Background
According to WHO, there were an estimated 219 million cases of malaria (range 154–289 million) and 660 000 deaths (range 610 000–971 000) in 2010 [
1]. Insecticide-treated mosquito nets (ITNs) have been shown to be an effective and cost-effective means for the control of malaria, especially among children under 5 years [
2]. The use of insecticide treated nets is effective in reducing all cause malaria mortality and morbidity between 17 and 43 % in children under 5 years and provides protection to pregnant women who are most susceptible to malaria. ITNs (Insecticide Treated Nets) are easy to use and require less technical and capital outlay to implement compared with other vector control methods. They are cost-effective, which has led to widespread implementation of ITNs by countries on a large scale [
3].
Access to bed nets or their delivery, acceptability and compliance with net use are the other critical issues in the success of any ITNs programme. Aside from access to mosquito nets and insecticides, one of the problems in the large-scale implementation of the ITNs programme is re-treatment of the net [
4]. ITN use has however been limited due to the cost outlay households require to make towards the purchase of nets, households’ inability to associate the effectiveness of the net with the insecticide leading to low re-treatment rates in most settings and the seasonality associated with the spread of malaria [
3].
In Ethiopia, almost 68 % of the 73 million populations in the country live in malarious areas covering almost 75 % of the land. The strategy for selective vector control measure was ITNs distribution based on segmented market approach and through health facilities and campaigns with prioritizing high risk areas and population group. The target for ITNs is to achieve distribution of 2 ITNs per household (on average) in 90 % of the ITNs targeted areas by 2007 [
5]. The determination of consumer preferences and demand for different vector control strategies becomes pertinent, when viewed against the background of community involvement as part and parcel of vector control tools and as consumers are expected to contribute some money for the financial sustainability of the delivery of the strategies. Consumer preferences should also guide resource allocation decisions so that people preferences and potential demand for the different tools are satisfied [
6].
Several studies documented for the willingness to pay for the ITN in the country. In a baseline survey in four regions of Ethiopia, SNNPR, Tigray, Amhara and Oromia, the main reasons cited being lack of money to purchase it and affordability is one of the determinant factors that impede the possession and use of ITNs. As to their maximum WTP, 47 % suggested 10 Birr or less, 11 % said 11–20 Birr, 28 % from 21 to 50 Birr [
7], in Western Shoa Zone, shows that, 99 % did not have prior experience of using bed net but only 4 % of them were unwilling to pay for ITN. The main reasons for unwillingness were inability to afford and lack of confidence in the bed net [
8] and 850 (86.5 %) were willing to buy an ITN (if supplied by the market) in Arba Minch area, the common reasons for their unwillingness-to-buy were inability to afford and believed that they do not have to buy it since some people are getting ITNs free of charge [
9]. Many studies have provided estimates of mean willingness to pay (WTP) for malaria prevention and treatment [
10]. But studies on WTP for malaria control interventions have been uncommon [
11]. Therefore, this study is aimed to determine willingness to pay/demand for the retreatment of Insecticide treated mosquito nets for malaria control in Ethiopia.
Discussion
This study aimed at examines the willingness to pay for retreatment for ITN. To assess the demand of the ITN it is better to see how people value the nets and estimated the potential demand for the nets. For this, it is illustrated either examining actual willingness to pay (WTP) as revealed by people’s purchase decisions (revealed preferences), or by determining their stated or hypothetical level of willingness to pay (WTP) for the nets through the contingent valuation method (CVM) [
19]. In this study, the demand for ITN purchase was fair and able to obtain freely. This is also supported by studies across the discipline. According to Obinna (2002), stated that communities can possibly pay for the poor to benefit from a community-based insecticide-treated nets (ITNs) programme using the various financing mechanisms that exist at the community level for ITNs and ITNs re-impregnation for those unable to pay for themselves [
20].
