Posts or Comments 01 March 2021

Monthly Archive for "August 2012"



ITNs &Morbidity &Mortality Bill Brieger | 26 Aug 2012

Mosquito Nets – are we ready to restock?

The 2012 Millennium Development Goals annual report/update has been released. Progress for malaria has been noted, but below target. In summary the report notes that …

“The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of the 99 countries with ongoing malaria transmission.”

mdg-report-2012-net-progress-a.jpgWhile the overall tenor of the report veers toward the positive, the authors had to explain that, “Although these rates of decline were not sufficient to meet the internationally agreed targets for 2010 of a 50 per cent reduction, they nonetheless represent a major achievement.”  Ironically, the map at the right, taken from the report does not even include a shading for 80% and higher – the Roll Back Malaria target for 2012. Inadequate intervention coverage and the financial and health systems weaknesses contributed to the coverage gap, in spite of calls for universal coverage in 2009.

The big push toward universal coverage did result in more nets, but some countries are still in the process of trying to get the first round of mass distribution finished.  In light of Global Fund Round 11 cancellation and the world economic crisis, fears exist that replacement nets, likely needed by 2013, can be bought. The MDG report echos this concern: “There are worrisome signs, however, that momentum, impressive as it has been, is slowing, largely due to inadequate resources.”

Fortunately there is a bight light. Rwanda just announced that –

Over six million treated mosquito nets will be distributed to households in 2012 and 2013 and around 500,000 Long Lasting Insecticidal Nets (LLINs) will be given to pregnant women and children under five years in 2012, the National Malaria Control Program Director, Dr. Corine Karema, has said. “Currently we are in the phase of replacing the Long Lasting Insecticidal Nets (LLINs) distributed in 2010,” Dr Karema said, adding that families which didn’t receive them in 2010 will be assessed so that they can also get nets.

Not only does Rwanda’s effort represent replacement of the old nets, but also recognizes the need to provide nets in an ongoing manner during routine health services like antenatal care. Let’s hope that this sets a good example for other countries to make a commitment to find the funds – locally and/or internationally to ensure that the MDG for malaria morbidity and mortality reduction will not be sidetracked.

Asia &Borders &Resistance Bill Brieger | 25 Aug 2012

Asia-Pacific: a region of contrasting hopes for eliminating malaria

The burden of malaria in the Asia-Pacific region, being much lower than that of Africa, has led to some neglect in the past when it comes to rolling back the disease. Two news reports today show why neglect is not an option is global country-by-country elimination os the disease is to be achieved.

eliminating-malaria-in-the-philippines-sm.jpgHope was expressed clearly by national Department of Health authorities in the Philippines who exclaimed that “THE Philippines could be malaria-free by 2020 as the number of cases declined by 80 percent in the recent years, the Department of Health (DOH) said on Friday.” The article in the Manila Sun-Star quoted Health Secretary Enrique Ona who said “The government has recorded 9,642 malaria cases in 2011 as compared to 43,441 in 2003.”

A close accounting of the 58 provinces that are considered endemic in the Philippines found that nine have had no cases in the past three years, and forty have been reporting less than 1 case per 1000. While definitely being optimistic about the prospects of overall elimination from the country, the Health Secretary is realistic as quoted by the Sun-Times: “The journey towards elimination status is more difficult than working for a reduction in cases and we will need more commitments and resolutions of the different sectors to be consolidated into a singular, comprehensive initiative so that the whole country, not just the 58 endemic provinces, will be declared malaria-free by 2020.”

The situation in another regional partner is more dire. VOA reports that the problem of malaria drug resistance is “more severe in Cambodia than anywhere else in the world.” The National malaria Center in Cambodia found that, “About 17 percent of all cases in the Cambodian-Thai border area of Pailin were drug-resistant in 2011, up from 10 percent the year before.”

On the positive side, even though the proportion of drug-resistant cases in increasing, the total number of cases continues to decrease. Still, there is concern about ramification of the situation “beyond borders.” Travel and migration among the Mekong region countries means that resistance may not stay put in Pailin. A comprehensive control program, not just reliance on treatment, needs to be in place throughout the region.

