Tanzania has three main ITN distribution mechanisms, the commercial market, a voucher system for subsidized net purchases and free nets distributed during campaigns. Khatib and colleagues found that, “All three delivery strategies enabled a poor rural community to achieve net coverage high enough to yield both personal and community level protection for the entire population. Each of them reached their relevant target group and free nets only temporarily suppressed the net market, illustrating that in this setting that these are complementary rather than mutually exclusive approaches.”
Different distribution strategies reached different groups: vouchers and free nets were more likely to be obtained for young children, while nets purchased at market price were more likely to be obtained for adults. In the study district, “Net use was 62.7% overall, 87.2% amongst infants (0 to1 year), 81.8% amongst young children (>1 to 5 years).” This process appears to have enabled achievement of RBM 2010 targets as early as 2006. Technically since LLINs were not introduced until after the study and some of the ITNs had not been treated in more than six months, the coverage results are not a perfect match for the RBM target, but they do indicate that products can actually be put in place for a large portion of the population.
Another important aspect of the complementarity of the strategies was, “Provision of nets at no cost through the public sector did not compromise the viability of either the voucher scheme or the commercial market.”
While the authors explain that a number of strategies are available to the National Malaria Control Program, it does not appear that the NMCP actually sat down with partners to plan how to achieve coverage using a multi-strategy approach. The results in a way appear to be that of a ‘natural experiment,’ i.e. that it just so happens that three different approaches were in place at the same time in the same district.
We discussed the involvement of the private sector yesterday, and this Tanzanian example reinforces the points made. The challenge is getting partners to sit down together and ensure that coordination happens – that one district does not get only free net distribution while another depends solely on vouchers. Planning is needed to ensure that each strategy reaches its appropriate audience depending in part on service utilization patterns and ability to pay.