Estimating the Risk of Declining Funding for Malaria in Ghana: The case for continued investment in the malaria response

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These gains have been facilitated in part, due to increased financial commitment from both government and donors. Between 2006 and 2011, total resources for malaria increased from less than USD 25 million in 2006 to over USD 100 million. However, the country still faces a high burden of disease and is at risk of declining external financing due to its strong economic growth and the consequential increased donor requirements for domestic contributions. The resulting financial gap will need to be met domestically to accelerate progress. The purpose of this study was to provide evidence of the economic impact of malaria elimination and the potential risks of withdrawing financing to shape an advocacy strategy for resource mobilization. Methods: A compartmental transmission model was developed to estimate the impact of a range of malaria interventions on the transmission of Plasmodium falciparum malaria between 2018 and 2030. The model projected scenarios that allowed the attainment of elimination using a package of common interventions and scenarios that predicted transmission if interventions were withheld. The outputs of this model were used to generate costs and economic benefits of each option. Results: Elimination was predicted using the interventions outlined in the national strategy, particularly increased net usage and improved case management. Malaria elimination in Ghana was predicted cost USD 961 million between 2020 and 2029. Compared to the baseline, elimination is estimated to prevent 85.5 million cases, save 4,468 lives, and avert USD 2.2 billion in health system expenditures. The economic gain was estimated at USD 32 billion in reduced expenditure, increased household prosperity and productivity gains. Through malaria elimination, Ghana can expect to see a 32-fold return on their investment. Withdrawing interventions, predicted an additional 38.2 clinical cases, 2,500 deaths and additional economic losses of USD 14.1 billion. Conclusions: Although government financing has increased in the past decade, the amount is less than 25% of total malaria financing. The study findings can be used to develop a robust strategy to overcome financial barriers for malaria elimination in Ghana. Infectious Diseases Malaria Ghana investment case costs benefits economic funding financing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background Ghana has made impressive progress in its fight against malaria. Malaria cases and deaths have decreased by over 50 and 65%, respectively between 2005 and 2015 [1]. The current strategy is based on the National Malaria Control Strategic Plan (NSP) for 2014-2020, which was finalized in August 2014 by the National Malaria Control Program (NMCP) [2]. The scope of the strategic plan was to consolidate the gains and accelerate malaria control in the high transmission areas to further reduce malaria burden and move towards establishing lower-transmission areas in Ghana by the end of 2020. The plan calls for reducing the malaria morbidity and mortality burden by 75% (using 2012 as baseline) by the year 2020. The gains experienced in the past decade can be attributed in part due to the increased financing available to scale up effective interventions. Since 2003, Ghana has benefited from a succession of grants from Global Fund for AIDS, Tuberculosis and Malaria (Global Fund) [3] with disbursements over USD 408 million. The country currently has 2 active grants totaling USD 109 million (2018-2020). Several other external donors have provided financial support to the malaria program including the United States Presidents Malaria Initiative (PMI, the U.K. Department for International Development (DFID), the United Nations Children’s Fund (UNICEF), the World Bank, and the governments of Japan, China, and Cuba [1]. Nevertheless, the country still faces a financing gap estimated at 187 million for 2019-20 by the Ghana National Strategic Plan for malaria (NSP) [2]. Government contributions made up 38% of the total financing for malaria in 2018 [4]. Curative services for malaria are covered by the National Health Insurance Scheme (NHIS) benefit package which is financed by a mix of funding from earmarked taxes and premiums paid by members. However, collection rates are a challenge and therefore revenue received from capitation does not offset any significant portion of the expenditure. The current level of financial support the country receives from external partners is unlikely to be sustained in the longer term. Between 2002 and 2016, Ghana experienced a five-fold increase in GDP per capita from USD 309 to USD 1,517 [5, 6]. As Ghana’s economy transitions towards middle income, external donor financing for health is expected to decline, with domestic or other sources of financing having to fill the resulting gap. However, experience with other countries points to a significant time-lag between rising national income and increased government health expenditure unless accompanied by effective advocacy backed by evidence outlining the risks associated with funding withdrawal. Historical evidence demonstrates that almost all resurgence events could be attributed, at least in part, to the weakening of malaria control programs for a variety of reasons, of which resource constraints were the most common [7]. The aim of this analysis was therefore to quantify the epidemiological and economic impact of both a fully-funded malaria response that will achieve malaria elimination and that of a partially-funded response that may potentially lead to disease resurgence. The findings of this work can be used to shape the advocacy strategy for mobilizing increased domestic resources for malaria. Methodology This investment case projected the financial requirements of the malaria program to reach malaria elimination by 2030 and values the economic and financial returns of reducing malaria transmission compared to alternative scenarios. To accomplish this, the investment case leveraged multiple methodologies and data sources. The study design incorporated a variety of quantitative methods: numerical and regression techniques to develop a transmission model to predict the epidemiological impact of various interventions used for malaria control and elimination and economic analysis to estimate the cost and economic impact of the interventions nationally and regionally. The economic analysis was informed by the outputs of a transmission model. All monetary figures are expressed in 2018 constant US dollars (USD) [ 8 ]. This investment case projected the financial requirements of the malaria program to reach malaria elimination by 2030 and values the economic and financial returns of reducing malaria transmission compared to alternative scenarios. To accomplish this, the investment case leveraged multiple methodologies and data sources. The study design incorporated a variety of quantitative methods: numerical and regression techniques to develop a transmission model to predict the epidemiological impact of various interventions used for malaria control and elimination and economic analysis to estimate the cost and economic impact of the interventions nationally and regionally. The economic analysis was informed by the outputs of a transmission model. All monetary figures are expressed in 2018 constant US dollars (USD) [8]. Epidemiological model framework A spatially explicit, compartmental, nonlinear, ordinary differential equation model is an extension of previously published models and have been implemented in R and C++ [9, 10]. The model simulated a range of malaria interventions and estimated their impact on the transmission of Plasmodium falciparum malaria between 2018 and 2030 nationally and in the three ecological zones in Ghana (Coastal, Forest and Savanna). Historical data from 2012-2018 was used to parameterize and fit the model. The key transmission features and drivers of transmission in the model included: Infection classes dependent on the level of severity of infection Development and loss of immunity against clinical infection Superinfection Subnational climatic variation (seasonality) Importation of infection More details on the model have been published elsewhere [9, 10, 11]. Interventions modelled included: Passive Case detection (routine diagnosis and treatment in health facilities and the community) Vector Control: Distribution of LLINs IRS Health System Strengthening (supportive supervision, training for improved malaria testing and treatment and supply chain management support) Social and Behavioral Change (SBC) for improved health seeking behavior Seasonal Malaria Chemoprevention (SMC) Data sources used were: Data from the NMCP (monthly incidence and deaths by district from the Health Management Information System (HMIS)) WHO World Malaria Reports and Annexes Peer reviewed literature Expert opinion (for assumptions where data was unavailable) Four scenarios and two reverse scenarios were developed in collaboration with the NMCP: Baseline scenario: existing set of malaria control activities as implemented in 2018 with coverage levels of 2018 Fully funded response (FFR): fully funding the activities and coverage levels in the NSP Better use of nets: added to the “fully funded response” through the use of SBC (social and behavioral change) to increase the usage of LLINs Increase treatment seeking from 73% to 90% (through SBC): added to the “better use of nets” scenario. Reverse scenarios: Reduce the amount of funding for the implementation of activities from the 2018 baseline coverage. Where: Reverse 1: cutting out IRS, SMC and LLINs by 50% Reverse 2: cutting out IRS, SMC (LLINs remain at 2018 levels) Table 1. describes the scenarios in detail. Economic analysis Using a societal perspective and cost of illness approach [11, 12], the economic burden of malaria in 2018 was evaluated. Specifically, (i) direct health system costs, (ii) direct household costs, and (iii) indirect costs were estimated. Table 2 illustrates the framework used. Direct health system costs To facilitate the gathering of direct cost data, an interview guide and data entry sheet were developed to collect existing costing data, identify gaps, and locate additional data to fill gaps. These interviews were conducted in a semi-structured format with key malaria program personnel who were familiar with program spending patterns and records. Data on government and external spending were collated. National health system costs outside of vertical malaria program expenditures were included as much as possible to obtain the total actual cost to the health system in Ghana. When expenditures were unavailable, budget figures, National Health Accounts (NHA) and secondary sources such as peer-reviewed or grey literature or deduction were used. Costs of treating outpatient and inpatient malaria cases were obtained from the NHA [13, 14]. Individual costs were extracted and aggregated to obtain estimates of the costs of each intervention. The cost of each scenario was estimated using a cost estimation model fed by outputs of the transmission model. The cost of each scenario was then used to obtain the incremental or additional cost of a fully funded response compared to the baseline. All costs were discounted at 7%. The discount rate used was based on the inflation rate and the expert opinion of economists in-country. Additional table 1.1 contains the cost inputs used in the analysis. Direct household costs Malaria exacts a significant financial burden on households. Malaria patients often pay for transportation to access health facilities, diagnostic services, and medicines. In Ghana, although testing and treatment for malaria are free, prepaid or covered by the NHIS, malaria patients still incur out-of-pocket expenditures (OOP) for transport, food and other expenses not covered through the public sector. To estimate direct household costs on malaria, the number of reported OP and IP malaria cases in 2018 was multiplied by the mean OOP spending (separately for OP and IP cases). Data on OOP was obtained from published literature [15, 16]. Indirect Costs The economic impact of malaria extends beyond the health system. Patients forego income while recovering from malaria, and caregivers looking after ill children and the elderly also lose out on potential earnings. Society also incurs an indirect cost due to premature deaths through losses in lifetime productivity and in the social value people place in living longer, healthier lives. To evaluate the economic impact of malaria-related morbidity, the foregone income of malaria patients and caregivers was calculated. The gross domestic product (GDP) per capita per day was obtained from 2018 GDP estimates from World Bank Data [5]. The resulting figure was used as a proxy for the average income per capita and multiplied by the duration of OP and IP illness from published literature and the number of reported OP and IP cases. In addition, the effect of reduced productivity from “presenteeism” was calculating by assuming that adults retuning to work would be 50% less productive for an additional six days. This assumption was made based on interviews in Ghana. A full income accounting approach was used to quantify the economic impact of premature death as postulated by the Lancet Commission on health [17]. Assuming 40 years as the average age of malaria-related adult deaths and 2.5 years as the average death amongst children under 5 years, the average remaining life expectancy of males and females was multiplied by the value of each additional life year (VLY). Life expectancy was retrieved from the Central Statistics Service [18]. One VLY was assumed to be 4.2 times the 2018 GDP per capita of Ghana [17]. Cost savings from reduced public and private expenditures on malaria are likely to spur consumer spending and create new businesses thus injecting more money into the local economy. Throughout the process, overall disposable incomes increase, creating more markets for local businesses. These induced responses result in an economic multiplier or “ripple” effect. A 2011 USAID report [19] estimated that income multipliers in West Africa lay between 1.58 and 2.43. An average multiplier of 2 was therefore used for the purposes of this analysis. Economic benefits estimation The mortality and morbidity averted from malaria elimination were obtained by subtracting the estimated cases and deaths in the fully funded scenarios from the corresponding outputs of the “business as usual” scenario. Similarly, the excess cases and deaths in the reverse scenarios were calculated by subtracting from the corresponding outputs of the “business as usual” scenario. These health benefits were calculated using the methodology and inputs previously outlined. Direct costs averted to the health system includes costs associated with