NextBillion.net - Development Through Enterprise - To Give or Not to Give: Academics Study Bednet Distribution - Comments

Follow-up: Number of Bednets

Abigail Keene-Babcock — Tue, 15 Jan 2008 10:32:18 -0500

Nigel, all very relevant and important points that must be considered in order to arrive at solutions that not only sound good in theory, but also have credible, long-term, scalable, and widespread impact on the ground. With regards to the numbers, these were figures stated by a PSI representative who attended the research presentation. I may be that those numbers were not accurate, although since bednet distribution by PSI took place over a number of years we may also be looking at cumulative numbers over time v. current estimates of saturation. Sorry I cannot shed more light on this discrepancy. However, I do think one thing that can still be taken away from this is that reliable data and accurate numbers, even just describing the current market saturation and usage rates of bednets, is very difficult to come by and this makes for extremely challenging experimental work!

On the number of nets sold by PSI in western Kenya

Nigel Motts — Mon, 14 Jan 2008 12:29:56 -0500

Referring to the following statement by Abigail, (in paragraph 4) ..."PSI had sold 500 million nets in that area prior to the beginning of the experiment - amounting to a theoretical coverage of 1.4 nets per household ...", either the population of western Kenya is rather larger than I had thought or the coverage figure of 1.4 nets per household figure is somewhat low. Some fuzzy number crunching at work here? That aside, it is unfortunate that the 'what is the best method' question has become so polarized (eg: free versus other not so free 'get nets out there' options). There is no single 'one size fits all' magic bullet solution to be had. Political corruption in some countries virtually ensures that commodities like ITNs (which have cash market value) issued free through the public health system are likely to run into catastrophic 'leakage' (the nets mysteriously appear into local markets at a fraction of actual cost)missing those ostensibly being targeted. ITNs distributed by NGOs are not 'free': somebody has to foot the bill for the cost of distribution/promotion. Are such NGOs any more cost effective than the private sector at this task? Who will be around 5, 10 or more years hence to keep things going? Health education targeting the intended ITN user, adoption advocacy by trusted sources (friends) and demonstration effects all seem important to persuading 'her' to hang on to the item. It may matter less how much she actully pays in cash to obtain it. How much do poor households already spend on health care costs that stem from malaria (coils, curative treatment costs, etc)? Should we assume that some of the poor cannot afford or would not make the decision to buy a net, or a second one, or a larger one? And, what of the costs of net replacement after it becomes stained, tired, torn and no longer effective? The promise of permanently treated long lasting nets may be a partial solution (at a cost). But, it seems likely that sooner or later that first ITN will need to be replaced. Who will pay for the cost of the replacement? How many 'free' ITNs are needed, at what cost, to give coverage to all those at risk around the world? And, what do we know of pressures within a family concerning alloocation of an ITN (scarce commodity). If there's only 1 net, a pregnant mom, a 3 year old, a daughter going off to boarding school and a need to work the family farm 5 kilometres away, who gets the net? If ITNs are given out free of charge, should everyone get one? If not, is the productivity of the 'still uncovered' to be ignored? Some might think that such families might simply buy another net from a vendor hopefully close to hand. But why would the private sector invest in ITN distribution at full market cost in the face of a largish scale free ITN distribution schemes? The challenge is scarcely as simple as the 'give free or make em pay' debate seems to suggest. I appreciate Abigail's call for critical reflection and openmindedness. Effective solutions are likely to require a breadth of vision and flexibility on the part of the architects that is, in some cases, still absent: blends of methods, artfully combined, are more likely to 'skin the cat' than ideologically-inspored dogmatic adherence to one particular method or another.

Utility of bednets

Rob Katz — Mon, 14 Jan 2008 08:22:47 -0500

Thanks Cat for your thoughtful comment. It is good to have the perspective of a trained epidemiologist. I tend to agree that the study is limited by its dataset - which Abigail also argues in the original post. It's a shame, since Cohen and Dupas were careful throughout not to jump to conclusions.

As far as proving the utility of a bednet (or bednet usage), that is certainly a relevant question. But it's very difficult to answer. Those with an economics background will tell you that utility is one of the most-discussed and least-practical concepts in microeconomics. In order to "prove" the utility of a bednet, you must first measure utility - not easy. Assuming you can do that, it comes down to a series of economics formulations - beginning with the construction of an indifference curve.

Anyway, between public health and economics, there's a lot that academia can tell us - but I'm not sure it's going to be practically applied in this case.

Based on your description of

Cat Laine — Sun, 13 Jan 2008 12:06:36 -0500

Based on your description of the study, it does NOT seem to answer the general question of whether free distribution of bednets is better than cost-sharing. The data required (i.e. impact of pre-existing social marketing on the study participants) does not exist to do the necessary statistical analysis (FYI: I'm a former epidemiologist).

Rather the results only refer to the very specific case where the 2 are applied in a community where there has been significant public health promotion or intervention. Given PSI's extensive work in the area, it is in no way surprising that cost is not the most important deciding factor affecting bednet usage. It also seems unlikely that their results would be generalizable to other populations where a high level of promotion was not present.

In the face of the study's data limitations, a reasonable take home message COULD BE that when the utility of bednets has been successfully proven, cost-sharing isn't necessary. This is incredibly useful info to have.

But what I really want to know how does one successfully "prove" the utility of a bednet and who tends to be better at it.

To Give or Not to Give: Academics Study Bednet Distribution

Abigail Keene-Babcock — Thu, 10 Jan 2008 16:59:15 -0500

On Wednesday, I attended a presentation by Jessica Cohen on her doctoral research experiment (co-authored with Pascaline Dupas) about distribution schemes for anti-malarial long-lasting bednets. The randomized experiment, conducted in rural, western Kenya, aimed to test the difference between free distribution and cost-sharing schemes in terms of their direct impact on malaria prevention in pregnant women and their infants. A draft of their paper is available through the Brookings Institution.

In the past, I have been an advocate for the continued use of social marketing (cost-sharing) and for profit-based BoP business models to produce and distribute insecticide treated nets (ITNs). Because of this history, I was a little apprehensive about what Cohen's presentation would reveal. After all, the report's summary stated clearly that the experiment produced "no evidence that cost-sharing reduces wastage on those that will not use the product: women who received free ITNs [insecticide-treated nets] are not less likely to use them than those who paid subsidized positive prices."

It turns out, though, that the real conclusion of the experiment in no way supports any blanket claims, such as those made to the New York Times by Dr. Arata Kochi, Director of the WHO's malaria program: "Virtually the only way to get the nets to poor people is to hand out millions free." Instead, the study arrives at this cautious and tempered conclusion: free distribution of bednets is not the way but also a way, in some cases, for lowering malaria rates in a cost-effective manner.

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