Table 3. Characteristics associated with financial and economic costs of insecticide-treated nets (ITNs) in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria, by delivery strategya.
| Delivery strategy | Country, scale | Perspective, interval | Cost |
Net lifespanc | Sensitivity analysis | Outcomed | ||
|---|---|---|---|---|---|---|---|---|
| Financial | Economic | Distributionb | ||||||
| Continuous | ||||||||
| Full subsidy (free); routine health services (ANC clinic) and/or community-based | ||||||||
| ANC clinics to PW (free); implemented in 2006 | Burkina Faso, 1 district (Kossi)22 | Societal, 2006–2007 | ANC clinic: provider costs for MoH, including training, supervision, LLIN transport | Capital costs annualized (LLINs over 5 y, vehicles over 7 y) and discounted (3%); all prices at 2006 levels were converted to US dollars; detailed opportunity costs were calculated for space and personnel on project | ANC clinic: ITNs, 23%; transport, 15%; staff, 54% | LLIN, 5 years (physical and treatment) | Discount rate; LLIN lifespan; costs of transport, personnel, rent and IEC materials; leakage of LLINs | Financial cost per LLIN delivered, US$ 8.20; economic cost per LLIN delivered, US$ 5.47 (range: 5.38–6.83); all outcomes were most sensitive to LLIN lifespan and leakage |
| From 2001, ANC clinics to PW (free) and in HF and CHW to GP (full cost; free after 2003) | Eritrea, national (Stevens)25 | Provider, 2001–2005 | All direct costs to provider, including commodities, delivery, IEC activities, staff, taxes | Capital costs were annualized and discounted (3%); all prices at 2005 levels converted to US dollars; Shared costs for personnel and space on project calculated | ITNs and insecticide, 64%; staff, 21% | ITN, 3-year physical lifespan; new ITN or retreatment provide 1 TNY | Discount rate; ITN cost, use, lifespan and effectiveness; proportion of shared costs | Outcomes most sensitive to ITN costs and shared cost allocation: financial cost per ITN delivered, US$ 10.67; financial cost per TNY, US$ 3.23; economic cost per ITN delivered, US$ 9.00 (range: 7.44–23.29); economic cost per TNY, US$ 2.74 Outcomes most sensitive to ITN effectiveness and use: cost per child death averted, US$ 3276 (range: 1637–13 104); cost per DALY averted, US$ 100 (range: 81–398) |
| ANC clinics to PW (free) in 2001 | Kenya, 35 districts26 | Provider, 2001 | ITNs and transport (international, to district, to ANC facilities) | Not reported | Not reported | Not reported | Not reported | Financial cost per ITN delivered to ANC clinics, US$ 7.64; financial cost per ITN delivered to PW, US$ 10.54 |
| ANC clinics to PW (free) in 2007 | Uganda, 2 districts (Adjumani, Jinja)27 | Provider, 2007 | Detailed costs of LLINs, transport, storage, distribution, IEC activities, training, personnel | Capital costs annualized (ITNs over 3 y, vehicles over 7.5 y); shared costs of personnel time and overhead; all costs were incurred in 2007, so no inflation adjustment was made; prices converted to US dollars | LLIN transport, 33%; IEC, 23%; training, 23%; and management, 12%e | LLIN, 3 years (physical and treated) | Discount rate; LLIN lifespan and cost; net use and retention | Financial cost per LLIN delivered, US$ 8.83; economic cost per LLIN delivered, US$ 5.89 (range: 4.93–7.08); economic cost per TNY, US$ 1.96; all outcomes were most sensitive to LLIN lifespan |
| Partial subsidy; routine health services (HFs; ANC and/or MCH clinics) and/or retailers and/or community-based | ||||||||
| Retail to GP (partial subsidy); implemented in 2006 | Burkina Faso, 1 district (Kossi)22 | Societal, 2006–2007 | Retailer: provider costs incurred by NGO, wholesalers and shopkeepers, including transport, storage, labour, profit, IEC materials | Capital costs annualized (LLINs over 5 y, vehicles over 7 y) and discounted (3%); all prices at 2005 levels were converted to US dollars; detailed opportunity costs for space and personnel; user contribution calculated difference between provider’s financial costs and actual costs recovered | Retail: ITNs, 23%; wholesaler/retailers, 25%; staff 22% | LLIN, 5 years (physical and treatment) | Discount rate; LLIN lifespan; costs of transport, personnel, rent and IEC materials; leakage of LLINs | Financial cost per LLIN delivered, US$ 9.19; economic cost per LLIN delivered, US$ 5.47 (range: 5.38–6.83); all outcomes were most sensitive to LLIN lifespan and leakage |
| From 2002, MCH clinics to PW and children < 5; after 2003, to GP by community-based groups (partial subsidy) | Malawi, national3 | Provider, 1999–2003 | Capital and recurrent costs, including ITNs, vehicles, staff, brand creation, advertising, promotion | Capital costs annualized (ITNs over 5 y, brand over 7 y, vehicles over 8 y) and discounted (3%); all prices at 1999 levels converted to US dollars | ITNs, 55%; staff, 10%; supplies/ overhead, 10%; fuel, 9% | ITN, 5-year physical lifespan; treatment provides 0.5 TNY | Not reported | Average economic cost per ITN delivered, US$ 11.16 (decreased from US$ 21.39 in 1999 to US$ 8.15 in 2003 as number of ITNs distributed increased, suggesting economies of scale); average economic cost per TNY, US$ 18.72 (decreased from US$ 32.64 in 1999 to US$ 14.60 in 2003) |
