The cost of making the poor pay

Boy carrying bednets: the nets should be made free of charge, say Sachs and colleagues Copyright: CDC

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Every year, up to three million people die from malaria. Most of these people live in the poorest countries on Earth. Controlling malaria is one of the Millennium Development Goals set in 2000 to tackle the health problems of the world’s poor, and this must be achieved if Africa is to escape from the cycle of extreme poverty and disease.

In January 2005, the UN Millennium Project’s working group on malaria recommended that countries where malaria is rife should use an integrated package of preventive and treatment methods to achieve this goal.

The project also recommended that bednets and effective malaria drugs be given away free of charge, a move endorsed by the UN secretary-general Kofi Annan in March, and by heads of state at the UN World Summit in September 2005.

We know how to control malaria: prevent people being bitten by mosquitoes — using bednets or insecticides — and treat those who to get infected with effective drugs called artemisinin-based combination therapies (ACTs).

Yet, malaria continues to exert a huge toll on developing countries, because even these basic and effective methods remain out of reach to the very poorest. No matter how cheaply bednets, insecticides, or drugs are sold, many people in developing countries simply cannot afford them. Without a massive push to get bednets and effective drugs to those who need them most, malaria will never be controlled.

Necessary measures

Nine out of ten people sick or dying from malaria are African. Of the 720 million people living in sub-Saharan Africa, about 615 million in 42 countries are at risk of contracting malaria.

Despite the number of people at risk of malaria on the continent, the World Health Organization (WHO) estimates that only three per cent of Africans use insecticide-treated bednets, far below the target of 60 per cent set by the WHO’s Roll Back Malaria initiative in 2000. The proportion of these bednets that are long-lasting — and therefore not in need of regular re-treatment with insecticide — is even smaller.

A health worker explaining the benefits to a young
mother and child in Senegal
Photo Credit (USAID)

The situation is the same for ACTs, which are needed to replace drugs such as chloroquine and sulfadoxine-pyrimethamine. These older treatments no longer work because malaria parasites have developed resistance to them. Yet, ACTs are used in only a tiny fraction of cases where they are needed, even in countries that have officially adopted them as the drug of choice.

Few people in rural Africa can afford to pay US$5–7 for a long-lasting bednet. Social marketing (i.e. selling at a discounted price, with subsidies from official aid programmes) has been used in several countries in an effort to convince people to buy bednets. But on the whole, it has had only a slight effect, and continues to leave many among the population at risk of malaria unprotected.

This is particularly worrying since bednets have a ‘mass action effect’ — that is, the protective effect of the net on any individual depends on the overall use of nets across a village.

Other methods used to get bednets to the poor such as voucher systems are time-consuming and excessively costly. For these reasons, the UN Millennium Project strongly recommends that bednets be given away for free, at least in rural areas, to ensure that everyone at risk has one by 2008.

Unless they are designed to be
long-lasting, bednets often need
to be re-treated with insecticide
Photo Credit (IDRC)

Counting the costs

A lack of funding is a major barrier to curbing malaria in Africa. About US$200 million is spent every year on malaria control in the continent by both African and donor governments and by UN agencies. In addition, the Global Fund to Fight AIDS, TB, and Malaria has given around US$220 million for malaria in Africa this year.

But current annual funding remains far below the estimated US$2–3 billion required per year to scale-up malaria control programmes throughout endemic countries in sub-Saharan Africa. Recent sources of increased funding include the World Bank’s Booster Programme for Malaria Control, which amounts to between US$500 million and US$1 billion over the next five years, and the Bush Initiative on Malaria announced at the G8 Summit (July 2005) of US$1.2 billion over five years for 15 countries.

We estimate that by 2008, 660 million people will be at risk of malaria in sub-Saharan Africa. With approximately one net needed for every two people, about 330 million nets will be needed. Using WHO data (see table) we can estimate that the cost for treatment will be about $875 million in 2005, increasing to around $938 million in 2008.


Cost of treatment in US$

Frequency of malaria attacks

Younger than five years



5–9 years



10–14 years



Older than 14 years



Unblocking production bottlenecks

Long-lasting nets and ACTs are not being produced quickly enough. Although we estimate that 110 million new nets and 550 million treatment courses of ACTs will be needed this year, only about 25 million nets and 30 million treatment courses of ACTs are being produced.

Meanwhile, most countries have no alternative but to use drugs that are largely ineffective. Fortunately, the major producers of both nets and ACTs are committed to a dramatic scaling up of production in 2006 and after.

But producers will need reassurance from donors that there will be enough money made available to buy their products.

African countries are delaying getting these products because they lack information about where and how to buy them on the global market, and are faced with administrative hurdles and high prices.

To solve this problem, the Global Fund is now offering to buy nets and anti-malarial drugs on behalf of a large number of poor countries through international agents or suppliers, which should help ensure quality, a fair price, and timely delivery.

This mechanism is one we strongly support because it should, if widely applied, give manufacturers of nets and drugs enough lead time for orders and a reliable market for their products, enabling them to scale-up production.

Equally important for every malaria-ridden country is to develop a reliable system for storing and distributing the products, from national orders and policies down to individual villagers. The most sustainable coverage and distribution system would be to organise delivery through local health facilities as part of routine services.

Clinics, antenatal services and immunisation programmes, for example, could all be used to distribute bednets and drugs. But this will not be enough. Complementary delivery approaches will also be needed, including distribution through non-governmental organisations.

Crosshead: Clearing the final hurdle

For countries to achieve the Millennium Development Goal of bringing malaria under control, the hurdles of funding, procurement, supply and distribution of essential commodities will need to be cleared.

Universal coverage of long-lasting bed nets and ACTs cannot be achieved until all donors abandon the idea of social marketing and other methods that attempt to extract payment from people who are living below the poverty line.

It is urgent, therefore, that all donor and recipient countries adopt a policy of mass distribution of free nets and mass free access to ACTs, in accordance with the recommendations of the UN Millennium Project.

Jeffrey D. Sachs (director), Awash Teklehaimanot (member of the Task Force on Malaria) and Gordon McCord (Special Assistant to Sachs) are at the UN Millennium Development Project, which was commissioned to recommend practical strategies for achieving the Millennium Development Goals, and is based in New York, USA.

Read more about increasing the use of bednets in the SciDev.Net policy brief ‘Insecticide-treated bednets to prevent malaria’

Further reading

UN Millennium Project, Task Force on HIV/AIDS, Malaria, TB and Access to Essential Medicines, Working Group on Malaria. Coming to grips with malaria in the new millennium (Earthscan, London, 2005).

UN Millennium Project. Investing in Development: a Practical Plan to Achieve the Millennium Development Goals (Earthscan, New York, 2005).

Sachs JD, Malaney P. The economic and social burden of malaria. Nature 15, 680–85 (2002).

Curtis C., et al.  Scaling up coverage with insecticide-treated nets against malaria in Africa: who should pay? Lancet Inf Dis 3, 304–307 (2003).

Narasimhan V, Attaran A. Roll back malaria? The scarcity of international aid for malaria control.  Malaria J 2, 8 (2004).

WHO/RBM/UNICEF/PSI/MSH. Sources and Prices of Selected Products for the Prevention, Diagnosis and Treatment of Malaria. (WHO, France, 2004).