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.

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