Cost-effectiveness of malaria prevention strategies in children under five in high-endemic settings

Optimising malaria prevention in resource-constrained high-endemic areas remains a global health priority. Evidence on the cost-effectiveness of combined prevention strategies remains limited. This study assesses alternative strategies to inform policy and resources allocation decisions. We developed a decision tree model to compare 5 strategies for children under 5: vaccine+seasonal malaria chemoprevention(SMC)+insecticide-treated nets(ITNs); SMC+ITNs; SMC alone; ITNs alone; and no prevention. The analysis adopted a healthcare system perspective. Probabilities of clinical malaria, hospitalisation and death were derived from Burkina Faso surveillance data (2010–24). Costs were obtained from the literature and standardised to 2024 values. A scenario analysis including major complications used RCT data from West Africa. Treatment duration was assumed to be 7 days for mild or moderate and 14 days for severe cases. Outcomes were expressed as disability-adjusted life years (DALYs). Incremental cost-effectiveness ratios (ICERs) were estimated with one way and probabilistic sensitivity analyses. The strategy vaccine+SMC+ITNs achieved the greatest reduction in disease burden (0.023 DALYs) at higher cost (US$23.06) with an ICER of $97.43 per DALY averted. SMC alone showed the lowest-cost ($16.58) with relatively low disease burden (0.027 DALYs). Strategies SMC+ITNs and ITNs alone were dominated, showing higher costs and worse outcomes compared to SMC alone. No prevention resulted in the highest disease burden. Sensitivity analyses confirmed the robustness of findings, with the combined strategy remaining cost-effective across scenarios. The addition of vaccination to existing preventive measures provides the greatest health gains and remains cost-effective, despite higher costs. SMC alone is a pragmatic alternative where resources are limited. These findings support prioritising integrated prevention strategies to maximise population health impact in malaria-endemic regions.

Key messages

• Combining vaccination, SMC, and ITNs yields the greatest reduction in malaria burden in children and remains cost-effective across scenarios in high-endemic, resource-limited settings.

• Where resources are limited, SMC alone is a low-cost, effective option, but integrated strategies deliver the highest health impact and should guide policy priorities.