Global Health Policy
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October 11, 2007
Battle Over Bednets
Posted by April Harding at 04:06 PM
Readers of the recent New York Times article "Distribution of Nets Splits Malaria Fighters" were led to believe that there is a raging debate about the best way to improve coverage of insecticide-treated nets (ITNs), pitting those who believe in free net giveaways against those who believe in multi-prong strategies using not just giveaways, but also marketing to stimulate demand, and actions to promote supply by the commercial sector. But in point of fact, the evidence is fairly clear: multi-prong strategies are needed to both "catch up" (increase coverage in one year) and "keep up" (sustain coverage in the future). The major policy statements on the issue, the Roll Back Malaria Strategic Framework for Scaling-Up Insecticide-Treated Netting Programmes in Africa and the WHO's ITN position statement both reflect this. The RBM Framework in particular emphasizes a dual strategy to increase coverage rapidly and support sustainability:
Integration of delivery systems into existing public sector programmes, including free distribution of ITNs or high value ITN vouchers to vulnerable groups through [routine] services, can achieve rapid scale-up to high coverage. For long-term sustainability, subsidized programmes should be complemented by support to grow the commercial sector for production and distribution of ITNs.
The giveaway campaign strategy, as noted by the NY Times article, relies on "hiring armies of workers, paid a few dollars a day" who hand out ITNs. What could possibly be challenged with such an approach? Actually, quite a few things as it turns out:
- Campaign giveaways by themselves don't achieve high ownership of ITNs. In fact, in Kenya, where, as the NYT article mentions, the use of bed nets lead to a 44% reduction in child mortality, a recent study showed that nearly equal proportions of nets came from free mass distribution and through social marketing.
- The ownership that is achieved doesn't translate directly into utilization. Niger, where some 2 million nets were distributed for free in 2005, is a case in point. Though net ownership shot up to close to 70%, only 15% of young children - the most vulnerable to malaria - were reported to be actually using the net. Similarly, in Zambia, free distribution of nets in Zambia’s Western Province resulted in ownership of 73%, but left utilization languishing at below 20%.
- Campaigns rely heavily on effectiveness of government management of donor support. When the Global Fund froze funding to Uganda due to government mismanagement of funds, it led to a 3-year delay in net distribution.
- Lacking attention to demand, and supply promotion, coverage achieved by giveaway campaigns are dependent on constancy of donor attention and funding; when these wane, so do the campaigns and so does the coverage they've achieved.
Given the general consensus among the policy community, and in the official guidelines, on the need for multi-prong strategies, it is worrisome to see the single-prong free giveaway approach enjoying renewed support - and not just in the pages of the New York Times. The ringing endorsement of Dr. Arata Kochi, Head of WHO's Malaria program, for free giveaways diverges from both the evidence and his own organization's official policy guidelines and is particularly troubling. And the negative impact goes far beyond rhetoric, as malaria programs in Africa are increasingly focusing on net giveaway campaigns. While the emerging drift toward this "feel good" strategy may let the global community pat themselves on their collective backs for achieving large volumes of handouts, it sadly comes at the expense of contributing to sustainable reductions in malaria through less sexy but more effective combination programs.
See also: Further elaboration of the debate and the underlying program and policy choices are summarized nicely by Jenny Hill and colleagues, and by Christian Lengeler and Don deSavigny in The Lancet.
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Comments
Dear April Harding
Many thanks for this comment, which reflects the position of the vast majority of individuals in the field of vector control / ITNs!
I would just add one more element: Giving out a mosquito net for every sleeping place involves a total cost that is close to the total annual health budget of most malaria-endemic countries (excluding vertical HIV programmes. We are arguing that at this point in time the additional money spent on protecting adults with free nets might be more wisely spent on strengthening the health system. Even though we promote ITNs with great enthusiasm we should never forget that there are other health problems and that we need to keep the whole system in our focus.
Regards
Christian Lengeler
Posted by: Christian Lengeler at October 15, 2007 03:15 AM
Thanks for weighing in on this issue and contributing to a more balanced discussion of the realities of malaria control via the ditribution of LLINs. For readers who are interested in reading more of the consensus and context for the 'debate' fueled by the NYT coverage, I posted some excerpts and links to original publications at On Social Marketing and Social Change.
