and institutional and administrative conditions. Such exercises can greatly improve resource allocation and program decisions by local-level managers.

In two studies (Kaewsonthi, 1989; Mills, 1987), comparisons among techniques of vector control, and between vector control and therapy, were illuminated by carefully calculating the costs at the local level. The authors also were able to propose a set of practical recommendations based on their analyses. Mills, for example, was able to suggest reducing active malaria case detection and increasing investment in malaria clinics (or other treatment-based facilities) in Nepal. According to that study, either alternative was more cost-effective than spraying pesticide to kill mosquitoes.

Although few studies have done so, operational research can be used to assess “decreasing effectiveness”—the point at which the cost-effectiveness ratio of a given intervention drops enough to merit a reevaluation of its worth. Using such a method, Ettling et al. (1990) documented the increasing costs of expanding clinic coverage in a district in Thailand, making clear the trade-off between numbers of cases treated and the cost per case. Researchers at the Centers for Disease Control (Sudre et al., 1990) examined the relative costs of alternative drug therapies under differing degrees of chloroquine resistance. The salient variables in this decision-making process, including patient compliance with drug regimens, were also identified.

A review of the regulation and control of pharmaceuticals in Africa south of the Sahara (Foster, 1990) highlights the savings and improved health resulting from the effective use of drugs, and the costs of misdiagnosis, prescribing errors, and compliance failure. Another study took a more theoretical approach: the relative merits of over-the-counter and prescription drug sales were examined, and the possible loss of accurate drug use of the former was compared with its potential for increasing access and affordability (Hammer, in press). Other ongoing work has highlighted the problems of malaria-related infant and child mortality in endemic regions of Africa. One conclusion emerging from that work is that prenatal prophylaxis, undertaken early in pregnancy and especially for first pregnancies, can reduce low birth weight and infant mortality. From a policy perspective, this raises the issue of how women who have not felt sick from malaria for years and who do not normally seek prenatal care can be convinced to take preventive measures. All of these studies suggest that improved education of prescribers or patients about drug therapies can have beneficial effects.

Economics and Policymaking

In any analysis of any government program, such as malaria control, it is important to realize that different decision makers have fundamentally



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