Mosquito nets do not eliminate malaria but save lives

By Ibrahim Kasirye

Malaria as a leading killer disease in Uganda ahead of HIV/ AIDS. Uganda face over 10 million malaria cases annually and about 100,000 Ugandans lose their lives due to contracting malaria most of whom are children. It is responsible for 40% of all outpatients and 25% of all hospital admissions in health facilities. During the World Malaria Day celebration last week, the Speaker of the Parliament of Uganda Hon Rebecca Kadaga was quoted saying “Mosquito nets are a waste of money”. Although one may share the Speaker’s frustration that malaria remains a menace in Uganda whereas other tropical countries e.g. Cuba have managed to eliminate the malaria parasite, it is also worth appreciating the dilemma faced by public health officials and the environment within which they operate.

At an estimated expenditure of US$ 150 million for 21 million  long lasting insecticide treated nets (LLINs) every 3 years (or about US$ 50 million per year), Uganda’s expenditures on mosquito nets at a glance appears as wasteful investment; funds that could spent on other causes. Nonetheless, given the prevailing disease burden in Uganda, spending on mosquito nets is justified.

According the World Health Organization, LLINs reduce the risk of contracting malaria by as much as 63%. Without spending on mosquito nets or other methods of malaria prevention, deaths from malaria in Uganda would be much higher the annual 100,000 deaths. The average cost of malaria drugs in Uganda is over US$ 5 per dose while costs associated with deaths (i.e. lost lifetime earnings) are far much higher—especially when lost earnings are considered. Hence the cost preventing i.e. the cost of a mosquito net of US$ 7 is lower than treatment if one takes into account the higher likelihood of subsequent malaria episodes, if one is not using any protection. So if one considers the wider benefits of malaria prevention i.e. through the avoided costs of malaria illness and death, then the US$ 50 million annual expenditure becomes a very good investment.

Alternatives methods of malaria prevention would be indoor residual spraying (IRS); however, even with IRS, you need to spray households at least twice in year to ensure effective protection. Hence even with an IRS intervention, annual or recurring costs cannot be avoided. Furthermore, at the moment in Uganda there is far much more resistance to interventions using chemicals such as IRS than LLINs (from the environmental stand point). 

It is also worth considering the behavioural response to malaria prevention interventions that may affect the overall effectiveness of any given intervention.  As rightly pointed out by the Speaker, some households are using the LLINs as part of the fishing gear while other have tailored them to wedding gowns. However, households that have resorted to alternative uses of mosquito nets are few compared to millions that sleep under a mosquito net each night in Uganda.

For instance, based on the 2011 Uganda Demographic and Health Survey, at least 74% of households own at least one mosquito net but only 54% of households with a net report an individual sleeping under a net, in the night prior to the survey. As such, even without using nets for fishing, individuals may not sleep under a mosquito net for a number reasons—in the surveys, more than half on the non-users cited “the net not hang” as one of the reasons why a net was not used last night. Such behavioural responses may be beyond the control of public health officials. However, it is worth noting that children under five years are pregnant women have far higher rates of mosquito net usage compared to other individuals.

 So I do not agree with the honourable speaker that spending on mosquito nets is a waste of money just because it does not totally eliminate mosquitos. It is okay for the speaker to question the effectiveness of nets in reducing the burden due to malaria. However, she should also consider the environment in which such prevention interventions are implemented—the most effective method may all turn out to be most difficult to sell to all stakeholders concerned. The benefits of spending on mosquitos can be realised through reduced incidents falling ill from malaria and associated deaths—and not from eliminating this particular expenditure item from the Ministry of Health budget, as the speaker seems to suggest. Indeed, this is why countries are spending even larger sums on treatment of HIV/AIDS-even when it is known that expensive ARVs are not a cure.

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About the Author:

Dr Ibrahim Kasirye is Principal Research Fellow at the Economic Policy Research Centre (EPRC), Uganda

Follow him on Twitter: @nal_ug