**Costs of malaria surveillance**

**Costs of case detection and treatment:** According to the number of personnel required by the surveillance program (8), there were 2,210 professionals in 105 townships from 2005 to 2015, 170 professionals in 85 counties from 2010 to 2015, and 85 professionals in 85 counties from 2016 to 2019. According to wages in institutions during the same period, the average annual total staff wage from 2005 to 2019 was about 31,823,563.67 yuan. The annual blood test rate required by the surveillance program from 2005 to 2009 was not less than 2% in Nanping and Sanming, not less than 5/1,000 in southern Fujian, and not less than 1/1,000 in other cities(8). From 2010 to 2019, if the annual blood test rate was not less than 5/10,000, the annual number of blood tests was 110,178, and the annual cost of blood tests for febrile patients was about 2,203,560.00 yuan. A total of 1,191 cases of malaria were reported from 2005 to 2019. The cost of antimalarial drugs, examination fees, and nursing fees per capita was 319.35 yuan, and the annual average cost of direct treatment was about 38,002.65 yuan. According to the average annual consumption level in Fujian Province in the same period, the estimated cost of transportation, accommodation, and other expenses was about 218.94 yuan, while the annual average direct non-medical costs was about 52,107.72 yuan. In the same period, the net income per capita in urban and rural areas of Fujian Province was about 19 million yuan per year, and the estimated cost of missed work was 1,407.05 yuan per person, so the average annual cost of missed work was about 334,877.90 yuan.

**Cost of ****epidemic ****surveillance: **According to the requirements of the surveillance program, each surveillance site was equipped with 2 professionals, and there were 5 surveillance sites for floating population gathering places. From 2005 to 2015, there were 15 counties in the southern Fujian area and 22 counties in the northwestern Fujian area. A survey of residual Anopheles anthropophagus distribution was carried out in Nanping and Sanming from 2016 to 2019, with 20 sites monitored in two counties each year and 7 sites monitored in one county each year in the remaining cities. There were 74 staff members during the period 2005–2015 and 64 professionals from 2016 to 2019. According to the salary of public institutions in the same period, the average annual total staff salary was about 3,970,643.60 yuan. The surveillance site carried out media density surveillance 6 times per year, with a cost totaling about 1000 yuan for 2 professionals and 2 nights each time. Thus, the cost of media density surveillance in the whole province is about 214,000.00 yuan. For the treatment of pesticide retention spraying and mosquito control in epidemic sites, we calculated the annual average cost of extermination drugs based on actual dosages and market prices at the time to be about 51,333.33 yuan. The cases were investigated and verified by two professionals. Labor service and transportation subsidies were about 90 yuan per person, and the annual average was about 21,420.00 yuan.

**Cost of**** training meetings:** The training course lasted about 3 days each time. There were 3,121 professionals (clinicians, prevention and treatment personnel, and inspectors) who participated in the training from 2005 to 2013.and 15,421 professionals from 2014 to 2019. The average annual cost of training was about 1,314,826.00 yuan. The conference cost was calculated as 5% of the training cost, with an average annual cost of about 65,741.30 yuan.

**Cost of health education**: Every April 26, the “National Malaria Day” propaganda and education activities were held in the province, for which the average annual cost of health education activities was calculated to be around 20,000 yuan. Publicity and education activities were carried out 86 times in 85 counties and in 9 cities in the province and their districts, with 94 professionals participating. The average annual salary of public institution professionals was about 571,000 yuan, with a total salary and subsidy of about 5,895,074.53 yuan

**Costs of supervision and assessment:** During 2005–2019, 36 professionals from higher units went to lower units for supervision and assessment a total of 188 times, and their annual average salary and total labor costs were about 2,075,614.40 yuan. The material cost was estimated to be about 40 yuan each time, with an annual average material cost of about 7,520 yuan. The cost of transportation and accommodation was estimated to be about 200 yuan per capita according to the consumption expenditure in the same period, with an annual average of about 75,200.00 yuan.

Table 1 shows that the annual average cost of surveillance measures in the malaria elimination phase from 2005 to 2019 was about 481,635.10 yuan. In terms of the cost component ratio of each surveillance project (Figure 1), the cost of case detection and treatment (34,452,111.94 yuan) accounted for the highest at 71.53%, followed by the cost of health education (5,915,074.53 yuan), which accounted for 12.28%. The cost of epidemic surveillance (4,257,396.93 yuan) accounted for 8.84%, the cost of training meetings (1,380,567.30 yuan) accounted for 2.87%, and the cost of supervision and assessment (2,158,334.40 yuan) accounted for 4.48%.

**Economic and Social Benefits of Malaria Surveillance**

The average annual resident population of Fujian Province from 2005 to 2019 was 37.56 million. We used the incidence rate of 1,972 (238.25/10,000) as the study control and calculated that 894,867 cases were avoided due to malaria surveillance(8). The actual number of reported cases was 1,191 (about 119 cases per year); thus, from 2005 to 2019, the annual average number of cases actually avoided was 894,748 cases.

We assumed that without effective malaria surveillance, all cases would have been hospitalized for antimalarial treatment. The direct treatment cost of each case was 319.35 yuan, and the annual average benefit of avoiding hospitalization was about 285.74 million yuan. The direct non-medical cost of each case was 218.94 yuan with an accompanying rate of 1, so the annual average direct non-medical benefits avoided was about 391.79 million yuan. The indirect cost of each case was 1,407.05 yuan with an accompanying rate of 1, so the benefit of avoiding hospitalization-related work absence was about 2.52 billion yuan, as shown in Table 2.

We used the number of professionals trained in Fujian Province from 2005 to 2019 multiplied by the per capita training benefit to calculate the benefit of improving professionals’ surveillance ability. The estimated per capita training benefit was about 250 yuan. The total number of professionals trained from 2005 to 2019 was 18,542, and the average annual benefit of improving their surveillance ability was about 309,033.33 yuan. Combining the level of per capita health care expenditure and the results of a resident survey in Fujian Province during 2005–2019, it was estimated that residents would be willing to pay about 300 yuan to avoid the health loss caused by malaria. According to the actual number of cases avoided in this stage, we estimated that the average annual benefit of improving residents’ health level was about 268 million yuan. We supposed that through different forms of health education and propaganda, the residents acquired enough knowledge about malaria protection to avoid malaria infection and suppress malaria incidence, and the per capita social benefit was estimated at 100 yuan. Then, the average annual benefit of the residents’ awareness of malaria protection was about 3.756 billion yuan. As shown in Table 2, the total economic benefit was about 3.195 billion yuan, accounting for 44.26% of the total benefit. The social benefit was about 4.025 billion yuan, accounting for 55.74% (notably more than 50%).

**Cost-benefit analysis of malaria surveillance**

The average annual cost of malaria surveillance measures in Fujian Province during 2005–2019 was about 481.635 million yuan, and the total annual benefit obtained was about 722 billion yuan. Thus, the per capita cost of malaria surveillance for residents was 1.28 yuan, and the per capita benefit of malaria surveillance for residents was 192.23 yuan. This shows that the investment per capita cost of malaria surveillance measures in Fujian Province was lower than the per capita benefit that was obtained. Hence, the effect of the malaria surveillance work was very beneficial.

By subtracting the annual average cost from the annual average total benefit, we calculated that the annual average net benefit resulting from malaria surveillance was 7.172 billion yuan. We calculated an annual average benefit-cost ratio of 149.91:1, which indicates that every input of 1 yuan for malaria surveillance could produce social benefits of 149.91 yuan.