I’m planning to devote Wednesdays to simple solutions that have a big impact in Global Health. In anticipation of World Malaria Day (April 25th), I thought I’d highlight some of the latest research on insecticide-treated nets and some of the simple solutions that are being utilized to get them where they are needed most.
Quick facts on Malaria – There are 350-500 million cases of malaria annually, causing up to 3 million deaths, ninety percent of which are in sub-Saharan Africa. In recent years, there has been a significant mobilization of resources, particularly to get malaria nets to women and children. Last year, funding for malaria interventions reached a peak of $1.7 billion, which represents a 10-fold increase since 2004.
The international community has a goal to achieve universal bednet coverage in targeted countries by this year. The efforts to get malaria nets to women and children in sub-Saharan Africa have gotten huge press in recent years, including celebrity endorsements such as Ashton Kutcher and David Beckham at Malaria No More. I was curious about how malaria nets actually get to the people needing them, particularly since this is a relatively new addition to the global supply chain.
First, who procures and supplies these nets? A visit to UNICEF’s website (where you can download a fascinating read, UNICEF’s supply catalogue), revealed that UNICEF is the world’s largest buyer of nets, spending $100 million on bednets in 2008 and supplying more than one-third of the world’s total annual net supply of nearly 60 million nets. This represents and enormous increase in the supply of this commodity, considering that the number of nets procured in 2000 was only 100,000. Also, interestingly, nets are particularly bulky, so warehousing and transport has been a tremendously tricky feat of logistics. The people at UNICEF’s Supply Community are clearly not getting enough recognition – a round of applause to them!
And how do the nets get to the people who need them? Typically, distribution is done through governments or local NGOS. I found the description of one program on the website of a project in Uganda:
We sell mosquito nets at all village outreaches, bought in the capital (Kampala) and subsidized by UVP so as to be affordable in the village. While the Ugandan government gave out free mosquito nets in 2007, the nets were of poor quality, and the government did not educate the public on how to properly use the nets. Our stronger, insecticide-treated nets are usually viewed as a bargain. Our detailed instruction on the use of mosquito nets, which involve sample-net demonstrations, ensures their proper use and therefore effectiveness.
Besides selling nets directly (through outreaches and from their house), our summer volunteer teams set up a ‘malaria net distributor’ (usually a member of the Village Health Team), in each Healthy Village. This individual sells UVP-subsidized nets for all three years that we work in their village. Our goal is to increase net coverage, and therefore decrease instances of malaria, dramatically by the time we leave each Healthy Village, and to create a culture of awareness about the disease and the benefits of mosquito nets. Uganda Village Project staff conduct follow-up with all villagers who buy mosquito nets, to ensure that they are using the product properly and to survey the household on the frequency that malaria is experienced.
Fee-for-product versus free is a subject of fierce debate: Poverty Action Lab, a group out of MIT which has a comprehensive collection of randomized evaluations, has posted a study by Jessica Cohen and Pascaline Dupas which analyzes the effectiveness of free distribution versus subsidization as a means of distribution. Much has been made about the possibility of cost-sharing (having poor people pay for nets) as a possible means of expanding distribution and increasing the perceived value and possible usage of nets. However, this study found that cost-sharing dampened demand for nets significantly and did not increase the usage of them.
The result of these efforts? A recent report from UNICEF and the Roll Back Malaria Partnership (released on Monday) indicates that 200 million of the 350 million nets needed to achieve universal coverage have been received by people in African countries, saving 908,000 lives since 2000.
