Cost·effective control in Brazil

30 World Health • SlstYeor, No. 3, Moy-June 1998

Cost·effective control in Brazil

Renato d' A. Gusmiio

Between 1989 and 1996, Brazil's malaria control programme cost USS 616 million but prevented

1 830 OOO cases and over 100 OOO deaths; the reduced incidence led to savings on treatment costs estimated at

S 42.7 million.

M

alaria has been endemic in Brazil for most of the last 300 years, but it was only in the early twentieth century that a concerted effort was launched against the disease. The initial emphasis was on reducing mosquito breeding sites close to the expanding industrial towns, and on distributing cinchona bark to treat patients.

By the middle of the twentieth century, there was heavy investment in a national programme to eradi- cate malaria from around the cities and from the rural areas. The pro- gramme relied heavily on indoor spraying with the newly developed DDT insecticide and the availability of chloroquine for treatment. Early efforts met with considerable suc- cess: while the country's population almost doubled in size up to 1974, the number of malaria cases fell to half what it was in 1960.

But then the techniques of house- spraying and active case-detection for supervised treatment became progressively less effective. Malaria cases increased almost tenfold, from 66 481 notifications in 1974 to 614 431 registered cases in 1991.

A strategy was tried in the 1980s called "zonification", based on the permanent presence in each highly endemic zone of a national pro- gramme worker, responsible for mass treatment and house-spraying

with insecticide. The high mainte- nance costs of this operation soon proved unsustainable.

By 1989, the Ministry of Health had obtained a World Bank loan to support a strengthened malaria eradication drive based on a classical campaign approach by a single institution, the National Health Foundation (NHF). It focused on vector control by indoor spraying with residual insecticides, and active case-detection. It was clear by 1992 that these activities were ineffective, and three factors particularly were blamed: the fact that the disease was mostly transmitted outside the home, the logistic difficulties of reaching the population at risk, and the lim- ited coverage of the health services delivery system. In addition, the massive migration of labour to forested areas of the Amazon Basin drastically reduced the potential effectiveness of the control mea- sures.

The NHF asked WHO's Regional Office for the Americas - the Pan American Health Organization - to step up its technical cooperation so that activities could be reoriented in line with the Global Malaria Control Strategy. This was the first country- wide application of the new Strategy in the Americas. The long-standing objective of eradicating malaria was replaced by the goal of preventing mortality and reducing the socio- economic and morbidity burden of the disease on those at risk.

Alongside a rapid improvement in local health services, there was new emphasis on disease manage- ment (particularly early diagnosis and immediate treatment), on tar- geted preventive and protective measures for individuals, families and communities, including vector control, and on increased capability to detect, control and avoid malaria epidemics. Local and regional health education institutions also targeted such high-risk groups as

Preparing blood samples for analysis in the Amazon Region. Case detection is an impor·

font element in Brazil's elimination campaign.

Photo WHO/TDR/M. Edwards

mining prospectors, lumber workers and farming families. The number of diagnostic and treatment centres, now integrated into the general health services, expanded between 1992 and 1996 from 618 to 1038.

Over the same period, malaria mortality fell by 20.8% and the Plasmodium falciparum incidence rate dropped from 13 per 1 OOO population exposed to transmission to 8 per 1000. Subsequent evalua- tion of this programme found that, between 1989 and 1996, the total cost of the control programme was US$ 616 million, while the total number of cases and deaths pre- vented amounted to 1 830 OOO and over 100 OOO respectively. The reduced incidence led to savings on treatment costs estimated at$ 42.7 million - a result that amply demon- strates the cost-effectiveness of the control strategy in demographically and ecologically unstable areas of development such as the Amazon region of Brazil. •

Dr Renato d'A. Gusmao is Regional Adviser, Communicable Diseases Programme, World Health Organization Regional Office for the Americas/Pan American Sanitary Bureau, 525, 23rd Street NW, Washington, DC 20037, USA.