The Devil in the Malaria Details

Have you ever had to buy a long-lasting insecticide-treated bed net (LLIN)? Probably not, even if you live in Africa, where nine out of ten malaria-related deaths occur.
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Have you ever had to buy a long-lasting insecticide-treated bed net (LLIN)? Probably not, even if you live in Africa, where nine out of ten malaria-related deaths occur.

From 2004 to 2011, annual net distribution grew exponentially from 5 million to 130 million nets, yet few people have ever paid for one. Studies have shown that even in places where almost everyone willingly uses a free LLIN, a heavily subsidized price of just 60 cents drops demand almost to zero, particularly amongst the poor in Africa who often live on less than $1.25 per day.

With these constraints -- and with 1,795 people dying unnecessarily every day from malaria -- the public sector has stepped up to meet the demand for LLINs. With the financial support of three main donor organizations, the Global Fund to Fight Aids Tuberculosis and Malaria, the (U.S.) President's Malaria Initiative, and the World Bank, Ministries of Health in malaria-affected countries purchase 90 percent of LLINs worldwide, mostly for free public distribution, with the goal of achieving universal coverage.

Unfortunately, purchasing LLINs turns out to be a haphazard affair. One might think "a net is a net," but the devil is in the details.

There are 12 different net brands with varying lifespan in the field (or 'durability') and over 200 variations in 'specifications' across shape, size, color, and labeling. But there isn't much in the way of information on the end-user benefits of each of these LLINs, leaving public health administrators mostly in the dark when it comes to determining which LLINs are the best value for money.

According to analysis led by Kanika Bahl and Pooja Shaw from Results for Development's (R4D's) Market Dynamics team, improved global incentives and information on cost-effectiveness could save the fight against malaria up to $630 million over the next five years, while encouraging manufacturers to produce better-performing nets.

Currently, there are 10 World Health Organization (WHO)-recommended LLIN suppliers, up from only three suppliers in 2007. Despite the diverse supplier base, only two suppliers still hold approximately 75 percent of the total market share today.

Prices have fallen since the entry of new LLIN suppliers, from an average of $5.63 for a standard-sized net in 2007 to $3.73 per net in 2011. To keep that price down, current suppliers will have to stay in the market to foster competition. More transparent and consistent LLIN markets would help with that, by giving manufacturers more predictability as to what their LLIN customers will expect for any given order.

Constantly faced with limited resources, public health administrators have historically been more concerned with about up-front pricing than long-term cost effectiveness, particularly in the absence of global guidance on net durability. The nets they end up purchasing may last just three years instead of three and half, even though the longer lasting nets each cost just pennies more up-front.

So, how to tame the devil in the malaria details? Using their central position in global LLIN markets, donor institutions can introduce policy incentives to focus on cost-effectiveness and also rationalize specifications to allow suppliers to take advantage of economies of scale in production. In order to implement these policies, global guidance on the cost-effectiveness of various nets is urgently needed -- which is where normative bodies such as the WHO can play an important role.

Those aren't simple tasks, but they're worth it. In addition to creating a more sustainable and transparent global LLIN marketplace, the $630 million saved by those changes could finance 150 million more nets than under the current system -- which would protect around 300 million more people.

What's more, mosquito populations around the world are starting to develop resistance to the standard insecticides used for LLINs, making current nets increasingly ineffective. The global fight against malaria will need supplier innovation to address this threat. Suppliers, however, face research and development costs of over $200M to develop new nets that are effective against insecticide-resistant mosquitoes. Donors can again use their position to develop policy incentives that reward innovation in order to ensure future populations retain access to effective nets for malaria prevention.

For more on how to save millions of dollars in the global fight against malaria, and how R4D plans to work with donor institutions, suppliers, the WHO and Ministries of Health around the world to make it all happen, download R4D's full public report, Expanding Access to LLINs: A Global Market Dynamics Approach.

An estimated 655,000 unnecessary deaths worldwide still occur annually from malaria. LLINs have been instrumental in reversing the trend, leading to a 25 percent decline in malaria-related deaths over the past decade. Taming the devil in the malaria details will ensure that trend doesn't change.

David de Ferranti is president of Results for Development Institute. The co-authors of this post, Kanika Bahl and Pooja Shaw, are managing director and program officer, respectively, at Results for Development Institute.

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