POST 00768E : MEASLES CAMPAIGN AND ITN DISTRIBUTION
Follow-up on Posts 00763E, 00765E and 00767E
27 March 2005
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Two more contributions on this debate. The first is from Christian Lengeler
(mailto:
[email protected]) from the Swiss Tropical Institute in
Switzerland, followed by a second contribution from Mike Favin
(mailto:
[email protected]) of the Manoff Group in the United States.
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Dear Matt and Dear colleagues,
The debate so far seems to have been polarized between two antagonistic
camps... which is not any more the point at which many of us stand... it is
also not the position of the RBM group on ITNs which is currently revising
the global ITN strategy to accommodate different models.
- Firstly and foremost, we all agree that neither the Abuja not the MDG
goals can be attained without a massive increase in activities in many
areas of health care and social development. At this point we should all be
aware that there is not a single "magic bullet" approach to reaching these
targets but many and often complementary approaches. Reaching MDG is
feasible, as shown for example by the TEHIP project in Tanzania.
- Secondly, with malaria we have the "advantage" of having a clearly
defined risk group (pregnant women and small children) and we all agree (I
believe) that something special must be done for that group (pregnant women
make up 4% of the population and children under 5 years roughly 15%). We
also all agree that the majority of the population in malaria-endemic
countries is too poor to pay for all basic health services - preventive or
curative.
- Thirdly, the debate about "campaigns versus a system approach" can not
be conducted in an abstract universe... the best mix of approaches will be
different for each country, mainly as a function of how well the existing
system is functioning. Roughly, the worse the system the higher the
rationale for campaigns, with every shade of grey in-between. As a
consequence, the potential detrimental effects of campaigns are also likely
to be different according to the existing systems - for vaccination as well
as for malaria prevention.
- Fourthly, campaigns by definition address short-term targets, while we
probably all agree that longer-term targets are also important. The obvious
disadvantage of campaigns is that women do not only get pregnant and
children are not only born every 3-5 years... In any case there must be a
system that offers services on a permanent basis (essential for malaria
prevention and cure, probably less crucial in the case of vaccines for
which creating a high level of herd immunity might be good enough to
protect everybody over an inter-campaign period). We must create a
situation in which we can guarantee malaria prevention with ITNs for the
coming decades... and in doing so the financial burden is the smallest
problem of them all. Creating a strong infrastructure and health system is
by far a bigger challenge. In that sense having a strong commercial sector
for ITNs is attractive because it is fully sustainable over an indefinite
time period.
- Fifth,social marketing relying solely on sold nets (via shops or
clinics, whatever) and free nets are not the only models for discussion.
Both options are potentially complementary if so designed and coordinated.
A good example is provided by Tanzania, where social marketing has moved
away from distributing ITNs to supporting the existing commercial actors in
many different and innovative ways (SMARTNET programme run by PSI). In
parallel, a national voucher scheme supported by the Global Fund ensures
that every pregnant woman receives a voucher allowing her to get a
virtually free net (0.5 to 1 USD) from any outlet she chooses, giving her
choice and control. AN ABSOLUTELY CRUCIAL ELEMENT IS THAT THIS IS
COORDINATED PROPERLY AT NATIONAL LEVEL BY ALL STAKEHOLDERS. Only a national
"team" of stakeholders can design such an overall ITN programme and prepare
the relevant policies. This can not and should not be decided in
Washington, Harare or Geneva...
Finally, it is very obvious that the jury is still out with regard to what
constitutes the best system... At this stage none of us can honestly start
selling a "magic bullet" approach because (1) we simply do not know, and
(2) every country is a special case. In Togo I applaud the Red Cross for
the free ITN distribution... In Tanzania it would be a disaster!
So much for starters...
Regards to all,
Christian
Dr. Christian Lengeler
Swiss Tropical Institute,
Basel, Switzerland
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Hi Guys,
I can see that this is not going to be a one minute diversion! I totally
agree that distributing nets via social marketing is no better for ensuring
appropriate use. The point is that however nets are sold or distributed --
via vouchers, Neighborhood Health Committees, stores, vendors, campaigns --
real education on use needs to be built in; and that this is probably much
more difficult, although certainly not impossible, during a campaign.
If the campaign distribution is of the "permanently" treated nets, I'd
expect that to be a big advantage as far as reducing -- but not eliminating
-- the need for "education." There would also be an advantage in having
treated nets in most of the homes in a community, in that the area's
mosquito population as a whole should go down.
If we want to take some useful steps in understanding these issues better,
maybe we could think of some operational research, although certainly we'd
want to first learn what we can from existing studies and programs.
It wouldn't be hard at all to track the use of nets where they've been
distributed via a campaign, observing and briefly interviewing selected
families every month or two for 6 months or a year. While I'm just a tiny
bit concerned about people not valuing things that are "free," I'd guess
the obvious advantages of treated nets (immediate reduction in mosquito and
other bites) would make them well appreciated.
Regards,
Mike
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