1. Cost and cost effectiveness of long-lasting insecticide-treated bed nets: A model-based analysis A-M Pulkki-Brännström 1§, C Wolff 2, N Brännström 3 and J Skordis-Worrall 1 1 UCL Centre for International Health and Development, University College London, UK, 2 Stockholm School of Economics, Sweden, 3 University of Helsinki, Finland Bed nets are integral to national malaria programmes. Bed nets are integral to national malaria programmes. WHO recommends using long-lasting insecticide-treated bed nets (LLINs). WHO recommends using long-lasting insecticide-treated bed nets (LLINs). Few comparative studies of bed net distribution, and fewer economic evaluations of LLIN distribution Few comparative studies of bed net distribution, and fewer economic evaluations of LLIN distribution Need to better understand determinants of cost effectiveness of different bed net types Need to better understand determinants of cost effectiveness of different bed net types When and why are LLINs preferred to conventional insecticide-treated nets? When and why are LLINs preferred to conventional insecticide-treated nets? Which lifespan should be selected for LLIN? Which lifespan should be selected for LLIN? 1. Background Explore impact of parameters on cost effectiveness in an Excel model. Choice Variables: Coverage (no of nets to population size), usage rate, net type, price, lifespan, delivery method, replenishment need & delivery, procurement costs, geographic area. Coverage (no of nets to population size), usage rate, net type, price, lifespan, delivery method, replenishment need & delivery, procurement costs, geographic area. Outcome Variables: No. of people protected, cost per person protected, U5 deaths averted, cost per U5 death averted, DALYs averted. No. of people protected, cost per person protected, U5 deaths averted, cost per U5 death averted, DALYs averted. 2. Methods 10-year period considered Regular distribution rounds: procurement and distribution costs procurement and distribution costs choice of distribution method: choice of distribution method: 1.Free distribution in campaign (USD 2.7) 2.Free distribution through routine services (USD 2.65/USD 1.4) 3.Subsidised sales and social marketing (USD 3.9) Annual replenishment rounds (keeping coverage constant, smaller number of nets distributed, every year until next main distribution round) 3 Scenarios of replenishment need: 1.Annual loss rate constant proportion of nets distributed initially. 2.Annual loss rate constant proportion of nets of nets still in use 3.Loss rate increases until 50% of initially distributed nets remain Large-scale programme with high coverage & use Large-scale programme with high coverage & use ITNs distributed through existing health services. ITNs distributed through existing health services. ITNs regularly retreated at low cost ITNs regularly retreated at low cost Parameters from literature review where possible Parameters from literature review where possible Sensitivity analysis Sensitivity analysis 3. The Model: VariableBenchmark caseSensitivity analysisSources ITN/LLIN effectiveness 5.5 deaths averted / 1000 under-5s protected pa. -Lengeler 2004 Coverage 1m nets, 4m people 20% under 5 -comparable to WMR 2010 Usage rate (Year 1) 50% overall 70% under-5s 30% total, 50% under-5s 30% both DHS surveys and various studies Purchase price USD 4 USD 3-7 (LLINs) USD 1-5 (ITNs) Kolaczinski 2010 and assumptions Lifespan 3 years 3 - 5 years (LLINs) 1 - 4 years (ITNs) WHOPES 2009, Erlanger 2004 Delivery cost and method USD 1.4 per net; Free integrated dbn (>0.75m) USD 3.86 per net Subs. sales & social marketing 12 sources, 17 programmes Insecticide retreatment 75% treated annually USD 0.64 per net 50% annually / 75% biannually USD 1.28 per net 9 sources Replenishment need None Increasing/constant/decreasing proportion lost per annum A. Kilian (increasing loss) Replenishment delivery cost -USD 1.4 or USD 3.86 per net See Table 2 4. Findings 5. Conclusions LLINs more cost effective than ITNs with same lifespan - unless US$ 1.5 more expensive. For each year of a longer lifespan a bed net can be US$ 1 more expensive, while still being more cost effective. Replenishing nets raises protective effectiveness by 5-14%. – Replenishment costs: US$ 17-25 per person per annum  US$ 1080-1610 per under-5 death averted. Limitations: Limitations: 1.Treatment costs, household costs of malaria: No robust estimates for different geographic areas available. 2.Effectiveness of untreated nets: Not enough available data Program planners should be willing to pay a premium for nets which have a longer lifespan up to a price threshold. Program planners should be willing to pay a premium for nets which have a longer lifespan up to a price threshold. Replenishment (incrementally) cost effective if planners willing to spend US$ 1610 per U5 death averted. Replenishment (incrementally) cost effective if planners willing to spend US$ 1610 per U5 death averted.