Role of the private sector in production and distribution of long lasting insecticide treated nets for malaria control

This report provides a review of key literature and evidence on the LLINs and private sector. The evidence base for this report is vast and spans more than twenty years of research evidence, policy documents and implementation programme evaluations and data from sub Saharan Africa and Asia. The relevant literature spans academic publications in biological and social sciences as well as implementation science and health economics. The private sector producing and distributing mosquito nets in malaria control has been exposed to factors beyond usual market influences. The supply of untreated nets was diverse and often local. It was maintained with the introduction of insecticide treatment sachets (supplied by donors) to bundle with untreated nets sold by retailers. Voucher schemes aimed at targeting vulnerable groups e.g. pregnant women and young children aimed to sustain and expand the commercial sector through public private partnership. The biggest influences on the private sector was a huge increase in donor funding of free mass campaigns and the WHO and the Global Malaria Programme change in 2007 in the overall global strategy from targeted protection of vulnerable groups (pregnant women and children under 5 years old) to universal coverage and recommendation of long lasting insecticide treated nets (LLINs) instead of insecticide treated nets (ITNs). The private sector then had to compete with international companies with the technology to produce LLINs; bulk purchasing by donors; higher unit costs; and competition with free distribution by donors through the established network of the healthcare system

Towards An Economics Policy Framework to Combat Malaria, in An Era of Insecticide Resistance

Malaria causes close to half a million deaths per year, the majority of which are in children under five years of age who live in sub-Saharan Africa. Despite significant progress in reducing malaria deaths in the past fifteen years, there is still a long way to go before universal coverage with key interventions like LLINs and IRS is reached, which is an essential step towards achieving malaria elimination. While severe resource constraints pose a fundamental challenge, growing resistance to insecticides used in LLIN and for IRS exacerbates this issue, and threatens to undermine the significant gains achieved to date. This IPPI Policy Brief draws from economic theory to analyse the case of insecticide resistance. It highlights some fundamental trade-offs brought about by the emergence of resistance to insecticides, as well as the lack of data that is necessary to analyse them. The paper also explores how the concept of market failure is applied in the field of malaria control, and where market inefficiencies have not yet been adequately addressed. Overall, while there is no doubt that significant additional funding is needed to combat malaria and hopefully to move closer to its elimination, there is an urgent need to use sound economic analysis to help develop and strengthen a global rationale for further public investment in malaria vector control and to better take account of insecticide resistance in the prioritisation and deployment of national, in-country programmes

Challenges and opportunities associated with the introduction of next generation long lasting insecticidal nets for malaria control: a case study from Burkina Faso.

BACKGROUND Reductions in malaria incidence in Africa can largely be attributed to increases in malaria vector control activities; predominately the use of long lasting insecticidal nets (LLINs). With insecticide resistance affecting an increasing number of malaria endemic countries and threatening the effectiveness of conventional LLINs, there is an increasing urgency to implement alternative tools that control these resistant populations. The aim of this study was to identify potential challenges and opportunities for accelerating access to next generation LLINs in Burkina Faso, a country with areas of high levels of insecticide resistance. METHODS An analytical framework was used to guide the selection of interviewees, data collection and analysis. Semi structured interviews were carried out with key informants in April 2014 in Burkina Faso. Interviews were conducted in French and English, audio recorded, transcribed and entered into NVivo10 for data management and analysis. Data were coded according to the framework themes and then analysed to provide a description of the key points and explain patterns in the data. RESULTS Interviewees reported that the policy architecture in Burkina Faso is characterised by a strong framework of actors that contribute to policymaking and strong national research capacity which indirectly contributes to national policy change via collaboration with internationally led research. Financing significantly impacts the potential adoption, availability and affordability of next generation LLINs. This confers significant power on international donors that fund vector control. National decisions around which LLINs to procure were restricted to quantity and delivery dates; the potential to tackle insecticide resistance was not part of the decision-making process. Furthermore, at the time of the study there was no World Health Organisation (WHO) guidance on where and when next generation LLINs might positively impact on malaria transmission, severely limiting their adoption, availability and affordability. CONCLUSIONS This study shows that access to next generation LLINs was severely compromised by the lack of global guidance. In a country like Burkina Faso where WHO recommendations are relatively quickly adopted, a clear WHO recommendation and adequate financing will be key to accelerate access to next generation LLINs. Key Words: Malaria, Next generation long lasting insecticidal nets, LLINs, PBO nets, Policy Analysis, Vector Control, Burkina Faso

Conditional trust:Community perceptions of drone use in malaria control in Zanzibar