Fortunately there are groups like the Asia Pacific Malaria Elimination Network (APMEN) that brings countries in the region together to address common and cross-border challenges. APMEN recognizes that, “Elimination requires a different strategy than sustained control,” and is thus, in am important position to help the rest of the world learn innovative approaches to put paid to malaria.

Health Systems Bill Brieger | 24 Aug 2012

Will Superlatives Eliminate Malaria in Nigeria?

Oluyombo Awojobi is an innovative primary care surgeon in Eruwa, Oyo State, Nigeria.  His focus is on making basic and appropriate technology work in delivering care to  the bulk of Nigeria’s population, especially in rural areas.  Below he has shared his thoughts on the weakness of the grandiose. We agree with his perspective and doubt whether six regional mega hospitals will help eliminate one of Nigeria’s main killers – malaria – in the near future.

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Nigerians have a penchant to use the superlative in describing events, institutions and personalities. For example, the country is the GIANT of Africa, members of the national football team are the SUPER eagles, Lagos, the old capital is the centre OF EXCELLENCE and plans are afoot to make it a MEGA city. Being a petroleum exporting country, there are MEGA petrol stations. In religious circles, there are the MOST HOLINESS, the MOST REVD SENIOR APOSTLE PROPHET DR Abrahams, the head of an orthodox religious denomination has transformed from the SECRETARY to the PRESIDENT. When the old market is renovated, it becomes an ULTRAMODERN shopping plaza with no functioning toilets!!

The health sector is not left out. Over three decades ago, the teaching hospitals in the geopolitical zones became CENTRES OF EXCELLENCE in neurosciences, cardiovascular medicine/surgery, oncology and immunology. That was the golden era in medical practice in Nigeria when these public institutions were blazing the trail in open heart surgery, renal transplantation, Siamese twins separation etc.

With economic depression and corruption in high and low places, the decline set in until the advent of the third republic in 1999 when the civilian government initiated the Famed programme that would turn the teaching hospitals into world class centres and stem the outflow of Nigerians to foreign countries for medical care. A decade later, the teaching hospitals are still prostrate. In some, their laboratories and investigation units have been outsourced to private outfits.

guardian-mega-hospitals-sm.jpgAlthough the federal authorities had identified the challenge as that of poor work ethics and SURGICAL TURF PROTECTION, they seemed not to know how to set about rectifying it. The latest effort is headlined “Govt begins MEGA hospital projects in six zones.”

“Health Minister, Prof. Onyebuchi Chukwu, who inaugurated the panel, tasked the members to conduct a critical analysis of low private sector investment in high-end specialist hospitals and medical diagnostic centres in Nigeria.

“They are also to identify and engage potential investors with a view to guiding them to develop business models and plans for the establishment of world-class hospitals in the country.

“The team will also look into and propose an accreditation scheme that would ensure full compliance with global best practices in the operations of the proposed facilities.

“Chukwu said: ‘As many of you have observed, tertiary healthcare services in Nigeria have been largely in the domain of the public sector. However, inefficiency in resource management and service delivery, and the ever dwindling financial resources per capita for the health sector have made it difficult for many of the government-owned hospitals to keep up with global best practices

‘The associated failure to provide high-end medical services in many instances coupled with globalisation has resulted in loss of patients to medical tourism with its attendant capital flight from the economy further worsening the economic situation in the country.  In the circumstances, it is obvious that government alone cannot provide all the facilities needed to provide adequate healthcare services to the teeming population, now at 167 million and still expanding. These issues have been a source of concern to the President who in his transformation agenda for the health sector has decided to engage the private sector under different models of Public Private Partnership.”

The question that bothers me is “Why should charity not begin at home?”. In countries that are attracting Nigerians in medical tourism, the infrastructure (electricity and water supply) is solid as is relative security and services from top to bottom are rendered by dedicated and efficient staff.

Most major surgeries known to man are routinely performed in Nigerian hospitals – mainly private, but out of the reach of most patients who are wary of the dedication of the specialists.

The other day at the maiden Free Medical/Health Outreach provided by Primus Super Specialty Hospital, (an Indian group) Abuja in collaboration with the Health and Human Services Secretariat of the Federal Capital Territory Administration (FCTA), the Indian High Commissioner in Nigeria was quoted as saying:

“The Indian government has advised Nigeria, to improve on the standard of health care facilities in order to ease the difficulties faced by Nigerians who go abroad for medical attention.

