Mosquito nets, Social marketing and equity in rural

southern Tanzania

1 Ifakara Health Research & Development Centre, Tanzania 2 Tanzania Essential Health Interventions Project, Tanzania

3 Swiss Tropical Institute, Switzerland

4 Federal University of Pelotas, Brazil 5 London School of Hygiene and Tropical Medicine, UK

Rose Nathan1, Honorati Masanja2, Hassan Mshinda1,Don de Savigny2, Christian Lengeler3, Marcel Tanner3, Cesar G. Victora4, Joanna Armstrong Schellenberg 1,5

Overview• Programme

characteristics• Methodology• Findings• Policy implications

Location (Africa –Tanzania)

0 150

Kilometers

300

Tanzania showing Kilombero andUlanga Districts withinMorogoro Region

UlangaDistrict

MOROGOROREGION

KilomberoDistrict

Kilombero District population: 322,000

Ulanga District population: 193,000

• Rural, poor– Median monthly

household expenditure <$20 on non-food items

• Subsistence farming• Malaria transmission

high all year round• Good access to health

facilities• Mosquitoes perceived

as a nuisance, high demand for nets

• Private sector active selling untreated nets

Program setting

The social marketing program (1) • Initial formative research

– Perceptions of nets, malaria, causes of child death

• Products– Dark green rectangular high-quality

nets, pre-treated with insecticide, sized according to local preferences

– Home treatment kits of insecticide sachet, gloves, instructions

• Prices

– Nets: $5 retail, Insecticide: $0.5

– Subsidy ~ $1 per item

– Discount voucher for pregnant women and young children<$1, through MCH clinics

• Place: in every village - private & public sector

• Promotion

– Posters, mobile videos, MCH clinic sessions, T-shirts, theatre groups, sports sponsorship ...

Launching in 5 phasesfrom 97-99

Mchombe

Mbingu

Mkangawalo

KalengakeloMlimba

Mpanga

ULANGADISTRICT

Zignali

Idete

Ichonde

Kiberege

Msolwa Station (B)

Kidatu

Ifakara

KILOMBERODISTRICT

Malinyi

Igawa

MbalinyiMbalinyiMbalinyiSali

Sofi Majiji

Kiswago

Minazini

Kichangani

NakafuluMilola

Msogezi

Kivukoni

Mwaya

Ruaha

Ebuyu

Gombe

Mahenge

SelousGameReserve

Phase 1, 1997

Phase 4, 1999

Phase 3, 1998

Phase 5, 1999

Phase 2, 1997

200

Kilometers

40

ITN distributionin 112 villages

KINET Project

85 000 nets & 32 000 net treatments sold by June 2001

The social marketing program (2)

Are the poorest reached?

Aim: To examine equity in malaria prevention using mosquito nets

Hypothesis: social marketing of treated nets decreases equity

WITH THE

PICTURE HERE !

Poverty and equity: methods

• Cross-sectional household surveys to collect data on assets, mosquito nets and other status (Ifakara DSS 1997, 2000 & 2002 )

• Household assets: bicycle, radio, tin roof, animals, ducks/chickens

• household head occupation – farmer, mason, business, petty trader, fisherman, driver,

government employee • house rented or owned

• Principal components analysis, socio-economic status score for each household, split into quintiles

Surveys coverage

Year 1997 2000 2002

Households 10294 11906 14227

The DSS area

Poorest-least poor: proxies and indicators

Measures used: –Reaching the poor: coverage in poorest group– Equity: poorest/least poor coverage ratioExample: SES score for Ifakara

DSS, 2002SES score

(quintile)

Radio Tin roof Mean SES score

Poorest 0.0 0.0 -1.4

Very poor 18.5 0.35 -0.7

Poor 53.7 18.7 -0.3

Less poor 68.8 29.1 0.5

Least poor 88.4 78.8 2.4

Household net ownership before social marketing and 3 to 5 years

later

Reaching the poorest20% coverage at baseline54% after 3 years73% after 5 years

Equity: Poorest/least poor ratio0.3 at baseline

0.6 after 3 years0.75 after 5 years

20

29 32

45

63

54

64

74

83

92

73

84 8592

97

0

20

40

60

80

100

120

Poorest 2 3 4 Least poorAsset score (quintile)

Ho

use

ho

lds

wit

h n

ets

(%) 1997 2000 2002

Comments

• Household net ownership is a necessary step to reach Abuja

targets

- An additional indicator, not a substitute for net use in under-fives.

• No evidence that social marketing decreases equity.–Rapid increase in net coverage in all SES groups.

–Largest improvements in the poorest households.

–Least poor are close to “saturation” (100% coverage).

–Equity of ownership has increased over 5 years.

–Cost remains an obstacle.

• Effects likely to be due to the social marketing approach and

two enabling factors.–High demand for mosquito nets.

–Active private sector for nets.

Policy implications

Given a high demand for mosquito nets and active private sector, social marketing can catalyze uptake without jeopardizing equity.

Aiming for 100% coverage of disease control tools can reduce socio-economic inequity.

Funding

• Governments of Switzerland & Tanzania, through Swiss agency for development & co-operation

• INDEPTH network