Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Friday, December 7, 2007

The Distribution of Subsidized ITNs in Third-World Countries: Why the Social Marketing Approach to Fighting Malaria is Ineffective - Sara Hudson

In the realm of global health crises, the mosquito-born malaria virus is arguably one of the most preventable and treatable maladies facing the health community. Indeed, millions of dollars have been donated to hundreds of organizations worldwide that have made fighting the malaria epidemic their mission. One such organization, Population Services International (PSI), is part of a global consortium of institutions that is working to achieve Millennium Development Goals to halt and begin to reverse the incidence of malaria worldwide by the year 2015 (1). Thus, the ultimate goal of PSI and its sister organizations is to eliminate malaria as a leading cause of death and as an impediment to social and economic development around the world (2). PSI works directly in more than 30 countries and supports more than 70 others across the Americas, Asia, and Africa to promote healthy behavior by selling products and services [in this case, Insecticide-Treated Nets, or ITNs] at subsidized prices rather than giving them away. This social marketing approach encourages involvement of the commercial sector in the fight against malaria (3).

PSI’s use of social marketing to distribute ITNs in malaria-rich areas is effective on many levels. It provides individuals access to an expensive item at a reduced price, it increases awareness about how malaria can be treated and contained, and it stimulates the local commercial sector. However, this strategy is flawed in three important ways: it does not consider economic, geographic, and educational limitations of the populations it targets.

This paper will argue that the social marketing approach is a flawed public health initiative because it assumes that individuals will be able (and willing) to spend money on bed nets, which is not always possible in third-world countries. If a parent must choose between meeting an immediate need (food) or a future need (no malaria), she will most likely address the immediate need first. It also assumes that women visit health clinics each time they give birth. It does not consider that many health clinics are not located in geographically strategic areas, that women always visit the clinics, or that women are physically able to reach a city, town, or village to purchase the nets or visit the clinic, due to geographic constraints. Finally, PSI’s social marketing approach does not take into account education initiatives. It does not focus on teaching individuals about the importance of obtaining a bed net, maintaining it, replacing it when it is no longer viable, or how to fight off mosquitoes in other ways.

Now or Later: Choosing Between Needs

Abraham Maslow’s theory of hierarchy of needs states that food, water and shelter are the basic physiological needs essential for survival. Second are those safety needs which provide the security necessary for higher forms of development (4). This implies that individuals are always striving to meet each of these primary needs before satisfying any other peripheral desires. In third world countries, where malaria is endemic, meeting those most basic of Maslow’s needs is a daily challenge. Procuring enough food to feed a family is a problem that faces 854 million people worldwide; 820 million of those are in developing countries (5).

Although socially-marketed ITNs are sold at a reduced cost, for many people in the developing world, money is spent on obtaining basic needs, such as food and shelter, rather than on a health product whose benefits may not be seen for months or even years. For the nearly three billion people around the world living on less than two dollars a day (6), a five-dollar ITN purchased commercially (with subsidization) is an inconceivable expenditure. A social marketing campaign in two districts in Tanzania between 1996 and 2000 that charged the user and their communities a subsidized price of approximately 5 USD in cash saw a rise in ITN coverage throughout each district. However, the difference in coverage between the least poor quintile and the poorest quintile was markedly different. In 1997, when the study began, 63% of the least poor households had a net, while only 20% of the poorest households did. In 2000, numbers for both groups rose, but the wealthiest quintile was now 92% covered, while the poorest quintile was only 54% covered (7). PSI institutes similar price subsidies in their campaigns (8), which suggests that individuals who have their basic needs met will be more likely to purchase an ITN. Those struggling to feed themselves will not be able to afford an ITN, whether it is subsidized or not. PSI does not take this economic stratification into account when intervening.

Research has shown that for most individuals struggling to stay malaria-free, economic limitations are the greatest barrier to protecting themselves, rather than knowledge of the efficacy of ITNs (7, p. 410). In two districts in southern Tanzania, research indicates that approximately 75% of monthly household income is used for food. With an average monthly income ranging from $77 to $96 a month (depending on the season), this leaves between $19 and $24 a month for other household expenses (7, p. 1122). Clearly, a $5 ITN would be a steep price for any family to pay for a preventative tool that may or may not prove effective.