“It is difficult for a sick person to travel, and it is even more difficult when you are seriously sick to travel that distance, and it is only humane for us to endeavor to come closer to the patients as possible.” India is the country where most Nigerians travel to receive surgical care.

Three years are not too long as incubation period for the mega hospitals project. We will “SIDDON LOOK”.

With kind regards. Yombo Awojobi

Communication &ITNs Bill Brieger | 24 Aug 2012

More on Insecticide Treated Bednet Experiences

In response to our blog on malaria and bednet perceptions, Stephen Goldstein of Johns Hopkins University’s Center for Communications Programs (JHUCCP) offers a compendium of experiences gleaned from their K4Health’s newly re-designed POPLINE database. Here are Stephen’s findings …

While many of the articles cite reasons of cost or concerns about safety and effects of chemicals, some mention that sleeping under them was too hot, and that they were used more during the rainy season than the dry.

super-market-3a.jpgSome other lessons:

  • Treated nets were more likely to be used than untreated ones;
  • Nets two years old or less were more likely to be used than older nets;
  • Nets that were paid for were more likely to be used than nets obtained for free;
  • Larger nets were more likely to be used than smaller ones, except in Ethiopia;
  • The more nets a family owned, the less likely that all of them would be used.

Other information from the articles include:

In Uganda a project to test the accuracy of reporting about bed net use was carried out through a questionnaire sent to schools vs. a more traditional and more expensive community survey method.The study concludes that in areas with high school attendance rates, school children’s report of bed net use monitored by school teachers could give a good approximation of household ownership of bed nets at community levels with about ±5% difference between community and school surveys.

In Timor-Leste, there was a widespread perception that nets could or should only be used by pregnant women and young children, and extensive re-purposing of nets (fishing, protecting crops) was both reported and observed, and may significantly decrease availability of nighttime sleeping space for all family members if distributed nets do not remain within the household.

In some parts of Kenya, despite insecticide treated nets ownership reaching more than 71%, compliance was low at 56.3%.

In Zambia, some bed net distribution strategies missed households occupied by the elderly and those without children, resulting in overall low use as well as a perception that the insecticide-treated mosquito nets wore out before they could be replaced.

In Tanzania, while 65 percent of some 200 respondents were aware of the use of insecticide treated nets (ITNs), the coverage of any mosquito net and ITN was 12.5% and 5%, respectively. Affordability, unavailability and gender inequality were identified to be major factors associated with the low ITN coverage.

As the body of information and knowledge about use and non use of ITNs becomes available one hopes that it will be easier for the “basic anthropological skills” to be employed by program managers and that “the pretty posters that convey nothing” will be a thing of the past.

Research Bill Brieger | 20 Aug 2012

Dr Agomo – Congratulations on a Productive Career in Malaria Research

The Nigerian Institute for Medical Research (NIMR) in Yaba, Lagos has been a major player in generating knowledge about malaria for national and international policy makers. Just a few days ago, one of its distinguished researchers Dr. P.U. Agomo (BSc Hons, MSc, PhD, AIMLS) retired after 32 years of service. He had attained the post of Director  of Research  (Biochemistry  and Nutrition) at NIMR. Below is the citation provided by NIMR on the occasion of his send-off party, 13 August 2012.

agomo2.jpgDr Philip Agomo was born in August, 1947. He graduated from Greenwich University, London,  UK with  a BSc (Hons)  in  Biochemistry  (1973),  MSc in Applied Immunology from Brunel University, Uxbridge, Middlesex, England, UK (1977) and PhD from University of London, UK (1980).

Dr Agomo joined NIMR in 1980 as a research Fellow II and rose through the ranks of leadership to become the Director of Research (Biochemistry and Nutrition)  in 2008 and acting Director General of NIMR  from  July 2008 to May, 2010. Dr Agomo has also served the World health Organization (WHO) as an adviser on Antimalarial drug packaging for home management of malaria, appropriateness of childhood fever treatment in Africa, Health Sector Reform for Capacity Strengthening  and Malaria control in Africa and implementation  of community based management of Acute respiratory  infection  (ARI)  in Africa.