Posted by: Craig Lefebvre at October 15, 2007 05:29 PM
Given the intensity of debate on this issue in recent months, we should all be pleased that MIT’s Poverty Action Lab has just produced a paper on this topic which bases its findings on a randomized trial – the agreed gold standard for development research. In the abstract the authors (Jessica Cohen and Pascaline Ducas) say:
“It is widely believed that cost-sharing—charging a subsidized, positive price—for a health product is necessary to avoid wasting resources on those who will not use the product. We explore this argument in the context of a field experiment in Kenya, in which we randomized the price at which pregnant women could buy long lasting anti-malarial insecticide-treated nets (ITNs) at prenatal clinics. We find no evidence that cost-sharing reduces wastage on those that will not use the product: women who received free ITNs are not less likely to use them than those who paid subsidized positive prices. Cost-sharing does, however, considerably dampen demand. We find that uptake drops by 75 percent when the price of ITNs increases from zero to $0.75, the price at which ITNs are currently sold to pregnant women in Kenya. When the price is between $0.15 and $0.30, we observe that pregnant women who purchase an ITN are, on average, in poorer health than those who receive a free ITN. However, the share of sick women getting access to an ITN at these prices is still lower than under free distribution. We use these estimates in a cost-effectiveness analysis of ITN prices on infant mortality that incorporates both private and social returns of ITN usage. Overall, given the large positive externality associated with widespread usage of insecticide-treated nets, our results suggest that free distribution is both more effective and more cost-effective than cost-sharing.”
This paper is not up on the PAL website yet but I would be delighted to send it to anyone who would like to send me an email (yatesug@infocom.co.ug)
However, in providing policy advice, we need to be careful not to abandon social marketing completely and adopt a “giveaway campaign” strategy characterised by April. Just piling up free nets in health centres or hurling them from a passing truck will not achieve the coverage rates we need. So when planning marketing strategies for ITNs why don’t take the best from both worlds? When it comes to 4 of the 5 magic “Ps” of marketing (Product, Packaging, Placement and Promotion) we should learn from the social marketing approach. When it comes to Price though, PAL have shown us that WHO are right, it should be zero.
Posted by: Rob Yates at November 8, 2007 09:47 AM
Given the intensity of debate on this issue in recent months, we should all be pleased that MIT’s Poverty Action Lab has just produced a paper on this topic which bases its findings on a randomized trial – the agreed gold standard for development research. In the abstract the authors (Jessica Cohen and Pascaline Ducas) say:
“It is widely believed that cost-sharing—charging a subsidized, positive price—for a health product is necessary to avoid wasting resources on those who will not use the product. We explore this argument in the context of a field experiment in Kenya, in which we randomized the price at which pregnant women could buy long lasting anti-malarial insecticide-treated nets (ITNs) at prenatal clinics. We find no evidence that cost-sharing reduces wastage on those that will not use the product: women who received free ITNs are not less likely to use them than those who paid subsidized positive prices. Cost-sharing does, however, considerably dampen demand. We find that uptake drops by 75 percent when the price of ITNs increases from zero to $0.75, the price at which ITNs are currently sold to pregnant women in Kenya. When the price is between $0.15 and $0.30, we observe that pregnant women who purchase an ITN are, on average, in poorer health than those who receive a free ITN. However, the share of sick women getting access to an ITN at these prices is still lower than under free distribution. We use these estimates in a cost-effectiveness analysis of ITN prices on infant mortality that incorporates both private and social returns of ITN usage. Overall, given the large positive externality associated with widespread usage of insecticide-treated nets, our results suggest that free distribution is both more effective and more cost-effective than cost-sharing.”
This paper is not up on the PAL website yet but I would be delighted to send it to anyone who would like to send me an email (yatesug@infocom.co.ug)
However, in providing policy advice, we need to be careful not to abandon social marketing completely and adopt a "giveaway" strategy characterised by April. Just piling up free nets in health centres or hurling them from a passing truck will not achieve the coverage rates we need. So when planning marketing strategies for ITNs why don’t take the best from both worlds. When it comes to 4 of the 5 magic “Ps” of marketing (Product, Packaging, Placement and Promotion) we should learn from social marketing. When it comes to Price though, PAL have shown us that WHO are right, it should be zero.
Posted by: RobYates at November 9, 2007 05:16 AM