TY - JOUR
T1 - Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations of long-lasting insecticidal net (LLIN) distribution channels in Kenya
T2 - a two-arm study under operational conditions
AU - Worrall, Eve
AU - Were, Vincent
AU - Matope, Agnes
AU - Gama, Elvis
AU - Olewe, Joseph
AU - Mwambi, Dennis
AU - Desai, Meghna
AU - Kariuki, Simon
AU - Buff, Ann M.
AU - Niessen, Louis W.
N1 - Funding Information:
We thank Willington Omoro, who assisted with cost data collection, Tiago Canales (LSTM) for assistance with producing the map shown in Fig. 1 , and Mphatso Phiri for comments on the draft manuscript. We also thank the participants who gave their time to this study.
Funding Information:
This publication was made possible through support provided by the U.S. President’s Malaria Initiative, U.S. Agency for International Development (USAID), and U.S. Centers for Disease Control and Prevention (CDC) via Liverpool School of Tropical Medicine. Eve Worrall is co-funded by PIIVEC, Medical Research Council of the UK (MR/P027873/1) through Global Challenges Research Fund, and MIRA, Wellcome Trust UK, Collaborative Award (200222/Z/15/Z). The contents are the responsibility of the authors and do not necessarily reflect the views of the CDC, USAID or United States Government. The funders were not involved in the design of the study nor did they contribute to the writing of the manuscript or the decision to submit the manuscript for publication. The corresponding author (EW) had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Publisher Copyright:
© 2020, The Author(s).
PY - 2020/12
Y1 - 2020/12
N2 - 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% range $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.
AB - 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% range $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.
KW - Cost-effectiveness
KW - Equity
KW - Insecticide-treated nets
KW - Kenya
KW - Malaria
KW - Universal coverage
KW - Vector control
UR - http://www.scopus.com/inward/record.url?scp=85097218912&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85097218912&partnerID=8YFLogxK
U2 - 10.1186/s12889-020-09846-4
DO - 10.1186/s12889-020-09846-4
M3 - Article
C2 - 33287766
AN - SCOPUS:85097218912
SN - 1471-2458
VL - 20
JO - BMC public health
JF - BMC public health
IS - 1
M1 - 1870
ER -