illnesses that are malaria (base case 8%) | 3% | C, 1, 2, 3 | $7,825 | $1,363 | $787 |
20% | C, 1, 2, 3 | $384 | $60 | $72 | |
Probability of death for non-malarial fever given other anti-malarial (base case 0.002) | 0.001 | C, 1, 2, 3 | $940 | $141 | $198 |
0.05 | C, 1, 2, 3 | DOM | DOM | DOM | |
Discount rate (base case 3%) | 0% | C, 1, 2, 3 | $673 | $106 | $117 |
5% | C, 1, 2, 3 | $1,592 | $253 | $269 | |
Probability of death for P. falciparum malaria given no anti-malarial (base case 0.03) | 0.005 | C, 1, 2, 3 | DOM | DOM | $9.960 |
0.04 | C, 1, 2, 3 | $829 | $128 | $149 | |
Life expectancy in Myanmar (base case 62) | 50 | C, 1, 2, 3 | $1,475 | $234 | $252 |
80 | C, 1, 2, 3 | $974 | $153 | $166 |