diagnosis and treatment costs of IPs and OPs; Direct cost averted to the individual households is out-of-pocket (OOP) expenditures for seeking care; and Indirect cost averted to the society due to patients’ lost productivity due to premature death and morbidity and caregivers’ reduced economic output. The benefits of investing and not investing in malaria control and elimination were estimated as the sum of the direct cost savings to the health system from reduced use of outpatient and inpatient health services and reduction in cost of delivering malaria control activities; the direct cost savings to households; and the indirect cost savings of reduced morbidity and mortality from malaria calculated above. The Net Present Value (NPV) was calculated to obtain the present value of the future revenue generated from elimination using standard economic techniques. The purpose was to give a true picture of the financial value of an investment made today whereby savings would be accrued in the future [12]. The timeframe used for calculating the NPV was 11 years and a 7% discount rate was applied as before. Return on investment To calculate the ROI from malaria investments, the NPV of the benefits of reduced transmission were subtracted from the incremental cost of elimination. The resulting figure was divided by the incremental cost of the fully funded response (compared to baseline). The ROI is interpreted as the economic return from every additional dollar spent on malaria above the business as usual scenario. Financial gap Various sources were consulted to estimate past, present, and future financing for malaria. Projected financing was estimated using projected figures from GOG, the Global Fund and PMI. Many of malaria services are covered under the NHIS via the health insurance levy. These estimated resources are included in under “domestic financing” (obtained from the NMCP). Sensitivity analysis A stochastic sensitivity analysis on the epidemiological and cost outputs of the malaria transmission model was performed. The minimum, median, and maximum malaria cases and deaths predicted by the model for each scenario were used to calculate the minimum, median, and maximum costs. Three hundred random samples were drawn, which generated a range of costs. From the range of costs generated, the minimum, maximum, median, mean, and other percentiles are presented. Data collection, tools and analysis A worksheet was been developed in Microsoft Excel® to facilitate the organization of cost data. Analysis of the cost data was conducted in Microsoft Excel to estimate the current and future costs of the malaria activities in each scenario. All quantitative data records (no identifying information), were stored in Microsoft Excel spreadsheets on encrypted, password-protected computers. Data was collected in August 2019. Ethical approval Ethical approval for this study was obtained from the Ethical Review Committee (ERC) of the Ghana Health Service prior to data collection (GHS/RDD/ERC Ref No. 1913445). Study limitations A number of known and unknown factors limit the findings of this report. Due to time and resource constraints, the transmission model estimated sub-national malaria transmission based on three climatic zones. Ideally, higher levels of spatial heterogeneity would be modelled to provide to enable subnational estimates of interventions and costs. The costs of interventions have been estimated based on available data from the NMCP and proxies when data were unavailable. For example, the costs of outpatients, in-patients and health worker salaries were estimated from the National Health Accounts (NHA). Separating out the cost of interventions in integrated systems is challenging and the analysts have relied on country-level partners to arrive at disaggregated costs. This report utilized reported cases from the HMIS and estimated cases and deaths from WHO World Malaria Reports. The wide variation in these two estimates of burden makes it harder to be sure of the resources required to eliminate the disease. As Ghana moves closer to elimination the impact of active surveillance on both the epidemiology and cost will need to be incorporated. This was not included due to a lack of historical data to enable fitting the model for impact or cost. The savings observed may well be offset by the increased costs of active surveillance required in elimination settings. At the same time, targeting of interventions rather than ubiquitous coverage to the entire country may reduce the costs of elimination and the financing gap. Without subnational estimates of incidence and coverage, targeted interventions are difficult to estimate and cost. Without an informed and complete understanding of the detailed current cartography of malaria risk and prevalence, future projections of the cost of eliminating malaria face an overwhelming uncertainty. While employee absenteeism was included in the estimates of benefits, the analysis did not include the economic benefits conferred by reductions in school absenteeism and subsequent improvements in cognitive development due to the lack of empirical evidence to enable converting these estimates to wages earned. Other benefits not included include potential benefits on tourism, the impact of economic development and housing improvements on malaria transmission as well as regional or cross border externalities. Results Transmission model predictions and projections Baseline response: Maintaining the interventions (LLIN distribution, IRS, SMC) and health system access and performance at 2018 levels, does not change the transmission intensity. Figure 1 shows malaria is predicted to continue unabated, with no further decrease expected until 2030 (the end point of the model). The slight upward trend in cases is a reflection of a growing population, rather than increased incidence of malaria. The lower line represents the reported cases using WHO estimates while the upper line represents the estimated clinical cases based on corrections for reporting rate in the public sector. The true number is likely to be somewhere in between. Fully-funded/NSP response This scenario modelled the impact of a fully funded scenario as mapped in the NSP. It must be noted that the current NSP was developed as a “malaria control strategy” rather than an “elimination” strategy. While transmission decreases starting 2020 when the interventions begin, the number of reported cases does not fall below 3.5 million annually during the 10-year period (2020-2029), as illustrated in Figure 2. Compared to the baseline, the fully funded NSP scenario will avert 37.4 million clinical cases, 21.2 million reported cases and 2,683 deaths. Better net use Given the low usage of nets in Ghana, interventions to increase usage beyond the estimated 41.7% recorded in 2016 [20, 21, 22] were added to simulate increased net use. The interventions modelled were a combination of activities of a “hang-up campaign” as well as SBC and IEC and based on a 2014 study in Ghana [23], where LLIN use by children under five years increased to 77.4% in households where some or all LLINs were hung by a campaign volunteer accompanied by SBC/IEC activities in the community, compared to 53.9% in households without these interventions. These interventions increased the odds of a child sleeping under an LLIN approximately 1.5 times when adjusted for other factors that may explain variation in use (adjusted OR: 1.57; 95% CI: 1.09, 2.27; p = 0.02). These odds when applied to 41.7% reported usage (with 40% protection given usage [1] ) result in a median protective efficacy of 24.9% [24]. Figure 3 shows that the impact of improved usage results in a considerable predicted decrease in malaria cases at the national level with reported cases falling below 1 million in 2029. These predictions assume that improved usage will be maintained consistently until 2030. It must be noted that studies have shown that LLIN use varies considerably by urbanization and socio-economic status with low net use being recorded among higher income households in urban areas [25]. Given that the only data available were national averages, it is likely that the impact of net use is overestimated if indeed, use is high amongst the population at risk in rural areas but low amongst those living in low-risk urban areas. Health system acceleration Figure 4 shows the impact of combining better net use with an increase in access to the public health system through SBC and IEC interventions. Modelling this improvement in access as an increase in treatment seeking behavior from 73% (reported) to 90%, results in a model prediction of reaching malaria elimination. Compared to the baseline, the HSA scenario will avert 85.6. million clinical cases, 51.3 million reported cases and 4,468 deaths. Reverse scenario 1 Removing IRS, SMC and reducing LLIN coverage by 50% will result in an almost immediate upsurge of cases. By 2028, reported cases increase to more than 10.6 million (Figure 5). Reverse scenario 2 Removing IRS and SMC similarly reverse the gains made with reported cases rising to over 8.5 million by 2029 and clinical cases to 13.5 million (Figure 6). Zonal differences Figure 7 illustrates the zonal differences of intervention impact. Better net use and the fully funded scenario have less of an impact on transmission in the forest zone compared to the other two zones. Indeed, it would appear that this zone, having the largest case load, has the greatest impact on the total national response. Figure 8 summarizes the total clinical cases and deaths (2020-2029) with the baseline, HSA and reverse scenarios. Over the course of 10 years, the baseline scenario will result in 105 million clinical cases and 5,122 deaths. The accelerated health system scenario will result in 19 million cases and 676 deaths while the reverse I scenario will result in 143 million cases and 7,642 deaths. Cost projections To account for potential underestimation of reported cases, clinical cases were used to calculate modelled costs and benefits, and both are shown here. The cost of implementing the HSA scenario is depicted in Figure 9. The model predicted that it will cost a total of USD 961.3 million over 10 years (2020-2029) to implement the HSA scenario (to reach elimination). This equates to about USD 133 million annually for the first five years, assuming that the aggressive interventions predicted by the model are implemented in the most efficient way. This includes the integrated health system cost of treating outpatients and inpatients. The cost for the HSA scenario in 2020, not taking integrated costs into account, is USD 41.6 million. The peaks represent LLIN procurement for national mass campaigns which occur every three years in Ghana. Benefits estimation To estimate the benefits of elimination, the averted costs, cases and deaths were calculated. The HSA scenario will avert 85.6 million clinical cases, 51.3 million reported cases and 4,468 deaths. Economic benefits of USD 31.73 billion (NPV) are generated through reductions in deaths, cases, and household and healthcare system spending as well as increases in productivity at a cost of USD 961.34 million (2020-2029). Reducing funding for IRS and SMC will incur additional (to the current baseline scenario) economic losses of USD 4.4 billion in addition to an additional 13 million clinical cases, 8.9 million reported cases and 1,350 deaths. Further reducing funding for LLINs by 50% as well will incur economic losses 14.1 billion in addition to an additional 38.2 million clinical cases, 24.4 million reported cases and 2,497 deaths. A summary of the results of various scenarios is shown in Table 3. Return on I nvestment The ROI was calculated by subtracting the NPV of the benefits of elimination by the discounted cost of elimination and dividing the resulting figure by the discounted cost of elimination (Table 3). Implementing the HSA scenario which will allow the country to progress to elimination and will produce a return on investment of 32:1 between 2020-2029. Gaps in malaria financing The expected influx of financing (both domestic and donor) was compared with the projected cost of the malaria program from 2020 to 2021. The modelled cost of the elimination scenario was estimated at 961.3 million (2020-2029). This equates to about USD 133 million annually for the first five years, assuming that the aggressive interventions predicted by the model are implemented in the most efficient way. This includes the integrated health system cost of treating outpatients and inpatients. In addition to domestic government financing, Ghana received about USD 44 million from the Global Fund in 2018 and an USD 29 million from other donors [26]. In order to scale up the interventions needed, the remaining USD 60 million annually will need to be met by domestically. It is important to note that these figures do not account for the increased levels of co-financing levels that may be required by the Global Fund. [1] A meta-analysis of protective efficacy from use predicted that LLINs had a protective efficacy of 39.8% (IQR 20.2–50.3%) and 28.5%, (IQR 8.8–47.3%) for IRS. Thus for LLINs there is a median effective protection of 16.6%. Discussion This analysis found that the cost of implementing the most effective scenario was USD 961.3 million over 10 years (2020-2029) equating to about USD 133 million annually for the first five years, assuming interventions are implemented efficiently. The health and economic benefits are enormous. Reducing transmission to elimination levels will avert 85.6 million clinical cases, 51.3 million reported cases and 4,468 deaths. Economic benefits of USD 31.73 billion are generated through reductions in deaths, cases, and household and healthcare system spending as well as increases in productivity. The economic return is significant at 32 times the investment. This by far exceeds the threshold on returns that are considered to be high impact investments. In contrast, reducing funding for IRS and SMC will incur additional economic losses of USD 4.4 billion, an excess of 13 million clinical cases, 8.9 million reported cases and 1,350 deaths. Further reducing funding for LLINs by 50% will incur economic losses USD 14.1 billion in addition to an excess of 38.2 million clinical cases, 24.4 million reported cases and 2,497 deaths. The benefits of investing in malaria elimination are likely to be undervalued as they exclude certain macro-economic costs that extend far beyond the health system. Studies have shown that indirect costs of malaria account for a large share of societal costs due to its debilitating effect on the economy through employee and school absenteeism, cognitive development in children as well as macroeconomic development by limiting foreign investments and tourism [27-31]. These have not been included due to the lack of accurate data to quantify these effects and to directly attribute them to malaria. Other costs to the health system such