The best bednets in life are free?

My CGD colleague April Harding has a nice post on the Global Health Policy blog where she critiques the ‘free bednet’ movement in malaria prevention:

With dismay, I read today this piece in The Economist – which adds their important voice to the chorus calling for bednet programs based on universal free giveaways. The Economist bases its endorsement on a recent study by the WHO assessing malaria interventions in four countries which purportedly overturns the prevailing wisdom.

First, the prevailing wisdom.

Two reviews, one by Roll Back Malaria, and another by the World Health Organization’s malaria department, have been conducted on how to achieve high and sustained coverage of bednets. Both concluded the same thing: to achieve and sustain bednet coverage, multiple distribution strategies involving both public and private sector distribution are more effective than public distribution alone. And, pregnant women and children should pay low or no price – while others continue to pay positive prices.

The logic of free bednets, and public sector distribution is obviously seductive…and now it can count The Economist among its conquests. So, perhaps it is worth reiterating why these reviews concluded there is a need for positive prices and private distribution and sale of bednets.

Why positive prices:

  • The effect of bednet coverage interventions relies crucially on the supply response. It is critical that suppliers be motivated to sell nets – and both public and private suppliers are more responsive when prices are positive. My colleague Mead Over recently blogged about how positive prices engender supply responses in public facilities.
  • Payment for bednets frees up program funding for other uses. African governments’ budgets for health are extremely limited; and donor resources are insufficient to cover the cost of the “big three” malaria interventions (bednets, treatment, and spraying). Other malaria program interventions, such as stimulating demand and use of nets, and improving case management of malaria are very effective; some scarce program dollars need to be allocated here rather than widening price subsidies. For example, despite widespread support, the Affordable Medicine Facility to fund malaria drugs is not yet funded.

Why public and private distribution is needed:

  • Private distribution and supply is less susceptible to breakdown related to the volatility of donor funding (Amanda Glassman and Christopher Lane recently drew much-needed attention to the destructive impact on program effectiveness linked to volatility of aid flows)
  • Private distribution and supply is less susceptible to breakdown related to public sector management problems (Richard Tren and colleagues at Africa Fighting Malaria describe here a three year freeze in public sector distribution of bednets in Uganda due to problems between the Ugandan government and the Global Fund)
  • Private distribution and sale is available outside the time parameters of public sector campaign – which is critical to ensure coverage of newly pregnant women and newly born children.
  • Private sellers increase use by sensing and responding to consumer preferences (people like different colored, different shaped nets and will buy more if they have product choice)
  • Private distribution chains are often more effective than public sector in getting products out to rural and hard-to-reach areas

Read the full post

April’s sound like good points, but I’m not clear what a public-private combination looks like. Who gets free bednets and who does not? Who decides?

I’d also like to hear more about the demand-side. Most of my knowledge of bednets comes from a nice paper by two friends, Jessica Cohen and Pascaline Dupas. They look at the difference in bednet wastage and demand when pregnant women in rural Kenya are asked to pay some of the cost rather than receive them for free. Women who pay a charge are no more likely to use their bednet, but demand drops 75 percent when the price goes from 0 to 75 cents.

I’m curious if this demand drop is less significant among the wealthier, or if it’s reduced by media campaigns and education. If yes, there’s likely to be a viable private market. If no, the social benefits of each extra bednets strike me as a good reason for more widespread free distribution in poor rural areas.

3 thoughts on “The best bednets in life are free?

  1. I sawe Jessica’s paper. I am not sure if her main conclusion (“uptake drops by 75 percent when the price of ITNs increases from zero to $0.75“) is right. She interprets her data as if the sample clinics have a monopoly on bed net distribution. That is not the case. Her data does not reveal, if a lower price of bed nets results in additionally distributed nets or if it only changes the market share of competing suppliers.

  2. Thanks for drawing attention to this issue Chris.
    On who gets the free nets – generally the priority in terms of targeting is children under five, and pregnant women. They are targeted because they suffer the most morbidity and mortality from malaria.
    How they are targeted varies with distribution method. If distribution is linked to immunization campaigns – the bednets are given to the same families who have children being immunized. If distribution is via public clinics, then guidelines are given to clinic staff about who to give nets to. When vouchers are used, the vouchers are given out at the clinics to the target people, and they obtain their nets at a store.
    There is a lot of evidence that behavior change communication/ social marketing campaigns can increase demand for and use of nets. In fact, one of the problems with the public-distribution-only approach is that they often include litte attention to demand/ use stimulation – with the result that a relatively smaller portion of the nets given away get hung up, or used.
    Don’t misunderstand my position on price – there is clearly a case for nets being as cheap as possible to as many users as possible. But the subsidies need to be delivered in such a way as to ensure a supply response, and accompanied by efforts to promote use. That’s why everyone who reviews all the evidence comes up with the conclusion that a multi-prong strategy is needed. Also, I think the case for vouchers rather than public distribution is quite strong – given that it relieves the price-related constraints on use – while also ensuring sustainable supply.