The New Vision (Kampala) reported on Sunday the abuse of a free ITN program in Tororo, Uganda. Not only was the paper concerned that, “The fight against malaria in Tororo district is facing setbacks as residents use mosquito nets, which are intended to control the spread of the disease, to make wedding gowns.” They were also appalled that members of the local council, “cannot support voluntary programs if there is no kitu kidogo (bribe).” Concern even extended to the health workers who manage the project and who were warned not to “use the project’s bicycle or motorcycle to take your wife or children for leisure rides.” This raises the age old question of whether people appreciate things they receive for free.
In contrast, Noor et al., in PLoS Medicine make the case for free distribution of nets as not only being pro-poor (equitable) but also effective in increasing coverage in neighboring Kenya. Their conclusions are in keeping with WHO’s Global Malaria Program in a recent position paper stated its preference for net distribution as follows:
“In most high-burden countries, ITN coverage is still below agreed targets. The best opportunity for rapidly scaling-up malaria prevention is the free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns). LLINs should be considered a public good for populations living in malaria-endemic areas. Distribution of LLINs should be systematically accompanied by provision of information on how to hang, use and maintain them properly.”
The Tororo experience contrasts with expectations in Benin Republic according to Aplogan and Ahanhanzo (Bull Soc Pathol Exot. 2007; 100(3): 216-7) where, “The major expectations of the households are supply of impregnated bed nets free of charge.” The key to successful ITN distribution and utilization rests on thorough community involvement, demand creation and culturally appropriate health education.