The western Kenya insecticide-treated bed net trial
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


We measured the two-week household-level economic impact of insecticide (permethrin)-treated bed nets (ITNs) used to prevent malaria among children less than five years of age in Asembo, Kenya. The ITNs induced a two-week reduction of 15 Kenyan shillings (KSH) (U.S. $0.25; < 0.0001) in health care expenditures, but a statistically insignificant 0.5 day ( = 0.280) reduction in household time lost due to caring for sick children. The equivalent annual threshold cost was estimated at U.S. $6.50 (95% confidence interval = 3.12–9.86). If the actual purchase price and maintenance costs of ITNs were greater than this threshold, then households would pay more than they would save (and vice-versa). Both seasonal effects and number of children per household had larger impacts than ITNs on health care expenditures and time lost from household activities. Health care expenditures by a household without ITNs and one child were only 32 KSH per two weeks (U.S. $0.50; = 0.002), leaving little opportunity for household-level, ITN-induced direct savings. The widespread adoption of the ITNs will therefore probably require a subsidy.


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  1. Gallup JL, Sachs JD, 2001. The economic burden of malaria. Am J Trop Med Hyg 64 (Suppl): 85–96. [Google Scholar]
  2. The World Bank, 2000. African Development Indicators 2000. Washington, DC: The World Bank.
  3. Habluetzel A, Diallo DA, Esposito F, Lamizana L, Pagnoni F, Lengler C, Trarore C, 1997. Do insecticide-treated curtains reduce all-cause child mortality in Burkina Faso? Trop Med Int Health 2 : 855–862. [Google Scholar]
  4. Nevill CG, Some ES, Mung’ala VO, Mutemi W, New L, Marsh K, Lengeler C, Snow RW, 1996. Insecticide-treated bednets reduce mortality and severe morbidity from malaria among children on the Kenyan coast. Trop Med Int Health 1 : 139–146. [Google Scholar]
  5. Binka FN, Kubaje A, Adjuik M, Williams LA, Lengeler C, Maude GH, Armah GE, Kajihara B, Adiamah JH, Smith PG, 1996. Impact of permethrin impregnated bednets on child mortality in Kassena-Nankana district, Ghana: a randomized controlled trial. Trop Med Int Health 1 : 147–154. [Google Scholar]
  6. D’Alessandro U, Olaleye BO, McGuire W, Langerock P, Bennett S, Aikins MK, Thomson MC, Cham MK, Cham BA, Greenwood BM, 1995. Mortality and morbidity from malaria in Gambian children after introduction of an impregnated bednet programme. Lancet 345 : 479–483. [Google Scholar]
  7. Phillips-Howard PA, ter Kuile FO, Nahlen BL, Alaii JA, Gimnig JE, Kolczak MS, Terlouw DJ, Kariuki SK, Shi YP, Kachur SP, Hightower AW, Vulule JM, Hawley WA, 2003. The efficacy of permethrin-treated bed nets on child mortality and morbidity in western Kenya. II. Study design and methods. Am J Trop Med Hyg 68 (Suppl 4): 10–15. [Google Scholar]
  8. ter Kuile FO, Terlouw DJ, Phillips-Howard PA, Hawley WA, Friedman JF, Kolczak MS, Kariuki SK, Shi YP, Kwena AM, Vulule JM, Nahlen BL, 2003. Impact of permethrin-treated bed nets on malaria and all-cause morbidity in young children in an area of intense perennial malaria transmission in western Kenya: cross-sectional survey. Am J Trop Med Hyg 68 (Suppl 4): 100–107. [Google Scholar]
  9. Phillips-Howard PA, Nahlen BL, Kolczak MS, Hightower AW, ter Kuile FO, Alaii JA, Gimnig JE, Arudo J, Vulule JM, Odacha A, Kachur SP, Schoute E, Rosen DH, Sexton JD, Oloo AJ, Hawley WA, 2003. Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 23–29. [Google Scholar]
  10. Goodman CA, Coleman PG, Mills A, 1999. Cost-effectiveness of malaria control in sub-Saharan Africa. Lancet 354 : 378–385. [Google Scholar]
  11. Picard J, Aikins M, Alonso PL, Armstrong Schellenberg JRM, Greenwood BM, Mills A, 1993. Cost-effectiveness of bed net impregnation alone or combined with chemoprophylaxis in preventing mortality and morbidity from malaria in Gambian children. Trans R Soc Trop Med Hyg 87 (Suppl 2): 53–57. [Google Scholar]
  12. Binka FN, Mensah OA, Mills A, 1997. The cost-effectiveness of permethrin impregnated bednets in preventing child mortality in Kassena-Nankana district of northern Ghana. Health Policy 41 : 229–239. [Google Scholar]
  13. Aikens MK, Fox-Rushby J, D’Alessandro U, Langerock P, Cham K, New L, Bennett S, Greenwood B, Mills A, 1998. The Gambian national impregnated bednet programme: Costs, consequences and net cost-effectiveness. Soc Sci Med 46 : 181–191. [Google Scholar]
  14. Goodman CA, Mnzava AEP, Dlamini SS, Sharp BL, Mthembu DJ, Gumede JK, 2001. Comparison of the cost and cost-effectiveness of insecticide-treated bednets and residual house-spraying in KwaZulu-Natal, South Africa. Trop Med Int Health 6 : 280–295. [Google Scholar]