Background The potential of drones to support public health interventions, such as malaria vector control, is beginning to be realised. Although permissions from civil aviation authorities are often needed for drone operations, the communities over which they fly tend to be ignored: How do affected communities perceive drones? Is drone deployment accepted by communities? How should communities be engaged? Methods An initiative in Zanzibar, United Republic of Tanzania is using drones to map malarial mosqutio breeding sites for targeting larval source management interventions. A community engagement framework was developed, based on participatory research, across three communities where drones will be deployed, to map local perceptions of drone use. Costs associated with this exercise were collated. Results A total of 778 participants took part in the study spanning a range of community and stakeholder groups. Overall there was a high level of acceptance and trust in drone use for public health research purposes. Despite this level of trust for drone operations this support was conditional: There was a strong desire for pre-deployment information across all stakeholder groups and regular updates of this information to be given about drone activities, as well as consent from community level governance. The cost of the perception study and resulting engagement strategy was US$24,411. Conclusions Mapping and responding to community perceptions should be a pre-requisite for drone activity in all public health applications and requires funding. The findings made in this study were used to design a community engagement plan providing a simple but effective means of building and maintaining trust and acceptability. We recommend this an essential investment

Factors influencing mass drug administration adherence and community drug distributor opportunity costs in Liberia: A mixed-methods approach

Background Preventive chemotherapy delivered via mass drug administration (MDA) is essential for the control of neglected tropical diseases (NTDs), including lymphatic filariasis (LF), schistosomiasis and onchocerciasis. Successful MDA relies heavily on community drug distributor (CDD) volunteers as the interface between households and the health system. This study sought to document and analyse demand-side (households) and supply-side (health system) factors that affect MDA delivery in Liberia. Methods Working in two purposively selected counties, we conducted a household MDA access and adherence survey; a CDD survey to obtain information on direct and opportunity costs associated with MDA work; an observational survey of CDDs; and key informant surveys (KIS) with community-level health workers. Data from the CDD survey and Liberian minimum wage rates were used to calculate the opportunity cost of CDD participation per MDA round. The observational data were used to calculate the time spent on individual household-level tasks and CDD time costs per house visited. KIS data on the organisation and management of the MDA in the communities, and researcher reflections of open-ended survey responses were thematically analysed to identify key demand- and supply-side challenges. Results More respondents were aware of MDA than NTD in both counties. In Bong, 39% (103/261) of respondents reported taking the MDA tablet in the last round, with “not being informed” as the most important reason for non-adherence. In Maryland, 56% (147/263) reported taking MDA with “being absent” at the time of distribution being important for non-adherence. The mean cost per CDD of participating in the MDA round was −$11.90 (median$5.04, range −$169.62 to$30.00), and the mean time per household visited was 17.14 min which equates to a mean opportunity cost of $0.03 to$0.05 per household visited. Thematic analysis identified challenges, including shortages of and delays in medicine availability; CDD frustration over costs; reporting challenges; and household concerns about drug side effects. Conclusions Improved adherence to MDA and subsequent elimination of NTDs in Liberia would be supported by an improved medicine supply chain, financial compensation for CDDs, improved training, healthcare workforce strengthening, greater community involvement, capacity building, and community awareness

Cost of digital technologies and family-observed DOT for the 9-month injectable-containing MDR-TB regimen

Background: In 2017 WHO recommended the use of digital technologies, such as medication monitors and video observed treatment (VOT) for directly-observed treatment (DOT) of drug-susceptible TB, with no policy recommendations for multidrug-resistant TB (MDR-TB), which imposes considerably higher patient-costs. Given the COVID-related demand on health systems, the benefits of transitioning towards more patient-centred approaches are increasingly relevant. Design/Methods: A decision-tree model was developed to explore the cost-effectiveness of several DOT replacement approaches including VOT, 99DOTS and family-observed DOT. Assuming a 9-month, injectable-containing regimen (as evaluated within the STREAM trial), we constructed base-case models to reflect the standard-of-care in Ethiopia, India, and Uganda. The model used STREAM data supplemented with published studies, with sensitivity analyses conducted on key parameters. Results: Modelling suggested that standard-of-care is the most expensive strategy in India and Uganda, with considerable direct- and indirect-costs incurred by patients. In Ethiopia, implementing VOT and 99DOTS increased health-system costs by US$402 and US$17 respectively, but patient-costs remained lower than for standard-of-care. These higher health-system costs were largely caused by up-front technology expenditure, with 80% of Ethiopians not owning a smartphone. Sensitivity analyses showed costs were sensitive to both loss-to-follow-up and relapse rates. However, only the VOT strategy in Uganda exceeded standard-of-care DOT costs, by US$70 per patient, when the relapse rate was equalled to the upper-bound of the confidence interval. Modelling suggested each of VOT, 99DOTS, and family-observed DOT would halve patients’ out-of-pocket costs. Taking a patient perspective, each strategy appeared highly cost-effective across all countries, even if implemented solely in continuation phase. Conclusions: While data on the costs and efficacy of switching MDR-TB treatment management to new technologies are lacking, our modelling suggests alternative DOT support strategies can significantly reduce patient-costs. Health-system costs however are more country-specific, depending heavily on both internet availability and smartphone penetration within the population

Cost of digital technologies and family-observed DOT for a shorter MDR-TB regimen: a modelling study in Ethiopia, India and Uganda

