A price to pay? Increasing insecticide-treated net coverage in Malawi

Nets treated with insecticide have proved to be an effective method of reducing malaria. Before increasing the scale of this intervention, however, policymakers need to be fully informed of the costs involved and the effect that the scaling-up will have. Cost-effectiveness has been measured in trials, but what does the intervention cost in practice?

One of the maingoals of the World Health Organization's Roll Back Malaria programme is toensure that at least 60 percent of pregnant women and children under five yearsold in sub-Saharan Africa use insecticide-treated nets. These nets are consideredone of the most cost-effective methods of reducing malaria-related deaths andillness. The estimated cost per disability adjusted life year (DALY) preventedis less than US$50. However, the real cost of different methods of financingand delivering the nets on a large scale is needed urgently. 

Research by theLondon School of Hygiene and Tropical Medicine, UK, UNICEF and PopulationServices International analysed the cost-effectiveness of usinginsecticide-treated nets in the Blantyre district of Malawi in 1998, prior to theintervention being extended countrywide. The study evaluated a specific, ongoingintervention by looking at the cost of insecticide-treated nets distributed andthe cost per year the nets (including re-treatment) are used.

The study foundthat the programme cost just over US$6 million in the first five years. In thisperiod about 1.5 million nets and 300,000 re-treatment kits were sold. Theinsecticide treatment is assumed to last six months. The cost of the nets andinsecticide made up 60 percent of the total costs. The report also states thefollowing findings:

• Theaverage cost per distributed net was US$2.63.
• Theaverage cost per treated-net-year was US$4.41.
• Thisintervention becomes cheaper as it is expanded.
• The costper treated-net-year dropped from US$7.69 to US$3.44 as the number of netsdistributed rose from just over 72,000 to about 720,000.
• Thecost per distributed net dropped from US$5.04 to US$1.92 as the programme wasexpanded.
• Abouthalf of the scale efficiency savings over the five years were due to reductionin product costs.

If policymakersuse cost estimates based on small-scale intervention trials, which are likely tosuggest constant returns to scale, it is probable that the true cost of scalingup the intervention will be overestimated. The study makes the following policyimplications:

• As insecticide-treatednets are effective at reducing malaria in sub-Saharan Africa, the best methodsfor a continued and high-level use of these nets need to be established incommunities that stand to benefit the most.
• Highlevels of coverage of heavily subsidised insecticide-treated nets could beachieved using a combination of social marketing techniques and the targetingof vulnerable communities through the commercial and formal health caresectors.
• High levels of insecticide-treatednet distribution and a rapid rise in coverage could be achieved at the sametime as keeping costs down and increasing savings.