Financing and Delivering Insecticide-treated Nets

Overview:

At the African Summit on Roll Back Malaria in Abuja, Nigeria 2000, the consensus was that at least 60% of children and pregnant women should be protected with Insecticide-treated Nets (ITNs) across malaria endemic areas by 2005. This coverage has not yet been reached in almost all areas, due to reasons of finance, delivery and education. There is also inequity in ITN use among various socio-economic groups with the poorest being the least likely to benefit from ITNs even where they are highly subsidised.

Delivery systems for nets rely on either public sectordistribution of ITNs which may be free or at a small charge and commercial sectorsales that are at full price or subsidised. There are limitations to both, and there is no single answer for the best, most cost effective delivery system. Public health programmes can achieve high coverage of nets, but they must be backed up by awareness campaigns and household education in the use of nets. Commercial delivery systems can ensure reliable availability of ITNs for maintaining high coverage, may suffer from inequitable access associated with household wealth, mother's education, distance from commercial centre and the coverage and use of nets. Social marketing - the use of commercial marketing techniques to change people's behaviour (in terms of purchasing and using a net regularly) - can be useful, but has not shown more equitable distribution, and few studies have compared its cost effectiveness with other approaches. An innovate approach, which is showing promise, focuses on local commercial sector development to encourage reach to rural markets and consumers whilst simultaneously delivering through the public sector to reach vulnerable populations.

ITNs are easy to use and require less technical and capital outlay to implement compared with other vector control methods. They are cost-effective, which has led to widespread implementation of ITNs by countries on a large scale. To optimize the cost effectiveness of ITNs, usage must be scaled up, but scaling up is challenging, requires substantial resources and a careful choice of delivery strategy (public and private/commercial). The greatest costs are for personnel and transport, therefore minimising these costs (e.g. by delivering nets and net re-treatment through existing public health programmes such as antenatal care or immunisation) is important.

As well as the initial costs to the household ITN use low retreatment rates, since conventionally treated nets need retreatment every 6 to 12 months. Long Lasting Insecticidal Nets (LLINs), such as Olyset® (permethrin-treated) or PermaNet® (deltamethrin-treated) are a major recent breakthrough. Although initial cost is slghtly higher, they will increase cost effectiveness by removing the need for retreatment. Another important strategy for keeping costs down is removal of taxes and tariffes on ITNs and LLINs, which was a commitment of the Abuja Summit, which has not been met by all countries.

There is now wide consensus around the WHO Strategic Framework for Scaling-Up Insecticide Treated Netting Programmes in Africa, which recognises a multi-sectoral role for both the public sector (targeting vulnerable groups for free distribution to promote equity) and the private sector (for commercial distribution systems). The integration of ITN delivery with maternal and child health programmes (and immunisation in particular), at the same time working with the private sector in a complementary and supportive manner to ensure that coverage can be maintained, is the way forward.

Key Points:

• Challenges exist with both private and public sector delivery systems for ITNs.
• A Strategic Framework to scale up net coverage includes both these sectors.
• LLINs are the most practical tool for longterm protection.
• It is vital to ensure high coverage in rural and poor districts, as inequitable access arises frequently in net use.
• Standardised costs of per unit coverage are needed to assess the most efficient, sustainable and cost effective method of delivery.

References:

1. RBM (2006). Scaling up Insecticide Treated Netting Programmes in Africa: A Strategic Framework for Coordinated Action.
2. Malaria Consortium (2003). Tax and Tariff Reduction on Nets, Netting and Insecticides. Lessons from Ghana, Mali, Nigeria, Senegal and Tanzania. Malaria Consortium Policy Briefing Paper.
3. Webster, J., Lines, J., Bruce, J., Armstrong Schellenberg, J,. & Hanson, K. (2005). Which delivery systems reach the poor? A review of equity of coverage of ever-treated nets, never-treated nets, and immunisation to reduce child mortality in Africa. Lancet Infectious Diseases 5: 709-719.
4. Kolaczinski, J. & Hanson, K. (2006). Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology. Malaria Journal 5:37.
5. Onwujekwe, O, Hanson, K. & Fox-Rushby, J. (2004). Inequality in purchase of mosquito nets and willingness to pay for insecticide treated nets in Nigeria: challenges for malaria control interventions. Malaria Journal 3:6.
6. Noor, A.M., Omumbo, J.A., Amin, A.A., Zurovac, D. & Snow, R.W. (2006). Wealth, mother's education and physical access as determinants of retail sector net use in rural Kenya. Malaria Journal 5:5.
7. Snow, R.W., McCabe, E., Mbogo, C.N.M., Molyneux, C.S., Some, E.S., Mung'Ala, V.O. & Nevill, C.G. (1999). The effect of delivery mechanisms on the uptake of bed net re-impregnation in Kilifi District, Kenya. Health Policy and Planning 14: 18-25.
8. Stevens, W., Wiseman, V., Ortiz, J. & Chavasse. D. (2005). The costs and effects of a nationwide insecticide-treated net programme: the case of Malawi. Malaria Journal 4:22.