Near or Far: Access to Health Care Facilities

Another facet to the PSI campaign and other similar social marketing campaigns is targeting specific populations during distribution. One population that is greatly affected by malaria is pregnant women. In order to reach these women, PSI and other organizations distribute ITNs at public health facilities and prenatal clinics. In theory, this is a great idea. However, one aspect that is not taken into consideration is the geographic constraints that may prevent women from reaching these facilities. In many rural communities in developing countries, health clinics are neither geographically convenient nor easy to reach.

The geographical distribution of health care facilities is of vital importance when implementing a public health intervention. Rural residents have to travel long distances, often by foot, to reach health centers in urban areas (9). Admittedly, some health centers in poor countries engage in outreach activities to rural areas, but many lack adequate resources such as vehicles, gasoline, and medicine, and are further inhibited by poor road conditions (10). Added to the already difficult experience of physically getting to a clinic (while pregnant, no less) is the issue of how to pay for the visit and what to do with the children that are inevitably left at home while the mother is at the clinic. A pregnant mother cannot afford the loss of money, labor, or childcare for a day trip to the city to get a net to prevent a condition that may never affect her.

The Next Step: Education Initiatives

Finally, the social marketing approach does not take into account the necessity for education initiatives. An ITN is worthless if the recipients do not know how to use or replace them, or how to fight off mosquitoes in other ways. PSI’s campaign implements advertising and mass media channels to explain proper ITN use, but does little to explain the cause of malaria, how it is transmitted, and alternative methods to controlling it in lieu of possessing a bed net. Community-based health education programs must be implemented alongside the distribution and marketing of ITNs in order for the campaign against malaria to be effective. Social marketing campaigns that have been successful have been implemented following months of community training and education programs provided by local health practitioners, religious leaders, and village government officials (7, p. 1122). These education initiatives provide villagers with an incentive to spend $5 on an ITN because they have knowledge about the importance of preventing malaria transmission and the support of their community to continue to do so.

Resolution: A Multi-Faceted Approach

It is abundantly clear that the social marketing approach utilized by PSI is effective in many ways, but that there are glaring omissions to the intervention. Selling subsidized bed nets to communities already struggling to obtain adequate financial resources only serves to further exacerbate the gap between the richest of the poor and the poorest of the poor. Those individuals living in rural communities with little access to health care facilities, educational opportunities, and economic resources stand little chance of obtaining and implementing an ITN appropriately. A better alternative would be to engage in coordinated efforts with local medical practitioners to distribute ITNs at no or very low cost to rural communities, an approach that several studies have shown significantly reduces the level of malaria coverage. One program in Vietnam that distributed ITNs free of charge and provided free diagnosis and treatment of malaria dropped the rate of infection in children under two from 37% to 4%, and from 56% to 7% in children two to ten (11). The social marketing approach is a great improvement to some of the previous malaria initiatives, but lacks several key components that are necessary for the malaria epidemic to be wiped clean.


1. United Nations. UN Millennium Development Goals. New York, New York: United Nations.

2. World Health Organization. What is the Roll Back Malaria (RBM) Partnership? Geneva, Switzerland: World Health Organization.

3. Population Services International. About PSI. Washington, D.C: Population Services International.

4. Stichick, Theresa and Claude Bruderlein. Children Facing Insecurity: New Strategies for Survival in a Global Era. Harvard Program on Humanitarian Policy and Conflict Research.

5. World Food Programme. What is Hunger? Rome, Italy: World Food Programme.

6. Shah, Anup. Poverty Facts and Stats. United States: Global Issues.

7. Nathan, Rose, Masanja, Honorati, et al. Mosquito nets and the poor: can social marketing redress inequities in access? Tropical Medicine & International Health 2004; 9 (10): 1121–1126.

8. Stevens, Warren, et al. The costs and effect of a nationwide insecticide-treated net programme: the case of Malawi. Malaria Journal 2005; 4: 1-6.

9. Mbatia, Paul N. and York W. Bradshaw. Responding to Crisis: Patterns of Health Care Utilization in Central Kenya Amid Economic Decline. African Studies Review 2003; 46: 69-92.

10. Glik, Deborah C. et al. Malaria Treatment Practices Among Mothers in Guinea. Journal of Health and Social Behavior 1989; 30: 421-435.

11. Brentlinger, Paula E. Health, Human Rights, and Malaria Control: Historical Background and Current Challenges. Health and Human Rights 2006; 9: 10-38.

Labels: ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home