The effect of price on demand for and use of bednets: evidence from a randomized experiment in Madagascar

Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub-Saharan Africa

Financial barriers may restrict women's ability to use their preferred contraceptive methods, especially long-acting reversible contraceptives (LARC). Providing free access to a broad contraceptive method mix, including both LARC and short-acting reversible contraceptives (SARC), may increase contraceptive use, meet women's various fertility needs, and increase their agency in contraceptive decisions. Linking facility and individual data from eight countries in sub-Saharan Africa, we use a propensity score approach combined with machine learning techniques to examine how free access to a broad contraceptive method mix affects women's contraceptive choice. Free access to both LARC and SARC was associated with an increase of 3.2 percentage points (95 percent confidence interval: 0.006, 0.058) in the likelihood of contraceptive use, driven by greater use of SARC. Among contraceptive users, free access did not prompt women to switch to LARC and had no effect on contraceptive decision-making. The price effects were larger among older and more educated women, but free access was associated with lower contraceptive use among adolescents. While free access to contraceptives is associated with a modest increase in contraceptive use for some women, removing user fees alone does not address all barriers women face, especially for the most vulnerable groups of women.

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy

BACKGROUND

Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes.

METHODS

We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access.

RESULTS

We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children.

CONCLUSIONS

Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.

Use of long-lasting insecticidal nets among women attending antenatal clinic at a tertiary hospital in Bayelsa State, Nigeria 2019

Background

Malaria in pregnancy remains a major contributor to maternal and infant morbidity and mortality despite scale up in interventions. Its prevention is one of the major interventions in reducing maternal and infant morbidity and mortality. The ownership, utilization and predictors of use of long-lasting insecticide-treated nets (LLINs) for malaria prevention among women attending antenatal clinic (ANC) at a tertiary hospital in Bayelsa State Nigeria was assessed.

Methods

A cross-sectional study of 297 women recruited through systematic sampling was carried out. Information on sociodemographic characteristics, ownership, source and utilization of LLINs, were collected with a pre-tested structured interviewer-administered questionnaire. The relationship between use of LLIN and sociodemographic characteristics was examined using chi square and logistic regression at 5% level of significance.

Results

The mean age of respondents was 28.8 ± 2.6 years. Most (59.2%) had tertiary education and were mainly (88.2%) urban dwellers. Two hundred and fifty (84.2%) owned LLINs, and 196 (78%) used LLIN the night prior to the interview. Almost half of the respondents purchased their LLINs. Those who purchased LLINs were 3 times more likely to have used it (OR: 3.13, 95% CI 1.62–6.04) compared to those that got it free. Those who were gainfully employed (OR: 3.16, 95% CI 1.59–6.29) and those who earned above the minimum wage (OR: 2.88, 95% CI 1.45–5.72) were 3 times more likely to have used LLIN in their index pregnancy.

Conclusion

The use of LLIN as a preventive measure against malaria was relatively high among the participants in this study, though still below national target. The major factors determining the use of LLIN among these women were purchase of LLINs and being gainfully employed. It was recommended that efforts should be made to enforce the policy of free LLINs at ANC registration at the tertiary hospitals, as this would further drive up ownership and utilization rates.

Evidence of high bed net usage from a list randomization experiments in rural Gambia

BACKGROUND

Recording behaviours that have the potential to impact health can be doubly challenging if the behaviour takes place in private spaces that cannot be observed directly, and where respondents answer what they think the recorder may want to hear. Sleeping under a long-lasting insecticidal net (LLIN) is an important intervention for malaria prevention, yet it is difficult to gauge the extent to which coverage (how many nets are in the community) differs from usage (how many people actually sleep under a net). List randomization, a novel method which partially obscures respondents' answers to sensitive questions, was employed to estimate LLIN usage in The Gambia.

METHODS

802 heads-of-household from 15 villages were recruited into a randomized controlled trial assessing the effect of a housing intervention on malaria. These houses were randomly assigned to a housing intervention versus control, with stratification by village so as to ensure balance between arms. From these, 125 households (63 intervention, 52 control) were randomly selected for participation in the list randomization experiment, along with 68 households from the same villages but which were not part of the housing improvement study, resulting in a total of 196 households for the list randomization experiment. Approximately half (n = 97) of the 196 study participants were randomly assigned to the control group and received a four-question list about non-sensitive behaviours; the intervention group (n = 99) received the same list, with the addition of one question on a sensitive behaviour: whether or not they had used a bed net the previous night. Participants were read the list of questions and then said how many of the statements were true. Bed net usage was estimated by calculating the difference in means between the number of affirmative responses between the two groups.

RESULTS

The mean number of affirmative responses in the control group was 2.60 of four statements (95% confidence interval, 95% CI 2.50-2.70), compared with 3.68 (95% CI 3.59-3.78) in the intervention group. Such difference (1.08; 95% CI 94.9-100%) suggests near universal bed net usage.

CONCLUSIONS

Bed net usage by household heads in these rural villages was found to be high. Though not entirely unexpected given other studies' estimates of high bed net usage in the area, the list randomization method should be further validated in an area with lower coverage.

Willingness-to-pay for long-lasting insecticide-treated bed nets: a discrete choice experiment with real payment in Ghana

Background

Expanding access to long-lasting insecticidal nets (LLINs) is difficult if one is limited to government and donor financial resources. Private commercial markets could play a larger role in the continuous distribution of LLINs by offering differentiated LLINs to middle-class Ghanaians. This population segment has disposable income and may be willing to pay for LLINs that meet their preferences. Measuring the willingness-to-pay (WTP) for LLINs with specialty features that appeal to middle-class Ghanaians could help malaria control programmes understand what is the potential for private markets to work alongside fully subsidized LLIN distribution channels to assist in spreading this commodity.

