Malaria Journal Andrade et al. Malaria Journal (2022) 21:283 https://doi.org/10.1186/s12936-022-04303-6 RESEARCH Open Access The economic burden of malaria: a systematic review Mônica V. Andrade1, Kenya Noronha1, Bernardo P. C. Diniz1, Gilvan Guedes1, Lucas R. Carvalho1, Valéria A. Silva1, Júlia A. Calazans2, André S. Santos1, Daniel N. Silva1 and Marcia C. Castro3* Abstract Background: Quantifying disease costs is critical for policymakers to set priorities, allocate resources, select control and prevention strategies, and evaluate the cost-effectiveness of interventions. Although malaria carries a very large disease burden, the availability of comprehensive and comparable estimates of malaria costs across endemic coun- tries is scarce. Methods: A literature review to summarize methodologies utilized to estimate malaria treatment costs was con- ducted to identify gaps in knowledge. Results: Only 45 publications met the inclusion criteria. They utilize different methods, include distinct cost compo- nents, have varied geographical coverage (a country vs a city), include different periods in the analysis, and focus on specific parasite types or population groups (e.g., pregnant women). Conclusions: Cost estimates currently available are not comparable, hindering broad statements on the costs of malaria, and constraining advocacy efforts towards investment in malaria control and elimination, particularly with the finance and development sectors of the government. Keywords: Malaria, Economic burden, Cost, Cost analysis Background transmission, the Gross Domestic Product (GDP) grew In 2020, 241 million cases and 627 thousand deaths of 1.3% less per person per year, accounting for relevant malaria were estimated worldwide. Between 2000 and social and economic factors [2]. 2015, malaria case incidence reduced by 27%, while the Haakenstad et al. [3] estimated that global malaria mortality rate reduced by 60%. Since 2015 the decline spending—accounting both for government and out- has slowed (and even reversed in some countries) [1]. of-pocket spending—amounted to $4.3 billion (95% UI Ten countries eliminated malaria between 2000 and 4.2–4.4) in 2016, which is an 8.6% (95% UI 8.1–8.9) per 2019, and 21 remained 3 years without an indigenous year increase over malaria spending in 2000. Estimates case. Reducing the malaria burden minimizes out-of- were mainly based on national accounts systems from pocket expenses, avoids days lost at school or work due 106 countries and included expenses to prevent and treat to an infection, and is likely to contribute to economic malaria. However, macro-analyses such as these, while development. Among countries with intense malaria useful for understanding the landscape of malaria financ- ing, have limited use for strategic planning since they are not able to break down the costs. Quantifying the *Correspondence: mcastro@hsph.harvard.edu economic cost of malaria is critical for policymakers to 3 Department of Global Health and Population, Harvard T.H. Chan School set priorities, allocate resources, select control and pre- of Public Health, Boston, MA 02115, USA vention strategies, and evaluate the cost-effectiveness of Full list of author information is available at the end of the article interventions. © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Andrade et al. Malaria Journal (2022) 21:283 Page 2 of 10 Among the principles for a world free of malaria is the Preferred Reporting Items for Systematic Reviews and stratification by malaria burden, which facilitates opti- Meta-Analysis (PRISMA) statement [10, 11]. mizing the selection of malaria interventions that are likely to be most effective given the local context. The Search strategy and selection criteria process of stratification supports decision-making and Studies published between 2000 and 2020 (up to May considers financial resources available for malaria con- 8) were selected from three scientific articles databases: trol [4] helping governments to achieve the best out- Medline (via PubMed), Lilacs (via BVS), and Embase. comes given limited resources. In 2019, the World Health Since the epidemiology of the disease has changed world- Organization (WHO) Regional Office for Africa pro- wide, the search included only articles published from posed a costing tool for countries to plan the budget of 2000 onwards to capture the recent trends in the eco- their national malaria control programmes [5]. The tool nomic burden of malaria. The research question in PECO supports budget planning, but it does not assess executed format (Population, Exposure, Comparator, and Out- services and does not include indirect costs. Although comes) and the full search strategy are available in Addi- frameworks for analysis of the economic costs of malaria tional file 1. The terms used were “economics, medical”, have been proposed [6–8] comprehensive estimates that “economics, hospital”, “cost and cost analysis”, “cost of ill- break down costs by different stakeholders (health pro- ness”, “cost control”, “health care costs”, “health expendi- viders, individuals, community), that consider inequities tures”, and “malaria” or “paludism”. across geographies, and that account for productivity References were imported into EndNote X9 [12] and losses and other non-tangible costs are scarce. Only two transported into Rayyan for duplicates removal and reviews on the economic burden of malaria are available screening [13]. All references were screened by title and [7–9]. The first, published in 2003, compiled evidence on abstract, and those selected had the full texts retrieved direct and indirect costs of malaria for both families and and assessed. The exclusion criteria were: (i) cost-effec- the healthcare system [7]. They estimated monthly per tiveness analyses of treatments, (ii) vaccine efficacy/cost capita expenditures incurred by households for malaria studies, (iii) evaluations of long-term consequences of prevention and treatment ranging from, respectively, malaria during childhood, (iv) analyses of specific inter- US$0.05 and US$0.41 in Malawi to US$2.10 and US$3.88 ventions to control or to eliminate malaria, (v) cost analy- in the urban area of Cameroon. Overall, the average ses of malaria combined with other infectious diseases duration of absenteeism due to illness ranged from one that did not allow for the disaggregation of costs by dis- to 5 days, reaching 18 days in Ethiopia. Despite detailed ease, (vi) treatment guidelines, (vii) systematic reviews/ estimates of costs, the study was based on critical instead literature reviews, (viii) studies without cost components of a systematic review and focused only on African coun- disaggregation or with at most one cost component, tries. The second, published in 2016, only focused on the and (ix) cost studies about imported malaria. Economic economic and financial costs of malaria control, elimina- analyses of specific programmes were excluded since tion, and eradication, without considering the treatment they usually report expenditures that are context-related costs, either direct or indirect [9]. to the intervention. Only full texts were included. No This study aims to conduct a systematic review of the restrictions on language or geographical focus were economic burden of malaria. The analysis was conducted made. to assess whether estimates are available, for different Seven researchers performed the screening and each regions where malaria is endemic, considering the per- paper was independently assessed for inclusion by at spectives of both individuals and health systems. Also, least two of them. Any differences were resolved by con- it aims at appraising the comprehensiveness and com- sensus, following recommendations from the Cochrane parability of the estimates. Addressing this knowledge Collaboration [14]. gap is important to target public policies that reduce the welfare losses due to malaria. Identifying and mitigating Data extraction and analysis the costs incurred by families is particularly relevant to A qualitative synthesis of the results was performed by reducing inequalities. systematically organizing the information extracted from the included studies. Data extracted included country and year of study, year of publication, currency, cost com- Methods ponents, cost disaggregated by selected attributes (age Study design and severity of the disease), source of research funding, A systematic review was conducted to examine the and perspective of the study (healthcare system, house- empirical evidence on the economic burden of malaria hold, and societal). A societal perspective is a compre- and its cost components following the principles of the hensive approach that considers healthcare system costs Andrade et al. Malaria Journal (2022) 21:283 Page 3 of 10 and direct and indirect household costs. The economic costs often fall into two categories. First, direct costs that include medical (treatment and control) and non-medical (transport, lodging, and food) expenses. Second, indirect costs that include absenteeism (short-term absence from work or school due to health problems), presenteeism (reduced performance while working or at school due to health problems), and value of lost time due to morbidity or premature mortality. Economic burden estimates are a broad framework to evaluate the wellbeing impacts as it considers all the economic costs associated with the dis- ease. A broader perspective includes all stakeholders, and the costs are presented as the share of the gross domestic product. Other estimates consider all expenses financed by a specific agent, such as families. In this case, the eco- nomic burden is defined as a proportion of the household budget. One researcher performed data extraction, which was then checked by other two. Information