| From 1997; HF, community-based delivery and retailers to GP (partial subsidy) | United Republic of Tanzania, 2 districts (Kilombero, Ulanga)36 | Provider, user, 1996–2000 | Capital and recurrent costs divided into set-up (branding, sensitization) and ongoing supply (ITNs, personnel, transport, training, promotion) | Capital costs annualized (ITNs over 5 y, brand over 7 y, vehicles over 10 y) and discounted (3%); opportunity costs providers and users (including price for ITN); all prices at 2000 levels converted to US dollars | ITNs and insecticide, 31%; staff, 28%; other recurrent costs, 32% | ITN, 5-year physical lifespan; treatment provides 0.5 TNY | Health measures (ITN coverage, inclusion of untreated nets, duration of effectiveness) | Economic cost per TNY, US$ 25.09 and US$ 12.57 if insecticide lasts 6 and 12 months, respectively; economic cost per child death averted, US$ 2924 (range: 1101–1909); economic cost per DALY averted, US$ 107 (range: 41–69); all outcomes were sensitive to all measured assumptions |
| From 2004, ANC clinics to PW (partial subsidy via voucher at retailer) |
United Republic of Tanzania, national35
|
Provider, user, 2004–2006 |
Capital and recurrent costs, including formative research, planning, training, vehicles, ITNs, IEC, personnel, overhead |
Capital costs annualized (ITNs over 3 y, vehicles over 8 y) and discounted (3%); opportunity costs for providers and users (including top up paid for ITN); all prices at 2006 levels converted to US levels |
ITN: 20% subsidised, 8% to user 8%; staff, 25%; promotion activities, 16% |
ITN, 3-year physical lifespan; new ITN or retreatment provide 1 TNY |
Discount rate; user top up; ITN price, effective lifespan and re-treatment use; LLINs |
Financial cost per ITN delivered, US$ 12.09; economic cost per ITN delivered, US$ 10.77 (range: 10.53–12.23); economic cost per TNY, US$ 6.02 (range: 5.88–12.03]; economic cost per child death averted, US$ 1 242 (range: 1 219–2496); all outcomes were most sensitive to ITN lifespan and use |
| Time-limited | ||||||||
| Full subsidy (free); stand-alone campaign | ||||||||
| Stand-alone net campaign to children < 5 (free) in 2007 | Uganda, 2 districts (Adjumani, Jinja)27 | Provider, 2007 | Detailed costs of LLINs, transport, storage, distribution, IEC activities, training, personnel | Capital costs annualized (ITNs over 3 y, vehicles over 7.5 y); Shared costs of personnel time and overheads; all costs were incurred in 2007, so no inflation adjustment was made; prices converted to US dollars | Distribution, 30%; LLIN transport, 15%; registration, 16%; IEC, 13%e | LLIN, 3 years (physical and treated) | Discount rate, LLIN lifespan and cost; net use and retention | Financial cost per LLIN delivered, US$ 8.30 (Jinja) and US$ 9.49 (Adjumani); economic cost per LLIN delivered, US$ 3.86 (Jinja) and US$ 4.76 (Adjumani) (range: 2.91–6.06); economic cost per TNY, US$ 1.29 (Jinja) and US$ 1.58 (Adjumani); all outcomes were most sensitive to LLIN lifespan |
| Full subsidy (free); integrated with public health campaign | ||||||||
| Distribution integrated with measles vaccination campaign to children < 5 (free) in 2002 | Ghana, 1 district (Lawra)30 | Provider, 2002 | ITNs, transportation, training, supervision, social mobilization; campaign costs that would have been incurred for measles vaccination without inclusion of ITNs were excluded | Not reported | Financial costs only; ITNs, 91%; other elements of delivery, 9% | Not reported | Not reported | Financial cost per ITN delivered, US$ 11.53 |
| Distribution integrated with measles vaccination campaign to children < 5 (free) in 2005 | United Republic of Tanzania, 1 region (Lindi)45 | Provider, 2005 | ITNs, transport to district, IEC activities, NMCP staff | Not included | Financial costs only: ITNs 88%; other elements of delivery, 12% | Not reported | Not reported | Financial cost per ITN delivered, US$ 3.71 |
| Distribution integrated with measles vaccination campaign to children < 5 | Zambia, 5 districts (Chilubi, Kaputa, Mambwe, Nyimba, Kalalushi49 | Provider, 2003 | ITNs, transport, training, IEC activities; campaign costs that would have been incurred for measles vaccination without inclusion of ITNs were excluded | Not reported | Financial costs only: ITNs, 94%; other elements of delivery, 6% | Not reported | Not reported | Financial cost per ITN delivered, US$ 10.88 in rural areas and US$ 11.79 in urban areas |
ANC, antenatal care; CHW, community health worker; DALY, disability-adjusted life year; GP, general population; HF, health facility; IEC, information education communication; LLIN, long-lasting insecticide-treated net; MCH, maternal and child health; MoH, ministry of health; NGO, nongovernmental organization; NMCP, national malaria control programme; PW, pregnant women; TNY, treated-net-year (incorporates ITNs and retreatment kits distributed); US$, United States dollars.
a Studies may appear in more than one category if multiple strategies were used to deliver ITNs at scale or if strategies changed over time.
b Reported as the percentage of total economic costs (unless specified otherwise). Only main costs are reported.
c Defined as physical viability and duration of insecticide protection.
d Adjusted for inflation and reported in 2010 US dollars to allow comparison across different countries and years.
e Reported as the percentage of total costs, excluding LLIN cost.