Voir page 659 le resume en francais. En la pagina 659 figura un resumen en espanol.
When China introduced market reforms in the 1990s, government finance for public health fell and disease-control programmes depended on regulated user fees (1, 2). Henan Province (Fig. 1), with its population of 90 million, provides a clear illustration of this trend. In 1970, for example, Henan had the highest annual incidence of malaria in China (17%; 10.22 million cases). But in 1992, only 318 cases were reported (0.37 cases per 100000 population), and by 1993, Henan achieved the consolidation phase ("basic elimination"), only one step away from eradicating the disease. As a result, free insecticide impregnation of bednets and insecticide spraying of houses was stopped (but bednet support was later reinstated after an epidemic of vivax malaria) (3). These actions were taken, even though the economic costs of malaria control were unknown.
[FIGURE 1 OMITTED]
The problems in Henan are typical of many of the 19 malaria-endemic areas in China, especially those above latitude 25[degrees]N (4). Malaria incidence remains relatively high in four southern counties of Henan, with rates per 1000 population ranging from 3.91 to 41.3 (5). The 29 039 malaria cases reported by. China in 1999 (resulting in 67 deaths) were estimated to represent about 10% of the actual totals (6). Henan contributes about 10% of the national burden and remains at risk of major malaria epidemics (3).
To estimate the costs of controlling malaria in Henan, where disease control is at the consolidation stage, we examined input costs for each of Henan's three malaria control outputs: vector surveillance; population blood surveys; and case-management (7). We compared costs borne by the community and the government, and concluded that further cuts in malaria control will increase the risk of epidemics. This is important, since The world health report 2000 (8) ranks China a low 139th for health expenditure per capita, and even though population health is good (ranked 61st), it will deteriorate unless the health system improves.
Our report provides policy makers with timely information for planning malaria control and shows how such information can be collected. Other studies have examined control costs in areas, such as Sri Lanka and Thailand, where malaria is endemic (9, 10), but these have limited relevance to the situation in China. In contrast, our cost analysis takes account of the bureaucratic structure set up in China in the 1950s and allows malaria programmes throughout China to be compared. As such, it provides a model for mainland China.
In 1994 and 1995 we prospectively collected data from primary sources for the government and the community, and calculated the total cost for the three products of Henan Province's malaria programme: vector surveillance, population blood surveys, and case-management of suspected malaria cases. The first two comprised government outlays only, whereas case-management included costs for both the government and the community. All costs were estimated and compared within the two counties of Gushi and Shangcheng. Community costs were estimated from a sample of 12 325 reported cases of suspected malaria.
For government costs, we studied four levels: i) provincial: the capital, Zhengzhou; ii) prefectural: Xin Yang; iii) county: Gushi and Shangcheng (the worst malaria areas in the Xin Yang prefecture); and iv) township (former commune): all 55 townships in Gushi and Shangcheng. Most government inputs went to four malaria-endemic counties in Xin Yang prefecture, with 61.5% of provincial and prefectural costs going to Gushi and Shangcheng, reflecting their share of the total population in the malaria-endemic areas. Costs arising within the two counties were measured directly. Administrative input costs for all three malaria control components were obtained from the Henan government budget allocations, and found to be 10% for vector surveillance, 30% for blood surveys, and 60% for case-management. …