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Bioeconomic analysis of child-targeted subsidies for artemisinin combination therapies: a cost-effectiveness analysis.

Klein EY, Smith DL, Cohen JM, Laxminarayan R - J R Soc Interface (2015)

Bottom Line: Because the vast majority of malaria deaths occur in children, targeting children could potentially improve the cost-effectiveness of the subsidy, though it would avert significantly fewer deaths.However, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage (i.e. older individuals taking young child-targeted doses) increases, with few of the benefits of a universal subsidy gained (i.e. reductions in overall prevalence).Although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage.

View Article: PubMed Central - PubMed

Affiliation: Center for Disease Dynamics, Economics and Policy, Washington, DC, USA Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.

ABSTRACT
The Affordable Medicines Facility for malaria (AMFm) was conceived as a global market-based mechanism to increase access to effective malaria treatment and prolong effectiveness of artemisinin. Although results from a pilot implementation suggested that the subsidy was effective in increasing access to high-quality artemisinin combination therapies (ACTs), the Global Fund has converted AMFm into a country-driven mechanism whereby individual countries could choose to fund the subsidy from within their country envelopes. Because the initial costs of the subsidy in the pilot countries was higher than expected, countries are also exploring alternatives to a universal subsidy, such as subsidizing only child doses. We examined the incremental cost-effectiveness of a child-targeted policy using an age-structured bioeconomic model of malaria from the provider perspective. Because the vast majority of malaria deaths occur in children, targeting children could potentially improve the cost-effectiveness of the subsidy, though it would avert significantly fewer deaths. However, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage (i.e. older individuals taking young child-targeted doses) increases, with few of the benefits of a universal subsidy gained (i.e. reductions in overall prevalence). Although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage.

No MeSH data available.


Related in: MedlinePlus

Estimated demand for quality-assured ACTs (ACTq) with child-targeted subsidy in pilot countries over 5-year time frame. Estimated demand for ACTq assuming that the subsidy targets only doses for children less than 5 with varying levels of leakage for two different demand elasticites, low (a) and high (b). Leakage assumes that older individuals are taking doses intended for children less than 5. Older individuals who take child doses are assumed to either ‘stack’ (take more than one child dose) or underdose. For those who underdose, only a proportion of population is assumed to adequately clear an infection, and the rest have an increase in the probability of resistance. The universal subsidy scenario is a subsidy for all ages. Because the universal subsidy reduces the prevalence rate, fewer children are infected and the total treatments for children is less than in the universal subsidy case. Bar heights are the mean and error bars are the uncertainty range (one standard deviation of the mean) of the sensitivity analysis. These are compared to an estimate of the total number of ACTq doses that would be demanded by the private-for-profit sector of each country based on data from the Global Fund for ACTq requested (not delivered) through the AMFm subsidy from 2011 to 2013 for child doses. The error bars are 1 s.d. of the mean of our sensitivity analysis of ACTq requested.
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RSIF20141356F3: Estimated demand for quality-assured ACTs (ACTq) with child-targeted subsidy in pilot countries over 5-year time frame. Estimated demand for ACTq assuming that the subsidy targets only doses for children less than 5 with varying levels of leakage for two different demand elasticites, low (a) and high (b). Leakage assumes that older individuals are taking doses intended for children less than 5. Older individuals who take child doses are assumed to either ‘stack’ (take more than one child dose) or underdose. For those who underdose, only a proportion of population is assumed to adequately clear an infection, and the rest have an increase in the probability of resistance. The universal subsidy scenario is a subsidy for all ages. Because the universal subsidy reduces the prevalence rate, fewer children are infected and the total treatments for children is less than in the universal subsidy case. Bar heights are the mean and error bars are the uncertainty range (one standard deviation of the mean) of the sensitivity analysis. These are compared to an estimate of the total number of ACTq doses that would be demanded by the private-for-profit sector of each country based on data from the Global Fund for ACTq requested (not delivered) through the AMFm subsidy from 2011 to 2013 for child doses. The error bars are 1 s.d. of the mean of our sensitivity analysis of ACTq requested.

Mentions: One important aspect of the analysis of projected ACT demand is that the majority of ACT treatments go to individuals over the age of 5 (the difference would be even greater if we used adult-equivalent dosing). This effect, combined with the fact that the majority of deaths may well occur in children, has led to the notion that the cost-effectiveness of the subsidy could be increased significantly by targeting child dosages. However, leakage could reduce the benefits of such a targeted proposal, we therefore estimated the effect of an age-targeted subsidy in each country assuming different levels of leakage to those 5 years and older. As leakage increased from 0% up to 50%, the number of ACT treatments demanded increased (figure 3). The age-targeted subsidy was also compared with a universal subsidy, and the number of child doses requested through the subsidy mechanism with 50% leakage is approximately equal to the total number requested under a universal subsidy because we are counting individual doses and not adult-equivalent, and a portion of those 5 years and older are assumed to be stacking.Figure 3.


Bioeconomic analysis of child-targeted subsidies for artemisinin combination therapies: a cost-effectiveness analysis.

