|Malaria Diagnosis: New Perspectives (WHO - OMS, 2000, 57 p.)|
|6. ISSUES IN THE APPLICATION OF RDTs|
Cost considerations are often perceived as being the most important obstacle to the widespread introduction of RDTs. The cost per test is higher for RDTs than for microscopy, except at low levels of utilization. Nevertheless, this is balanced by the fact that the costs for organization, supervision, quality control and skilled personnel, as well as the cost to patients, are likely to be lower for RDTs than for microscopy.
Overall, it is unlikely that the introduction of RDTs would result in net savings in areas of high transmission where relatively inexpensive first-line antimalarial drugs are still used. Cost savings from the use of RDTs are more likely to occur in areas of low to moderate transmission, where microscopic diagnosis is unavailable or of low quality and where multidrug resistance dictates the use of more expensive therapy.
Policy decisions on diagnostic approaches will rely on quantitative data such as the cost-effectiveness of the different approaches. Assessing cost-effectiveness through theoretical models, though necessary, will be difficult because the potential effects on health of diagnostic tests (e.g. improved disease management or inhibition of the development of drug resistance) are ambiguous, difficult to quantify and measured by a range of non-comparable intermediate outcome indicators.
Affordability will be a major consideration for the widespread use of RDTs in low-income countries. The cost of RDTs includes not only the manufacturers costs (research and development and production) but also distribution costs, import fees and local taxes. The latter can be substantial, but could be reduced through government intervention. Other approaches to reducing costs include technology transfer and local production, bulk purchase and technical improvements. The prices of RDTs should drop when their patents expire. Even at a cost of US$ 0.30-0.50 per test, however, wide use in most developing countries is unlikely to be affordable without substantial and sustained external assistance.
Affordability issues might be addressed in two ways. One could be to target those patients for whom the tests would be most beneficial. This would reduce net costs to the health system and would improve individual case management. Another approach might consist of a multi-tier system whereby tests that are of higher performance and more costly (e.g. that identify specific species or are of very high sensitivity) would be made available only to reference facilities and should be marketed to a different population than the more basic tests intended for use at the periphery of the health care system.