By David Tellett
Our estimates indicate that a full course of the R21/Matrix-M malaria vaccine can be delivered for around $25 per child. These estimates include the use of resources like medical staff and infrastructure necessary to deliver the vaccine. We also note that the net costs would be lower, as the costs of treating clinical malaria are significant and vaccines can significantly reduce the number of cases. Put another way: not vaccinating under 5s also results in significant medical costs that we will attempt to estimate here.
The burden malaria places on local facilities is considerable. For example, malaria represents 30% of outpatient visits to hospitals in Cameroon.1Gavi (2024) In high malaria prevalence areas, children will be bitten by malarial mosquitos multiple times, and surviving children often develop clinical malaria symptoms on multiple occasions. A peer-reviewed study by Imperial College researchers and the developers of R21, recently published in The Lancet, estimated that fully vaccinating 100,000 children in a region with typical sub-Saharan malaria prevalence could result in over 188,000 fewer cases of clinical malaria in future years – nearly two fewer cases per child2Schmit et al. (2024) (for more information on potential lives saved, see our blog article).
Malaria treatment is expensive in comparison to vaccination. A 2018 meta-analysis of various prophylactic and treatment options concluded that the median cost to the provider of a full course of malaria treatment was $9.31 for uncomplicated malaria and $89.31 for severe malaria.3Conteh et al. (2021) There is a high amount of variation and uncertainty around these estimates, and the number of cases reduced by R21 or RTS,S vaccination will depend on local malaria prevalence as well as the efficacy of the vaccine. The Imperial study’s assumptions in calculating the number of clinical malaria cases averted were based on a 20% prevalence of malarial parasites in young children (millions of children live in regions where malaria prevalence is at that level or higher).4Schmit et al. (2024), Appendix 1
Not all children will have access to adequate treatment or even diagnosis, but access to treatment is improving. Recent studies suggest that over 95% of children in Zambia and Tanzania with clinical malaria symptoms received some sort of artemisinin-based combination therapy (ACT, a combination of two or more drugs and the preferred treatment for malaria). Percentages were high and increasing in most other sub-Saharan African countries as well.5Figures from DHS program stat compiler Many of those not receiving ACT were given some alternative antimalarial treatment, including quinine and artemisinin monotherapy, which are regarded as inferior by the WHO.
Who pays for malaria treatment?
As with estimates of how much vaccination programs cost, any estimate of the cost of malaria treatment needs to factor in the economic cost of resources like staff time, hospital beds, and direct expenditures on diagnostic kits, drugs, and other materials. The Imperial study estimates that around 23% of patients’ families pay some of these costs out of pocket.6Schmit et al. (2024), Appendix 1, p. 29 Other studies have suggested that in some countries such as Nigeria, up to half of parents use private facilities to treat their children with malaria symptoms, primarily by skipping diagnosis and purchasing drugs directly from pharmacies.7The DHS program stat compiler indicates that less than half of patients use a public medical facility for treatment in many countries. Unlicensed Patent Medicine Vendors are regarded as the most common suppliers of antimalarial drugs in Nigeria. Households using public options still incurred average out-of-pocket costs of $4.91, nearly half of which was spent on transport to medical facilities. See Dalaba et al. (2018). So not all the costs of malaria treatment are paid by the governments funding vaccination programs: the rest of that burden is borne by families living in malarial areas, many living on incomes around the global poverty line of $2.15 per person per day. One Nigerian study found that 40% of household medical spending was on malaria treatments, and this represented 3% of total household annual income.8Onwujekwe et al. (2013)
What are the costs of treating routine (non-severe) malaria infections?
The drugs needed to treat clinical malaria are expensive to both governments and end users. The WHO recommends a course of Artemether/Lumefantrine for children with regular malaria symptoms. Artemether and Lumefantrine are drugs suited to treating the chloroquine-resistant strains prevalent in sub-Saharan Africa, and cost around $5 for a full course of 12 doses; the Imperial study adds a handling charge of ~15% per course,9Based on Pooled Procurement Mechanism prices for sub Saharan Africa plus an assumed 15% handling charge. and diagnosis kits cost between 0.28 and 0.65 per test.10The Global Fund (2023)
Public healthcare facilities supplying drugs also require clinicians’ time to administer tests and prescribe drugs – the Imperial study estimates an overhead of a couple of dollars,11Schmit et al. (2024), Appendix 1, apparently a median value derived from WHO-CHOICE data which is lower than some other estimates.12Conteh et al. (2021) estimates an average cost of $6.06 to administer a rapid diagnostic test. Testing based on electron microscopy was $2.53. This brings their estimate of the total cost of diagnosing and treating an uncomplicated case of malaria to $8.05 13(Schmit et al. (2024), Appendix 1, Table S10 (note that this estimates that $6.20 of this is paid by government). This is a little lower than the $9.31 average cost to treat uncomplicated malaria found by analyzing studies of real-world data,14 Conteh et al. (2021) and studies of some individual facilities have indicated much higher costs per case treated.15For example, 45% of outpatient visits at one public medical facility in Nigeria were for malaria. Accounting for resources and drug costs worked out to $31.49 per case of uncomplicated malaria (2013 USD). See Ezenduka et al. (2017). Onwujekwe et al. (2013) found similarly high outpatient costs for public medical facilities in Nigeria.
