mosquito nets, social marketing and equity in rural southern tanzania 1 ifakara health research...
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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