QUESTION:
Why do people have to pay for the bed nets? I think that is mean to the people and they should get them for free.
ANSWER:
You have hit on a very important and on-going debate in the malaria control community. In many places around the world, organisations such as UNICEF have distributed free, insecticide-treated bednets, and especially to mothers—pregnant women and children under five are the groups most at risk from dying from malaria.
In 2010, UNICEF reported that together with its partners (WHO, the EU and the World Bank, to name a few) 5.5 million free bednets have been distributed in DR Congo alone. Similarly, in Mozambique, the Malaria Consortium has been working in a partnership with DFID and the public sector to distribute 400,000 bednets to pregnant women as part of an ante-natal service, again targeting some of the most at-risk people.
However, you are right to say that in some cases, people have to pay for bednets; in some of the poorest countries in the world, this can seem like an unjustifiable expense. However, there are some arguments in favor of having people buy their bednets.
For example, some people argue that a purely public donation initiative is unsustainable, and in order to have an on-going distribution campaign, the private sector has to be involved at some level, and this usually means charging a fee for each bednet. Moreover, forcing people to buy their own nets would free up donor funds for other purposes. Similarly, it is thought in some circles that having payment encourages suppliers to continue producing and selling nets. Finally, there are suggestions that purchasing a bednet increases their value to the recipient, who subsequently uses their net more frequently and more reliably in the manner in which it is intended (and not, for example, as a spare fishing net, as I’ve seen in parts of Uganda!).
I believe a study in Malawi showed that by asking people in urban areas, who have a bit more disposable income, to purchase full-price bednets, the program was able to generate sufficient funds to offer bednets at a highly subsidized cost in rural, poorer areas of the country; by asking people to purchase the nets, the program believed bednet usage among its recipients was higher overall, than if the nets had been given out for free.
I think the organization that tried this approach was called PSI (Population Services International)—they also offered nurses a small monetary incentive to sell bed nets (at the small sum of 50 cents each) to the rural women who attended pre-natal clinics, thus encouraging them to offer the nets widely to pregnant women.
As the final word, a study in Kenya recently showed that as costs for services such as bednets increased, demand for the service among the poorest sectors of the population declined sharply. Instead, it seemed most economical and efficient to target high-risk groups with free bednets, who are also incentivized to use the product properly and value the protection it confers, such as pregnant women in ante-natal settings, rather than doling them out to the community at large.
So we’re back to where I started with this response; the great job that many organizations out there are doing in distribution insecticide-treated bednets to the people who need it the most, and who can’t afford to buy them themselves, although it is worth bearing in mind that alternative models of bednet funding and distribution might prove equally beneficial and potentially more sustainable, at least in certain areas.
I’m also going to ask Hugo Gouvras to weigh in on this one—he works for Malaria No More, an organization that has recently launched an innovative mechanism for accelerating funding provision for bednet distribution to Africa. Hopefully he can update anything that I have said which is old news, and provide additional information!
This is a very important issue. Providing free prevention tools like bednets not only averts millions of cases of malaria and saves lives but can reduce the country’s long term health and social costs and thus a wise strategy. We are now seeing an increase of free nets being distributed. In the past we saw countries (using donor aid) using various strategies to distribute bed nets (some were completely free, others subsidized etc). Now it’s shifted to mainly giving them out for free as the long-term effects are obvious.
There are however some problems that occur when nets are distributed free of charge. In some countries, commodities that are supposed to be free are sometimes resold for profit. When I traveled to Sierra Leone to speak with the national malaria control program manager, he mentioned that treatment and prevention tools, initially free, were being resold. This happens in several other countries. In the case of Sierra Leone, they are bringing out a new security strategy where they will label the mosquito nets with the donors logo and a message stating “free of charge.” This is to ensure retailers do not sell them.
A free bednet does not necessarily mean easily accessible. When we look at the distribution channels for free of charge nets there are essentially 2 strategies: Routine Distribution (RD) (which mainly targets antenatal clinics) and universal coverage (UC) campaigns that target the whole population (on a province by province basis). For RD bed net stock-outs are frequent. UC campaigns are scheduled based on when funds from donors are disbursed. To access a bednet immediately, turning to the private sector may be faster then waiting for the free net.
Finally we can also learn from the ACT (treatment for malaria) market the importance of educating the population on malaria prevention/treatment tools and how to access them. For example ACTs were free in Uganda. However the free effective drug was not in demand. They saw that people were more likely to go to the private sector and buy drugs that were actually ineffective (and sometimes counterfeit). People trusted the private sector more than the public. We have to educate people about the commodities out there and how to access them and change their behavioral patterns.