  15. Evans DB, Azene G, Kitigia J, 1997. Should governments subsidize the use of insecticide-impregnated mosquito nets in Africa? Implications of a cost-effectiveness analysis. Health Policy Plann 12 : 107–114. [Google Scholar]
  16. Goodman CA, Mills AJ, 1999. The evidence base on the cost-effectiveness of malaria control in Africa. Health Policy Plann 14 : 301–312. [Google Scholar]
  17. Brinkmann U, Brinkmann A, 1995. Economic aspects of the use of impregnated mosquito nest for malaria control. Bull World Health Organ 73 : 651–658. [Google Scholar]
  18. Onwujekwe O, Chima R, Shu E, Nwagbo D, Okonkwo P, 2001. Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities. Trop Med Int Health 6 : 545–553. [Google Scholar]
  19. Cropper ML, Haile M, Lampiett JA, Poulos C, Whittington D, 2001. The Value of Preventing Malaria in Tembien, Ethiopia. Washington, DC: The World Bank.
  20. Messonnier M, Meltzer MI, 2002. Cost-benefit analysis. Haddix A, Teutsch S, Corso P, eds. Prevention Effectiveness. Second edition. Oxford, United Kingdom: Oxford University Press, 127–155.
  21. Mills A, Fox-Rushby J, Aikins M, D’Alessandro U, Cham K, Greenwood B, 1994. Financing mechanisms for village activities in The Gambia and their implications for financing insecticide impregnation. J Trop Med Hyg 97 : 325–332. [Google Scholar]
  22. Mills A, 1998. Operational research on the economics of insecticide-treated mosquito nets: lessons of experience. Ann Trop Med Parasitol 92 : 435–447. [Google Scholar]
  23. Shepard DS, Ettling MB, Brinkmann U, Sauerborn R, 1991. The economic cost of malaria in Africa. Trop Med Parasitol 42 (Suppl 1): 199–203. [Google Scholar]
  24. Sauerborn R, Shepard DS, Ettling MB, Brinkmann U, Nougtara A, Diesfeld HJ, 1991. Estimating the direct and indirect economic costs of malaria in a rural district of Burkina Faso. Trop Med Parasitol 42 (Suppl 1): 219–223. [Google Scholar]
  25. Ettling M, McFarland DA, Schultz LJ, Chitsulo I, 1994. Economic impact of malaria in Malawian households. Trop Med Parasitol 45 : 74–79. [Google Scholar]
  26. Kennedy P, 1992. A Guide to Econometrics. Third edition. Cambridge, MA: The MIT Press.
  27. Koenker R, Hallock K, 2000. Quantile regression: An introduction. Available online at: www.econ.uiuc.edu/~roger/research/intro/intro.html.
  28. Nuwaha F, 2001. Factors influencing the use of bed nets in Mbarara municipality of Uganda. Am J Trop Med Hyg 65 : 877–882. [Google Scholar]
  29. Alaii JA, van den Borne HW, Kachur SP, Shelley K, Mwenesi H, Vulule JM, Hawley WA, Nahlen BL, Phillips-Howard PA, 2003. Community reactions to the introduction of permethrin-treated bed nets for malaria control during a randomized controlled trial in western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 128–136. [Google Scholar]
  30. Mwabu GM, 1988. Seasonality, the shadow price of time and effectiveness of tropical disease control programs. Herrin AN, Rosenfield PL, eds. Economics, Health and Tropical Diseases. Manilia, The Philippines: School of Economics, University of the Philippines, 259–270.
  31. Beier JC, Oster CN, Onyango FK, Bales JD, Sherwood JA, Perkins PV, Chumo DK, Koech DV, Whitmire RE, Roberts CR, 1994. Plasmodium falciparum incidence relative to entomologic inoculation rates at a site proposed for testing malaria vaccines in western Kenya. Am J Trop Med Hyg 50 : 529–536. [Google Scholar]
  32. Schellenberg JR, Abdulla S, Nathan R, Mukasa O, Marchant TJ, Kikumbih N, Mushi AK, Mponda H, Minja H, Mshinda H, Tanner M, Lengeler C, 2001. Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania. Lancet 357 : 1241–1247. [Google Scholar]
  33. Cham MK, Olaleye B, D’Alessandro U, Aikins M, Cham B, Maine N, Williams LA, Mills A, Greenwood BM, 1997. The impact of charging for insecticide on the Gambian national impregnated bednet programme. Health Policy Plann 12 : 240–247. [Google Scholar]
  34. Meltzer MI, Terlouw DJ, Kolczak MS, Odhacha A, ter Kuile FO, Vulule JM, Alaii JA, Nahlen BL, Hawley WA, Phillips-Howard PA, 2003. The household-level economics of using permethrin-treated bed nets to prevent malaria in children less than five years of age. Am J Trop Med Hyg 68 (Suppl 4): 149–160. [Google Scholar]
  35. Phillips-Howard PA, ter Kuile FO, Nahlen BL, Alaii JA, Gimnig JE, Kolczak MS, Terlouw DJ, Kariuki S, Shi YP, Kachur SP, High-tower AW, Vulule JM, Hawley WA, 2003. The efficacy of permethrin-treated bed nets on child mortality and morbidity in western Kenya: II. Study design and methods of evaluation. Am J Trop Med Hyg 68 (Suppl 4): 10–15. [Google Scholar]

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