on cost com- ponents sought in each study is detailed in Additional file 2. Average values in local currency were extracted and, to facilitate comparison, all cost values were con- verted into Purchase Power Parity 2020 American dollars (PPP-USD) using the Campbell and Cochrane Econom- Fig. 1 Flow diagram of the systematic review article selection ics Methods Group (CCEMG)—Evidence for Policy and Practice Information and Coordinating Centre (EPPI- Centre) cost converter [15]. Descriptive analyses summa- rized the main characteristics of the selected studies, and Characteristics of the studies all with valid information were included in the qualitative The selected studies analysed 27 countries, almost half synthesis. from Africa. The most studied countries were Nigeria (n = 7) and Kenya (n = 5). Only three studies involved Quality assessment a cross-country comparison [19–21]. Studies were There is no standard method to evaluate the quality of mostly published between the years 2015 and 2020 cost studies. Drawing from the available literature [16– (44.4%). From 2005 to 2015 only countries from Africa 18] nine items were selected to assess the reporting qual- and the Pacific were investigated, while studies analys- ity of the selected studies (Additional file 3). For each ing the Americas only appeared after 2015 (Fig. 2). item, there were four possible response categories: (i) Most selected studies (76%) received financial sup- fully meet the item; (ii) partially meet the item; (iii) did port (Additional file 6). The most frequent donors were not meet the item; (iv) not applicable. One researcher the World Bank/United Nations Development Pro- checked the quality assessment for each paper and any gramme—UNDP/WHO Special Programme for Train- uncertainties were decided by consensus. ing and Research in Tropical Diseases, and the Bill and Melinda Gates Foundation, which funded 20% and Results 15.5% of the studies, respectively. International health Study selection organizations (e.g., WHO) and foreign agencies (e.g., A total of 6408 articles were initially identified through European Union) were important funders for studies in the database search (Fig. 1). After the removal of 722 Africa. Only one study was funded by the private sec- duplicates and 5472 references not eligible based on titles tor, specifically the pharmaceutical industry [21]. and abstracts, 214 studies were suitable for a full review. Two-thirds of the selected papers (67%) carried out Following exclusion criteria detailed in Additional file 4, the cost analysis using some form of stratification 140 articles were excluded. Despite multiple attempts, it (Additional file 7), such as individual attributes (age was not possible to obtain the full text of 29 studies (only and socioeconomic status), access conditions (type of abstracts were available). The final sample included 45 service and distance to the hospital), illness attributes publications (Additional file 5). (type of parasite, type of care, and disease severity), Andrade et al. Malaria Journal (2022) 21:283 Page 4 of 10 20 15 Number of articles WHO Region African Region 10 Eastern Mediterranean Region Region for the Americas South−East Asia Region Western Pacific Region 5 0 2000−2004 2005−2009 2010−2014 2015−2020* Years Fig. 2 Distribution of studies according to the World Health Organization (WHO) regions from 2000 to 2020. The systematic review covers the period of January 1, 2000, to May 8, 2020. Some studies refer to more than one country endemicity level, seasonality/raining period, and place organization (Table 2). Therefore, estimated costs vary of residence. widely, with total and indirect household costs show- ing the largest variation (e.g., total per capita household Qualitative synthesis costs varied from US$0.48 in Sri Lanka to US$214.68 in There was variation in the cost analysis in terms of the India, and total per capita indirect costs was US$0.25 in components investigated, source of costs (household Kenya and US$182 in India). Patient absenteeism ranged or healthcare system), unit of measurement (cost per from 1.3 days in Brazil to 11 days in India, while days of episode, per household, or per capita), and summary caregiver absenteeism varied from 0.2 in Brazil to 9.2 in statistics (mean or median). Cost estimates based on Malawi. household data were the most prevalent (95.5% of the In addition to cost components, ten studies estimated studies), but the number of cost items included varied the economic burden of malaria. Seven considered a significantly; 88.9% investigated at least one household household perspective, two utilized a societal perspec- direct cost, and 75.6% at least one indirect cost. Medi- tive, and one included household and healthcare system cation and treatment/diagnosis were the most reported costs components but did not consider indirect costs direct medical cost (Table 1). The