Malaria prevention – can social marketing net the poorest?

The impact of malaria is worst for the poor and marginalised. Insecticide-treated mosquito nets (ITNs) are a practical malaria control tool, but their spread across Africa has been slow. Can social marketing increase ownership of nets without decreasing equity? A study in Morogoro Region, southern Tanzania suggests that the reverse may in fact be true.

Researchers at the Ifakara HealthResearch and Development Centre point out that the target of 60 percent coverageof ITNs by 2005 set at the Abuja summit in 2000 seemsincreasingly out of reach. The spread of net usage has been slowed by perceiveddifficulties in delivering insecticide re-treatment and by uncertainties aboutthe best way to distribute nets in poor rural areas of Africa.

ITNs are probably too expensive for most people at risk ofmalaria, so health agencies are looking for ways to reduce prices throughsubsidies. Social marketing – where commercial marketing methods are applied fora health gain without a profit motive – offers a way to increase demand fornets whilst also subsidising prices. Good social marketing uses intense,well-informed promotion. It ca improve access through a subsidiseddistribution network. But are subsidies sustainable? Is social marketing thebest way to use resources? Most importantly, because nets are sold, rather thangiven away for free, does social marketing increase inequity?

Before the start of a socialmarketing programme, the researchers asked about 12,000 household heads whetherthey owned nets and other assets, such as a tin roof, radio or bicycle. They developeda socio-economic score for each household, thenrepeated the survey three years later. Between the first and the second survey:

• The proportion ofhouseholds with at least one net increased from 37 to 73 percent.
• Net ownershiprose from 20 to 54 percent among the poorest households and from 63 to 92percent among the least poor.
• The ratio of netownership in the poorest to the least poor households increased from 0.3 to0.6.

These results suggest thatequity improved over the three years. The researchers acknowledge that theprivate sector, which was very active at the time of the study, probably helpedthe increase in net ownership. There is a dynamic market for mosquito nets inTanzania, which is reaching further and futher intorural communities. Recommendations for sustaining this rate of improvement inequity of net ownership include:

• continuing theefforts of the ongoing social marketing campaign
• tailoring moreeffectively the campaign’s promotional messages
• researching thecharacteristics of non-users
• building on theopportunities for large-scale distribution provided by the private sector
• investigating other ways to help the poorest to purchase nets, suchas the voucher scheme currently under development in Tanzania.