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

Demographic and socio-economic factors affecting bed net ownership, usage, and malaria transmission among adult patients seeking healthcare in two Ghanaian urban cities

BACKGROUND

The most cost-effective malaria prevention and control strategy is the use of a bed net. However, several factors affect the ownership and usage of bed nets among the adult population. Hence, this study aimed to examine socio-demographic factors affecting bed net ownership, usage and malaria transmission among adult patients seeking healthcare in two Ghanaian urban cities.

METHODS

This hospital-based cross-sectional study was conducted, between January and September 2021, at Bremang Seventh-Day Adventist Hospital, Suame Municipal, Ashanti Region and Sunyani Municipal Hospital, Sunyani, Bono Region, Ghana. Structured questionnaires were administered to a total of 550 participants to ascertain their ownership and usage of the bed nets. Afterwards, finger prick blood samples were collected for malaria microscopy. Crude and adjusted prevalence ratios (PR) and their respective 95% CIs were calculated, using Poisson regression with robust standard errors, to show associated variables in bivariate and multivariate analyses respectively. R software (version 4.1.1) was used to perform all statistical analyses.

RESULTS

About 53.3% (n = 293) of participants owned at least one-bed net but only 21.5% (n = 118) slept under it the previous night. Those married were 2.0 (95% CI: 1.6 - 2.5) and 2.4 (95% CI: 1.6 - 3.5) times more likely to own and use a bed net respectively than those who never married. Also, pregnant women were 1.3 (95% CI: 1.1 - 1.6) and 1.8 (95% CI: 1.3 - 2.5) times more likely to own and use a bed net respectively than non-pregnant. Even though income levels were not associated with bed net ownership and usage, students were 0.4 (95% CI: 0.2 - 0.6) and 0.2 (95% CI: 0.1 - 0.5) times less likely to own and use bed net respectively compared to formally employed persons. The overall malaria prevalence rate was 7.8%. Malaria-negative patients were 1.6 (95% CI: 1.2 - 2.0) and 2.4 (95% CI: 1.4 - 4.1) times more likely to own and use bed nets respectively than malaria positive. Patients with tertiary education recorded the lowest malaria prevalence (3.5%, n = 4). None of those with a monthly income > $300 recorded a case of malaria. On the contrary, majority 83%, n/N = 25/30) of the malaria-positive patients earned ≤ $150.

CONCLUSION

The National Malaria Control Program should conduct comprehensive mapping of all urban population segments before launching mass bed net distribution campaigns, taking into account demographic and socioeconomic factors to enhance bed net utilization and reduce malaria prevalence.

The fight against malaria: Diminishing gains and growing challenges

Since the year 2000, historic reductions in malaria incidence and mortality have been driven by the widespread distribution of bed nets, drugs, and insecticides for the prevention and treatment of malaria. Scale-up of these tools has been enabled by an increase in malaria financing compounded by price reductions, yet these trends are unlikely to continue at the same rate. Rapid population growth in high-endemic areas requires procurement of more of these tools just to maintain current coverage, even as prices are likely to increase as resistance to drugs and insecticides forces shifts to newer products. Further progress toward the long-term goal of malaria eradication requires a combination of greater funding, more cost-effective resource allocation, and fundamental changes to the global malaria control strategy.

Using donor funding to catalyse investment in malaria prevention in Ghana: an analysis of the potential impact on public and private sector expenditure

Background

An estimated 1.5 billion malaria cases and 7.6 million malaria deaths have been averted globally since 2000; long-lasting insecticidal nets (LLINs) have contributed an estimated 68% of this reduction. Insufficient funding at the international and domestic levels poses a significant threat to future progress and there is growing emphasis on the need for enhanced domestic resource mobilization. The Private Sector Malaria Prevention (PSMP) project was a 3-year intervention to catalyse private sector investment in malaria prevention in Ghana.

Methods

To assess value for money of the intervention, non-donor expenditure in the 5 years post-project catalysed by the initial donor investment was predicted. Non-donor expenditure catalysed by this investment included: workplace partner costs of malaria prevention activities; household costs in purchasing LLINs from retail outlets; domestic resource mobilization (public sector financing and private investors). Annual ratios of projected non-donor expenditure to annualized donor costs were calculated for the 5 years post-project. Alternative scenarios were constructed to explore uncertainty around future consequences of the intervention.

