Economic evaluation of anti-malarial drug policies across presidential regimes in Nigeria: A comparative analysis from 1999 to present

Figures Abstract Background Malaria remains a significant public health challenge in Nigeria, accounting for substantial morbidity, mortality, and economic loss. Successive administrations have implemented various anti-malarial drug policies aimed at curbing this endemic disease. This study applies a formal economic evaluation framework—integrating both cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA)—to assess and compare anti-malarial drug policies across different presidential regimes. Methods A comparative economic evaluation was conducted using incremental cost-effectiveness ratios (ICERs) and benefit-cost ratios (BCRs) derived from regime-specific expenditure and health outcome data. The study reviewed policy documents, drug procurement records, and health outcome data spanning multiple administrations from 1999 to the present. Costs were calculated based on drug procurement expenses, implementation costs, and healthcare savings from reduced malaria incidence. Effectiveness was measured by reductions in malaria morbidity and mortality, along with improvements in health-adjusted life years (HALYs). Analyses were conducted from both the healthcare system and societal perspectives, with all financial figures adjusted for inflation and purchasing power parity (PPP) to 2024 Naira equivalents. Results The study found varying effectiveness and cost-efficiency across different administrations. During the 1999–2007 administration, the National Malaria Control Program (NMCP) had an implementation cost of ?120 billion, leading to a 35% reduction in malaria prevalence and an ICER of ?150,000 per HALY gained. The 2007–2010 administration saw a decrease in malaria control investment to ?75 billion, resulting in only a 15% reduction in cases and a less favorable ICER of ?220,000 per HALY. In 2010–2015, funding increased to ?140 billion, achieving a 40% reduction in malaria cases and improving cost-effectiveness to ?130,000 per HALY, corresponding to a BCR of 1.25. From 2015 to 2023, despite economic challenges, ?200 billion was invested in expanding access to Artemisinin-based Combination Therapy (ACT), reducing malaria mortality by 20% and yielding a moderate ICER of ?170,000 per HALY and a BCR of 1.10. Preliminary data from the 2023–present administration indicate an allocation of ?220 billion, focusing on innovative financing models and domestic production of ACTs, with early results suggesting potential cost reductions to ?160,000 per HALY and an estimated BCR of 1.30. Conclusion The scientific evaluation demonstrates that while all regimes contributed to progress in malaria control, the degree of cost-effectiveness varied significantly based on policy focus, funding efficiency, and governance structure. Regimes that prioritized evidence-based drug policy and stable financing achieved superior health gains per Naira spent. This underscores the importance of data-driven, economically sustainable policy design to sustain malaria control achievements and improve population health outcomes in Nigeria. Citation: Elendu C (2026) Economic evaluation of anti-malarial drug policies across presidential regimes in Nigeria: A comparative analysis from 1999 to present. PLoS One 21(3): e0344909. https://doi.org/10.1371/journal.pone.0344909 Editor: Benedikt Ley, Menzies School of Health Research, AUSTRALIA Received: October 10, 2024; Accepted: February 25, 2026; Published: March 11, 2026 Copyright: © 2026 Chukwuka Elendu. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All data supporting the findings of this study were obtained from publicly available sources, including program reports and published literature, and are fully cited and described within the article; no primary data were collected. Funding: The author(s) received no specific funding for this work. Competing interests: No conflict of interest. 1. Introduction and background Malaria remains one of the most severe public health challenges globally, with sub-Saharan Africa bearing the highest burden of the disease. Nigeria, the most populous country in Africa, accounts for a significant proportion of the global malaria burden. The World Health Organization (WHO) estimated that in 2022, Nigeria contributed to approximately 27% of global malaria cases and 23% of malaria deaths, making it the country with the highest malaria mortality worldwide [1,2]. The persistence of malaria in Nigeria is driven by multiple factors, including high transmission rates, socioeconomic conditions, weak health infrastructure, and, importantly, the implementation and effectiveness of anti-malarial drug policies. While malaria control programs have been studied extensively in Nigeria, few studies have employed a systematic economic evaluation framework to compare the cost-effectiveness of malaria drug policies across