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BLANTYRE, Malawi, May 10, 2005 - Combining the strengths of commercial markets and public health centers has allowed efficient, cost-effective delivery of life-saving mosquito nets in Malawi, says a new study in the Malaria Journal, ensuring the country is one of the first to reach the 2005 targets set by world leaders in the Abuja Declaration. The Government of Malawi has scaled up distribution of life-saving
mosquito nets to its people from 13% to 60% of households in just four
years, and has seen program costs decrease significantly while doing
so, according to a new study of economists and public health experts
published in the Malaria Journal this month (see the study at www.malariajournal.com).
"With one of the main Abuja Declaration goals being to achieve at least 60% coverage of pregnant women and children under five years of age with ITNs, more programs need to see the results that combining public and private efforts can have in achieving rapid results in a sustainable manner," the authors say in the report. The strategy involves segmenting the total market to sell a more expensive blue conical net to consumers for $5-6 through private sector outlets targeting those who can afford it. In public health facilities, a highly subsidized green rectangular net is sold to pregnant women and children under five - those most vulnerable to malaria - for $0.50. All nets are branded and heavily promoted to the public through a range of mass media and interpersonal communications channels. ITNs are a proven effective intervention to reduce the incidence of malaria morbidity and mortality and one of the most cost-effective ways of reducing the burden of malaria. The difficulty is in finding the most effective way to deliver nets - to rapidly achieve household coverage with minimum delivery costs, ensuring that the poorest households are covered and that a sustainable delivery system is put in place. The key finding of this study is that, in the Malawi model, costs are decreasing as the program grows - an increasing return to scale the authors call "scale efficiency savings". As shown in the graph below, the economic cost per ITN distributed drops from over $5 to under $2 (including commodity costs) in Malawi as the number of nets distributed per year rises from 70,000 to 1 million.
Scale Efficiency Savings in Malawi ITN Distribution This finding leads report authors to suggest that the current debate between free distribution and market development on the best way to achieve long term increases in ITN use may be missing the point. "Those who advocate the universal distribution of free nets have prioritized the need for immediate results in terms of health gain, whereas those who argue for the development of domestic markets for ITNs wish to ensure the long-term sustainability of utilization of ITNs," say the authors. "The Malawi model is a way for national malaria programs, NGOs, donors, and international aid agencies to combine the strengths of commercial market delivery with heavily subsidized, highly targeted distribution through the nationwide network of public health facilities to achieve both rapid and sustainable results." A key element missing for public health decision-makers is information on the costs and effects of scaling up malaria interventions including the provision of ITNs. While lessons learned from other ITN delivery programs are now being shared, the costs of scaling up ITNs are currently restricted to a relatively small number of studies based on the evaluation of trials or research studies that are often of limited scale, according to report authors. "These studies fail to account for the inevitable growth of scaling up over time that is necessary in implementation of many public health interventions," say the authors. "The purpose of this study is to start to address these gaps by incorporating ongoing fieldwork into the cost-effectiveness debate around the delivery of ITNs." This evaluation looks at the cost-effectiveness of a specific ITN delivery program in Malawi in terms of cost per ITN distributed and cost per treated net year. The costs were taken from financial expenditure data collected over the course of the first five years of the program. Report authors found that the average economic cost per net delivered, over the five years, was $2.49. This compares favorably to other studies where estimates of $8 and $4 were found. This paper suggests that a combination of commercial market delivery combined with targeting vulnerable groups with highly subsidized ITNs through the formal health care sector could achieve high levels of coverage in both urban and rural areas and in vulnerable groups. — Dr. Desmond Chavasse, PSI Malaria Control Programme, Nairobi, Kenya
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