as cost of drug and insecticide resistance, the cost of higher price alternatives, the cost associated with their implementation, and the cost of research and development have also been omitted. The total income approach was used to compute income losses from malaria mortality. Although this methodology provides more generous estimates of economic losses than other methods, it is unlikely to account for all the aforementioned losses. There are several limitations to the data and methods used in this study. Obtaining accurate data on the cost of program operations, particularly in an integrated health system, is challenging. Several malaria program resources are shared across other public health programs, particularly for activities that are financed through government funding. Facility staff perform other health functions and therefore outpatient and inpatient costs are derived from estimates from the NHA. The scenarios were developed in collaboration with the NMCP based on the current knowledge of interventions and strategic direction of the program. As the program progresses and transmission is reduced, these interventions are likely to the reviewed and revised. Despite the robust benefits associated with investing in malaria, Ghana’s program is likely to face a gap in funding in the immediate future. Funding for malaria from government sources met less than 30% of the total needs. Ghana is currently highly dependent on financing from the Global Fund at USD 36 million per year on average [32]. The current Global Fund grant ends in 2020. A funding request to the Global Fund for malaria will be developed for the period of 2021-2023. However, given that Ghana is already a lower middle-income country, as cases decline, it is unlikely that the Global Fund will maintain its current levels of funding, particularly if the co-financing requirement remains unpaid. These financing gaps will need to be met by increased domestic financing. A robust resource mobilization strategy bolstered by the epidemiological and economic evidence generated by this report will be needed. In 2015, a Resource Mobilization Plan for National Malaria Control Strategy (2014-2020) [33] was developed and laid the foundation for resource mobilization efforts for malaria in Ghana. The subsequent Ghana Health Service Resource Mobilization Strategy for National Malaria Control and Elimination (2019–2023) [4] is awaiting finalization and ratification. At the same time, several actions have since been taken: The Ghana Malaria Foundation (GMF), established in 2015/2016 and officially inaugurated in 2017 has been accredited as a limited guarantee corporate body. However, a renewed effort incorporating the evidence from this report is needed, which includes outlining clear actions for implementing identified strategies for resource mobilization. Ghana’s private sector is large and growing, and its engagement in supporting the implementation of malaria control interventions during the past decade has increased. Engagement includes corporate social responsibility programs (e.g., through oil companies), workplace wellness programs (e.g., plantations), marketing of effective malaria treatment and prevention products and services and other public-private partnerships including market catalyzation for malaria control products. Several opportunities exist to expand these efforts in support of the new strategy. Remittances are one of the largest sources of funding flows next to international aid. Providing a small portion of each transaction to malaria — possibly through a Corporate Social Responsibility model via mobile transaction companies should be explored, especially since these funds could be applied to a matching fund scheme. In 2017, remittances made up 5.1% of Ghana’s GDP to the tune of USD 2.19 billion and which, according to the Bank of Ghana, grew to USD 3.52 billion in 2018 [4]. Public and private sector donors can enter into matching fund programs, which would substantially increase donations for Ghana’s national malaria programming. For example, in Mozambique, DFID and the Global Fund matched Ecobank Foundation’s USD 750,000 donation for an LLIN campaign in the country, raising the value of that donation to USD 2.5 million. Ghana could explore developing a matching co-financing facility with private sector companies, such as those from the extraction industry and financial sector, and other donors. Other opportunities to create an enabling environment include tax incentives from the government for private sector involvement. Engagement with companies to raise funds from middle- and upper-class customers and employees to contribute to the GMF may be a viable option. Potential mechanisms are voluntary contributions through online banking platforms or similar online systems. For example, the Ecobank Foundation asked Ecobank employees on World Malaria Day 2017 to donate USD 3.00 for an LLIN to be distributed to vulnerable populations. With little effort, out of 16,000 employees, Ecobank raised USD 22,000. This can serve as an example for other companies to help fill the NMCP gaps [4]. Currently, the Government collects taxes on tobacco products, alcohol and soda, tourism and airport levies, petroleum revenues, lottery funds and others. However, none of these are currently earmarked for health and present a potential opportunity for increased resources. By law, 0.5% of new funding allocated within the District Assembly Common Fund is mandated to be used toward malaria control and elimination efforts at the district level. Currently, these funds are frequently not being used for this purpose and advocacy to ring-fence the funds is needed. Other opportunities include using existing resources more efficiently. The current cost of the program does not include measures to improve efficiencies. Targeted interventions such as vector control to high risk areas and populations will likely provide considerable cost-efficiencies. The implementation of efficiency measures in malaria programming can also serve as an advocacy tool to approach existing and new donors. These strategies can be made more effective through the use of key influencers or ambassadors to ensure accountability. Conclusions The findings indicate that while the interventions outlined in the NSP will lower transmission of malaria, they are not likely to allow the elimination of the disease. Elimination will only be achieved through increased use of nets, improved health seeking behavior and strengthened malaria case management at the facility level. The effects of these interventions vary by zone and there is a need for risk stratification and to target interventions particularly as transmission declines and the country moves closer to elimination. Furthermore, as cases decline and the epidemiology of the disease changes, a similar exercise with revised elimination interventions will need to be conducted with the additional costs of surveillance built in. There are several critical reasons why malaria should receive a special focus for financing. Malaria is a major ongoing cost driver burdening national health systems and eliminating the disease will confer public health benefits as well as major cost savings to national health systems. Although the short-term investment needed may seem substantial at USD 961.3 million over 10 years (2020-2029), front loading investments will provide cost savings in the longer term as well as substantial health and economic returns. Eliminating malaria will avert 85.6 million cases and 4,500 deaths. 1.06 billion days of employee absenteeism will be avoided conferring economic benefits of 31.73 billion providing a return on investment of 32:1. Reducing investments and a resulting resurgence will lead to an additional 38.2 clinical cases, 2500 deaths and additional economic losses of USD 14.1 billion. At the same time, Ghana could be at the frontier of elimination in Africa amongst the identified WHO High-Burden High-Impact countries in Africa. There is a need for a robust and effective resource mobilization and advocacy strategy backed by the evidence produced by this body of work. Abbreviations ACT: Artemisinin-based combination therapy; AL Artemether-lumefantrine; BCR: Benefit-cost ratio; CCP: Center for Communication Programs; CHPs: Community Health Planning Services; CHW: Community Health Workers; DFID: Department for International Development; ERC: Ethical Review Committee GDP: Gross Domestic Product; GHC: Ghanaian Cedi: GHS: Ghana Health Service Global Fund: Global Fund to Fight AIDS, Tuberculosis and Malaria: GNI: Gross National Income: GOG: Government of Ghana: GVA: Gross Value Added: IEC: Information, education, and communication: IPT: Intermittent preventive treatment for pregnant women: IRS : Indoor residual spraying: ITN : Insecticide-treated mosquito net: JHU: Johns Hopkins University: LLIN : Long-lasting insecticide-treated mosquito net: MICS: Multiple Indicator Cluster Survey: MIS: Malaria Indicator Survey: MOP: Malaria Operational Plan: MOH : Ministry of Health: NHIS: National Health Insurance Scheme: NMCP: National Malaria Control Programme: NPV: Net Present Value: NSP: National Malaria Strategic Plan: PMI : President’s Malaria Initiative: RDT : Rapid Diagnostic Test: ROI: Return on Investment: SBC : Social behavioral change: SMC: Seasonal Malaria Chemoprevention: SP/AQ: Sulfadoxine-pyrimethamine and amodiaquine SP: Sulfadoxine-pyrimethamine: USAID: United States Agency for International Development: USD: United States Dollar: WHO : World Health Organization Declarations A uthors’ contributions RS conceived the paper and prepared the manuscript. RS collected the data and conducted the cost and economic analysis. SPS developed the transmission model and its outputs. RS coordinated inputs to the draft. KM provided NMCP data and inputs into the methodology. DP, KB, JR and ML reviewed the draft paper. All authors read and approved the final manuscript. RS and JR were contracted as consultants to JHUCCP for this project. Ack nowledgements The authors are grateful for the collaboration with the National Malaria Control Programme and the inputs of James Frimpong and Patricia Bentil, in addition, thank you for the support provided by the JHUCCP Ghana team, Felix Nyanor-Fosu and Richard Kpabitey. Dr Koku Awoonor and Mr Daniel Osei provided valuable data on integrated health sector costs. Olivier Celhay is acknowledged for technical support provided in the model application. This work was funded by the UK Department of International Development (DFID). Competing interests The authors declare that they have no competing interests. A vailability of data and materials The datasets used and/or analyzed during the current study are available in a separate database[11] online and as additional tables included in this submission. Other raw data is available from the corresponding author on reasonable request. F unding This research was supported by the Government of the United Kingdom of Great Britain and Northern Ireland, acting through the Department for International Development (DFID) ) as part of the grant to the Private Sector Malaria Prevention Project of the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (grant 300191, Components 101, 102 and 103). The content is solely the responsibility of the authors and does not necessarily represent the official views of DFID or its member countries. The authors were not paid to write this manuscript. The development of the transmission model was supported by the Wellcome Trust [214236/Z/18/Z]. Ethics approval and consent to participate Ethical approval for this study was obtained from the Ethical Review Committee (ERC) of the Ghana Health Service prior to data collection (GHS/RDD/ERC Ref No. 1913445). The ERC of the Johns Hopkins Bloomberg School of Public Health, Baltimore deemed this study exempt from needing ethical approval given that the work did not directly involve patients or patient data. Consent for publication Not applicable RReferences 2018. World Malaria Report. Available at: https://www.who.int/malaria/publications/world-malaria-report-2018/en/ Ghana Health Services. 2014. National Malaria Strategic Plan 2014-2020 . National Malaria Control Programme, Accra. Global Fund. 2019. https://data.theglobalfund.org/locations/GHA 2019. Ghana Health Service Resource Mobilization Strategy for National Malaria Control and Elimination (2019–2023) . Draft. World Bank Open Data. GDP per capita (current USD). The World Bank Website. Washington: World Bank; 2019 [cited June 2019]; Available from: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=GH International Monetary Fund. 2019. World Economic Outlook Database April 2018. Washington: IMF; 2018. https://www.imf.org/external/pubs/ft/weo/2018/01/weodata/index.aspx. Cohen J, Smith D, Cotter C, et al. 2012. Malaria resurgence: a systematic review and assessment of its causes. Malaria journal 11(1):122 Oanda 2019. https://www1.oanda.com/fx-for-business/historical-rates Silal SP, Shretta R, Celhay OJ, Mercado CEG, Saralamba S, Maude RJ, White LJ. 2019. Malaria elimination transmission and costing in the Asia-Pacific: a multi-species dynamic transmission model. 2019 [version 1; peer review: awaiting peer review]. Wellcome Open Res 4:62 ( https://doi.org/10.12688/wellcomeopenres.14771.1 ). 2020. https://github.com/sheetalsilal/SPPf_tool Shretta R, Silal SP, Celhay OJ, Mercado CEG, Kyaw SS, Avanceña A.L.V, Zelman B, Fox K, Baral R, White L, Maude R. 2019. Malaria elimination transmission and costing in the Asia-Pacific: Developing an investment case [version 2; peer review: 2 approved]. Wellcome Open Res 2020, 4 :60. Jamison DT, Summers LH, Alleyne G, et al. 2013. Global health 2035: a world converging within a generation. The Lancet ; 382(9908): 1898-955 2017. National Health Accounts. Draft. 2016. National Health Accounts. Oct 2017. Dalaba MA, Welaga P, Oduro A, Danchaka LL, Matsubara C. 2018. Cost of malaria treatment and health seeking behaviour of children under-five years in the Upper West Region of Ghana. PLoS ONE 13(4): e0195533. https://doi . org/10.1371/journal.pone.0195533. Tawiah, T., Asante, K. P., Dwommoh, R. A. et al. 2016. Economic costs of fever to households in the middle belt of Ghana. Malaria journal , 15 , 68. doi:10.1186/s12936-016-1116x. Ghana Statistical Service. 2016. Ghana multiple indicator cluster survey with an enhanced malaria module and biomarker. Final Report. Accra, Ghana: Ghana Statistical Service. 2011. Exports, employment and incomes in West Africa. West Africa Trade Hub Report # 39 . www.africancashewalliance.com/sites/default/files/documents/th_-_multiplier_effects_- exports_employment_and_incomes_in_wa_2011.pdf Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. 2005. Methods for economic evaluation of health care programmes . Third ed. Oxford: Oxford University Press. President’s Malaria Initiative Ghana. 2018. Malaria Operational Plan. