Voir page 308 le resume en francais. En la pagina 309 figura un resumen en espanol.
A large proportion of Sri Lanka's health budget is spent on malaria control. The most recent year for which a central figure is available is 1989, prior to the devolution of the health budgets to the provinces. At that time 11.6% of the total budget was spent on all forms of antimalaria activities nationwide, including both malarious and nonmalarious parts of the country (1). In 1992, it was estimated that 36% of the total health expenditure in a malaria-endemic district of the country was used to combat the disease (2). The cost to the government of antimalarial activities relates mainly to vector control, e.g. spraying houses with insecticides and larviciding vector breeding habitats, supporting diagnostic and treatment facilities, and maintaining an information system. The bulk of malaria control expenditure is currently used on importing insecticides. However, since the implementation of a selective spraying programme in 1994 the total amount of insecticides used has declined significantly (1).
Discussion of the most cost-effective use of the budget allocation for antimalaria activities in Sri Lanka requires comparison of the cost-effectiveness of a range of preventive and curative interventions. This comparison needs to be based on standardized cost estimate procedures and comparable units of effective outputs. Furthermore, to be able to discuss the most suitable interventions, we need to include the cost to households and not only the cost estimates borne by government agencies.
In Sri Lanka, the transmission of malaria exhibits considerable seasonal and annual changes, the population is highly knowledgeable about the disease, the majority of the cases are caused by Plasmodium vivax, and the health facilities provide relatively good coverage. All of these make it very difficult to compare health intervention strategies in Sri Lanka with cost-effectiveness studies carried out in Africa. To the best of our knowledge the only studies of the cost of malaria control to the government in Sri Lanka are those by Attanayake (2) and Graves et al. (1). The present study includes a number of additional interventions not dealt with by these two previous studies, such as water management for vector control and a village-level treatment centre.
The cost estimates were generated from data for a rural area in the malaria-endemic part of Sri Lanka, where ongoing research activities made it possible to estimate the cost to the government and households of both traditional and novel malaria control interventions. Results from epidemiological studies and surveys of treatment-seeking behaviour undertaken among the study population were used to assess the most appropriate interventions for the area.
Materials and methods
The study was carried out in Anuradhapura District, in the North-Central Province of Sri Lanka, in an area covered by seven neighbouring villages, consisting of 512 households and a total population of 2575 (average household size, 5 persons). The office of the Anti-Malaria Campaign (AMC) in Anuradhapura is headed by a regional malaria officer (RMO) who undertakes entomological surveillance and special surveys and provides advice to the divisional director of health services, the public health inspectors, and other personnel responsible for malaria control activities within the district. The majority of the households are engaged in agriculture, primarily subsistence farming.
In 1995, a survey in the study area showed that 48% of malaria patients first sought treatment at the government hospital in Kekirawa, approximately 25 km from the cluster of study villages; 30% used the government managed mobile clinics; and the remaining 22% private or other Western-style facilities (3). In fact, a number of patients attended both the mobile clinics and hospital. …