A few weeks back I wrote about the potential side effects of free bed net programs that rely exclusively upon public distribution channels, which is only one small part of a much larger debate regarding how bed nets should most appropriately be distributed to achieve high levels of coverage and to reduce mortality from malaria.

Other aspects of this debate, highlighted by Bill Brieger in his comments to my blog posting, is on the use of “catch up” vs. “keep up” strategies. In addition, there is also debate regarding whether bed nets should be delivered through standalone campaigns or delivered through as a part of integrated routine health services. Countries are experimenting with different approaches, and as more and more evaluations of these programs are conducted and compared, a better sense of what works where may become clearer in the coming years.

In a recent issue of the BMJ, Kara Hanson and colleagues published the results of one such evaluation. Their paper evaluates the effect of the Tanzanian National Voucher Scheme (TNVS) on the level and equitable distribution of insecticide treated net (ITN) in that country. The program was rolled out progressively across the country starting in 2004 and lasting until 2006. The program design used a voucher to allow people to purchase the nets through private distribution channels. The vouchers themselves were delivered through antenatal clinics and were targeted for pregnant women and for children. In the lingo from the above discussion, this program would likely be qualified as a “keep up” strategy, delivered through routine health services using private distribution channels.

Using a “plausibility” study design, the authors found relatively large and significant increases in net ownership over the time period: from about 44% of all households in 2005 to about 65% in 2007. There were also increases in the proportion of nets that were treated with insecticide, used by infants under the age of 1, and other indicators. While it is difficult to directly attribute all of the observed changes to the TNVS program itself, the “plausibility” design provides ample evidence that such changes were likely the result of the program by collecting changes in indicators along the program delivery pathway.

In addition to the TNVS, many of the districts had also been exposed to other programs, including three that had been exposed to “catch up” free bed net distribution programs. While all of these districts saw sizable increases, about half of the districts without free distribution programs saw increases of the same magnitude. In addition, the authors point out that net ownership actually declined in some of the free bed net regions. Not exactly glowing evidence of the effectiveness of those programs, but I would have liked to have seen more details on those programs to know more.

So while this evaluation showed that the TNVS is probably an effective “keep up” strategy, none of the none of the districts – even those with free bed net programs – achieved coverage levels anywhere near those advocated by the World Health Organization and Roll Back Malaria – even after two years. The distribution of bed nets ownership was highly inequitable, with the lowest levels of ownership among the poor (no data was given on whether the free bed net districts achieved more equitable outcomes). In addition, all changes were based on within district changes in treated areas, so it is not clear how bet net ownership would have improved even without these programs. Just the same, the evaluation points to the important role of ongoing distribution programs delivered through routine health services (95% of women did attend the clinics, and the vast majority did receive the voucher when they were available) and through private channels.

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