Results

The total donor financial cost of the 3-year PSMP project was USD 4,418,996. The average annual economic donor cost per LLIN distributed through retail sector and workplace partners was USD 21.17 and USD 7.55, respectively. Taking a 5-year post-project time horizon, the annualized donor investment costs were USD 735,805. In the best-case scenario, each USD of annualized donor investment led to USD 4.82 in annual projected non-donor expenditure by the fifth-year post-project. With increasingly conservative assumptions around the project consequences, this ratio decreased to 3.58, 2.16, 1.07 and 0.93 in the “very good”, “good”, “poor” and “worst” case scenarios, respectively. This suggests that in all but the worst-case scenario, donor investment would be exceeded by the non-donor expenditure it catalysed.

Conclusions

The unit cost per net delivered was high, reflecting considerable initial investment costs and relatively low volumes of LLINs sold during the short duration of the project. However, taking a longer time horizon and broader perspective on the consequences of this complex catalytic intervention suggests that considerable domestic resources for malaria control could be mobilized, exceeding the value of the initial donor investment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04218-2.

What Africa can do to accelerate and sustain progress against malaria

After a longstanding global presence, malaria is now largely non-existent or suppressed in most parts of the world. Today, cases and deaths are primarily concentrated in sub-Saharan Africa. According to many experts, this persistence on the African continent reflects factors such as resistance to insecticides and drugs as well as insufficient access to essential commodities such as insecticide-treated nets and effective drugs. Crucially, however, this narrative ignores many central weaknesses in the fight against malaria and instead reinforces a narrow, commodity-driven vision of disease control. This paper therefore describes the core challenges hindering malaria programs in Africa and highlights key opportunities to rethink current strategies for sustainable control and elimination. The epidemiology of malaria in Africa presents far greater challenges than elsewhere and requires context-specific initiatives tailored to national and sub-national targets. To sustain progress, African countries must systematically address key weaknesses in its health systems, improve the quality and use of data for surveillance-responses, improve both technical and leadership competencies for malaria control, and gradually reduce overreliance on commodities while expanding multisectoral initiatives such as improved housing and environmental sanitation. They must also leverage increased funding from both domestic and international sources, and support pivotal research and development efforts locally. Effective vaccines and drugs, or other potentially transformative technologies such as genedrive modified mosquitoes, could further accelerate malaria control by complementing current tools. However, our underlying strategies remain insufficient and must be expanded to include more holistic and context-specific approaches critical to achieve and sustain effective malaria control.

"In starvation, a bone can also be meat": a mixed methods evaluation of factors associated with discarding of long-lasting insecticidal nets in Bagamoyo, Tanzania

Background

Between 2000 and 2019, more than 1.8 billion long-lasting insecticidal nets (LLINs) were distributed in Africa. While the insecticidal durability of LLINs is around 3 years, nets are commonly discarded 2 years post distribution. This study investigated the factors associated with the decision of users to discard LLINs.

Methods

A mixed-method sequential explanatory approach using a structured questionnaire followed by focus group discussions (FGDs) to collect information on experiences, views, reasons, how and when LLINs are discarded. Out of 6,526 households that responded to the questionnaire of LLINs durability trial, 160 households were randomly selected from the households in four villages in Bagamoyo Tanzania for FGDs but only 155 households participated in the FGDs. Five of the household representatives couldn’t participate due to unexpected circumstances. A total of sixteen FGDs each comprising of 8–10 adults were conducted; older women (40–60 years), older men (40–60 years), younger women (18–39 years), younger men (18–39 years). During the FGDs, participants visually inspected seven samples of LLINs that were “too-torn” based on Proportionate Hole Index recommended by the World Health Organization (WHO) guidelines on LLIN testing, the nets were brought to the discussion and participants had to determine if such LLINs were to be kept or discarded. The study assessed responses from the same participants that attended FGD and also responded to the structured questionnaire, 117 participants fulfilled the criteria, thus data from only 117 participants are analysed in this study.

