Invest in Indoor Residual Spraying to end malaria and accelerate Universal Health Coverage

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Malaria still presents enormous health and economic burden in Africa and particularly Uganda. Eradicating it in Uganda means averting at least 200 deaths that occur due to the epidemic every day, and saving households from colossal direct and indirect costs of healthcare, and overall, saving the economy from devastating effects on Gross Domestic Product and growth.

It is endemic in about 95% of the country, implying almost the entire population is exposed to the risk of malaria. Accordingly, tackling malaria is critical for population healthcare coverage, or rescuing the whole population from the scourge. This is why malaria eradication must be seen as one critical pathway to speed-up Universal Health Coverage (UHC) in Uganda. Ending malaria means a milestone in the expansion of population coverage and easing financial burden due to reduced malaria-related healthcare costs for individuals or households.

In Uganda, malaria control interventions are implemented in three main forms, that is – distribution of Insecticide Treated Nets (ITNs), Indoor Residual Spraying (IRS), and Larval Source Management, in addition to case management. Over the past decades, more public efforts have been dedicated to ITNs rather than IRS due to perceived high cost of IRS. However, there is now renewed interest in IRS, as the Malaria Reduction Strategic Plan (MRSP) has included scaling up of IRS among priority areas, spearheaded by the National Malaria Control Programme (NMCP). There is also a surge in political interest in malaria prevention through IRS that has never been seen before. In addition to instituting the Uganda Parliamentary Forum on Malaria, last year H.E President Yoweri K. Museveni launched the Maas Action Against Malaria initiative. This renewed interest arises from the fact that both technocrats and politicians are undoubtedly convinced based on available evidence, that malaria burden in the country is real, and IRS is the most effective in eradicating malaria compared to all other control interventions.

In view of inadequate empirical evidence on the cost implications of scaling up this most effective strategy (IRS), the Economic Policy Research Centre in collaboration with the National Health Consumer’s Organization and School of Public Health – Makerere University, under the SPEED initiative, commissioned a study to provide insights into the cost implications of implementing IRS with universal coverage goal, as well as implementing it in a phased manner, in order to facilitate evidence-based programming and related policy discourse.

Evidence from the study reveals that the perception that IRS is an extremely costly intervention that requires over a trillion for universal coverage per spray round (roughly per year – depending on insecticide type) is an over-exaggerated fear. IRS is only prohibitively costly if implemented in a projectized fashion due to unnecessary cost items and inflated unit costs involved in project mode of delivery. If implemented through the Integrated District Led Approach (IDLA), which requires the utilization of locally available or district-based resources including personnel, then financing IRS for country-wide coverage requires about 235 billion shillings per spray round (universal coverage), compared to about 1.3 trillion shillings required under projectized mode. The costs per structure and population protected against malaria under the IDLA are as well much lower than that of the project led approach, simply because the IDLA gets rid of unnecessary cost items and deploys local resources that are less costly. However, it is clear that the government still has to invest more resources into IRS to end malaria, beyond the current annual financing level of about 2 billion shillings.

It is important that if the government is to scale up the IRS for universal coverage and minimize costs, the implementation should follow the Integrated District Led Approach. This necessitates strengthening the capacity of local governments (especially district health offices) to promote the IDLA. It is an approach that has been successfully tested in selected IRS pilot districts as an epidemic response by NMCP. Domestic financing of IRS is paramount in fostering this approach and reducing costs. This is because using government money (unlike donor funding) creates flexibility in; sourcing insecticides from relatively cheaper but credible and WHO-accredited insecticide manufacturers, as well as determining what resources or service delivery approaches to deploy. The government can also consider fiscal incentives to support initiatives for domestic production of IRS insecticides, given that insecticides constitute a disproportionately large share of cost in an IRS programme.

Tonny Odokonyero is a Researcher at Economic Policy Research Centre – SPEED for Universal Health Coverage.

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