successive governments. This comparison is scientifically relevant because shifts in political leadership often translate into differences in resource allocation, policy design, and sustainability of interventions [3,4]. Understanding these variations is crucial for identifying which strategies provided the highest value for money and the best health outcomes. This study defines economic evaluation as a systematic assessment of anti-malarial policies’ costs and health benefits across different administrations. This involves comparative analysis and formal economic modeling using cost-effectiveness and cost-benefit metrics. We assess cost per HALY gained, ICERs, and total program expenditure relative to malaria morbidity reduction. By employing these standardized economic evaluation methods, this study provides a structured framework for comparing policy outcomes and informing future malaria control strategies in Nigeria. 1.1 Evaluation of anti-malarial policies across regimes A structured evaluation framework is essential to objectively assess the impact of anti-malarial policies across different political regimes. This study employs a cost-effectiveness evaluation approach to compare policy efficiency, considering key economic and epidemiological indicators. By systematically analyzing government spending, malaria incidence reduction, and inflation-adjusted treatment costs, this research aims to identify the most impactful policy interventions. Furthermore, the study explores how fluctuations in foreign aid and exchange rate adjustments have influenced Nigeria’s malaria control programs’ sustainability. This evaluation framework ensures that the effectiveness of policies is not merely discussed in absolute terms but assessed through a comparative, data-driven lens that accounts for economic and demographic variations over time. 1.2 Economic and inflation-adjusted analysis of malaria control policies The role of inflation adjustments in evaluating the cost-effectiveness of malaria policies cannot be overstated. Adjusting for inflation across different regimes provides a more accurate picture of the relative cost-efficiency of interventions. Without such adjustments, cost comparisons may overstate or understate the financial burden borne during certain administrations, potentially skewing the effectiveness rankings. For instance, recalculating the cost-effectiveness ratios of interventions in Naira adjusted to a constant inflation rate could reveal previously unnoticed efficiencies or inefficiencies in specific periods. Similarly, fluctuations or inaccuracies in the Consumer Price Index (CPI) could compromise the reliability of these adjustments. Alternative inflation adjustment mechanisms, such as sector-specific inflation indices or PPP, may yield substantially different results, offering fresh insights into each administration’s economic stewardship in malaria control. Moreover, exchange rate volatility adds another layer of complexity. Foreign currency costs distort cross-regime comparisons when converted to Nigerian Naira using variable exchange rates. Employing a fixed exchange rate for the entire study period could standardize the analysis but might obscure the effects of economic shocks. Incorporating these inflation and exchange rate adjustments into the policy evaluation framework ensures a more precise understanding of the true financial commitment and efficiency of each administration’s malaria control initiatives. This warrants further investigation into whether exchange rate adjustments would expose hidden costs or benefits associated with malaria policies, especially regarding long-term sustainability. Exchange rate fluctuations and inflation adjustments directly impact the sustainability assessment of malaria policies. A closer examination of these factors might unveil hidden costs or long-term benefits that could alter interventions’ perceived sustainability and cost-effectiveness. For example, the affordability of insecticide-treated nets (ITNs) and ACT could vary significantly when viewed through an inflation-adjusted lens, offering critical insights for future planning. 1.3 International support and foreign aid in malaria control The significant role of foreign aid in Nigeria’s malaria control efforts deserves closer scrutiny. Programs like the Presidential Malaria Initiative, WHO interventions, and grants from organizations like the Gates Foundation have undeniably bolstered the country’s fight against malaria. However, the extent to which the observed reductions in malaria prevalence can be attributed to external funding versus domestic policy efforts remains an open question. While international support has enhanced resource availability, this reliance could obscure the contributions of domestic policies, particularly in sustainability evaluations. By integrating foreign aid trends into the evaluation model, this study examines whether reliance on international funding has resulted in policy inertia or has genuinely enhanced domestic malaria control capacity. A nuanced analysis must disentangle these effects to ensure a fair assessment of Nigeria’s self-sufficiency and policy effectiveness in combating malaria. 