Is combination therapy for malaria based on user-fees worthwhile and equitable to consumers? Assessment of costs and willingness to pay in Southeast Nigeria.

OBJECTIVES: To examine the equity implications of the costs of an episode of malaria, the benefit/cost ratios of using two artemisinin-based combination therapy (CT) from the consumers' view and inequities in willingness to pay (WTP) for CT. METHODS: A cross-sectional survey was conducted in Southeast Nigeria, where there is a moderate to high level of malaria resistance to chloroquine and sulfadoxine-pyrimethamine formulations. WTP was elicited from respondents using the bidding game (BG) and the structured haggling technique (SH). A socio-economic status (SES) index was used to examine the level of inequity in the key variables. In the benefit/cost ratios, the average cost of CT in Nigeria and price of Coartem were, respectively, used as the cost inputs while the mean WTP was the measure of benefit. Multiple regression analyses were used to determine the validity of the WTP estimates. RESULTS: More than 90% of the respondents were willing to pay for CT. The mean WTP in the BG was 301.1 Naira while it was 438.0 Naira in the SH. People in the highest SES quartile (Q4) were more willing to pay for CT than the lowest SES quartile (Q1). In the regression models, the SES quartiles were significantly related to levels of WTP. The benefit/cost ratios were higher in the SH group, and the ratio was only more than 1 using Coartem in only the SH group. The Q1 groups had the least benefit cost-ratios but the trend of SES differentials in benefit/cost ratios were not statistically significant in the BG group but was in the SH group. CONCLUSION: CT based on user-fees may not be worthwhile and equitable because there are economic and equity constraints to its wide-scale use. Benefit/cost ratios depend on the type of questions that were used to elicit WTP. Governments and donors should be willing to commit funds to make CT affordable to the poor consumers for the intervention to be used to significantly reduce the burden of malaria.