Antimalarial drugs are not the only pressing health care need in sub-Saharan Africa, where AIDS, tuberculosis, and a host of other infectious and other diseases also claim lives prematurely. And resources allocated to malaria can be spent on bednets, indoor spraying, or other measures, and not necessarily on antimalarial drugs. Thus drugs must compete for both public and private funds on grounds of their value for the dollars spent: their cost-effectiveness.

The question most relevant to this study is the cost-effectiveness of treating versus not treating acute episodes of malaria (the latter includes using an ineffective drug as well as no treatment). In the short term (possibly the next 5 years), it also is relevant to ask whether it would be beneficial to switch from failing but affordable chloroquine, to an intermediate drug that is as inexpensive as chloroquine, but which can only last a few years because of rapidly evolving resistance. In this scenario, a switch to more expensive ACTs would be expected within a few years, but in the meantime, considerable funds might be saved. The only drug that currently meets the conditions for such an intermediate is SP, but the analysis might apply in the future to other drugs. We look at both the cost-effectiveness of treatment versus no treatment, and of switching to a stopgap drug and then to ACTs.

Benchmarks for Cost-Effectiveness

There are no firm benchmarks or cutoff points to separate interventions that are deemed worth the cost (“cost-effective”) and those that are not, but there are some guidelines.5 At one end, a 1996 WHO Ad Hoc Committee recommended that, for low-income countries with a GDP per capita of less than $765, interventions that cost $25 or less per disability-adjusted life-year (DALY)6 were “highly attractive,” and those costing $150 or less per DALY were “attractive” (all figures in 1996 dollars) (World Health Organization, 1996).

More recently, the Commission on Macroeconomics and Health suggested that interventions costing less than three times GDP per capita for


All link cost-effectiveness judgments to some measure of national wealth. Cost-effectiveness is a relative concept: what is considered a bargain in a high-income country may be completely out of range for a low-income country.


The DALY is a summary measure of disease burden that incorporates years lost by premature death with years of life lived with disability. It allows comparison of the influence of different diseases whose effects on mortality, morbidity, and disability differ. One DALY can be considered as one year of “healthy” life.

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