The Economist (!) Succumbs to the "Siren Song" of Universal Bednet Giveaways

With dismay, I read today this piece in The Economist - which adds their important voice to the chorus calling for bednet programs based on universal free giveaways. The Economist bases its endorsement on a recent study by the WHO assessing malaria interventions in four countries which purportedly overturns the prevailing wisdom.

First, the prevailing wisdom.

Two reviews, one by Roll Back Malaria, and another by the World Health Organization's malaria department, have been conducted on how to achieve high and sustained coverage of bednets. Both concluded the same thing: to achieve and sustain bednet coverage, multiple distribution strategies involving both public and private sector distribution are more effective than public distribution alone. And, pregnant women and children should pay low or no price - while others continue to pay positive prices.

The logic of free bednets, and public sector distribution is obviously seductive...and now it can count The Economist among its conquests. So, perhaps it is worth reiterating why these reviews concluded there is a need for positive prices and private distribution and sale of bednets.

Why positive prices:

• The effect of bednet coverage interventions relies crucially on the supply response. It is critical that suppliers be motivated to sell nets - and both public and private suppliers are more responsive when prices are positive. My colleague Mead Over recently blogged about how positive prices engender supply responses in public facilities.
• Payment for bednets frees up program funding for other uses. African governments' budgets for health are extremely limited; and donor resources are insufficient to cover the cost of the "big three" malaria interventions (bednets, treatment, and spraying). Other malaria program interventions, such as stimulating demand and use of nets, and improving case management of malaria are very effective; some scarce program dollars need to be allocated here rather than widening price subsidies. For example, despite widespread support, the Affordable Medicine Facility to fund malaria drugs is not yet funded.

Why public and private distribution is needed:

• Private distribution and supply is less susceptible to breakdown related to the volatility of donor funding (Amanda Glassman and Christopher Lane recently drew much-needed attention to the destructive impact on program effectiveness linked to volatility of aid flows)
• Private distribution and supply is less susceptible to breakdown related to public sector management problems (Richard Tren and colleagues at Africa Fighting Malaria describe here a three year freeze in public sector distribution of bednets in Uganda due to problems between the Ugandan government and the Global Fund)
• Private distribution and sale is available outside the time parameters of public sector campaign - which is critical to ensure coverage of newly pregnant women and newly born children.
• Private sellers increase use by sensing and responding to consumer preferences (people like different colored, different shaped nets and will buy more if they have product choice)
• Private distribution chains are often more effective than public sector in getting products out to rural and hard-to-reach areas

As new studies are done, they most assuredly should be considered together with all the other evidence, to see if the balance has shifted enough to justify altering the guidelines. As noted in The Economist, the interventions assessed included simultaneous free distribution of bednets and free distribution of artemisinin drugs - the highly-effective malaria treatment. So these reviews do not shed light on the relative effectiveness of bednet coverage interventions.

While the review can’t shed light on bednet coverage interventions, the very high mortality reductions in Ethiopia, Rwanda and Zambia from the dual (bednet/ drug) intervention are striking. These findings should be examined as quickly as possible to inform malaria programs being designed now.

Unfortunately, the WHO review mentioned in The Economist is not published or available for review - so it is not possible to judge the quality of the analysis. Nor do we know how to interpret the findings. Mr. Kochi, who is quoted in the article, has demonstrated a tendency to "get ahead of the facts" on this very topic in the not-too-distant past (subscription required). Malaria program funders are urged to be a bit more cautious than The Economist in interpreting the findings pending their review.