Klein EY, Smith DL, Cohen JM, Laxminarayan R - J R Soc Interface (2015)

Estimated demand for quality-assured ACTs (ACTq) with child-targeted subsidy in pilot countries over 5-year time frame. Estimated demand for ACTq assuming that the subsidy targets only doses for children less than 5 with varying levels of leakage for two different demand elasticites, low (a) and high (b). Leakage assumes that older individuals are taking doses intended for children less than 5. Older individuals who take child doses are assumed to either ‘stack’ (take more than one child dose) or underdose. For those who underdose, only a proportion of population is assumed to adequately clear an infection, and the rest have an increase in the probability of resistance. The universal subsidy scenario is a subsidy for all ages. Because the universal subsidy reduces the prevalence rate, fewer children are infected and the total treatments for children is less than in the universal subsidy case. Bar heights are the mean and error bars are the uncertainty range (one standard deviation of the mean) of the sensitivity analysis. These are compared to an estimate of the total number of ACTq doses that would be demanded by the private-for-profit sector of each country based on data from the Global Fund for ACTq requested (not delivered) through the AMFm subsidy from 2011 to 2013 for child doses. The error bars are 1 s.d. of the mean of our sensitivity analysis of ACTq requested.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4590492&req=5

RSIF20141356F3: Estimated demand for quality-assured ACTs (ACTq) with child-targeted subsidy in pilot countries over 5-year time frame. Estimated demand for ACTq assuming that the subsidy targets only doses for children less than 5 with varying levels of leakage for two different demand elasticites, low (a) and high (b). Leakage assumes that older individuals are taking doses intended for children less than 5. Older individuals who take child doses are assumed to either ‘stack’ (take more than one child dose) or underdose. For those who underdose, only a proportion of population is assumed to adequately clear an infection, and the rest have an increase in the probability of resistance. The universal subsidy scenario is a subsidy for all ages. Because the universal subsidy reduces the prevalence rate, fewer children are infected and the total treatments for children is less than in the universal subsidy case. Bar heights are the mean and error bars are the uncertainty range (one standard deviation of the mean) of the sensitivity analysis. These are compared to an estimate of the total number of ACTq doses that would be demanded by the private-for-profit sector of each country based on data from the Global Fund for ACTq requested (not delivered) through the AMFm subsidy from 2011 to 2013 for child doses. The error bars are 1 s.d. of the mean of our sensitivity analysis of ACTq requested.
Mentions: One important aspect of the analysis of projected ACT demand is that the majority of ACT treatments go to individuals over the age of 5 (the difference would be even greater if we used adult-equivalent dosing). This effect, combined with the fact that the majority of deaths may well occur in children, has led to the notion that the cost-effectiveness of the subsidy could be increased significantly by targeting child dosages. However, leakage could reduce the benefits of such a targeted proposal, we therefore estimated the effect of an age-targeted subsidy in each country assuming different levels of leakage to those 5 years and older. As leakage increased from 0% up to 50%, the number of ACT treatments demanded increased (figure 3). The age-targeted subsidy was also compared with a universal subsidy, and the number of child doses requested through the subsidy mechanism with 50% leakage is approximately equal to the total number requested under a universal subsidy because we are counting individual doses and not adult-equivalent, and a portion of those 5 years and older are assumed to be stacking.Figure 3.

Bottom Line: Because the vast majority of malaria deaths occur in children, targeting children could potentially improve the cost-effectiveness of the subsidy, though it would avert significantly fewer deaths.However, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage (i.e. older individuals taking young child-targeted doses) increases, with few of the benefits of a universal subsidy gained (i.e. reductions in overall prevalence).Although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage.

View Article: PubMed Central - PubMed

Affiliation: Center for Disease Dynamics, Economics and Policy, Washington, DC, USA Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA.

ABSTRACT
The Affordable Medicines Facility for malaria (AMFm) was conceived as a global market-based mechanism to increase access to effective malaria treatment and prolong effectiveness of artemisinin. Although results from a pilot implementation suggested that the subsidy was effective in increasing access to high-quality artemisinin combination therapies (ACTs), the Global Fund has converted AMFm into a country-driven mechanism whereby individual countries could choose to fund the subsidy from within their country envelopes. Because the initial costs of the subsidy in the pilot countries was higher than expected, countries are also exploring alternatives to a universal subsidy, such as subsidizing only child doses. We examined the incremental cost-effectiveness of a child-targeted policy using an age-structured bioeconomic model of malaria from the provider perspective. Because the vast majority of malaria deaths occur in children, targeting children could potentially improve the cost-effectiveness of the subsidy, though it would avert significantly fewer deaths. However, the benefits of a child-targeted subsidy (i.e. deaths averted) are eroded as leakage (i.e. older individuals taking young child-targeted doses) increases, with few of the benefits of a universal subsidy gained (i.e. reductions in overall prevalence). Although potentially more cost-effective, a child-targeted subsidy must contain measures to reduce the possibility of leakage.

No MeSH data available.


Related in: MedlinePlus