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2018/fy-2018-ghana-malaria-operational-plan.pdf?sfvrsn=5 President’s Malaria Initiative Ghana. 2017. Malaria Operational Plan. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2017/fy-2017-ghana-malaria-operational-plan.pdf?sfvrsn=5 Ghana Statistical Service. 2010. Population and Housing Census Report . Women and Men in Ghana. July 2013, Accra. Smith, Paintain L, Awini E, Addei S et al . Evaluation of a universal long-lasting insecticidal net (LLIN) distribution campaign in Ghana: cost effectiveness of distribution and hang-up activities. Malaria Journal 2014 13:71. Koenker H, Ricotta E, Olapeju B, Choiriyyah I. 2019. Insecticide-Treated Nets (ITN) Access and Use Report. Baltimore, MD. PMI | VectorWorks Project, Johns Hopkins Center for Communication Programs. Kesteman T, Randrianarivelojosia M, Rogier C. 2017. The protective effectiveness of control interventions for malaria prevention: a systematic review of the literature. F1000Research . 6: Lucas AM, 2010. Malaria eradication and educational attainment: evidence from Paraguay and Sri Lanka. Am Econ J Appl Econ 2: 46–71. Fernando SD, Rodrigo C, Rajapakse S, 2010. The “hidden” burden of malaria: cognitive impairment following infection. Malar J 9: 366. Bleakeley H, 2010. Malaria eradication in the Americas: a retrospective analysis of childhood exposure. Am Econ J Appl Econ 2: 1–45. Modrek S, Liu J, Gosling R, Feachem RG, 2012. The economic benefits of malaria elimination: do they include increases in tourism? Malar J 11: 24. Maartens F, Sharp B, Curtis B, Mthembu J, Hatting I, 2007. The impact of malaria control on perceptions of tourists and tourism operators concerning malaria prevalence in KwaZulu-Natal, 1999/2000 versus 2002/2003. J Travel Med 14: 96–104. doi:10.12688/f1000research.12952.1 President’s Malaria Initiative Ghana. 2016. Malaria Operational Plan. President’s Malaria Initiative Ghana. 2017. Malaria Operational Plan. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2016/fy-2016-ghana-malaria-operational-plan.pdf?sfvrsn=5 . 2015. Resource Mobilization Plan for National Malaria Control Strategy (2014-2020) Tables Table 1. Scenarios modelled No. Name Description Assumptions 1. Baseline Existing set of malaria control activities in 2018. Passive testing and treating of positive malaria cases (community and facility-based) Distribution of LLINs with coverage* and usage levels maintained at 2018 levels IRS coverage continued at 2018 levels Seasonal malaria chemoprophylaxis continued at 2018 levels IPTp continued at 2018 levels (~47%) Maintain proportions of participants who receive 1, 2, 3, 4, 5 doses Distribute routine LLINs to participants of IPTp No cost and service difference between community and facility-based treatment avenues Mass distribution of LLINs every 3 years, in line with data Proportion of participants who take 1,2 ,3, 4, 5 doses of IPTp remains constant 2. Fully-funded response (FFR) Baseline + Test 100% of all suspected cases and treat 100% of positive cases IRS coverage > 80% (to cover Upper East, Upper West, Northern and Brong Ahafo Region (78% of population of the Savanna zone)) Increase IPTp3 to 80% SMC extended to Northern in 2019 Supportive supervision and training to enable better testing and treating (applied annually per PAR) IRS is an annual cost IPTp costs for dosage only (through existing ANC) 3. Better use of nets Fully-funded response + SBC (social and behavioral change) to increase the usage of LLINs. Distribution of LLINs every 3 years, en masse SBC costs applied to cover 1/3 of the country per year, allowing for full coverage with every mass distribution. Costs applied annually at 1/3 coverage per par Impact of SBC: Increase in net use by 50% 4. Health System Acceleration Better use of nets + Increase treatment seeking from 73% to 90% (through increasing SBC) Increased SBC costs to increase treatment seeking Costs applied annually per par 5. Reverse Cut IRS Cut SMC Cut nets by 50% 6. Reverse 2 Cut IRS Cut SMC *LLIN coverage determined by LLIN usage and effectiveness at reducing transmission Table 2. Framework for estimating the economic burden of malaria in Ghana Direct health system costs Direct household costs Indirect costs National and subnational expenditures on malaria interventions Out-of-pocket expenditures for treatment seeking Productivity losses among malaria patients and caregivers Value of life years lost due to premature death Table 3. Median costs and benefits of the baseline response against malaria compared to counterfactuals, 2020-2030 Scenario comparisons (Baseline – Intervention) Clinical cases averted Reported cases averted Deaths averted Economic benefits (NPV USD) Cost (USD) (discounted) Fully funded NSP scenario vs baseline 37434462 21,221,433 2,683 14.1 billion 1.31 billion Elimination scenario (HSA) vs baseline 85,571,086 51,251,099 4,468 31.73 billion 961 .3 million Additional clinical cases Additional reported cases Additional deaths Additional economic losses (NPV USD) Baseline vs. reverse I 38,220,597 24,411,310 2,497 14.1 billion Baseline vs. reverse II 12,974,304 8,914,008 1,350 4.4 billion Supplementary Files Additionaltable1.docx Cite Share Download PDF Status: Published Journal Publication published 01 Jun, 2020 Read the published version in Malaria Journal → Version 1 posted Editorial decision: Major Revision 01 Apr, 2020 Review # 1 received at journal 31 Mar, 2020 Review # 2 received at journal 31 Mar, 2020 Reviewer # 1 agreed at journal 11 Mar, 2020 Reviewer # 2 agreed at journal 11 Mar, 2020 Reviewers invited by journal 15 Feb, 2020 Editor assigned by journal 14 Feb, 2020 First submitted to journal 13 Feb, 2020 Submission checks completed at journal 13 Feb, 2020 Editor invited by journal 13 Feb, 2020 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1.docx"}],"financialInterests":"","formattedTitle":"Estimating the Risk of Declining Funding for Malaria in Ghana: The case for continued investment in the malaria response","fulltext":[{"header":"Background","content":"\u003cp\u003eGhana has made impressive progress in its fight against malaria. Malaria cases and deaths have decreased by over 50 and 65%, respectively between 2005 and 2015 [1]. The current strategy is based on the National Malaria Control Strategic Plan (NSP) for 2014-2020, which was finalized in August 2014 by the National Malaria Control Program (NMCP) [2]. The scope of the strategic plan was to consolidate the gains and accelerate malaria control in the high transmission areas to further reduce malaria burden and move towards establishing lower-transmission areas in Ghana by the end of 2020. The plan calls for reducing the malaria morbidity and mortality burden by 75% (using 2012 as baseline) by the year 2020.\u003c/p\u003e\n\u003cp\u003eThe gains experienced in the past decade can be attributed in part due to the increased financing available to scale up effective interventions. Since 2003, Ghana has benefited from a succession of grants from Global Fund for AIDS, Tuberculosis and Malaria (Global Fund) [3] with disbursements over USD 408 million. The country currently has 2 active grants totaling USD 109 million (2018-2020). Several other external donors have provided financial support to the malaria program including the United States Presidents Malaria Initiative (PMI, the U.K. Department for International Development (DFID), the United Nations Children\u0026rsquo;s Fund (UNICEF), the World Bank, and the governments of Japan, China, and Cuba [1]. Nevertheless, the country still faces a financing gap estimated at 187 million for 2019-20 by the Ghana National Strategic Plan for malaria (NSP) [2].\u003c/p\u003e\n\u003cp\u003eGovernment contributions made up 38% of the total financing for malaria in 2018 [4]. Curative services for malaria are covered by the National Health Insurance Scheme (NHIS) benefit package which is financed by a mix of funding from earmarked taxes and premiums paid by members. However, collection rates are a challenge and therefore revenue received from capitation does not offset any significant portion of the expenditure.\u003c/p\u003e\n\u003cp\u003eThe current level of financial support the country receives from external partners is unlikely to be sustained in the longer term. Between 2002 and 2016, Ghana experienced a five-fold increase in GDP per capita from USD 309 to USD 1,517 [5, 6]. As Ghana\u0026rsquo;s economy transitions towards middle income, external donor financing for health is expected to decline, with domestic or other sources of financing having to fill the resulting gap. However, experience with other countries points to a significant time-lag between rising national income and increased government health expenditure unless accompanied by effective advocacy backed by evidence outlining the risks associated with funding withdrawal. Historical evidence demonstrates that almost all resurgence events could be attributed, at least in part, to the weakening of malaria control programs for a variety of reasons, of which resource constraints were the most common [7].\u003c/p\u003e\n\u003cp\u003eThe aim of this analysis was therefore to quantify the epidemiological and economic impact of both a fully-funded malaria response that will achieve malaria elimination and that of a partially-funded response that may potentially lead to disease resurgence. The findings of this work can be used to shape the advocacy strategy for mobilizing increased domestic resources for malaria.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis investment case projected the financial requirements of the malaria program to reach malaria elimination by 2030 and values the economic and financial returns of reducing malaria transmission compared to alternative scenarios. To accomplish this, the investment case leveraged multiple methodologies and data sources. The study design incorporated a variety of quantitative methods: numerical and regression techniques to develop a transmission model to predict the epidemiological impact of various interventions used for malaria control and elimination and economic analysis to estimate the cost and economic impact of the interventions nationally and regionally. The economic analysis was informed by the outputs of a transmission model. All monetary figures are expressed in 2018 constant US dollars (USD) [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThis investment case projected the financial requirements of the malaria program to reach malaria elimination by 2030 and values the economic and financial returns of reducing malaria transmission compared to alternative scenarios. To accomplish this, the investment case leveraged multiple methodologies and data sources. The study design incorporated a variety of quantitative methods: numerical and regression techniques to develop a transmission model to predict the epidemiological impact of various interventions used for malaria control and elimination and economic analysis to estimate the cost and economic impact of the interventions nationally and regionally. The economic analysis was informed by the outputs of a transmission model. All monetary figures are expressed in 2018 constant US dollars (USD) [8].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEpidemiological model framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA spatially explicit, compartmental, nonlinear, ordinary differential equation model is an extension of previously published models and have been implemented in R and C++ [9, 10]. The model simulated a range of malaria interventions and estimated their impact on the transmission of \u003cem\u003ePlasmodium falciparum \u003c/em\u003emalaria between 2018 and 2030 nationally and in the three ecological zones in Ghana (Coastal, Forest and Savanna). Historical data from 2012-2018 was used to parameterize and fit the model. The key transmission features and drivers of transmission in the model included:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eInfection classes dependent on the level of severity of infection\u003c/li\u003e\n\u003cli\u003eDevelopment and loss of immunity against clinical infection\u003c/li\u003e\n\u003cli\u003eSuperinfection\u003c/li\u003e\n\u003cli\u003eSubnational climatic variation (seasonality)\u003c/li\u003e\n\u003cli\u003eImportation of infection\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMore details on the model have been published elsewhere [9, 10, 11].\u003c/p\u003e\n\u003cp\u003eInterventions modelled included:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003ePassive Case detection (routine diagnosis and treatment in health facilities and the community)\u003c/li\u003e\n\u003cli\u003eVector Control:\n\u003cul\u003e\n\u003cli\u003eDistribution of LLINs\u003c/li\u003e\n\u003cli\u003eIRS\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003cli\u003eHealth System Strengthening (supportive supervision, training for improved malaria testing and treatment and supply chain management support)\u003c/li\u003e\n\u003cli\u003eSocial and Behavioral Change (SBC) for improved health seeking behavior\u003c/li\u003e\n\u003cli\u003eSeasonal Malaria Chemoprevention (SMC)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eData sources used were:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eData from the NMCP (monthly incidence and deaths by district from the Health Management Information System (HMIS))\u003c/li\u003e\n\u003cli\u003eWHO World Malaria Reports and Annexes\u003c/li\u003e\n\u003cli\u003ePeer reviewed literature\u003c/li\u003e\n\u003cli\u003eExpert opinion (for assumptions where data was unavailable)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFour scenarios and two reverse scenarios were developed in collaboration with the NMCP:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eBaseline scenario: existing set of malaria control activities as implemented in 2018 with coverage levels of 2018\u003c/li\u003e\n\u003cli\u003eFully funded response (FFR): fully funding the activities and coverage levels in the NSP\u003c/li\u003e\n\u003cli\u003eBetter use of nets: added to the \u0026ldquo;fully funded response\u0026rdquo; through the use of SBC (social and behavioral change) to increase the usage of LLINs\u003c/li\u003e\n\u003cli\u003eIncrease treatment seeking from 73% to 90% (through SBC): added to the \u0026ldquo;better use of nets\u0026rdquo; scenario.\u003c/li\u003e\n\u003cli\u003eReverse scenarios: Reduce the amount of funding for the implementation of activities from the 2018 baseline coverage. Where:\n\u003cul\u003e\n\u003cli\u003eReverse 1: cutting out IRS, SMC and LLINs by 50%\u003c/li\u003e\n\u003cli\u003eReverse 2: cutting out IRS, SMC (LLINs remain at 2018 levels)\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTable 1. describes the scenarios in detail.