If the Imperial study estimate of R21 long-run efficacy is correct, then vaccinating a child would save $15-$17.50 in total expenditures on treatment of routine malaria alone.16Based on the Imperial study (Schmit et al.), the ~188,000 infections prevented per 100,000 fully vaccinated children in a region with median malaria prevalence for malarial regions of sub-Saharan Africa and an $8.05 cost per uncomplicated case of clinical malaria implies a cost saving of $15.13 per child from non-severe malaria alone. Taking the slightly higher $9.31 average malaria treatment cost based on real world data from Conteh et al., the figure would be $17.51.
What about the costs of treating severe malaria?
Not all children have timely access to effective antimalarial drugs, and cases of malaria that go untreated are significantly more likely to progress to severe malaria, which requires a hospital inpatient stay.17Mousa et al. (2020) The reduced use of drugs or the use of cheaper and less effective therapies may not mean less expenditure on health overall if the rates of severe malaria are not curbed.
Because severe cases of malaria require inpatient treatment, vaccines that reduce severe cases could have a particularly positive impact, freeing up hospital resources to be used to treat other conditions. In Cameroon, the senior health official responsible for immunization programs estimates that optimal use of the vaccinations could result in a 60% reduction in hospital admissions for malaria.18Gavi (2024)
The Imperial study estimates that governments pay $28.83 per child case of severe malaria out of a total cost of $37.44 per hospitalization, on the assumption of a typical three day stay.19Schmit et al. (2024), Appendix 1 This is quite modest in comparison with other studies of the hospitalization costs of malaria, such as the earlier study which found an average cost of $89.31.20Conteh et al. (2021) estimated $89.31 in 2018 US dollars This difference may be because the Imperial study does not try to factor in the cost of additional drugs such as artesunate injections, the cost of treating common comorbidities such as anemia, or the high expense associated with complications like cerebral malaria.21Sicuri et al. (2013) estimates the cost of treating cerebral malaria with neurological sequelae in Kenya at $288 in 2013 dollars.
Costs of inpatient treatment vary significantly between countries and even individual medical centers. Countries with lower costs to treat malaria will also tend to be those with lower costs to deliver vaccines. Estimates of the average cost per night for a hospital stay range from $2.41 in the Democratic Republic of Congo (an outlier) to $21.69 in Nigeria,22WHO-CHOICE (2010) and an inpatient stay will also incur the costs of diagnosis and drugs outlined above.
The Imperial study estimates that R21 will reduce the risk of severe malaria by close to 3000 cases per 100,000 vaccinated children in a region with average malaria prevalence,23Schmit et al. (2024), Appendix 1 doesn’t directly tabulate this, but provides a “deaths averted” statistic, and says this was based on a fixed proportion (0.215) of severe cases averted estimated by the model. This implies the predicted severe cases in a perennial setting with the predicted 629 deaths averted was 2925. saving an additional $1 – $2.60 treatment costs per fully vaccinated child.
Conclusions, limitations, and additional considerations
In all, we estimate that the R21 malaria vaccine could result in cost savings of ~$16-20 USD per vaccination while costing ~$25. This estimate is centered around areas with average malarial presence, but the savings could be higher in areas with high malaria prevalence.
There are some limitations to our estimate: access to treatment, malaria prevalence, and who pays varies, and up-to-date data is lacking. In regions with lower malaria prevalence, the costs of treating unvaccinated children will be lower, and not everyone has access to “gold standard” treatment. But there are also potential costs over and above that standard: additional drugs to treat comorbidities, intensive care for cerebral malaria, costs associated with post-viral sequelae, and the economic costs to families of taking time off work to look after sick children and traveling to healthcare facilities can all add increased costs to those estimated here.
Reduction in clinical malaria cases could also reduce children’s susceptibility to other common infections in the future. This may be part of the reason behind a 13% decrease in all-cause morbidities (excluding accidents) in under-5 deaths in areas where RTS,S vaccinations were carried out, and similar effects have been noted for vaccination programs targeting other common ailments like tuberculosis.24Wadman (2023) If this is the case, R21 and RTS,S vaccination may indirectly reduce hospitalizations and drug expenditure for illnesses such as pneumonia and diarrhea. Potential cost savings are also something local governments will need to consider when deciding whether to administer RTS,S and R21 vaccinations alongside other routine EPI vaccinations (lowest cost) or on a vaccination schedule optimized for the seasonal nature of malaria in their region (higher efficacy, but significantly more complex and costly logistics).