Malaria control: the power of integrated action
Cost-effectiveness of IVM
There is a need for more frequent and rigorous economic analysis of malaria-control programmes at field and country level, so that the costs and benefits of alternative approaches may be compared (25,28). Many malaria vector-control programmes lack the capacity to carry out thorough cost-effectiveness evaluation of the intervention options at their disposal, even though WHO guidelines for such analysis have been available for over a decade (25, 28, 29).
Nonetheless, analysis of certain environmental management experiences indicates that integrated management could potentially be more cost effective than ‘single-intervention’ malaria control efforts. A successful environmental management programme for malaria, undertaken in the 1930s in four copper mining communities of colonial Zambia (northern Rhodesia), has been the focus of interest recently - due to the very detailed records that were maintained of programme costs and illness rates (see also case studies). A retrospective analysis of the programme estimated that net costs per death averted averaged US $333.42 in present-day terms. This value is at the lower end when compared with cost-effectiveness analyses of contemporary programmes for insecticide-treated nets; residual spraying of houses; chemoprophylaxis; and improved malaria treatment; conducted in the Gambia, Ghana, Kenya and South Africa, (30, 31, 32).
In a more recent experience, an environmental management effort in an industrial township of India has been positively reviewed for its operational feasibility, sustainability and cost effectiveness (33). Significantly, the same improvements that were integral to integrated malaria control, e.g. better housing, or medical services, yielded other social, economic, and health co-benefits.
Another recent study, in Sri Lanka, has indicated that the costs of periodic river flushing to eliminate mosquito breeding habitats compared favourably with the use of insecticide-impregnated bednets as a mosquito-control measure (34). When the broader macroeconomic benefits of such approaches are considered, then the benefits of integrated vector control may outweigh additional costs to an even greater extent.
Successful environmental management of malaria was not only a feature of colonial Zambia's copper industry growth, but was a critical factor in the success of other development projects of the early part of the last century. These included the Panama Canal, the Tennessee Valley Authority, and the development of rubber and tea plantations and port cities in Malaysia. Environmental management also has been regarded as a key to the success of malaria control in Italy in the 1920s, and in the Indonesian archipelago between 1920 and 1935.
To achieve results, however, malaria control needs to be redefined as not only a health-service function, but one that includes agricultural, water-management, and entomological expertise. Design of integrated control programmes needs to be locally managed and flexible, and to include continuous evaluation of the results in order to target strategies for the best outcome. This approach fits well with the new emphasis being placed on decentralization, community participation, and the harnessing of local knowledgein many developing countries.
But malaria control also has something to learn from the private sector. By adopting the ‘evolutionary operation’ practices of industrial management (EVOP) – which promote a process of constant tuning and adaptation of management approaches – mistaken assumptions can be corrected and support development of more successful, highly-tuned programmes, rather than leading to programme collapse and failure (25).