Results

In FGDs, integrity of LLIN influenced the decision to discard or keep a net. Those of older age, women, and householders with lower income were more likely to classify a WHO “too-torn” net as “good”. The common methods used to discard LLINs were burning and burying. The findings were seen in the quantitative analysis. For every additional hole, the odds of discarding a WHO “too-torn” LLIN increased [OR = 1.05 (95%CI (1.04–1.07)), p < 0.001]. Younger age group [OR = 4.97 (95%CI (3.25–7.32)), p < 0.001], male-headed households [OR = 6.85 (95%CI (4.44 –10.59)), p < 0.001], and wealthy households [OR = 3.88 (95%CI (2.33–6.46)), p < 0.001] were more likely to discard LLINs.

Conclusion

Integrity of LLIN was the main determinant for discarding or keeping LLINs and the decision to discard the net is associated with socioeconomic status of the household, and the age and gender of respondents. WHO “too torn” nets are encouraged to be used instead of none until replacement, and disposal of nets should be based on recommendation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04126-5.

Coverage enhancement and community empowerment via commercial availability of the long-lasting nets for malaria in India

Achieving malaria elimination goal in India will require supplemental measures to plug in the gaps in implementation of malaria control programmes. Use of long-lasting insecticide nets is one of the two core interventions for vector control in malaria. The most common distribution channel is free delivery via national malaria control programme of various countries and in India, this is the only channel to provide nets to the masses. Understandably, there are gaps in the optimum coverage of at-risk population due to multiple reasons ranging from population growth to time lag in replacements, emergency conditions like floods and logistical impediments among others. At this juncture, it is crucial for India to explore complementary routes to expand access for nets by its people and one is making them available in private sector at an affordable price. The commercial availability of nets offers several advantages like filling in coverage gaps, overcoming additional requirements by families and financial resources being freed up for poor households. However, there are barriers to the successful operationalization of net commercialization like affordability issues, economic viability for manufacturers, regulatory issues etc. All the so-called barriers can be addressed in a concerted and pragmatic way to make access and availability of nets in private market a reality as that is a need of the hour, if India wants to achieve malaria elimination goal by 2030.

A retail audit of mosquito control products in Busia County, western Kenya

Background

Approximately 70% of Kenya’s population is at risk for malaria. The core vector control methods in Kenya are insecticide-treated mosquito nets (ITNs) and indoor residual spraying, with supplementary larval source management. In 2015, 21% of ITNs were accessed through the private retail sector. Despite the private sector role in supplying mosquito control products (MCPs), there is little evidence on the availability, sales trends, and consumer preferences for MCPs other than ITNs. This study, a component of a larger research programme focused on evaluating a spatial repellent intervention class for mosquito-borne disease control, addressed this evidence gap on the role of the private sector in supplying MCPs.

Methods

A cross-sectional survey was deployed in a range of retail outlets in Busia County to characterize MCP availability, sales trends, and distribution channels. The questionnaire included 32 closed-ended and four open-ended questions with short answer responses. Descriptive analysis of frequency counts and percentages was carried out to glean insights about commercially available MCPs and the weighted average rank was used to determine consumer preferences for MCPs. Open-ended data was analysed thematically.

Results

Retail outlets that stocked MCPs commonly stocked mosquito coils (73.0%), topical repellents (38.1%), aerosol insecticide sprays (23.8%) and ITNs (14.3%). Overall, retailers reported the profits from selling MCPs were adequate and they overwhelmingly planned to continue stocking the products. Of respondents who stocked MCPs, 96.8% responded that sales increased during long rains and 36.5% that sales also surged during short rains. ITNs and baby-size nets were often delivered by the wholesaler. Retailers of aerosol sprays, mosquito coils, and topical repellents either collected stock from the wholesaler or products were delivered to them. Other commercially available MCPs included insecticide incense sticks, electric mosquito strikers, insecticide soaps, electrically heated insecticide mats, and electric insecticide emanators, indicating a well-established market.

Conclusions

The wide range of MCPs in local retail outlets within the study area suggests the need and demand for mosquito control tools, in addition to ITNs, that are affordable, easy to use and effective. The presence of a wide range of MCPs, is a promising sign for the introduction of a spatial repellent intervention class of products that meets consumer needs and preferences.