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
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Chapter 002. Global Issues in Medicine (Part 8) Chapter 002. Global Issues in Medicine (Part 8) Limited success in scaling-up ITN coverage reflects the inadequatelyacknowledged economic barriers that prevent the destitute sick from accessingcritical preventive technologies. Despite proven efficacy and what are consideredreasonable costs, the 2003 RBM report reveals disappointing levels of ITNcoverage. In 28 African countries surveyed, only 1.3% (range, 0.2–4.9%) ofhouseholds owned at least one ITN, and distribution system with points of sale. However, even with the application ofsubsidized social marketing strategies, this market approach has not resulted inlarge increases in coverage during the first years of the RBM campaign. Severalstudies have attempted to define willingness to pay (WTP) and actual payment forITNs in African countries and thereby to determine why market-based strategieshave been unsuccessful. Policy-makers often use WTP figures to determineappropriate pricing for social marketing projects and to project revenue anddemand. A cross-sectional study in a rural Nigerian community administered twoquestionnaires, 1 month apart, to examine community members WTP for ITNs,actual purchase of ITNs (with the second questionnaire accompanied by theopportunity to buy a subsidized ITN), and factors (such as socioeconomic statusand recent history of malarial illness) contributing to hypothetical and actual ITNpurchase. Among the 453 persons answering both surveys, the poorest quintileperceived 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 anet, or express a hypothetical WTP. Even the most well-off quintile was willing topay only 51% of the government-set price for an ITN. This finding suggests thateven the relatively well-off may not be willing or able to pay for bed nets at setprices. The authors of this study concluded that reliance on the sale of nets alonemay prove inadequate and that further studies are needed to define the degrees towhich costs can be lowered and/or demand increased. A 2002 study in highland Kenya compared the attitudes of people living inhomesteads provided with heavily subsidized ITNs (n = 190) with those ofresidents of households that had no ITNs and had not been targeted by other healthcare initiatives (n = 200). Of all households, 97% expressed willingness to pay forITNs. However, only 4% of those willing to pay offered spontaneously to meet thesuggested price of 350 Kenyan shillings. After being prompted that nets areexpensive, 26% of respondents expressed willingness to pay the full price. Thisstudy did not offer nets for sale; therefore, the number of nets that would actuallyhave been purchased is unknown. However, the study did contextualize thehypothetical 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 primaryschool for a year. By placing the nets relative cost in context, the authors of thisstudy call into question the likelihood that families in this district, over half ofwhom fall below the Kenyan poverty line, would actually be able to purchaseITNs. Given the documented barriers to purchasing ITNs, especially among thepoorest of the poor, many researchers and development professionals involved inmalaria programs have called for the free distribution of ITNs, comparing theirimportance as a public health measure with that of childhood vaccination. Theadoption of free ITN distribution strategies has been limited, however, byconcerns about their feasibility and potential ITN misuse (for example, as nets forfishing). Evidence from a targeted free-distribution program discounts bothconcerns. In 2001, a Kenyan program sponsored by UNICEF sought to distribute70,000 ITNs to pregnant women through antenatal clinics. Within 12 weeks,>50% of the ITNs had reached their intended recipients. A 1-year follow-upevaluation of 294 women who had received bed nets while pregnant—152 womenfrom a high-transmission area and 142 from a low-transmission area—revealedthat 84% of women in the high-transmission area used the ITNs throughoutpregnancy. 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 freenets may not be used because recipients do not value them. Given the scope and magnitude of the challenge posed by malaria, it isunlikely that any one strategy will work for every region or population within acountry or across the world. Encouraging results from an employer-based ITNdistribution system in K ...