Mosquito Nets and Development

Stephen DeAngelis

October 11, 2007

Even when people are of a single mind about an objective, they can have differences of opinion about how to get achieve that goal. That is what is happening with efforts to reduce cases of malaria in Africa. One of the most effective methods for eliminating the threat (mosquitoes that carry a protozoan parasite that causes malaria) is to get people to use mosquito nets impregnated with insecticide. The debate has been about the best way to distribute the nets [“Distribution of Nets Splits Malaria Fighters,” by Reuben Kyama and Donald G. McNeil, Jr., New York Times, 9 October 2007].

“Veronica Njeri, 45, says she has ‘never healed’ since losing two of her six children to malaria 20 years ago, and she still feels vulnerable. While her oldest are adults or teenagers, and have presumably built up immunity to the disease, she worries about her youngest, Anthony, who is 4. But since hundreds of free mosquito nets came to Maendeleo, her rice-farming village in west-central Kenya, ‘malaria epidemics have become rare,’ she said happily, even though the village sits amid stagnant paddies where swarms of mosquitoes breed. Villages like Maendeleo are at the center of a debate that has split malaria fighters: how to distribute mosquito nets.”

The debate is over whether to sell the nets or give them away. Those who want to sell them are looking to reduce the cases of malaria while at the same time helping develop the economy. Those who want to give them away are only interested in eliminating the disease. The “give away” group believes they have finally won the day.

“Recently, Dr. Arata Kochi, the blunt new director of the World Health Organization’s malaria program, declared that as far as he was concerned, ‘the debate is at an end.’ Virtually the only way to get the nets to poor people, he said, is to hand out millions free. In doing so, Dr. Kochi turned his back on an alternative long favored by the Clinton and Bush administrations — distribution by so-called social marketing, in which mosquito nets are sold through local shops at low, subsidized prices — $1 or so for an insecticide-impregnated net that costs $5 to $7 from the maker — with donors underwriting the losses and paying consultants to come up with brand names and advertise the nets. ‘The time for social marketing of bed nets in a big way is over,’ Dr. Kochi said in an interview. ‘It can become a supplemental strategy for urban areas and middle-income countries.'”

One might ask, what’s the point of “selling” nets at a loss? The idea was not a bad one. Proponents believed that people placed more value on things for which they paid, even if the amount was small. Get them to pay for a net, and the chances that they would actually use it would increase — or so the argument went. In addition, social marketing was aimed at creating an entrepreneurial mercantile class who would be able to help lift their local economies out of poverty. Unfortunately, there were several problems with how the strategy actually played out. First, it was in direct competition with net give away programs. People simply aren’t going to pay for something they can get free. Second, the nets were not penetrating the population as deeply as health officials hoped they would; and, finally, that penetration was uneven.

“Dr. Kochi … argues that the insecticide-filled nets, when used by 80 percent or more of a village, create a barrier that kills or drives off mosquitoes, protecting everyone in the area, including those without nets. Individual nets tended to just drive mosquitoes next door, to bite someone else. As such, he said, nets ought to be treated as a public good, like the measles or polio vaccines, which the world does not charge the poor for. Free net distributions are usually done in a week or two, by armies of workers who are paid a few dollars a day by the Red Cross or health ministry to cover a country or other large region. Distributions have been tried in Sierra Leone, Niger, Togo and elsewhere, sometimes in conjunction with measles shots or deworming drugs. The new model is beginning to prevail but has not completely swept the field. Some donors still use some social marketing. Unicef, the world’s largest buyer of nets, distributed 25 million last year, of which 92 percent were given away, said its medical director, Dr. Peter Salama. The main American program, the President’s Malaria Initiative, plans to hand out more than 15 million nets by 2008, of which about 75 percent will be free, said its coordinator, Rear Adm. Tim Ziemer. … Experiences in Kenya played a large part in persuading the W.H.O. to change its policy, said Dr. Peter Olumese, a medical officer in the agency’s malaria program. Maendeleo, a village of about 140 mud-walled shacks with tin roofs, was part of a five-year study of 40 health districts. When it started in 2002, the only nets were those for sale in small shops, Dr. Olumese said, and only about 7 percent of people had them. Social marketing was introduced by Population Services International, a large aid contractor. That increased coverage to about 21 percent by early 2006. Then, late last year, the health ministry got a big grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria that allowed it to hand out 3.4 million free nets in two weeks. Coverage rose to 67 percent, and distribution became more equitable. Under social marketing, Dr. Olumese said, the ‘richest of the poor’ had 38 percent coverage, while the ‘poorest of the poor’ … had only 15 percent. After the handouts, they were about equal. Deaths of children dropped 44 percent. It also turned out to be cheaper, Dr. Olumese said. With consultant fees, transportation, advertising and shipping, social marketing added about $10 to the cost of each net beyond the $5 to $7 that Danish or Japanese makers charged. But even with payments to volunteers, the added cost of free distribution was only about $1.25 per net.”

The lessons learned from this situation are interesting. As readers of this blog know, I’m spending a lot of my time trying to interest groups in the Enterra Solutions® Development-in-a-Box™ approach, which has at its heart the implementation of best practices and standards in emerging economy countries. It is an approach much closer philosophically to the social marketing approach than the give away approach. Development-in-a-Box, however, requires certain pre-conditions that help ensure its efforts are not made in vain. A minimum level of security is the most important of those conditions, but having a healthy and educated population also helps enormously. What the anti-malaria programs teach us is that efforts to achieve these minimum conditions should be implemented without regards to markets. Historically, most efforts to achieve minimum conditions (like building critical infrastructure) have been carried out by governments or government-granted monopolies. Once minimum conditions have been achieved, then market pressures arise as does a new market logic. When a critical mass of people arises that understands the importance of the continued use of mosquito nets and can afford to buy them, the time to move from give away programs to markets will have arrived. The nets only remain effective (i.e., the insecticide remains potent) for about five years, so there is a continuing need to replace them. That sounds like a perfect market situation — but only if your customers live to see the day when they can afford to buy your product.

With the apparent victory of give away programs, merchants who took part in the social marketing experiment are only people left in the lurch.

“Francis Mureithi, a local shopkeeper, said he still had some 50-shilling nets for sale because the government had given free ones only to families with children under 5. … Mr. Mureithi [also] noted, sales of malaria pills were way down.”

If Mr. Mureithi can hang on long enough, the day will likely come when his mercantile efforts will pay off. Healthy populations are more likely to become customers than unhealthy ones. Unhealthy societies cannot rise above poverty because they cannot become productive enough to rise above a subsistence level economy. The social marketing experiment may not have worked, but it certainly wasn’t a wasted effort. Discovering best practices is always a good thing and that normally means discovering practices that are not so good.