At the regional level, Dr. Agomo served West African Health Organization (WAHO) as an adviser on Health Research System Strengthening in the West African region. He also served as the Chairman of the Monitoring and evaluation sub-Committee of the National Malaria Control Committee (transformed  to NMCP in 2005) from 2001 to date.

Dr Agomo has also participated in many malaria control programmes at international,  regional, national and state levels as a Principal Investigator winning many  academic awards and research grants. Notable among these is the placement of NIMR as a training sub-recipient in the implementation  of global fund round 4 phase 2 (2008)  and round 8 (2010),  funded with about N150m Naira.

Dr. Agomo is well recognized not only for scholastic, administrative  and leadership qualities but also as a mentor of students and junior research scientists at NIMR, in Nigerian universities and outside the country. He has produced more than 10 PhD holders as a co-supervisor  in Malaria research (Pharmacokinetics,  Drug Resistance and Immunology),  Nutritional  Biochemistry  and Toxicology.  Dr. Agomo has to his credit over 80 scientific publications in peer-reviewed journals. He is happily married and blessed with two children. He is also a grandfather. 

Below are a few of Dr Agomo’s malaria-related publications that span his 30-year career:

  • Prevalence of malaria in pregnant women in Lagos, South-West Nigeria. Agomo CO, Oyibo WA, Anorlu RI, Agomo PU. Korean J Parasitol. 2009 Jun;47(2):179-83. Epub 2009 May 27.
  • Efficacy, safety and tolerability of artesunate-mefloquine in the treatment of uncomplicated Plasmodium falciparum malaria in four geographic zones of Nigeria. Agomo PU, Meremikwu MM, Watila IM, Omalu IJ, Odey FA, Oguche S, Ezeiru VI, Aina OO. Malar J. 2008 Sep 9;7:172.
  • Treatment of childhood fevers and other illnesses in three rural Nigerian communities. Salako LA, Brieger WR, Afolabi BM, Umeh RE, Agomo PU, Asa S, Adeneye AK, Nwankwo BO, Akinlade CO. J Trop Pediatr. 2001 Aug;47(4):230-8.
  • Analysis of human antibodies to erythrocyte binding antigen 175 of Plasmodium falciparum. Okenu DM, Riley EM, Bickle QD, Agomo PU, Barbosa A, Daugherty JR, Lanar DE, Conway DJ. Infect Immun. 2000 Oct;68(10):5559-66.
  • Effect of chlorpheniramine on the pharmacokinetics of and response to chloroquine of Nigerian children with falciparum malaria. Okonkwo CA, Coker HA, Agomo PU, Ogunbanwo JA, Mafe AG, Agomo CO, Afolabi BM. Trans R Soc Trop Med Hyg. 1999 May-Jun;93(3):306-11.
  • “Antimalarial” medicinal plants and their impact on cell populations in various organs of mice. Agomo PU, Idigo JC, Afolabi BM. Afr J Med Med Sci. 1992 Dec;21(2):39-46.
  • Cell-mediated immunity in the liver of mice vaccinated against malaria. Playfair JH, De Souza JB, Dockrell HM, Agomo PU, Taverne J. Nature. 1979 Dec 13;282(5740):731-4.
  • Development and suppression of a population of late-adhering macrophages in mouse malaria. Lelchuk R, Taverne J, Agomo PU, Playfair JH. Parasite Immunol. 1979 Spring;1(1):61-78.

Asia &Elimination &Policy Bill Brieger | 19 Aug 2012

Vietnam To Tackle Ending Malaria with Asia Pacific Malaria Elimination Network

apmen_banner.gifPress Release from APMEN

In an important step toward achieving malaria elimination, Vietnam officially joins the Asia Pacific Malaria Elimination Network (APMEN) today. APMEN brings together countries in the Asia Pacific that have adopted a national or sub-national goal for malaria elimination, and connects them with a broad range of regional and global malaria partners to develop best practices for eliminating malaria and to efficiently address region-specific challenges, like Plasmodium vivax.

Vietnam has made great strides in improving the health of its citizens, which includes reducing the risk of malaria throughout the country. Malaria deaths have plummeted by 91% in the last decade, from 71 deaths in 2000 to 14 in 2011. Reported cases of malaria have also dropped by 85%, declining from 300,000 cases to 45,000 in 2011. However, similar to other countries in the Asia Pacific region, Vietnam faces substantial challenges to eliminating malaria, which include the increasing spread of drug-resistant malaria parasites and continuous movement of populations between malaria-free and malaria-endemic areas.