majority (n = 41) of (Table 3). All studies focused on African countries except the studies reported average cost estimates, and cost per one that used data from India. Estimates were based on episode (n = 35) was the most common unit of measure- the nominal value of total costs [21, 22], or its share in ment. These differences in estimating and presenting the the gross domestic product (GDP) [23] or the house- results limit the comparability of malaria costs across hold budget [24–26]. Considering the economic burden countries. of malaria as a percentage of the family budget, results The magnitude of costs depends on several factors such range from 3.12% in India to 8.23% in Nigeria. Cata- as the healthcare system organization, the level of health- strophic health expenses due to malaria, measured as care coverage, treatment protocols, and private market the household healthcare expenses exceeding a specified Andrade et al. Malaria Journal (2022) 21:283 Page 5 of 10 Table 1 Attributes of the studies included (n = 45) in the threshold of household income or household capacity systematic review to pay, ranged from 17.8% to 22.5% of families in Sudan, Item/Component Number %* Mozambique, and Zimbabwe [20, 27, 28]. of studies Study perspective Quality assessment Healthcare System (only) 2 4.4 Overall, the selected studies met the items that should Household (only) 33 73.3 be presented in economic cost studies (Additional file 8). Both (Healthcare System and Household) 10 22.2 The description and analysis of the cost components as Societal (include household direct and indirect 7 15.6 well as the inclusion of detailed information about the costs) currency and adjustment for inflation were the main lim- Non-Societal (either household direct or indirect 3 6.7 itations encountered. costs) Cost components Discussion Direct Costs A systematic review is presented to extract and synthe-   Healthcare System size evidence on the economic costs of malaria published    Prevention 2 4.4 since 2000. Only 45 publications met the inclusion crite-    Treatment/Diagnosis 7 15.6 ria, out of the 6,408 search results. Most analysed Afri-    Hospitalization 4 8.9 can countries (about 75%), where the highest burden    Medication 6 13.3 of malaria is concentrated [1]. Indeed, seven of the 11    At least one component 12 26.7 high-burden countries (which concentrate about 70% of   Household medical direct cost malaria burden) were analyzed: Burkina Faso, the Demo-    Prevention 6 13.3 cratic Republic of the Congo, Ghana, Mozambique, Nige-    Treatment/Diagnosis 25 55.6 ria, United Republic of Tanzania, and India. While the    Hospitalization 11 24.4 focus on African countries is not surprising, the scarcity    Medication 17 37.8 of cost estimates for countries in the Americas and Asia    Healers 5 11.1 is concerning for at least two reasons. First, as some of    At least one component 33 73.3 those countries approach elimination, cost estimates are   Household non-medical direct cost critical to inform and sensitize ministers of finance and    Travelling costs 30 66.7 health to prevent defunding elimination efforts. Second,    Food 12 26.7 estimates on costs of malaria as countries approach and    Lodging 5 11.1 achieve elimination will be essential knowledge to high-    At least one component 31 68.9 burden countries in the future. Therefore, cost estimates   At least one direct cost component 40 88.9 for countries with diverse transmission intensity remains Indirect Costs a gap in the literature.   Indirect costs—patients Global funding has been crucial for the development of    Travelling (cost of the time) 4 8.9 studies on the economic costs of malaria with 76% of the    Medical care 3 6.7 selected articles having had received a grant. Three main    Absenteeism (Days or $) 20 44.4 funders jointly financed 45% of the studies on economic     $ and days 6 13.3 costs of malaria: UNDP/WB/WHO special programme     Only days 8 17.8 for research and training in tropical diseases, the Bill     Only $ 6 13.3 and Melinda Gates Foundation, and the Wellcome Trust.    At least one component 29 64.4 These results align with previous analyses that show a   Indirect costs—caregiver concentration of the resources in a few funders. Viergever    Travelling (cost of the time) 2 4.4 and Hendriks [29] identified the 55 most important pub-    Absenteeism (Days or $) 14 31.1 lic and philanthropic funders. Among the public funders,     $ and days 8 17.8 the US National Institutes of Health ($26.1 billion), the     Only days 4 8.9 European Commission ($3.7 billion), and the UK Medical     Only $ 2 4.4 Research Council ($1.3 billion) stood out with the high-    At least one component 16 35.6 est annual research budgets. The largest philanthropic   At least one indirect cost component 34 75.6 funders were the Wellcome Trust ($909.1 million), How- * All percentages were calculated considering