1.4 Population dynamics and malaria control outcomes Population growth is another critical factor influencing the cost-effectiveness of malaria control policies. Over the studied period, Nigeria’s rapidly growing population likely affected the HALYs gained through these interventions. Failing to incorporate population dynamics into cost-effectiveness analyses may overestimate the sustainability of policies. For instance, effective interventions in the early 2000s might have been less impactful today, given the increased population density and malaria transmission risk. This study integrates demographic-adjusted cost-effectiveness metrics to account for shifting population structures and their impact on malaria policy sustainability. Adjusting for population growth would provide a more comprehensive picture of each policy’s long-term viability and effectiveness. 1.5 Ecological and regional considerations in malaria control Malaria transmission intensity in Nigeria varies significantly across ecological zones, necessitating region-specific strategies. Developing these strategies requires prioritizing factors such as vector control, environmental management, and healthcare access tailored to the unique needs of each region. For example, areas with high transmission rates benefit more from targeted ITN distribution and larvicidal treatments, while regions with lower prevalence prioritize surveillance and rapid diagnostic testing. Failure to account for these ecological nuances could lead to suboptimal resource allocation and reduced program efficacy. This study incorporates region-specific malaria burden metrics to strengthen the evaluation model, ensuring that policy effectiveness is assessed within relevant ecological contexts rather than as a one-size-fits-all approach. 1.6 Historical overview of Nigeria’s malaria control policies The Obasanjo administration (1999–2007) marked a turning point in Nigeria’s approach to malaria control. Following the return to civilian rule in 1999, the government launched the NMCP, a component of the broader Roll Back Malaria initiative spearheaded by the WHO and other global health partners [3]. The NMCP aimed to reduce malaria mortality by 50% by 2010 through the implementation of a comprehensive strategy that included the distribution of ITNs, intermittent preventive treatment for pregnant women (IPTp), and the introduction of ACT as the first-line treatment for malaria [4]. The Obasanjo government allocated significant financial resources to this program, amounting to approximately ?120 billion throughout the administration [5]. The NMCP’s impact was substantial, leading to a reported 35% reduction in malaria prevalence by 2007 [6]. However, the program was also criticized for its high cost, with a cost-effectiveness ratio of ?150,000 per HALY gained, raising concerns about the sustainability of such investments [7]. The subsequent Yar’Adua administration (2007–2010) inherited the NMCP but faced significant challenges, including economic instability and political uncertainty. During this period, the government’s commitment to malaria control appeared to wane, as evidenced by a reduction in funding to ?75 billion over three years [8]. This decline in investment was accompanied by a corresponding reduction in the effectiveness of malaria control efforts, with only a 15% reduction in malaria cases reported during this period [9]. The cost-effectiveness ratio during Yar’Adua’s tenure increased to ?220,000 per HALY, reflecting the reduced impact of the program and highlighting the need for more efficient use of resources [10]. The administration of President Goodluck Jonathan (2010–2015) saw a renewed focus on malaria control, driven in part by the recognition of malaria’s impact on economic productivity and national development. Under Jonathan’s leadership, the government significantly increased funding for malaria control to ?140 billion, with a particular emphasis on scaling up the distribution of ACTs and expanding access to IPTp for pregnant women [11]. These efforts were supported by partnerships with international organizations such as the Global Fund, which provided additional financial and technical support for malaria control in Nigeria [12]. The impact of these interventions was evident, with a reported 40% reduction in malaria cases and an improved cost-effectiveness ratio of ?130,000 per HALY [13]. However, despite these gains, the program faced challenges related to drug resistance, supply chain inefficiencies, and the need for more robust monitoring and evaluation systems [14]. The election of President Muhammadu Buhari in 2015 brought new challenges and opportunities for malaria control i