Analysis of insecticide-treated bednet market dynamics between 2004–2021 and monetary value of additional bednet longevity

Insecticide-treated bednets (ITNs), a cornerstone of malaria prevention, are distributed via mass campaigns across Africa every three years, at huge cost to National Ministries of Health and development partners. While WHO sets global standards for ITNs as a public health commodity, they typically remain in use for less than the assumed three years, due to accumulation of damage, and retention times vary according to the product and use context. However, it is currently unclear whether ITN prices reflect their value in terms of physical durability. We explored how various ITN product and market characteristics have influenced real ITN prices since 2004. We used ITN price and retention data across sub-Saharan Africa to calculate the country specific equivalent annual cost of ITNs and defined country-specific price thresholds that the market should be willing-to-pay to secure nets that would be retained and used for exactly three years or, separately for six months longer than current estimates suggest. The ITN market has become less concentrated in the last two decades, but it remains dominated by a few large buyers and suppliers. ITN prices have decreased dramatically since 2010. Among individual sales, we found no evidence that increased durability is rewarded through higher price. The value for equivalent annual cost per person protected and the willingness-to-pay for a net that is retained for longer depends on baseline net price and is greater in countries with shorter existing ITN retention times. Substantial public health and efficiency gains could be realized if bednets were used for longer periods. However, achieving this requires changes in the market on both the supply and demand sides, including a shift towards value-based procurement. This approach would better incentivize manufacturers to innovate and invest in producing more durable nets by linking pricing to their long-term effectiveness. An explicit price threshold, along with improved information on net durability across different contexts, could help foster innovation and direct investment where it is most needed. Though ITN market competition increased and prices fell in the last two decades, inefficiencies remain in this market. While ITN prices appear to reward chemical innovation, there is no evidence to suggest that they reflect the physical durability of the nets. Information asymmetry related to the physical durability of ITNs has potential to be reduced by a newly developed key performance metric, however market and price incentives will also be needed to encourage manufacturers to improve the physical durability of ITNs Value-based procurement provides an opportunity to set ITN prices that adequately reflect buyer’s willingness-to-pay for improved physical durability as well as chemical performance attributes, and to incentivise manufacturers to invest in improving physical durability Durability should be regarded as a critical component in defining the “value” of insecticide-treated nets (ITNs), and a measure of resistance to damage has been developed to evaluate this aspect.