Mosquito nets, Social marketing and equity in rural southern Tanzania

1. Mosquito nets, Social marketing and equity in rural southern Tanzania Rose Nathan1, Honorati Masanja2, Hassan Mshinda1, Don de Savigny2, Christian Lengeler3, Marcel Tanner3, Cesar G. Victora4, Joanna Armstrong Schellenberg 1,5 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

2. Overview • Programme characteristics • Methodology • Findings • Policy implications

3. Location (Africa –Tanzania)

4. Program setting • 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 Kilombero District population: 322,000 Ulanga District population: 193,000

5. 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 ... 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

6. The social marketing program (2) Launching in 5 phases from 97-99 85 000 nets & 32 000 net treatments sold by June 2001

7. 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 !

8. 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 Poverty and equity: methods

9. Surveys coverage The DSS area

10. Poorest-least poor: proxies and indicators • Measures used: • Reaching the poor: coverage in poorest group • Equity: poorest/least poor coverage ratio Example: SES score for Ifakara DSS, 2002

11. Household net ownership before social marketing and 3 to 5 years later Reaching the poorest 20% coverage at baseline 54% after 3 years 73% after 5 years Equity: Poorest/least poor ratio 0.3 at baseline 0.6 after 3 years 0.75 after 5 years

12. 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 andtwo enabling factors. • High demand for mosquito nets. • Active private sector for nets.

13. 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.

14. Governments of Switzerland & Tanzania, through Swiss agency for development & co-operation INDEPTH network Funding