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.