the 45 studies ard Hughes Medical Institute ($752 million), and Bill and Melinda Gates Foundation ($462.6 million). Offi- cial Development Assistance Agencies and Multilateral Andrade et al. Malaria Journal (2022) 21:283 Page 6 of 10 Table 2 Minimum and maximum values of cost components and average absenteeism days per episode Component Countries Costs (PPP values in 2020 US$) # Studies References Min Max Cost of the healthcare system Afghanistan, Brazil, Colombia, 3.91 (Afghanistan) 125.21 (Kenya) 5 [19, 21, 22, 53, 54] Ethiopia, Ghana, Indonesia, Kenya, Nigeria, Peru, Philippines, Tanzania, Thailand, and Vietnam Household costs Burkina Faso, China, Colombia, 0.48 (Sri Lanka) 214.68 (India) 14 [21, 22, 24, 35, 36, 45, 55–61] Ghana, India, Kenya, Malawi, Mozambique, Myanmar, Nigeria, Papua New Guinea, Peru, Sri Lanka, Tanzania, and Vietnam Household direct costs Afghanistan, Brazil, Colombia, 0.62 (Papua New 38.12 (Thailand) 14 [19, 22, 24, 27, 36, 38, 45–47, 51, Ethiopia, Ghana, India, Indonesia, Guinea, Indonesia) 54, 59–61] Kenya, Malawi, Mozambique, Nigeria, Papua New Guinea, Peru, Philippines, Sudan, Thailand, and Vietnam Household indirect costs Colombia, Ethiopia, Ghana, 0.25 (Kenya) 182.37 (India) 10 [21, 22, 24, 37, 45–47, 51, 59, 62] India, Kenya, Mozambique, Peru, Sudan, Tanzania, and Vietnam Days of patient absenteeism Afghanistan, Angola, Brazil, 1.30 (Brazil) 11.00 (India) 11 [19, 20, 24, 36, 45–48, 57, 62, 63] Colombia, Ethiopia, Ghana, India, Indonesia, Malawi, Mozambique, Myanmar, Peru, Philippines, Thailand, and Vietnam Days of caregiver absenteeism Afghanistan, Brazil, Colombia, 0.20 (Brazil) 9.20 (Malawi) 10 [19, 20, 24, 36, 45, 47, 48, 60–62] Ethiopia, India, Indonesia, Malawi, Mozambique, Nige- ria, Papua New Guinea, Peru, Philippines, Sudan, Thailand, and Vietnam organizations contributed smaller amounts; the most treatment and diagnosis from the healthcare system per- substantial funding was from the USAID ($186.4 million) spective were available only for four countries. The range and the World Health Organization ($135.0 million). of estimated values was relatively high, especially for Head et al. showed that between 1993 and 2017, 333 families, with the average total cost varying from US$8.7 different grants funded malaria-related research invest- in Afghanistan to US$254.7 in Colombia. The main com- ment in sub-Saharan Africa, totaling US$814.4 million ponent of the household cost was productivity loss due [30]. The US National Institutes of Health and the Bill & to illness. Melinda Gates Foundation were the main grantors, con- The methodological disparities across selected stud- tributing 60% of the funds [30]. ies stem from the challenges in investigating healthcare Results shows that there is no systematization of cost costs. Surveying costs from the provider’s perspective components of malaria and no comprehensive and com- depends on the availability of a systematic and organ- parable quantification of the economic burden of the ized information system that stores detailed categories of disease to society and governments. Comparability of health spending. Also, some categories of public expendi- results summarized in this review is difficult because ture may be aggregated for different health conditions or studies vary by the type of cost components included, programmes (e.g., surveillance, vector control), making the estimation method, and the regional level of analy- it necessary to implement apportionment strategies to sis. Even studies that estimated costs for more than one obtain numbers specific for malaria. Similarly, informa- country have limited comparability [19–21]. Devine et al. tion about the costs associated with the maintenance of [19] is the most comprehensive study, based on a multi- the health unit’s physical structure and human resources centric approach, including nine countries—Afghani- often must be partitioned among the different diseases stan, Brazil, Colombia, Ethiopia, Indonesia, Philippines, based on some criteria [16, 31–34]. Peru, Thailand, and Vietnam. It investigated direct and Most of the studies included in the review utilized indirect household costs for all countries, while costs of household surveys or interviews with patients/caregivers Andrade et al. Malaria Journal (2022) 21:283 Page 7 of 10 Table 3 Summary statistics of ten studies that presented economic burden analysis Country Perspective Estimation method Estimate (% or US$) Refs. Malaria expenditure as a percentage of GDP Tanzania Household Prevention and treatment of malaria (private, government, and donors) as % of GDP 1.10 [23] & Healthcare System Household economic burden of malaria India Household % of household income committed to malaria treatment 3.12 [24] Tanzania Household % of household consumption with malaria expenditures 3.30 [26] Kenya Household % of household income committed to malaria treatment 6.50 [51] Nigeria Household % of malaria expenditures in monthly non-food expenditure 8.23 [52] Percentage of households with catastrophic expenditures due to malaria Sudan Household Malaria treatment ≥ 15% of monthly income 17.80 [27] Mozambique Household Catastrophic expenditures > 10% of monthly income 17.87 [20] Mozambique Household Catastrophic expenditures > 40% of non-food expenditure 18.50 [20] Zimbabwe Household Catastrophic health expenditures 22.50 [28] Total expenditures as a proxy for economic burden (US$ of 2020) Mozambique Societal Unit cost per episode multiplied by the number of cases 345,258 [22] Ghana Societal Total costs of malaria treatment and prevention including costs associated with 80,843,886 [21] productivity loss due to death Tanzania Societal Total costs of malaria treatment and prevention including costs associated with 350,786,986 [21] productivity loss due to death Kenya Societal Total costs of malaria treatment and prevention including costs associated with 302,662,132 [21] productivity loss due to death Costs were converted into 2020 US dollars using the CCEMG—EPPI-Center Cost Converter [15] as the primary sources of information. Therefore, most of production [45]. Of note is the fact that just one study the costs were estimated from a household perspective. considered the costs of mortality in the estimates. Poten- Still, the comparability of costs across studies is ham- tial life-long productivity losses due to premature death pered by differences in the cost components included, were monetized considering the present value of the which varied depending on the specificity of the country/ institutional minimum wage. Considering children aged region, the organization of the healthcare system, and the 0–1 and 1–4 years, the costs of mortality (in thousands) families’ vulnerability conditions. due to malaria was equal to US$ 11.8 and US$ 13.8 in Transportation fees were the most investigated cost Ghana, US$ 7.6 and US$ 8.9 in Kenya, and US$ 6.9 and component, [19, 22, 24, 35–42] ranging from no cost in US$ 8.1 in Tanzania, respectively [21, 49]. the urban area of Benin [43], to US$47.49 for pregnant Only eight studies estimated the costs associated with women who received inpatient care in Manaus, Brazil prevention of malaria: six focused on costs incurred by [42]. High transportation costs in the Brazilian Amazon families [24, 26, 37, 42, 48, 50] and two focused on the reflect the long distances that some isolated communi- healthcare system [24, 37]. Since governments are usually ties need to travel to receive hospital care [44]. Absentee- in charge of implementing prevention and surveillance ism was the second most investigated cost component. actions, costs associated with these strategies should be In low-income malaria-endemic areas, with precarious one of the main components estimated from the health- labour market conditions, and where family farming is care system perspective [3]. one of the main economic activities, families usually have Ten studies estimated the economic burden of malaria, poor access to social security schemes and incur sig- but they differ in terms of the perspective and the meas- nificant losses in the event of illnesses episodes [45–48]. urement used to express the economic burden. Three The review showed that the number of workdays lost studies considered a broader estimation that included per episode of malaria ranged from 1.4 in Brazil [19] to both the household and healthcare system perspec- 11 days in high transmission areas of India [24]. Absen- tives [21–23]. To assess welfare losses, economic burden teeism days may translate into a high economic burden should be expressed as the share of the GDP. However, on families. In Vietnam, workdays lost in the treatment that measure was only calculated by one of those stud- of malaria reached 2% of the total annual household ies that was conducted for Tanzania and considered a Andrade et al. Malaria Journal (2022) 21:283 Page 8 of 10 comprehensive set of spending from private, government, System Online; PECO: Population, Exposure, Comparator, and Outcomes; PPP-USD: Purchase Power Parity American dollars; PRISMA: Preferred Reporting and international donors [23]. It showed that the burden Items for Systematic Reviews and Meta-Analysis; SCTIE: Innovation and Health reached 1.1% of the GDP and 39% of the public spending Strategic Products; UNDP/WHO: World Bank/United Nations Development on health; families bear most of the malaria expenditure Programme; WHO: World Health Organization. (71%), followed by the government (20%). The remaining seven papers conducted a more targeted estimate that Supplementary Information computed expenses incurred by households. In this case, The online version contains supplementary material available at https://​doi.​ org/​10.