The most malarious regions in Vietnam – remote, forested areas – are also the country’s hardest places to reach, and require more responsive surveillance systems to effectively track down and treat malaria cases. By joining APMEN, Vietnam aims to harness the region’s collective experience, research findings and program recommendations to take on the final – and perhaps most difficult – steps to eliminating malaria. itn-in-high-endemic-area-vietnam.jpgVietnam’s malaria program, the National Institute for Malariology, Parasitology, and Entomology (NIMPE), recently completed its National Strategy for Malaria Control, Prevention and Elimination 2011-2015. With this strategic plan,

Vietnam outlined its goals of controlling and reducing malaria in higher burden areas, and the implementation of a spatially progressive malaria elimination strategy in low transmission regions. APMEN is a country-led network focused on generating and disseminating evidence-based information on what works to drive down malaria and achieve elimination in the Asia Pacific.

APMEN was developed in 2009 in response to a call to action by countries in the region to tackle malaria elimination. With Vietnam as the newest addition, APMEN connects its 12 other network countries— Bhutan, Cambodia, China, Democratic People’s Republic of Korea, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu— in an effort to learn from each other’s malaria program approaches, translate research into action and consider optimal program implementation.

More reading about eliminating malaria in Vietnam can be found through the UCSF Global Health Group’s country profiles. APMEN country partners work together to sustain the gains made in malaria control and ensure financial and political support for malaria elimination in the region. Further information regarding APMEN can be viewed at www.apmen.org.

Community &ITNs Bill Brieger | 19 Aug 2012

Malaria, Bednets and Local Knowledge

I recently saw a posting on the HIFA2015 listserve that called for more culturally appropriate health information/behavior change communication in Kenya. Beatrice Muraguri a Health Information Officer with the Ministry of Health from Kenya observed, “barriers to LLINs use as an intervention in malaria control especially from Kenya’s Coastal region. In 2006 when we did our last mass distribution, refusals were many as rumours went round that the white rectangular nets were talking to the people and this hampered the use. We had to do a lot of social mobilization for acceptance.”

llins-for-goal-post-2.jpgI discussed this experience with colleagues, one of whom asked if there was any overview of such net experiences from which programs could learn. In fact I am not aware of any broad based publication on cultural aspects of net use and misuse, but there has certainly been much information generated locally that is of anthropological relevant.

In a sense the challenge is that relevant information about nets is often quite localized. It would be useful to find out how much this information was gathered before major campaigns and actually used, and how much information was gathered after the fact when coverage was less than expected.

The concept of an ‘overview’ is in fact embodied in the anthropological process of inquiry that guides people to look for local perceptions and also hold the attitude to respect these local ideas, not as curiosities, but a alternative realities. When we deal with “local knowledge” we must consider the components of the perception – in this case we must consider how people perceive ‘malaria’ and in that context what are appropriate (if possible) preventive measures (not every group perceives ‘malaria’ as something that can be prevented in the western orthodox sense).

Then we need to consider perceptions of the nets themselves as well as the perceptions about insecticides/chemicals. In one setting nets may make people think of funeral shrouds, while in another they may appear to be wedding veils or fishing nets. People are always re-purposing artifacts from one culture to fit into what they perceive as relevant in their own.

So it is such ‘general lessons’ about how to obtain and use local knowledge that can be an overview or guidance.  We need to assume first and foremost that innovations like LLINs will just as likely NOT be seen by a local community in the same way that we western scientists see them.

There are also basic lessons from marketing. People reject products that are inconvenient or poorly designed.  People have always complained about nets restricting ventilation, and recent research has shown this to be true. Scientists have previously persisted with the ‘it’s good for you’ approach and assume people will do what is ‘good’. In contrast commercial companies are usually very sensitive to how people react to product function and design and try to find out what people think before expending great resources scaling up something in the market.

In the marketplace the customer may not always be ‘right’, but the customer does have the money. Since many public health interventions are free, we act as though people should be so grateful for getting those free commodities that they should not question how we tell them to use the nets. We forget that people are still public health ‘customers’.