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEconomic analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing a societal perspective and cost of illness approach [11, 12], the economic burden of malaria in 2018 was evaluated. Specifically, (i) direct health system costs, (ii) direct household costs, and (iii) indirect costs were estimated. Table 2 illustrates the framework used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDirect health system costs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo facilitate the gathering of direct cost data, an interview guide and data entry sheet were developed to collect existing costing data, identify gaps, and locate additional data to fill gaps. These interviews were conducted in a semi-structured format with key malaria program personnel who were familiar with program spending patterns and records. Data on government and external spending were collated. National health system costs outside of vertical malaria program expenditures were included as much as possible to obtain the total actual cost to the health system in Ghana. When expenditures were unavailable, budget figures, National Health Accounts (NHA) and secondary sources such as peer-reviewed or grey literature or deduction were used. Costs of treating outpatient and inpatient malaria cases were obtained from the NHA [13, 14].\u003c/p\u003e\n\u003cp\u003eIndividual costs were extracted and aggregated to obtain estimates of the costs of each intervention. The cost of each scenario was estimated using a cost estimation model fed by outputs of the transmission model. The cost of each scenario was then used to obtain the incremental or additional cost of a fully funded response compared to the baseline. All costs were discounted at 7%. The discount rate used was based on the inflation rate and the expert opinion of economists in-country. Additional table 1.1 contains the cost inputs used in the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDirect household costs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMalaria exacts a significant financial burden on households. Malaria patients often pay for transportation to access health facilities, diagnostic services, and medicines. In Ghana, although testing and treatment for malaria are free, prepaid or covered by the NHIS, malaria patients still incur out-of-pocket expenditures (OOP) for transport, food and other expenses not covered through the public sector. To estimate direct household costs on malaria, the number of reported OP and IP malaria cases in 2018 was multiplied by the mean OOP spending (separately for OP and IP cases). Data on OOP was obtained from published literature [15, 16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndirect Costs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe economic impact of malaria extends beyond the health system. Patients forego income while recovering from malaria, and caregivers looking after ill children and the elderly also lose out on potential earnings. Society also incurs an indirect cost due to premature deaths through losses in lifetime productivity and in the social value people place in living longer, healthier lives.\u003c/p\u003e\n\u003cp\u003eTo evaluate the economic impact of malaria-related morbidity, the foregone income of malaria patients and caregivers was calculated. The gross domestic product (GDP) per capita per day was obtained from 2018 GDP estimates from World Bank Data [5]. The resulting figure was used as a proxy for the average income per capita and multiplied by the duration of OP and IP illness from published literature and the number of reported OP and IP cases. In addition, the effect of reduced productivity from \u0026ldquo;presenteeism\u0026rdquo; was calculating by assuming that adults retuning to work would be 50% less productive for an additional six days. This assumption was made based on interviews in Ghana.\u003c/p\u003e\n\u003cp\u003eA full income accounting approach was used to quantify the economic impact of premature death as postulated by the Lancet Commission on health [17]. Assuming 40 years as the average age of malaria-related adult deaths and 2.5 years as the average death amongst children under 5 years, the average remaining life expectancy of males and females was multiplied by the value of each additional life year (VLY). Life expectancy was retrieved from the Central Statistics Service [18]. One VLY was assumed to be 4.2 times the 2018 GDP per capita of Ghana [17].\u003c/p\u003e\n\u003cp\u003eCost savings from reduced public and private expenditures on malaria are likely to spur consumer spending and create new businesses thus injecting more money into the local economy. Throughout the process, overall disposable incomes increase, creating more markets for local businesses. These induced responses result in an economic multiplier or \u0026ldquo;ripple\u0026rdquo; effect. A 2011 USAID report [19] estimated that income multipliers in West Africa lay between 1.58 and 2.43. An average multiplier of 2 was therefore used for the purposes of this analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEconomic benefits estimation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mortality and morbidity averted from malaria elimination were obtained by subtracting the estimated cases and deaths in the fully funded scenarios from the corresponding outputs of the \u0026ldquo;business as usual\u0026rdquo; scenario. Similarly, the excess cases and deaths in the reverse scenarios were calculated by subtracting from the corresponding outputs of the \u0026ldquo;business as usual\u0026rdquo; scenario. These health benefits were calculated using the methodology and inputs previously outlined.\u003c/p\u003e\n\u003cp\u003eDirect costs averted to the health system includes costs associated with diagnosis and treatment costs of IPs and OPs;\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eDirect cost averted to the individual households is out-of-pocket (OOP) expenditures for seeking care; and\u003c/li\u003e\n\u003cli\u003eIndirect cost averted to the society due to patients\u0026rsquo; lost productivity due to premature death and morbidity and caregivers\u0026rsquo; reduced economic output.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe benefits of investing and not investing in malaria control and elimination were estimated as the sum of the direct cost savings to the health system from reduced use of outpatient and inpatient health services and reduction in cost of delivering malaria control activities; the direct cost savings to households; and the indirect cost savings of reduced morbidity and mortality from malaria calculated above.\u003c/p\u003e\n\u003cp\u003eThe Net Present Value (NPV) was calculated to obtain the present value of the future revenue generated from elimination using standard economic techniques. The purpose was to give a true picture of the financial value of an investment made today whereby savings would be accrued in the future [12]. The timeframe used for calculating the NPV was 11 years and a 7% discount rate was applied as before.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReturn on investment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo calculate the ROI from malaria investments, the NPV of the benefits of reduced transmission were subtracted from the incremental cost of elimination. The resulting figure was divided by the incremental cost of the fully funded response (compared to baseline). The ROI is interpreted as the economic return from every additional dollar spent on malaria above the business as usual scenario.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eFinancial\u0026nbsp;\u003c/strong\u003egap\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVarious sources were consulted to estimate past, present, and future financing for malaria. Projected financing was estimated using projected figures from GOG, the Global Fund and PMI. Many of malaria services are covered under the NHIS via the health insurance levy. These estimated resources are included in under \u0026ldquo;domestic financing\u0026rdquo; (obtained from the NMCP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eSensitivity\u003c/strong\u003e\u0026nbsp;analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA stochastic sensitivity analysis on the epidemiological and cost outputs of the malaria transmission model was performed. The minimum, median, and maximum malaria cases and deaths predicted by the model for each scenario were used to calculate the minimum, median, and maximum costs. Three hundred random samples were drawn, which generated a range of costs. From the range of costs generated, the minimum, maximum, median, mean, and other percentiles are presented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection, tools\u003c/strong\u003e\u003cstrong\u003e and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA worksheet was been developed in Microsoft Excel\u0026reg; to facilitate the organization of cost data. Analysis of the cost data was conducted in Microsoft Excel to estimate the current and future costs of the malaria activities in each scenario. All quantitative data records (no identifying information), were stored in Microsoft Excel spreadsheets on encrypted, password-protected computers. Data was collected in August 2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ethical Review Committee (ERC) of the Ghana Health Service prior to data collection (GHS/RDD/ERC Ref No. 1913445).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA number of known and unknown factors limit the findings of this report. Due to time and resource constraints, the transmission model estimated sub-national malaria transmission based on three climatic zones. Ideally, higher levels of spatial heterogeneity would be modelled to provide to enable subnational estimates of interventions and costs.\u003c/p\u003e\n\u003cp\u003eThe costs of interventions have been estimated based on available data from the NMCP and proxies when data were unavailable. For example, the costs of outpatients, in-patients and health worker salaries were estimated from the National Health Accounts (NHA). Separating out the cost of interventions in integrated systems is challenging and the analysts have relied on country-level partners to arrive at disaggregated costs. This report utilized reported cases from the HMIS and estimated cases and deaths from WHO World Malaria Reports. The wide variation in these two estimates of burden makes it harder to be sure of the resources required to eliminate the disease.\u003c/p\u003e\n\u003cp\u003eAs Ghana moves closer to elimination the impact of active surveillance on both the epidemiology and cost will need to be incorporated. This was not included due to a lack of historical data to enable fitting the model for impact or cost. The savings observed may well be offset by the increased costs of active surveillance required in elimination settings. At the same time, targeting of interventions rather than ubiquitous coverage to the entire country may reduce the costs of elimination and the financing gap. Without subnational estimates of incidence and coverage, targeted interventions are difficult to estimate and cost. Without an informed and complete understanding of the detailed current cartography of malaria risk and prevalence, future projections of the cost of eliminating malaria face an overwhelming uncertainty.\u003c/p\u003e\n\u003cp\u003eWhile employee absenteeism was included in the estimates of benefits, the analysis did not include the economic benefits conferred by reductions in school absenteeism and subsequent improvements in cognitive development due to the lack of empirical evidence to enable converting these estimates to wages earned. Other benefits not included include potential benefits on tourism, the impact of economic development and housing improvements on malaria transmission as well as regional or cross border externalities.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTransmission model predictions and projections\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBaseline response:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaintaining the interventions (LLIN distribution, IRS, SMC) and health system access and performance at 2018 levels, does not change the transmission intensity. Figure 1 shows malaria is predicted to continue unabated, with no further decrease expected until 2030 (the end point of the model). The slight upward trend in cases is a reflection of a growing population, rather than increased incidence of malaria. The lower line represents the reported cases using WHO estimates while the upper line represents the estimated clinical cases based on corrections for reporting rate in the public sector. The true number is likely to be somewhere in between.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFully-funded/NSP response\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis scenario modelled the impact of a fully funded scenario as mapped in the NSP. It must be noted that the current NSP was developed as a \u0026ldquo;malaria control strategy\u0026rdquo; rather than an \u0026ldquo;elimination\u0026rdquo; strategy. While transmission decreases starting 2020 when the interventions begin, the number of reported cases does not fall below 3.5 million annually during the 10-year period (2020-2029), as illustrated in Figure 2.\u003c/p\u003e\n\u003cp\u003eCompared to the baseline, the fully funded NSP scenario will avert 37.4 million clinical cases, 21.2 million reported cases and 2,683 deaths.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBetter net use\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the low usage of nets in Ghana, interventions to increase usage beyond the estimated 41.7% recorded in 2016 [20, 21, 22] were added to simulate increased net use. The interventions modelled were a combination of activities of a \u0026ldquo;hang-up campaign\u0026rdquo; as well as SBC and IEC and based on a 2014 study in Ghana [23], where LLIN use by children under five years increased to 77.4% in households where some or all LLINs were hung by a campaign volunteer accompanied by SBC/IEC activities in the community, compared to 53.9% in households without these interventions. These interventions increased the odds of a child sleeping under an LLIN approximately 1.5 times when adjusted for other factors that may explain variation in use (adjusted OR: 1.57; 95% CI: 1.09, 2.27; p = 0.02). These odds when applied to 41.7% reported usage (with 40% protection given usage\u003ca href=\"#_ftn1\" name=\"_ftnref1\"\u003e[1]\u003c/a\u003e) result in a median protective efficacy of 24.9% [24]. Figure 3 shows that the impact of improved usage results in a considerable predicted decrease in malaria cases at the national level with reported cases falling below 1 million in 2029. These predictions assume that improved usage will be maintained consistently until 2030.