Cost-effectiveness of intermittent preventive treatment of malaria in pregnancy in southern Mozambique

Elisa Sicuri, Azucena Bardají, Tacilta Nhampossa, Maria Maixenchs, Ariel Nhacolo, Delino Nhalungo, Pedro L Alonso, Clara Menéndez, Elisa Sicuri, Azucena Bardají, Tacilta Nhampossa, Maria Maixenchs, Ariel Nhacolo, Delino Nhalungo, Pedro L Alonso, Clara Menéndez

Abstract

Background: Malaria in pregnancy is a public health problem for endemic countries. Economic evaluations of malaria preventive strategies in pregnancy are needed to guide health policies.

Methods and findings: This analysis was carried out in the context of a trial of malaria intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP), where both intervention groups received an insecticide treated net through the antenatal clinic (ANC) in Mozambique. The cost-effectiveness of IPTp-SP on maternal clinical malaria and neonatal survival was estimated. Correlation and threshold analyses were undertaken to assess the main factors affecting the economic outcomes and the cut-off values beyond which the intervention is no longer cost-effective. In 2007 US$, the incremental cost-effectiveness ratio (ICER) for maternal malaria was 41.46 US$ (95% CI 20.5, 96.7) per disability-adjusted life-year (DALY) averted. The ICER per DALY averted due to the reduction in neonatal mortality was 1.08 US$ (95% CI 0.43, 3.48). The ICER including both the effect on the mother and on the newborn was 1.02 US$ (95% CI 0.42, 3.21) per DALY averted. Efficacy was the main factor affecting the economic evaluation of IPTp-SP. The intervention remained cost-effective with an increase in drug cost per dose up to 11 times in the case of maternal malaria and 183 times in the case of neonatal mortality.

Conclusions: IPTp-SP was highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in Mozambique. These findings are likely to hold for other settings where IPTp-SP is implemented through ANC visits. The intervention remained cost-effective even with a significant increase in drug and other intervention costs. Improvements in the protective efficacy of the intervention would increase its cost-effectiveness. Provision of IPTp with a more effective, although more expensive drug than SP may still remain a cost-effective public health measure to prevent malaria in pregnancy.

Trial registration: ClinicalTrials.gov NCT00209781.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Maternal malaria: acceptability curve of…
Figure 1. Maternal malaria: acceptability curve of the cost-effectiveness ratio of IPTp-SPa vs hypothetical willingness to payb.
a Intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine. b Acceptability curves were constructed by plotting the cumulative distribution of ICER of IPTp-SP per DALYs averted. The Y axis can be interpreted as probability that the intervention is cost-effective for every level of policy makers' ability or willingness to pay for each DALY averted (X axis). * 36 US$ per DALY averted = threshold of highly cost-effective intervention; 129 US$ per DALY averted = threshold of cost-effective intervention.
Figure 2. Correlation of cost-effectiveness ratios, savings,…
Figure 2. Correlation of cost-effectiveness ratios, savings, and input variables (Spearman's Rank).
a Intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine. bAntenatal Clinic (ANC) attendance at least twice during pregnancy. c Rate per person-year at risk in the placebo group. d Drug costs for inpatients refers to intravenous quinine. e Drug costs for outpatients are relative to artesunate plus SP. f It indicates the proportion of pregnant women with symptoms of malaria who seek formal health care.
Figure 3. Threshold analysis of the cost-effectiveness…
Figure 3. Threshold analysis of the cost-effectiveness of IPTp-SPa.
a Intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine b 129 US$/DALY averted. c 36 US$/DALY averted. Within the simulation ranges of each variable: * a threshold of 92.92 US$ was reached only. † a threshold of 96.79 US$ was reached only. ‡ a threshold of 85.99 US$ was reached only. ξ a threshold of 97.25 US$ was reached only.
Figure 4. Neonatal mortality: acceptability curve of…
Figure 4. Neonatal mortality: acceptability curve of the cost-effectiveness ratio of IPTp-SPa vs hypothetical willingness to payb.
a Intermittent preventive treatment of malaria in pregnancy with sulphadoxine-pyrimethamine. b Acceptability curves were constructed by plotting the cumulative distribution of ICER of IPTp-SP per DALYs averted. The Y axis can be interpreted as probability that the intervention is cost-effective for every level of policy makers' ability or willingness to pay for each DALY averted (X axis).

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