Chapter 002. Global Issues in Medicine (Part 8)

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Limited success in scaling-up ITN coverage reflects the inadequately acknowledged economic barriers that prevent the destitute sick from accessing critical preventive technologies. Despite proven efficacy and what are considered "reasonable costs," the 2003 RBM report reveals disappointing levels of ITN coverage. In 28 African countries surveyed, only 1.3% (range, 0.2–4.9%) of households owned at least one ITN, and

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Chapter 002. Global Issues in Medicine (Part 8) Limited success in scaling-up ITN coverage reflects the inadequately acknowledged economic barriers that prevent the destitute sick from accessing critical preventive technologies. Despite proven efficacy and what are considered "reasonable costs," the 2003 RBM report reveals disappointing levels of ITN coverage. In 28 African countries surveyed, only 1.3% (range, 0.2–4.9%) of households owned at least one ITN, and
distribution system with points of sale. However, even with the application of subsidized social marketing strategies, this market approach has not resulted in large increases in coverage during the first years of the RBM campaign. Several studies have attempted to define willingness to pay (WTP) and actual payment for ITNs in African countries and thereby to determine why market-based strategies have been unsuccessful. Policy-makers often use WTP figures to determine appropriate pricing for social marketing projects and to project revenue and demand. A cross-sectional study in a rural Nigerian community administered two questionnaires, 1 month apart, to examine community members' WTP for ITNs, actual purchase of ITNs (with the second questionnaire accompanied by the opportunity to buy a subsidized ITN), and factors (such as socioeconomic status and recent history of malarial illness) contributing to hypothetical and actual ITN purchase. Among the 453 persons answering both surveys, the poorest quintile perceived a greater risk of malaria than the other quintiles (27.3% vs. 12.9–21.6%, p < .05). However, the poorest quintile was least likely to own a net, purchase a net, or express a hypothetical WTP. Even the most well-off quintile was willing to pay only 51% of the government-set price for an ITN. This finding suggests that even the relatively well-off may not be willing or able to pay for bed nets at set prices. The authors of this study concluded that reliance on the sale of nets alone may prove inadequate and that further studies are needed to define the degrees to which costs can be lowered and/or demand increased.
A 2002 study in highland Kenya compared the attitudes of people living in homesteads provided with heavily subsidized ITNs (n = 190) with those of residents of households that had no ITNs and had not been targeted by other health care initiatives (n = 200). Of all households, 97% expressed willingness to pay for ITNs. However, only 4% of those willing to pay offered spontaneously to meet the suggested price of 350 Kenyan shillings. After being prompted that "nets are expensive," 26% of respondents expressed willingness to pay the full price. This study did not offer nets for sale; therefore, the number of nets that would actually have been purchased is unknown. However, the study did contextualize the hypothetical WTP for ITNs by comparing their cost with other household costs: the price of one ITN is equal to the cost of sending three children to primary school for a year. By placing the nets' relative cost in context, the authors of this study call into question the likelihood that families in this district, over half of whom fall below the Kenyan poverty line, would actually be able to purchase ITNs. Given the documented barriers to purchasing ITNs, especially among the poorest of the poor, many researchers and development professionals involved in malaria programs have called for the free distribution of ITNs, comparing their importance as a public health measure with that of childhood vaccination. The adoption of free ITN distribution strategies has been limited, however, by concerns about their feasibility and potential ITN misuse (for example, as nets for
fishing). Evidence from a targeted free-distribution program discounts both concerns. In 2001, a Kenyan program sponsored by UNICEF sought to distribute 70,000 ITNs to pregnant women through antenatal clinics. Within 12 weeks, >50% of the ITNs had reached their intended recipients. A 1-year follow-up evaluation of 294 women who had received bed nets while pregnant—152 women from a high-transmission area and 142 from a low-transmission area—revealed that 84% of women in the high-transmission area used the ITNs throughout pregnancy. One year later, 77% continued to use the bed nets. In the low- transmission area, 57% of women used the ITNs during pregnancy, and 46% continued to use them a year later. These results contradict suppositions that free nets may not be used because recipients do not value them. Given the scope and magnitude of the challenge posed by malaria, it is unlikely that any one strategy will work for every region or population within a country or across the world. Encouraging results from an employer-based ITN distribution system in Kenya highlight the potential role of public-private partnerships. Potential synergies between antimalaria programs and measles vaccine campaigns or possibly lymphatic filariasis eradication campaigns have been reported or suggested. Concerns about discomfort associated with sleeping under ITNs or about insecticide toxicities must be addressed through educational campaigns.
Meeting the challenge of malaria control will continue to require careful study of appropriate preventive and therapeutic strategies in the context of our increasingly sophisticated molecular understanding of the pathogen, vector, and host. However, an appreciation for the economic and structural devastation wrought by malaria—like that inflicted by diarrhea, AIDS, and TB—on the most vulnerable populations should heighten our commitment to the critical analysis of ways to implement proven strategies for the prevention and treatment of these diseases. 1 Nuwaha F: The challenge of chloroquine-resistant malaria in sub-Saharan Africa. Health Policy Plan 16:1, 2001.