So maybe there has not been a compendium written about net experiences from which one might draw lessons, but the basic anthropological skills exist and could be employed for each setting should program managers wish. Instead they often prefer to give IEC/BCC contracts to their friends and relatives to produce pretty posters at great cost that convey nothing meaningful to the public.

Maybe we can begin by sharing our experiences on listserve groups like HIFA2012 and our malaria update listserve and create a useful body of knowledge in terms of local approaches to improving net acceptance and use.This will work only if such feedback gets to the net designers and manufacturers!

Right now the comment function on this blog is ‘broken’ and the previous sponsors have withdrawn technical support. In the meantime people can comment on twitter at https://twitter.com/#!/bbbrieger

Malaria in Pregnancy &Universal Coverage Bill Brieger | 12 Aug 2012

Malaria Thoughts on International Youth Day

Youth, those 15-24 years old, are usually thought to be generally healthy and often do not occupy the minds of health planners. It is the pre-school age child who dies from infectious diseases and the older adult who succumbs to non-communicable afflictions. Actually as an e-mail today from USAID points out …

Approximately 16 million girls between the ages of 15 and 19 give birth each year. The impact of pregnancy on adolescent girls can be devastating: girls who become pregnant face a higher risk of maternal mortality, often drop out of school, and are sometimes forced into early marriage. In 2009, nearly 2.5 million boys and girls under the age of 15 were living with HIV, and 370,000 were born HIV-positive. For many, HIV has become a chronic disease that requires lifelong treatment, care, and support.

Pregnant teens living in malaria endemic areas are usually at high risk because it is the first and second pregnancies especially that are more prone to the disease and the anemia, miscarriage, still birth and possible death that comes in its wake. For example, researchers in Western Region, Ghana recently found that …

… adolescent pregnant girls were more likely to have malaria and anaemia compared to their adult pregnant counterpart. Results from this study shows that proactive adolescent friendly policies and control programmes for malaria and anaemia are needed in this region in order to protect this vulnerable group of pregnant women.

dscn2401sm.jpgOf course, youth are not only victims of malaria, but agents for change. A youth group in Uganda has launched the  Make Malaria History Campaign (MHC) and plans to distribute over 100,000 treated mosquito nets. Youth often organize community drama to highlight health issues as seen in the photo from Bauchi State, Nigeria.

Elimination of malaria means protecting all segments of the population in the spirit of universal coverage. Youth are not an exception.

ITNs &Universal Coverage Bill Brieger | 11 Aug 2012

Universal Coverage is not Universal Use

Philippa West and colleagues have demonstrated yet again that ownership of an insecticide treated bednet (ITN) does not guarantee that people are protected. Their study in Muleba District, one rural district in northwestern Tanzania points out the universal challenges of universal coverage.

In the study district the proportion of households (HH) owning ITNs increased from 63% to 91%.  The average number of ITNs per HH also rose from 1.2 to 2.1. The problem was that even with more nets in more homes, the proportion of residents actually sleeping under them did not rise to reach the desired target of at least 80%.  As an aside – statistical significance was achieved, but not program significance.

Here is what they found in the community from before and after universal coverage distribution:

  • proportion of all residents sleeping under ITNs rose from 41% to 56%
  • children under five years old – 56% to 63%
  • pregnant women  – 55% to 63%

What was happening? One crucial finding was that 42% of households and fewer nets than the number of sleeping spaces and 20% had more than enough.  This speaks poorly to pre-distribution planning and HH registration or lack of care and verification during the actual distribution.

sleeping-under-an-itn-in-tanzania-from-2010-sm.jpgAnother explanation documented by the researchers was that a fair number of HH did not redeem their net coupons at the distribution point – too busy, forgot, no transportation, etc. The program could have benefited from community directed distribution which guarantees that villagers take care of and ensure their own supplies of basic health commodities like ITNs.

These findings do not come as a surprise. Numerous reports from Demographic and Health or Malaria Indicator Surveys have shown a similar phenomenon – ownership of a net by the household does not guarantee that people actually use them.  In particular we can see this problem in the attached chart from the Tanzania 2010 DHS.

Fortunately the distribution in Muleba, though having problems, was equitable in terms of the economic status of recipients. Better planning, health education, community involvement and follow-up is required  if we are not to waste millions of dollars, not to mention lives, from poorly distributed nets.