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 Nathan 1, Honorati Masanja 2, Hassan Mshinda 1, Don de Savigny 2, Christian Lengeler 3, Marcel Tanner 3, Cesar G. Victora 4, Joanna Armstrong Schellenberg 1,5

Overview Programme characteristics Methodology Findings Policy implications

Location (Africa –Tanzania)

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 phases from nets & 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 Households The DSS area

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 SES score (quintile) RadioTin roofMean SES score Poorest Very poor Poor Less poor Least poor

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

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