Background: In 2017, the WHO recommended the use of digital technologies, such as medication monitors and video observed treatment (VOT), for directly observed treatment (DOT) of drug-susceptible TB. The WHO’s 2020 guidelines extended these recommendations to multidrug-resistant tuberculosis (MDR-TB), based on low evidence. The impact of COVID on health systems and patients underscored the need to use digital technologies in the management of MDR-TB. Methods: A decision-tree model was developed to explore the costs of several potential DOT alternatives: VOT, 99DOTS (Directly-observed Treatment, Short-course) and family-observed DOT. Assuming a 9-month, all-oral regimen (as evaluated within the STREAM trial), we constructed base-case cost models for the standard-of-care DOTs in Ethiopia, India, and Uganda, as well as for the three alternative DOT approaches. The models were populated with STREAM Stage 2 clinical trial outcome and cost data, supplemented with market prices data for the digital DOT strategies. Sensitivity analyses were conducted on key parameters. Results: Modelling suggested that the standard-of-care DOT approach is the most expensive DOT strategy from a societal perspective in all three countries evaluated (Ethiopia, India, Uganda), with considerable direct- and indirect-costs incurred by patients. The second most expensive DOT approach is VOT, with high health-system costs, largely caused by up-front technology expenditure. Each of VOT, 99DOTS and family-observed DOT would reduce by more than 90% patients’ direct and indirect costs compared to standard of care DOT. Results were robust to the sensitivity analyses. Conclusions: While data on the costs and efficacy of alternative DOT approaches in the context of shorter MDR-TB treatment is limited, our modelling suggests alternative DOT approaches can significantly reduce patient costs in all three countries. Health system costs are higher for VOT and lower for 99DOTS and family-observed therapy when compared to standard of care DOT, as low smartphone penetration and internet availability requires the VOT health system to fund the cost of making them available to patients

Improving the cost-effectiveness of IRS with climate informed health surveillance systems

<p>Abstract</p> <p>Background</p> <p>This paper examines how the cost-effectiveness of IRS varies depending on the severity of transmission and level of programme coverage and how efficiency could be improved by incorporating climate information into decision making for malaria control programmes as part of an integrated Malaria Early Warning and Response System (MEWS).</p> <p>Methods</p> <p>A climate driven model of malaria transmission was used to simulate cost-effectiveness of alternative IRS coverage levels over six epidemic and non-epidemic years. Decision rules for a potential MEWS system that triggers different IRS coverage are described. The average and marginal cost per case averted with baseline IRS coverage (24%) and under varying IRS coverage levels (50%, 75% and 100%) were calculated.</p> <p>Results</p> <p>Average cost-effectiveness of 24% coverage varies dramatically between years, from US$108 per case prevented in low transmission to US$0.42 in epidemic years. Similarly for higher coverage (24–100%) cost per case prevented is far higher in low than high transmission years ($108–$267 to $0.88–$2.26).</p> <p>Discussion</p> <p>Efficiency and health benefit gains could be achieved by implementing MEWS that provides timely, accurate information. Evidence from southern Africa, (especially Botswana) supports this.</p> <p>Conclusion</p> <p>Advance knowledge of transmission severity can help managers make coverage decisions which optimise resource use and exploit efficiency gains if a fully integrated MEWS is in place alongside a health system with sufficient flexibility to modify control plans in response to information. More countries and programmes should be supported to use the best available evidence and science to integrate climate informed MEWS into decision making within malaria control programmes.</p

Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations of long-lasting insecticidal net (LLIN) distribution channels in Kenya: a two-arm study under operational conditions

Background: Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya. Methods: Two combinations of five delivery channels were compared as ‘intervention’ and ‘control’ arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared costs and equity by channel. Results: The multiple distribution channels used in both arms of the study achieved high LLIN ownership and use. The intervention arm had significantly lower reported LLIN use the night before the survey (84·8% [95% CI 83·0–86·4%] versus 89·2% [95% CI 87·8–90·5%], p < 0·0001), higher unit costs ($10·56 versus$7·17), was less cost-effective ($86·44, 95$75·77–$102·77 versus$69·20, 95% range $63·66–$77·23) and more inequitable (Concentration index [C.Ind] = 0·076 [95% CI 0·057 to 0·095 versus C.Ind = 0.049 [95% CI 0·030 to 0·067]) than the control arm. Unit cost per LLIN distributed was lowest for MC ($3·10) followed by CHV ($10·81) with both channels being moderately inequitable in favour of least-poor households. Conclusion: In line with best practices, the multiple distribution channel model achieved high LLIN ownership and use in this Kenyan study setting. The control-arm combination, which included MC, was the most cost-effective way to increase UC at household level. Mass campaigns, combined with continuous distribution channels, are an effective and cost-effective way to achieve UC in Kenya. The findings are relevant to other countries and donors seeking to optimise LLIN distribution. Trial registration: The assignment of the intervention was not at the discretion of the investigators; therefore, this study did not require registration