In another studies, it was documented that hat potential commercial ITN markets will be undermined if free nets are widely distributed, leaving communities with even poorer access once donor funds run out [
21] and in Africa the point of to illustrated is to adopt ITNs as a public good—like childhood vaccines—through public sector involvement in highly subsidized or free provision for the vulnerable African lowland rural populations, where the great bulk of the world’s malaria burden is concentrated [
22]. In similar way, free insecticide and working with local health workers, more than 90 % of nets are retreated in 2–3 days in Tanzania [
23].
In multivariate analysis, income level has a greater contribution with willingness to pay for retreatment of ITN. This is evidenced that in Tanzania high rates of net purchase in towns was observed but much lower rates in rural areas, especially among the people with lowest incomes whose children have the poorest health [
22] and reaching the poorest of the poor with malaria control interventions poses great challenges, not solely because of financial barriers to accessing care and prevention services [
24]. Previous studies in Ethiopia shows the poor have shown their WTP for reduced cost of ITN [
25] and monthly income of the households was not a significant determinant of people’s willingness-to-pay for ITN [
9] and as the average monthly income decreased, the WTP for ITN has increased significantly [
26]. Along with this, in south western Ethiopia study, there is a close association between respondents economic status and willingness to pay for ITNs retreatment [
27].
In our study, distance to the health facility was associated with willingness to pay for the retreatment of ITN. Similar finding has been reported in other studies as well. Non-financial barriers, including distance from health services, and opportunity costs of lost time at work, may also be underlying factors for malaria infection in the poor [
24]. In one of Burkina Faso study, distance to health facility negatively influenced WTP, thus longer distance and less WTP [
28]. The explanation for this is that those who lived in the rural area cannot get access for the retreatment service and other service package. The poorest populations in developing countries often live in the most remote areas and are socially or culturally marginalized [
24].
The study has some limitations. It is difficult to elucidate/disclose the exact income of the household or at individual level and cross-sectional nature of the study for making causality and inference. On top of that, the WTP approach creates a hypothetical market and tries to capture how much they would be willing to pay for the benefits the malaria retreatment provides. Hence, the WTP methods by itself might lead to undervaluation or inflation of the value of the service based on the approach employed and the measure, whether the community understands or imagines the problem, their experience. Though the approach inherently depend on the value that the community gives to the benefit from the service, the findings can be widely used to design policies, prioritize intervention actions, implement cost sharing arrangements etc. As to the knowledge of the authors, this is the first of its kind to determine the WTP for retreatment of ITN services in the country and gives a shade of light for the policy makers to take appropriate decision. There has been discussions on whether public health interventions like malaria net or retreatment can be seen as a purely public good, or marketable good. Given the public importance of these interventions and their abundance in the market at least in many countries, that might not be an easy task to get a best fit. Nonetheless, that doesn’t matter as such in a valuation experiment with a hypothetical setting. And most importantly, an aggregate value by the community for such a service is pertinent in designing policies and strategies in malaria control and treatment. As the study time has passed, we didn’t anticipate what happened recently.
In conclusion, the mean with SD of the respondents for willingness to pay was 1 USD and 1.53 USD. Average income more than 10.4 USD per month and those household who live within a distance in 30 min to the health facility were all statistically significant (p < 0.01) for willingness to pay. So the government and other development partners should see the mechanism to make a subsidy or free of charge for the services hence the community can pay more value for the retreatment of ITN since free distribution of ITNs is not a solution unless retreatment services were available to the community to be implemented. Differential treatment from the public to address the poor and vulnerable households and those who are living far distance from the local health facility is warranted and applying other method of evaluation for estimation of willingness to pay may be warranted to probe and synthesize.
Competing interests
The authors declare that they have no conflict of interests.
Authors’ contributions
SB conceived and designed the study, performed analysis and interpretation of data, and drafted the paper. RAA and HK assisted with the design, interpretation of data, and the critical review of the paper. All authors approved and read the final paper.