title: Evaluation of a universal long-lasting insecticidal net (LLIN) distribution campaign in Ghana: cost effectiveness of distribution and hang-up activities.
abstract: BACKGROUND
  Between May 2010 and October 2012, approximately 12.5 million long-lasting insecticidal nets (LLINs) were distributed through a national universal mass distribution campaign in Ghana. The campaign included pre-registration of persons and sleeping places, door-to-door distribution of LLINs with 'hang-up' activities by volunteers and post-distribution 'keep-up' behaviour change communication activities. Hang-up activities were included to encourage high and sustained use.
  
  
  METHODS
  The cost and cost-effectiveness of the LLIN Campaign were evaluated using a before-after design in three regions: Brong Ahafo, Central and Western. The incremental cost effectiveness of the 'hang-up' component was estimated using reported variation in the implementation of hang-up activities and LLIN use. Economic costs were estimated from a societal perspective assuming LLINs would be replaced after three years, and included the time of unpaid volunteers and household contributions given to volunteers.
  
  
  RESULTS
  Across the three regions, 3.6 million campaign LLINs were distributed, and 45.5% of households reported the LLINs received were hung-up by a volunteer. The financial cost of the campaign was USD 6.51 per LLIN delivered. The average annual economic cost was USD 2.90 per LLIN delivered and USD 6,619 per additional child death averted by the campaign. The cost-effectiveness of the campaign was sensitive to the price, lifespan and protective efficacy of LLINs.Hang-up activities constituted 7% of the annual economic cost, though the additional financial cost was modest given the use of volunteers. LLIN use was greater in households in which one or more campaign LLINs were hung by a volunteer (OR=1.57; 95% CI=1.09, 2.27; p=0.02). The additional economic cost of the hang-up activities was USD 0.23 per LLIN delivered, and achieved a net saving per LLIN used and per death averted.
  
  
  CONCLUSIONS
  In this campaign, hang-up activities were estimated to be net saving if hang-up increased LLIN use by 10% or more. This suggests hang-up activities can make a LLIN campaign more cost-effective.
authors.affiliation: Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Lucy.Paintain@lshtm.ac.uk.
authors.forename: Lucy
authors.initials: L
authors.lastname: Smith Paintain
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Awini
authors.forename: Sheila
authors.initials: S
authors.lastname: Addei
authors.forename: Vida
authors.initials: V
authors.lastname: Kukula
authors.forename: Christian
authors.initials: C
authors.lastname: Nikoi
authors.forename: Doris
authors.initials: D
authors.lastname: Sarpong
authors.forename: Alfred
authors.initials: A
authors.lastname: Kwesi Manyei
authors.forename: Daniel
authors.initials: D
authors.lastname: Yayemain
authors.forename: Etienne
authors.initials: E
authors.lastname: Rusamira
authors.forename: Josephine
authors.initials: J
authors.lastname: Agborson
authors.forename: Aba
authors.initials: A
authors.lastname: Baffoe-Wilmot
authors.forename: Constance
authors.initials: C
authors.lastname: Bart-Plange
authors.forename: Anirban
authors.initials: A
authors.lastname: Chatterjee
authors.forename: Margaret
authors.initials: M
authors.lastname: Gyapong
authors.forename: Lindsay
authors.initials: L
authors.lastname: Mangham-Jefferies
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D057148:Insecticide-Treated Bednets / Q000191:economics / Q000706:statistics & numerical data; D007306:Insecticides / Q000494:pharmacology; D008288:Malaria / Q000453:epidemiology* / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009032:Mosquito Control / Q000191:economics / Q000379:methods; D011247:Pregnancy; D055815:Young Adult
chemical_list: D007306:Insecticides