Free insecticide for nets is cost effective

Abstract

Response from Guyatt and SnowThe two issues raised by Curtis and Maxwell demand further clarification. First, how much does it really cost to deliver insecticide-treated bednets (ITNs) to communities? Second, should they be provided free-of-charge to at-risk groups?Presenting the incremental financial costs of delivering insecticide to a few villages, where a research program has been operating for many years, can be misleading and different to the costs of operating in an entire district or at a national level. The cost of implementation is an important variable in the evaluation process and it is crucial that the costs are comprehensive, accounting for all resources consumed. When evaluating many interventions, research costs are often separated from the implementation costs, although these costs inherently support the delivery process. For example, the costs of expatriate salaries, field-workers and surveillance systems are rarely considered.These hidden costs are often excluded from analyses of other donor-supported, operational projects. For example, if only the costs directly attributable to an ITN and its delivery are considered for a non-governmental organization (NGO)-managed program in Kenya, the estimated cost per ITN is US$8.42 [1xA comparative cost analysis of insecticide treated nets and indoor residual spraying in highland Kenya. Guyatt, H.L. et al. Health Policy Plan. 2002; 17: 144–153Crossref | PubMedSee all References[1]. However, when the external costs are included (basically, the amount of money received from donors), the cost per ITN is closer to US$30 [1xA comparative cost analysis of insecticide treated nets and indoor residual spraying in highland Kenya. Guyatt, H.L. et al. Health Policy Plan. 2002; 17: 144–153Crossref | PubMedSee all References[1]. This is consistent with other donor- or research-funded project costs in Kenya (US$45 per AMREF employer-based net and US$29 per CDC research project net)†. We agree that precise details are required to provide robust cost-effectiveness analyses, but disagree with the estimates for their research villages in Tanzania because they fall prey to the general tendency to be exclusive rather than inclusive of the true delivery costs.Curtis and Maxwell also highlight an important issue that we were at pains to raise as a controversial area in the original paper: whether ITNs should be a free public health service. When better quality, inclusive cost-data become available from the project-approach to delivering ITN services, there will be a growing recognition that ensuring maximal coverage of this intervention will not be cheap. We believe that this intervention should be delivered free-of-charge to those most at-risk of the burden posed by malaria in Africa. Most of Africa's population lives below the absolute poverty line. The African Heads of State have pleaded with the global community to consider this as an option to protect the equity of health-service provision in their respective countries. Some donors and research scientists have resisted this position. What is clear is that the real costs to the donor community of maximizing equitable coverage of ITNs will be one of the most persuasive evidence-based criteria upon which to judge who is right in the debate on free bednets.