\u003c/p\u003e\n\u003cp\u003eIt must be noted that studies have shown that LLIN use varies considerably by urbanization and socio-economic status with low net use being recorded among higher income households in urban areas [25]. Given that the only data available were national averages, it is likely that the impact of net use is overestimated if indeed, use is high amongst the population at risk in rural areas but low amongst those living in low-risk urban areas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system acceleration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 4 shows the impact of combining better net use with an increase in access to the public health system through SBC and IEC interventions. Modelling this improvement in access as an increase in treatment seeking behavior from 73% (reported) to 90%, results in a model prediction of reaching malaria elimination.\u003c/p\u003e\n\u003cp\u003eCompared to the baseline, the HSA scenario will avert 85.6. million clinical cases, 51.3 million reported cases and 4,468 deaths.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReverse scenario 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRemoving IRS, SMC and reducing LLIN coverage by 50% will result in an almost immediate upsurge of cases. By 2028, reported cases increase to more than 10.6 million (Figure 5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReverse scenario 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRemoving IRS and SMC similarly reverse the gains made with reported cases rising to over 8.5 million by 2029 and clinical cases to 13.5 million (Figure 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eZonal differences\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 7 illustrates the zonal differences of intervention impact. Better net use and the fully funded scenario have less of an impact on transmission in the forest zone compared to the other two zones. Indeed, it would appear that this zone, having the largest case load, has the greatest impact on the total national response.\u003c/p\u003e\n\u003cp\u003eFigure 8 summarizes the total clinical cases and deaths (2020-2029) with the baseline, HSA and reverse scenarios. Over the course of 10 years, the baseline scenario will result in 105 million clinical cases and 5,122 deaths. The accelerated health system scenario will result in 19 million cases and 676 deaths while the reverse I scenario will result in 143 million cases and 7,642 deaths.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCost projections\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo account for potential underestimation of reported cases, clinical cases were used to calculate modelled costs and benefits, and both are shown here.\u003c/p\u003e\n\u003cp\u003eThe cost of implementing the HSA scenario is depicted in Figure 9. The model predicted that it will cost a total of USD 961.3 million over 10 years (2020-2029) to implement the HSA scenario (to reach elimination). This equates to about USD 133 million annually for the first five years, assuming that the aggressive interventions predicted by the model are implemented in the most efficient way. This includes the integrated health system cost of treating outpatients and inpatients. The cost for the HSA scenario in 2020, not taking integrated costs into account, is USD 41.6 million. The peaks represent LLIN procurement for national mass campaigns which occur every three years in Ghana.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBenefits estimation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo estimate the benefits of elimination, the averted costs, cases and deaths were calculated. The HSA scenario will avert 85.6 million clinical cases, 51.3 million reported cases and 4,468 deaths. Economic benefits of USD 31.73 billion (NPV) are generated through reductions in deaths, cases, and household and healthcare system spending as well as increases in productivity at a cost of USD 961.34 million (2020-2029).\u003c/p\u003e\n\u003cp\u003eReducing funding for IRS and SMC will incur additional (to the current baseline scenario) economic losses of USD 4.4 billion in addition to an additional 13 million clinical cases, 8.9 million reported cases and 1,350 deaths. Further reducing funding for LLINs by 50% as well will incur economic losses 14.1 billion in addition to an additional 38.2 million clinical cases, 24.4 million reported cases and 2,497 deaths.\u003c/p\u003e\n\u003cp\u003eA summary of the results of various scenarios is shown in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReturn on I\u003c/strong\u003e\u003cstrong\u003envestment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ROI was calculated by subtracting the NPV of the benefits of elimination by the discounted cost of elimination and dividing the resulting figure by the discounted cost of elimination (Table 3). Implementing the HSA scenario which will allow the country to progress to elimination and will produce a return on investment of 32:1 between 2020-2029.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGaps in malaria financing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe expected influx of financing (both domestic and donor) was compared with the projected cost of the malaria program from 2020 to 2021.\u003c/p\u003e\n\u003cp\u003eThe modelled cost of the elimination scenario was estimated at 961.3 million (2020-2029). This equates to about USD 133 million annually for the first five years, assuming that the aggressive interventions predicted by the model are implemented in the most efficient way. This includes the integrated health system cost of treating outpatients and inpatients. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to domestic government financing, Ghana received about USD 44 million from the Global Fund in 2018 and an USD 29 million from other donors [26]. In order to scale up the interventions needed, the remaining USD 60 million annually will need to be met by domestically.\u003c/p\u003e\n\u003cp\u003eIt is important to note that these figures do not account for the increased levels of co-financing levels that may be required by the Global Fund.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"#_ftnref1\" name=\"_ftn1\"\u003e[1]\u003c/a\u003e A meta-analysis of protective efficacy from use predicted that LLINs had a protective efficacy of 39.8% (IQR 20.2\u0026ndash;50.3%) and 28.5%, (IQR 8.8\u0026ndash;47.3%) for IRS. Thus for LLINs there is a median effective protection of 16.6%.\u003c/p\u003e"},{"header":"Discussion","content":"This analysis found that the cost of implementing the most effective scenario was USD 961.3 million over 10 years (2020-2029) equating to about USD 133 million annually for the first five years, assuming interventions are implemented efficiently. The health and economic benefits are enormous. Reducing transmission to elimination levels will avert 85.6 million clinical cases, 51.3 million reported cases and 4,468 deaths. Economic benefits of USD 31.73 billion are generated through reductions in deaths, cases, and household and healthcare system spending as well as increases in productivity. The economic return is significant at 32 times the investment. This by far exceeds the threshold on returns that are considered to be high impact investments. In contrast, reducing funding for IRS and SMC will incur additional economic losses of USD 4.4 billion, an excess of 13 million clinical cases, 8.9 million reported cases and 1,350 deaths. Further reducing funding for LLINs by 50% will incur economic losses USD 14.1 billion in addition to an excess of 38.2 million clinical cases, 24.4 million reported cases and 2,497 deaths.\n\nThe benefits of investing in malaria elimination are likely to be undervalued as they exclude certain macro-economic costs that extend far beyond the health system. Studies have shown that indirect costs of malaria account for a large share of societal costs due to its debilitating effect on the economy through employee and school absenteeism, cognitive development in children as well as macroeconomic development by limiting foreign investments and tourism [27-31]. These have not been included due to the lack of accurate data to quantify these effects and to directly attribute them to malaria. Other costs to the health system such as cost of drug and insecticide resistance, the cost of higher price alternatives, the cost associated with their implementation, and the cost of research and development have also been omitted. The total income approach was used to compute income losses from malaria mortality. Although this methodology provides more generous estimates of economic losses than other methods, it is unlikely to account for all the aforementioned losses.\n\nThere are several limitations to the data and methods used in this study. Obtaining accurate data on the cost of program operations, particularly in an integrated health system, is challenging. Several malaria program resources are shared across other public health programs, particularly for activities that are financed through government funding. Facility staff perform other health functions and therefore outpatient and inpatient costs are derived from estimates from the NHA.\n\nThe scenarios were developed in collaboration with the NMCP based on the current knowledge of interventions and strategic direction of the program. As the program progresses and transmission is reduced, these interventions are likely to the reviewed and revised.\n\nDespite the robust benefits associated with investing in malaria, Ghana’s program is likely to face a gap in funding in the immediate future. Funding for malaria from government sources met less than 30% of the total needs. Ghana is currently highly dependent on financing from the Global Fund at USD 36 million per year on average [32]. The current Global Fund grant ends in 2020. A funding request to the Global Fund for malaria will be developed for the period of 2021-2023. However, given that Ghana is already a lower middle-income country, as cases decline, it is unlikely that the Global Fund will maintain its current levels of funding, particularly if the co-financing requirement remains unpaid. These financing gaps will need to be met by increased domestic financing. A robust resource mobilization strategy bolstered by the epidemiological and economic evidence generated by this report will be needed.\n\n In 2015, a Resource Mobilization Plan for National Malaria Control Strategy (2014-2020) [33] was developed and laid the foundation for resource mobilization efforts for malaria in Ghana. The subsequent Ghana Health Service Resource Mobilization Strategy for National Malaria Control and Elimination (2019–2023) [4] is awaiting finalization and ratification. At the same time, several actions have since been taken: The Ghana Malaria Foundation (GMF), established in 2015/2016 and officially inaugurated in 2017 has been accredited as a limited guarantee corporate body. However, a renewed effort incorporating the evidence from this report is needed, which includes outlining clear actions for implementing identified strategies for resource mobilization.\n\nGhana’s private sector is large and growing, and its engagement in supporting the implementation of malaria control interventions during the past decade has increased. Engagement includes corporate social responsibility programs (e.g., through oil companies), workplace wellness programs (e.g., plantations), marketing of effective malaria treatment and prevention products and services and other public-private partnerships including market catalyzation for malaria control products. Several opportunities exist to expand these efforts in support of the new strategy.\n\nRemittances are one of the largest sources of funding flows next to international aid. Providing a small portion of each transaction to malaria — possibly through a Corporate Social Responsibility model via mobile transaction companies should be explored, especially since these funds could be applied to a matching fund scheme. In 2017, remittances made up 5.1% of Ghana’s GDP to the tune of USD 2.19 billion and which, according to the Bank of Ghana, grew to USD 3.52 billion in 2018 [4].\n\nPublic and private sector donors can enter into matching fund programs, which would substantially increase donations for Ghana’s national malaria programming. For example, in Mozambique, DFID and the Global Fund matched Ecobank Foundation’s USD 750,000 donation for an LLIN campaign in the country, raising the value of that donation to USD 2.5 million. Ghana could explore developing a matching co-financing facility with private sector companies, such as those from the extraction industry and financial sector, and other donors. Other opportunities to create an enabling environment include tax incentives from the government for private sector involvement.\n\nEngagement with companies to raise funds from middle- and upper-class customers and employees to contribute to the GMF may be a viable option. Potential mechanisms are voluntary contributions through online banking platforms or similar online systems. For example, the Ecobank Foundation asked Ecobank employees on World Malaria Day 2017 to donate USD 3.00 for an LLIN to be distributed to vulnerable populations. With little effort, out of 16,000 employees, Ecobank raised USD 22,000. This can serve as an example for other companies to help fill the NMCP gaps [4].\n\nCurrently, the Government collects taxes on tobacco products, alcohol and soda, tourism and airport levies, petroleum revenues, lottery funds and others. However, none of these are currently earmarked for health and present a potential opportunity for increased resources. By law, 0.5% of new funding allocated within the District Assembly Common Fund is mandated to be used toward malaria control and elimination efforts at the district level. Currently, these funds are frequently not being used for this purpose and advocacy to ring-fence the funds is needed.\n\nOther opportunities include using existing resources more efficiently. The current cost of the program does not include measures to improve efficiencies. Targeted interventions such as vector control to high risk areas and populations will likely provide considerable cost-efficiencies. The implementation of efficiency measures in malaria programming can also serve as an advocacy tool to approach existing and new donors. These strategies can be made more effective through the use of key influencers or ambassadors to ensure accountability."},{"header":"Conclusions","content":"\u003cp\u003eThe findings indicate that while the interventions outlined in the NSP will lower transmission of malaria, they are not likely to allow the elimination of the disease. Elimination will only be achieved through increased use of nets, improved health seeking behavior and strengthened malaria case management at the facility level. The effects of these interventions vary by zone and there is a need for risk stratification and to target interventions particularly as transmission declines and the country moves closer to elimination. Furthermore, as cases decline and the epidemiology of the disease changes, a similar exercise with revised elimination interventions will need to be conducted with the additional costs of surveillance built in.