Cost and cost effectiveness of long-lasting insecticide-treated bed nets: A model-based

analysisA-M Pulkki-Brännström1§, C Wolff2, N Brännström3 and J Skordis-Worrall1

 1UCL Centre for International Health and Development, University College London, UK, 2Stockholm School of Economics, Sweden, 3University of

Helsinki, Finland

• Bed nets are integral to national

malaria programmes.

• WHO recommends using long-lasting

insecticide-treated bed nets (LLINs).

• Few comparative studies of bed net

distribution, and fewer economic

evaluations of LLIN distribution

• Need to better understand

determinants of cost effectiveness

of different bed net types

• When and why are LLINs preferred

to conventional insecticide-treated

nets?

• Which lifespan should be selected

for LLIN?

1. Background

Explore impact of parameters on cost effectiveness in an Excel model.Choice Variables:

• Coverage (no of nets to population size),

usage rate, net type, price, lifespan,

delivery method, replenishment need &

delivery, procurement costs, geographic

area.

Outcome Variables:

• No. of people protected, cost per person

protected, U5 deaths averted, cost per U5

death averted, DALYs averted.

2. Methods

10-year period considered

Regular distribution rounds:

• procurement and distribution costs

• choice of distribution method:

1. Free distribution in campaign (USD

2.7)

2. Free distribution through routine

services (USD 2.65/USD 1.4)

3. Subsidised sales and social

marketing (USD 3.9)

Annual replenishment rounds (keeping coverage constant, smaller number of nets distributed, every year until next main distribution round)

3 Scenarios of replenishment need: 1. Annual loss rate constant proportion

of nets distributed initially.

2. Annual loss rate constant proportion of nets of nets still in use

3. Loss rate increases until 50% of initially distributed nets remain

• Large-scale programme

with high coverage & use

• ITNs distributed through

existing health services.

• ITNs regularly retreated at

low cost

• Parameters from literature

review where possible

• Sensitivity analysis

3. The Model: Variable Benchmark case Sensitivity analysis Sources

ITN/LLIN effectiveness 5.5 deaths averted / 1000 under-5s protected pa.

- Lengeler 2004

Coverage 1m nets, 4m people20% under 5

- comparable to WMR 2010

Usage rate (Year 1) 50% overall70% under-5s

30% total, 50% under-5s30% both

DHS surveys and various studies

Purchase price USD 4USD 3-7 (LLINs)USD 1-5 (ITNs)

Kolaczinski 2010and assumptions

Lifespan 3 years3 - 5 years (LLINs)1 - 4 years (ITNs)

WHOPES 2009, Erlanger 2004

Delivery cost and method

USD 1.4 per net; Free integrated dbn (>0.75m)

USD 3.86 per netSubs. sales & social marketing

12 sources, 17 programmes

Insecticide retreatment 75% treated annuallyUSD 0.64 per net

50% annually / 75% biannuallyUSD 1.28 per net

9 sources

Replenishment need NoneIncreasing/constant/decreasing proportion lost per annum

A. Kilian (increasing loss)

Replenishment delivery cost

- USD 1.4 or USD 3.86 per net See Table 24. Findings 5. Conclusions

• LLINs more cost effective than ITNs with

same lifespan - unless US$ 1.5 more

expensive.

• For each year of a longer lifespan a bed

net can be US$ 1 more expensive, while

still being more cost effective.

• Replenishing nets raises protective

effectiveness by 5-14% .

– Replenishment costs: US$ 17-25 per person per

annum US$ 1080-1610 per under-5 death

averted.

• Limitations:1. Treatment costs, household costs of

malaria: No robust estimates for different geographic areas available.

2. Effectiveness of untreated nets: Not enough available data

• Program planners should be willing to pay a premium for nets which have a longer lifespan up to a price threshold.

• Replenishment (incrementally) cost effective if planners willing to spend US$ 1610 per U5 death averted.