Methods

This study conducted a discrete choice experiment (DCE) including a real payment choice among a representative sample of 628 middle-income households living in Ashanti, Greater Accra, and Western regions in Ghana. The DCE presented 18 paired combinations of LLIN features and various prices. Respondents indicated which LLIN of each pair they preferred and whether they would purchase it. To validate stated willingness-to-pay, each participant was given a cash payment of $14.30 (GHS 65) that they could either keep or immediately spend on one of the LLIN products.

Results

The households’ average probability of purchasing a LLIN with specialty features was 43.8% (S.D. 0.07) and WTP was $7.48 (GHS34.0). The preferred LLIN features were conical or rectangular one-point-hang shape, queen size, and zipper entry. The average WTP for a LLIN with all the preferred features was $18.48 (GHS 84). In a scenario with the private LLIN market, the public sector outlay could be reduced by 39% and private LLIN sales would generate $8.1 million ($311 per every 100 households) in revenue in the study area that would support jobs for Ghanaian retailers, distributors, and importers of LLINs.

Conclusion

Results support a scenario in which commercial markets for LLINs could play a significant role in improving access to LLINs for middle-income Ghanaians. Manufacturers interested could offer LLIN designs with features that are most highly valued among middle-income households in Ghana and maintain a retail price that could yield sufficient economic returns.

Effect of Prices, Distribution Strategies, and Marketing on Demand for HIV Self-testing in Zimbabwe: A Randomized Clinical Trial

IMPORTANCE

HIV self-testing is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, particularly in Zimbabwe, where HIV prevalence is 13%. Evidence is lacking, however, on the optimal pricing policies and delivery strategies for maximizing the effect of HIV self-testing.

OBJECTIVE

To assess demand for HIV self-testing among adults and priority-population subgroups under alternative pricing and distribution strategies.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial recruited study participants between February 15, 2018, and April 25, 2018, in urban and rural communities in Zimbabwe. A factorial design was used to randomize participants to a combination of self-test price, distribution site, and promotional message. Individuals and their household members had to be at least 16 years old to be eligible for participation. This intention-to-treat population comprised 3996 participants.

INTERVENTIONS

Participants were given a voucher that could be redeemed for an HIV self-test within 1 month at varying prices (US $0-$3) and distribution sites (clinics or pharmacies in urban areas, and retail stores or community health workers in rural areas). Vouchers included randomly assigned promotional messages that emphasized the benefits of HIV testing.

MAIN OUTCOMES AND MEASURES

Proportion of participants who obtained self-tests in each trial arm, measured by distributor records.

RESULTS

Among the 4000 individuals enrolled, 3996 participants were included. In total, the mean (SD) age was 35 (14.7) years, and most participants (2841 [71.1%]) were female. Self-testing demand was highly price sensitive; 260 participants (32.5%) who were offered free self-tests redeemed their vouchers, compared with 55 participants (6.9%) who were offered self-tests for US $0.50 (odds ratio [OR], 0.14; 95% CI, 0.10-0.19), a reduction in demand of more than 25 percentage points. Demand was below 3% in the $1, $2, and $3 groups, which was statistically significantly lower than the demand in the free distribution group: in pooled analyses, demand was considerably lower among participants in higher-than-$0 price groups compared with the free distribution group (2.8% vs 32.5%; OR, 0.05; 95% CI, 0.04-0.07). In urban areas, demand was statistically significantly higher with pharmacy-based distribution compared with clinic-based distribution (6.8% vs 2.9%; adjusted OR, 2.78; 95% CI, 1.74-4.45). Price sensitivity was statistically significantly higher among rural residents, men, and those who had never received testing before. Promotional messages did not influence demand.

CONCLUSIONS AND RELEVANCE

This study found that demand for HIV self-testing in Zimbabwe was highly price sensitive, suggesting that free distribution may be essential for promoting testing among high-priority population groups; additionally, pharmacy-based distribution was preferable to clinic-based distribution in urban areas.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03559959.

Demand and willingness-to-pay for bed nets in Tanzania: results from a choice experiment

Background

Universal coverage campaigns for long-lasting insecticide-treated nets do not always reach the goal of one net for every two household members, and even when ownership of at least one net per household is high, many households may not own enough nets. The retail market provides these households options for replacing or increasing the number of nets they own with products that best fit their needs since a variety of net shapes, sizes, and colours are available. Hence, it is important to understand the factors affecting private net demand. This study explores private demand for nets in Tanzania using a discrete choice experiment. The experiment provides participants the option to buy nets with their own money, and thus should prove more accurate than a hypothetical survey of net preferences.

Results

Nearly 800 participants sampled in two regions showed an overall strong demand for nets, with 40% choosing to buy a net across all seven combinations of net prices and characteristics such as size, shape, and insecticide treatment. Only 8% of all participants chose not to buy a single net. A key factor influencing demand was whether a participant’s household currently owned sufficient nets for all members, with rural participants showing lower net coverage and greater demand than urban participants. Both poor and less poor households showed strong evidence of making purchase decisions based on more than price alone. Mean willingness-to-pay values for a net started at US$1.10 and grew by US$0.50–1.40 for various attributes such as rectangular shape, large size, and insecticide treatment. The impact of price on demand was negative but small, with elasticity values between −0.25 and −0.45.

Conclusions

The results suggest that private demand for nets in Tanzania could potentially supplement future coverage campaigns. Net manufacturers and retailers should advertise and promote consumers’ preferred net attributes to improve sales and further expand net access and coverage. To overcome household liquidity concerns and best replicate the experiment results, policy makers should consider making credit available for interested buyers.