\u003c/p\u003e\n\u003cp\u003eThere are several critical reasons why malaria should receive a special focus for financing. Malaria is a major ongoing cost driver burdening national health systems and eliminating the disease will confer public health benefits as well as major cost savings to national health systems. Although the short-term investment needed may seem substantial at USD 961.3 million over 10 years (2020-2029), front loading investments will provide cost savings in the longer term as well as substantial health and economic returns. Eliminating malaria will avert 85.6 million cases and 4,500 deaths. 1.06 billion days of employee absenteeism will be avoided conferring economic benefits of 31.73 billion providing a return on investment of 32:1. Reducing investments and a resulting resurgence will lead to an additional 38.2 clinical cases, 2500 deaths and additional economic losses of USD 14.1 billion. At the same time, Ghana could be at the frontier of elimination in Africa amongst the identified WHO High-Burden High-Impact countries in Africa. There is a need for a robust and effective resource mobilization and advocacy strategy backed by the evidence produced by this body of work.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACT: Artemisinin-based combination therapy; AL Artemether-lumefantrine; BCR: Benefit-cost ratio; CCP: Center for Communication Programs; CHPs: Community Health Planning Services; CHW: Community Health Workers; DFID: Department for International Development; ERC: Ethical Review Committee\u003c/p\u003e\n\u003cp\u003eGDP: Gross Domestic Product; GHC: Ghanaian Cedi: GHS: Ghana Health Service\u003c/p\u003e\n\u003cp\u003eGlobal Fund: Global Fund to Fight AIDS, Tuberculosis and Malaria: GNI: Gross National Income: GOG: Government of Ghana: GVA: Gross Value Added: IEC: Information, education, and communication: IPT: Intermittent preventive treatment for pregnant women: IRS : Indoor residual spraying: ITN : Insecticide-treated mosquito net: JHU: Johns Hopkins University: LLIN : Long-lasting insecticide-treated mosquito net: MICS: Multiple Indicator Cluster Survey: MIS: Malaria Indicator Survey: MOP: Malaria Operational Plan: MOH : Ministry of Health: NHIS: National Health Insurance Scheme: NMCP: National Malaria Control Programme: NPV: Net Present Value: NSP: National Malaria Strategic Plan: PMI : President\u0026rsquo;s Malaria Initiative: RDT : Rapid Diagnostic Test: ROI: Return on Investment: SBC : Social behavioral change: SMC: Seasonal Malaria Chemoprevention: SP/AQ: Sulfadoxine-pyrimethamine and amodiaquine\u003c/p\u003e\n\u003cp\u003eSP: Sulfadoxine-pyrimethamine: USAID: United States Agency for International Development: USD: United States Dollar: WHO : World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003euthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRS conceived the paper and prepared the manuscript. RS collected the data and conducted the cost and economic analysis. SPS developed the transmission model and its outputs. RS coordinated inputs to the draft. KM provided NMCP data and inputs into the methodology. DP, KB, JR and ML reviewed the draft paper. All authors read and approved the final manuscript. RS and JR were contracted as consultants to JHUCCP for this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAck\u003c/strong\u003e\u003cstrong\u003enowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful for the collaboration with the National Malaria Control Programme and the inputs of James Frimpong and Patricia Bentil, in addition, thank you for the support provided by the JHUCCP Ghana team, Felix\u0026nbsp;Nyanor-Fosu and Richard\u0026nbsp;Kpabitey. Dr Koku Awoonor and Mr Daniel Osei provided valuable data on integrated health sector costs. Olivier Celhay is acknowledged for technical support provided in the model application. This work was funded by the UK Department of International Development (DFID).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003evailability\u003c/strong\u003e \u003cstrong\u003eof data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available in a separate database[11] online\u0026nbsp; and as additional tables included in this submission. Other raw data is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003cstrong\u003eunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Government of the United Kingdom of Great Britain and Northern Ireland, acting through the Department for International Development (DFID) ) as part of the grant to the Private Sector Malaria Prevention Project of the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (grant 300191, Components 101, 102 and 103). The content is solely the responsibility of the authors and does not necessarily represent the official views of DFID or its member countries. The authors were not paid to write this manuscript. The development of the transmission model was supported by the Wellcome Trust [214236/Z/18/Z].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ethical Review Committee (ERC) of the Ghana Health Service prior to data collection (GHS/RDD/ERC Ref No. 1913445). The ERC of the Johns Hopkins Bloomberg School of Public Health, Baltimore deemed this study exempt from needing ethical approval given that the work did not directly involve patients or patient data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"RReferences","content":"\u003col\u003e\n\u003cli\u003e2018. World Malaria Report. Available at: https://www.who.int/malaria/publications/world-malaria-report-2018/en/\u003c/li\u003e\n\u003cli\u003eGhana Health Services. 2014. \u003cem\u003eNational Malaria Strategic Plan 2014-2020\u003c/em\u003e. \u003cstrong\u003eNational Malaria\u003c/strong\u003e Control Programme, Accra.\u003c/li\u003e\n\u003cli\u003eGlobal Fund. 2019. https://data.theglobalfund.org/locations/GHA\u003c/li\u003e\n\u003cli\u003e2019. \u003cem\u003eGhana Health Service Resource Mobilization Strategy for National Malaria Control and Elimination (2019\u0026ndash;2023)\u003c/em\u003e. Draft.\u003c/li\u003e\n\u003cli\u003eWorld Bank Open Data. GDP per capita (current USD). The World Bank Website. Washington: World Bank; 2019 [cited June 2019]; Available from: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=GH\u003c/li\u003e\n\u003cli\u003eInternational Monetary Fund. 2019. \u003cem\u003eWorld Economic Outlook Database\u003c/em\u003e April 2018. Washington: IMF; 2018. https://www.imf.org/external/pubs/ft/weo/2018/01/weodata/index.aspx.\u003c/li\u003e\n\u003cli\u003eCohen J, Smith D, Cotter C, et al. 2012. Malaria resurgence: a systematic review and assessment of its causes. \u003cem\u003eMalaria journal\u003c/em\u003e 11(1):122\u003c/li\u003e\n\u003cli\u003eOanda 2019. \u003ca href=\"https://www1.oanda.com/fx-for-business/historical-rates\"\u003ehttps://www1.oanda.com/fx-for-business/historical-rates\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003eSilal SP, Shretta R, Celhay OJ, Mercado CEG, Saralamba S, Maude RJ, White LJ. 2019. Malaria elimination transmission and costing in the Asia-Pacific: a multi-species dynamic transmission model. 2019 [version 1; peer review: awaiting peer review]. \u003cem\u003eWellcome Open Res\u003c/em\u003e 4:62 (\u003ca href=\"https://doi.org/10.12688/wellcomeopenres.14771.1\"\u003ehttps://doi.org/10.12688/wellcomeopenres.14771.1\u003c/a\u003e).\u003c/li\u003e\n\u003cli\u003e2020. https://github.com/sheetalsilal/SPPf_tool\u003c/li\u003e\n\u003cli\u003eShretta R, Silal SP, Celhay OJ, Mercado CEG, Kyaw SS, Avance\u0026ntilde;a A.L.V, Zelman B, Fox K, Baral R, White L, Maude R. 2019. Malaria elimination transmission and costing in the Asia-Pacific: Developing an investment case [version 2; peer review: 2 approved]. \u003cem\u003eWellcome Open Res\u003c/em\u003e 2020, \u003cstrong\u003e4\u003c/strong\u003e:60.\u003c/li\u003e\n\u003cli\u003eJamison DT, Summers LH, Alleyne G, et al. 2013. Global health 2035: a world converging within a generation. \u003cem\u003eThe Lancet\u003c/em\u003e; 382(9908): 1898-955\u003c/li\u003e\n\u003cli\u003e2017. National Health Accounts. Draft.\u003c/li\u003e\n\u003cli\u003e2016. National Health Accounts. Oct 2017.\u003c/li\u003e\n\u003cli\u003eDalaba MA, Welaga P, Oduro A, Danchaka LL, Matsubara C. 2018. Cost of malaria treatment and health seeking behaviour of children under-five years in the Upper West Region of Ghana. \u003cem\u003ePLoS ONE\u003c/em\u003e 13(4): e0195533. \u003ca href=\"https://doi\"\u003ehttps://doi\u003c/a\u003e. org/10.1371/journal.pone.0195533.\u003c/li\u003e\n\u003cli\u003eTawiah, T., Asante, K. P., Dwommoh, R. A. et al. 2016. Economic costs of fever to households in the middle belt of Ghana. \u003cem\u003eMalaria journal\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 68. doi:10.1186/s12936-016-1116x.\u003c/li\u003e\n\u003cli\u003eGhana Statistical Service. 2016. Ghana multiple indicator cluster survey with an enhanced malaria module and biomarker. Final Report. Accra, Ghana: Ghana Statistical Service.\u003c/li\u003e\n\u003cli\u003e2011. \u003cem\u003eExports, employment and incomes in West Africa. West Africa Trade Hub Report # 39\u003c/em\u003e. www.africancashewalliance.com/sites/default/files/documents/th_-_multiplier_effects_- exports_employment_and_incomes_in_wa_2011.pdf\u003c/li\u003e\n\u003cli\u003eDrummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. 2005. \u003cem\u003eMethods for economic evaluation of health care programmes\u003c/em\u003e. Third ed. Oxford: Oxford University Press.\u003c/li\u003e\n\u003cli\u003ePresident\u0026rsquo;s Malaria Initiative Ghana. 2018. Malaria Operational Plan. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2018/fy-2018-ghana-malaria-operational-plan.pdf?sfvrsn=5\u003c/li\u003e\n\u003cli\u003ePresident\u0026rsquo;s Malaria Initiative Ghana. 2017. Malaria Operational Plan. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2017/fy-2017-ghana-malaria-operational-plan.pdf?sfvrsn=5\u003c/li\u003e\n\u003cli\u003eGhana Statistical Service. 2010. \u003cem\u003ePopulation and Housing Census Report\u003c/em\u003e. Women and Men in Ghana. July 2013, Accra.\u003c/li\u003e\n\u003cli\u003eSmith, Paintain L, Awini E, Addei S \u003cem\u003eet al\u003c/em\u003e. Evaluation of a universal long-lasting insecticidal net (LLIN) distribution campaign in Ghana: cost effectiveness of distribution and hang-up activities. \u003cem\u003eMalaria Journal\u003c/em\u003e 2014 13:71.\u003c/li\u003e\n\u003cli\u003eKoenker H, Ricotta E, Olapeju B, Choiriyyah I. 2019. Insecticide-Treated Nets (ITN) Access and Use Report. Baltimore, MD. PMI | VectorWorks Project, Johns Hopkins Center for Communication Programs.\u003c/li\u003e\n\u003cli\u003eKesteman T, Randrianarivelojosia M, Rogier C. 2017. The protective effectiveness of control interventions for malaria prevention: a systematic review of the literature. \u003cem\u003eF1000Research\u003c/em\u003e. 6:\u003c/li\u003e\n\u003cli\u003eLucas AM, 2010. Malaria eradication and educational attainment: evidence from Paraguay and Sri Lanka. Am Econ J Appl Econ 2: 46\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eFernando SD, Rodrigo C, Rajapakse S, 2010. The \u0026ldquo;hidden\u0026rdquo; burden of malaria: cognitive impairment following infection. Malar J 9: 366.\u003c/li\u003e\n\u003cli\u003eBleakeley H, 2010. Malaria eradication in the Americas: a retrospective analysis of childhood exposure. Am Econ J Appl Econ 2: 1\u0026ndash;45.\u003c/li\u003e\n\u003cli\u003eModrek S, Liu J, Gosling R, Feachem RG, 2012. The economic benefits of malaria elimination: do they include increases in tourism? Malar J 11: 24.\u003c/li\u003e\n\u003cli\u003eMaartens F, Sharp B, Curtis B, Mthembu J, Hatting I, 2007. The impact of malaria control on perceptions of tourists and tourism operators concerning malaria prevalence in KwaZulu-Natal, 1999/2000 versus 2002/2003. J Travel Med 14: 96\u0026ndash;104. doi:10.12688/f1000research.12952.1\u003c/li\u003e\n\u003cli\u003ePresident\u0026rsquo;s Malaria Initiative Ghana. 2016. Malaria Operational Plan. President\u0026rsquo;s Malaria Initiative Ghana. 2017. Malaria Operational Plan. \u003ca href=\"https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2016/fy-2016-ghana-malaria-operational-plan.pdf?sfvrsn=5\"\u003ehttps://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2016/fy-2016-ghana-malaria-operational-plan.pdf?sfvrsn=5\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003e2015. \u003cem\u003eResource Mobilization Plan for National Malaria Control Strategy (2014-2020)\u003c/em\u003e\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:107%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003eTable 1. Scenarios modelled\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eName\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eAssumptions\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 188.2pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e1.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 188.2pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eBaseline\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 188.2pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left: 0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eExisting set of malaria control activities in 2018.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003ePassive testing and treating of positive malaria cases (community and facility-based)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;margin:0in;text-align:justify;vertical-align: baseline;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eDistribution of LLINs with coverage* and usage levels maintained at 2018 levels\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:13.0pt;margin-left: 0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;text-align:justify;vertical-align:baseline;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIRS coverage continued at 2018 levels\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:13.0pt;margin-left: 0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;text-align:justify;vertical-align:baseline;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eSeasonal malaria chemoprophylaxis continued at 2018 levels\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:13.0pt;margin-left: .25in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;text-align:justify;vertical-align:baseline;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIPTp continued at 2018 levels (~47%)\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eMaintain proportions of participants who receive 1, 2, 3, 4, 5 doses\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eDistribute routine LLINs to participants of IPTp\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 188.2pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left: 0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eNo cost and service difference between community and facility-based treatment avenues\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:0in;margin-left:.25in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eMass distribution of LLINs every 3 years, in line with data\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;margin:0in;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eProportion of participants who take 1,2 ,3, 4, 5 doses of IPTp remains constant\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height:107%;margin:0in;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e2.