​1186/​s12936-​022-​04303-6. the economic burden was expressed as the weight of malaria costs on the household budget or the percentage Additional file 1. PECO search framework. of families incurring in catastrophic expenditures with Additional file 2. Descriptive system of cost components. results showing that malaria can substantially affect the Additional file 3. Items included in the quality assessment of the family’s wellbeing [20, 24, 26–28, 51, 52]. included articles. In addition to the limited number of studies that pro- Additional file 4. Studies excluded after full-text review and reasons for vided estimates on the costs of malaria, the systematic exclusion. review showed that one of the main limitations was the Additional file 5. List of included references. lack of a standard conceptual framework of the costs to Additional file 6. Funding sources of studies included in the analysis. be included and a methodological approach for the cal- Additional file 7. Distribution of selected papers according to the type of culation. Estimates often vary in several aspects: (i) types stratification. of costs considered, (ii) number of years of data used, (iii) Additional file 8. Quality assessment of the selected papers. choice of cost analysis perspective (healthcare system, household or societal), (iv) geographical coverage, and Acknowledgements (v) types of parasites considered. Ideally, the conceptual The authors MVA, KN and GRG thanks to the Conselho Nacional de Desen- framework should distinguish different types of costs and volvimento Científico e Tecnológico (CNPq) for the Research Productivity Scholarships. stakeholders. Estimates should detail direct and indirect costs and consider differences due to parasite type and Author contributions spatial geographical heterogeneities in transmission. MVA, KN, MCC, and ASS conceived the study. MVA and MCC acquired funding and provided coordination and supervision of the study. MVA, KN, BC, GG, LRC, The cost estimation should also allow its decomposition VS, JC, DNS, and ADS conducted the bibliographic review. MVA, KN, JC, LRC, by different stakeholders (health providers, individual/ VS, BC, and DNS performed the screening of the papers. MVA, KN, JC, LRC, VS, household, and the community) to target public policies BC, and DNS extracted the data of the selected studies. MVA, KN, BPCD, GG, MCC, and ASS wrote the first draft of the manuscript. All authors contributed that reduce the welfare losses due to malaria. Identifying to data analysis and manuscript editing. All authors read and approved the the cost components incurred by families is particularly final manuscript. relevant as their economic burden depends on their vul- Funding nerability and the organization of the healthcare system. This work was supported, in whole or in part, by the Bill & Melinda Gates These differences are critical for implementing a proper Foundation [INV003970] and the DECIT/Brazilian Ministry of Health/CNPq decision-making process of control strategies and thus [#442842/2019-8]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the must be reflected in cost estimates. Author Accepted Manuscript version that might arise from this submission. Conclusion Availability of data and materials Not applicable. The limited available estimates are hardly comparable, and there are no comprehensive figures on the cost of Declarations malaria from both societal and healthcare system per- spectives. This knowledge gap affects proper resource Ethics approval and consent to participate allocation, selection of prevention and control strategies, Not applicable. and evaluation of the cost-effectiveness of interventions. Consent for publication Also, it constrains advocacy efforts towards investment Not applicable. in malaria control and elimination, particularly with the Competing interests finance and development sectors of the government. The authors declare that they have no competing interest. Author details 1 Abbreviations Centre of Regional Planning and Development (Cedeplar‑UFMG), Univer- BVS: Virtual Health Library; CCEMG: Campbell and Cochrane Economics sidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. 2 Centre Methods Group; CNPq: Brazilian National Council for Scientific and Technologi- d’Estudis Demogràfics, CED, Universitat Autònoma B, 08193 Barcelona, Spain. 3 cal Development; DECIT: Department of Science and Technology; EPPI-Centre: Department of Global Health and Population, Harvard T.H. Chan School Evidence for Policy and Practice Information and Coordinating Centre; GDP: of Public Health, Boston, MA 02115, USA. Gross Domestic Product; Medline: Medical Literature Analysis and Retrieval Andrade et al. Malaria Journal (2022) 21:283 Page 9 of 10 Received: 20 March 2022 Accepted: 25 September 2022 24. Singh MP, Saha KB, Chand SK, Sabin LL. The economic cost of malaria at the household level in high and low transmission areas of central India. 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