Resource allocation strategies to achieve malaria eradication

Reviewer #1 (Public Review):

The authors present a back-of-the-envelope exploration of various possible resource allocation strategies for ITNs. They identify two optimal strategies based on two slightly different objective functions and compare 3 simple strategies to the outcomes of the optimal strategies and to each other. The authors consider both P falciparum and P vivax and explore this question at the country level, using 2000 prevalence estimates to stratify countries into 4 burden categories.

This is a relevant question from a global funder perspective, though somewhat less relevant for individual countries since countries are not making decisions at the global scale. The authors have made various simplifications to enable the identification of optimal strategies, so much so that I question what exactly was learned. It is not surprising that strategies that prioritize high-burden settings would avert more cases. Generally, I found much of the text confusing and some concepts were barely explained, such that the logic was difficult to follow.

I am not sure why the authors chose to stratify countries by 2000 PfPR estimates and in essence explore a counterfactual set of resource allocation strategies rather than begin with the present and compare strategies moving forward. I would think that beginning in 2020 and modeling forward would be far more relevant, as we can't change the past. Furthermore, there was no comparison with allocations and funding decisions that were actually made between 2000 and 2020ish so the decision to begin at 2000 is rather confusing.

I realize this is a back-of-the-envelope assessment (although it is presented to be less approximate than it is, and the title does not reveal that the only intervention strategy considered is ITNs) but the number and scope of modeling assumptions made are simply enormous. First, that modeling is done at the national scale, when transmission within countries is incredibly heterogeneous. The authors note a differential impact of ITNs at various transmission levels and I wonder how the assumption of an intermediate average PfPR vs modeling higher and lower PfPR areas separately might impact the effect of the ITNs. Second, the effect of ITNs will differ across countries due to variations in vector and human behavior and variation in insecticide resistance and susceptibility to the ITNs. The authors note this as a limitation but it is a little mind-boggling that they chose not to account for either factor since estimates are available for the historical period over which they are modeling. Third, the assumption that elimination is permanent and nothing is needed to prevent resurgence is, as the authors know, a vast oversimplification. Since resources will be needed to prevent resurgence, it appears this assumption may have a substantial impact on the authors' results.

The decision to group all settings with EIR > 7 together as "high transmission" may perhaps be driven by WHO definitions but at a practical level this groups together countries with EIR 10 and EIR 500. Why not further subdivide this group, which makes sense from a technical perspective when thinking about optimal allocation strategies?

The relevance of this analysis for elimination is a little questionable since no one eliminates with ITNs alone, to the best of my understanding.

Reviewer #2 (Public Review):

Schmit et al. analyze and compare different strategies for the allocation of funding for insecticide-treated nets (ITNs) to reduce the global burden of malaria. They use previously published models of Plasmodium falciparum and Plasmodium vivax malaria transmission to quantify the effect of ITN distribution on clinical malaria numbers and the population at risk. The impact of different resource allocation strategies on the reduction of malaria cases or a combination of malaria cases and achieving pre-elimination is considered to determine the optimal strategy to allocate global resources to achieve malaria eradication.

Strengths:
Schmit et al. use previously published models and optimization for rigorous analysis and comparison of the global impact of different funding allocation strategies for ITN distribution. This provides evidence of the effect of three different approaches: the prioritization of high-transmission settings to reduce the disease burden, the prioritization of low-transmission settings to "shrink the malaria map", and a resource allocation proportional to the disease burden.

Weaknesses:
The analysis and optimization which provide the evidence for the conclusions and are thus the central part of this manuscript necessitate some simplifying assumptions which may have important practical implications for the allocation of resources to reduce the malaria burden. For example, seasonality, mosquito species-specific properties, stochasticity in low transmission settings, and changing population sizes were not included. Other challenges to the reduction or elimination of malaria such as resistance of parasites and mosquitoes or the spread of different mosquito species as well as other beneficial interventions such as indoor residual spraying, seasonal malaria chemoprevention, vaccinations, combinations of different interventions, or setting-specific interventions were also not included. Schmit et al. clearly state these limitations throughout their manuscript.

The focus of this work is on ITN distribution strategies, other interventions are not considered. It also provides a global perspective and analysis of the specific local setting (as also noted by Schmit et al.) and different interventions as well as combinations of interventions should also be taken into account for any decisions. Nonetheless, the rigorous analysis supports the authors' conclusions and provides evidence that supports the prioritization of funding of ITNs for settings with high Plasmodium falciparum transmission. Overall, this work may contribute to making evidence-based decisions regarding the optimal prioritization of funding and resources to achieve a reduction in the malaria burden.

Author Response

We thank the reviewers for their insightful comments, which raise several important points regarding our study. As the reviewers have recognised, we introduced a number of simplifications in order to perform this complex optimisation problem, such as by restricting the analysis to a single intervention (insecticide-treated nets) and modelling countries at a national level. Despite their clear relevance to the study, computationally it would not have been feasible to run the multitude of scenarios suggested by reviewer 1, which we recognise as a limitation. As such we agree with the assessment that this study primarily represents a thought experiment to assess whether current policies are aligned with an optimal allocation strategy or whether there might be a need to consider alternative strategies. The findings are relevant primarily to global funders and should not be used to inform individual country allocation decisions. This perspective also underlies our decision to start the analysis from a baseline of year 2000 as opposed to modelling the current 2023 malaria situation: the largest international donor (the Global Fund) also uses baseline malaria levels in the period 2000-2004 as the basis of their allocation calculations (The Global Fund, Description of the 2020-2022 Allocation Methodology, December 2019). A simplified version of this method is represented by our “proportional allocation” strategy. We will further address these points in a revised manuscript and detailed responses to the reviewer comments.