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eFully-funded response (FFR)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eBaseline +\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eTest 100% of all suspected cases and treat 100% of positive cases\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIRS coverage \u0026gt; 80% (to cover Upper East, Upper West, Northern and \u003cspan style=\"color:#111111;\"\u003eBrong Ahafo Region (78% of population of the Savanna zone))\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIncrease IPTp3 to 80%\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eSMC extended to Northern in 2019\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eSupportive supervision and training to enable better testing and treating (applied annually per PAR)\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIRS is an annual cost\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIPTp costs for dosage only (through existing ANC)\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e3.\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eBetter use of nets\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eFully-funded response +\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eSBC (social and behavioral change) to increase the usage of LLINs.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eDistribution of LLINs every 3 years, \u003cem\u003een masse\u003c/em\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eSBC costs applied to cover 1/3 of the country per year, allowing for full coverage with every mass distribution.\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCosts applied annually at 1/3 coverage per par\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eImpact of SBC: Increase in net use by 50%\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e4.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eHealth System Acceleration\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eBetter use of nets +\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIncrease treatment seeking from 73% to 90% (through increasing SBC)\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eIncreased SBC costs to increase treatment seeking\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCosts applied annually per par\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e5.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eReverse\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCut IRS\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCut SMC\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCut nets by 50%\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 26.5pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"5.645161290322581%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e6.\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75.4pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.29032258064516%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height: normal;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eReverse 2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 245.7pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"52.903225806451616%\"\u003e\n \u003cdiv style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\n \u003cul style=\"margin-bottom:0in;list-style-type: disc;margin-left:-0.25in;\"\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCut IRS\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003cli style=\"margin-top:0in;margin-right:0in;margin-bottom:8.0pt;margin-left:0in;line-height:107%;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eCut SMC\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.1pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"25.161290322580644%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:107%;text-align:justify;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"line-height: 107%;\"\u003e*LLIN coverage determined by LLIN usage and effectiveness at reducing transmission\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:12.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFramework for estimating the economic burden of malaria in Ghana\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\" width=\"562\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140.55pt;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 1.4pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eDirect health system costs\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140.55pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 1.4pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eDirect household costs\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140.55pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 1.4pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eIndirect costs\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 140.55pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 14.25pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eNational and subnational expenditures on malaria interventions\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 14.25pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eOut-of-pocket expenditures for treatment seeking\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 140.55pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 14.25pt;vertical-align: top;\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eProductivity losses among malaria patients and caregivers\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:2.0pt;margin-bottom: 2.0pt;line-height:normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003eValue of life years lost due to premature death\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eTable 3. Median costs and benefits of the baseline response against malaria compared to counterfactuals, 2020-2030\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"28.571428571428573%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003eScenario comparisons\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003e(Baseline – Intervention)\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003eClinical cases averted\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003eReported cases averted\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003eDeaths averted\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003eEconomic benefits (NPV USD)\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.38%;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003eCost (USD)\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cspan style=\"color: black;\"\u003e(discounted)\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"28.571428571428573%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eFully funded NSP scenario vs baseline\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e37434462\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e21,221,433\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e2,683\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e14.1 billion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.38%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 30pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e1.31 billion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"28.571428571428573%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eElimination scenario (HSA) vs baseline\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e85,571,086\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e51,251,099\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e4,468\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e31.73 billion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.38%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"14.285714285714286%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e961 .3 million\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"16.374269005847953%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"color: black;\"\u003eAdditional clinical cases\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"color: black;\"\u003eAdditional reported cases\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"color: black;\"\u003eAdditional deaths\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan style=\"color: black;\"\u003eAdditional economic losses (NPV USD)\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" width=\"50.87719298245614%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"16.374269005847953%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eBaseline vs. reverse I\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e38,220,597\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e24,411,310\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e2,497\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e14.1 billion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" width=\"50.87719298245614%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28.16%;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"16.374269005847953%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003eBaseline vs. reverse II\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e12,974,304\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e8,914,008\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e1,350\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14.36%;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;height: 15.75pt;vertical-align: top;\" valign=\"top\" width=\"8.187134502923977%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:.0001pt;line-height: normal;\"\u003e\u003cspan style=\"font-family: \n Verdana,Geneva,sans-serif;\"\u003e\u003cspan style=\"font-size: \n 11px;\"\u003e\u003cspan style=\"color: black;\"\u003e4.4 billion\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"border:none;padding:0in 0in 0in 0in;\" width=\"50.87719298245614%\"\u003e\n \u003cp style=\"margin-right:0in;margin-left:0in;font-size:15px;font-family:\u0026quot;Calibri\u0026quot;,sans-serif;margin-top:0in;margin-bottom:8.0pt;line-height:107%;\"\u003e\u003cspan style=\"font-size: 11px; font-family: Verdana, Geneva, sans-serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Malaria, Ghana, investment case, costs, benefits, economic, funding, financing","lastPublishedDoi":"10.21203/rs.2.23697/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.23697/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Ghana has made impressive progress against malaria, decreasing mortality and morbidity by over 50% between 2005-2015. These gains have been facilitated in part, due to increased financial commitment from both government and donors. Between 2006 and 2011, total resources for malaria increased from less than USD 25 million in 2006 to over USD 100 million. However, the country still faces a high burden of disease and is at risk of declining external financing due to its strong economic growth and the consequential increased donor requirements for domestic contributions. The resulting financial gap will need to be met domestically to accelerate progress. The purpose of this study was to provide evidence of the economic impact of malaria elimination and the potential risks of withdrawing financing to shape an advocacy strategy for resource mobilization.\u003c/p\u003e\u003cp\u003eMethods: A compartmental transmission model was developed to estimate the impact of a range of malaria interventions on the transmission of Plasmodium falciparum malaria between 2018 and 2030. The model projected scenarios that allowed the attainment of elimination using a package of common interventions and scenarios that predicted transmission if interventions were withheld. The outputs of this model were used to generate costs and economic benefits of each option.\u003c/p\u003e\u003cp\u003eResults: Elimination was predicted using the interventions outlined in the national strategy, particularly increased net usage and improved case management. Malaria elimination in Ghana was predicted cost USD 961 million between 2020 and 2029. Compared to the baseline, elimination is estimated to prevent 85.5 million cases, save 4,468 lives, and avert USD 2.2 billion in health system expenditures. The economic gain was estimated at USD 32 billion in reduced expenditure, increased household prosperity and productivity gains. Through malaria elimination, Ghana can expect to see a 32-fold return on their investment. Withdrawing interventions, predicted an additional 38.2 clinical cases, 2,500 deaths and additional economic losses of USD 14.1 billion.\u003c/p\u003e\u003cp\u003eConclusions: Although government financing has increased in the past decade, the amount is less than 25% of total malaria financing. The study findings can be used to develop a robust strategy to overcome financial barriers for malaria elimination in Ghana.\u003c/p\u003e","manuscriptTitle":"Estimating the Risk of Declining Funding for Malaria in Ghana: The case for continued investment in the malaria response","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-02-17 19:39:31","doi":"10.21203/rs.2.23697/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2020-04-01T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-03-31T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2020-03-31T12:00:00+00:00","index":2,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-03-11T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-03-11T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-02-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-14T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-13T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab35f553-9f6b-4018-8371-46d38200ac37","owner":[],"postedDate":"February 17th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":59449,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2021-07-27T21:10:03+00:00","versionOfRecord":{"articleIdentity":"rs-14263","link":"https://doi.org/10.1186/s12936-020-03267-9","journal":{"identity":"malaria-journal","isVorOnly":false,"title":"Malaria Journal"},"publishedOn":"2020-06-01 21:10:03","publishedOnDateReadable":"June 1st, 2020"},"versionCreatedAt":"2020-02-17 19:39:31","video":"","vorDoi":"10.1186/s12936-020-03267-9","vorDoiUrl":"https://doi.org/10.1186/s12936-020-03267-9","workflowStages":[]},"version":"v1","identity":"rs-14263","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-14263","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}