257 Health and Social Services 35524 December 2005 Findings reports on ongoing operational, economic, and sector work carried out by the World Bank and its member governments in the Africa Region. It is published periodically by the Knowledge and Learning Center on behalf of the Region. The views expressed in Findings are those of the author/s and should not be attributed to the World Bank Group. Social Marketing of Bednets in Tanzania Rose Nathan, Hadji Mponda, Hassan Mshinda Malaria is still a devastating signed the Abuja Declaration, disease in sub Saharan Africa with the commitment to protect where it kills at least one million 60 percent of African children people every year (UNICEF 2003). with a treated net by the year Children are most vulnerable to 2005 (RBM 2000). malaria attacks, which kill more The issue of how the nets than 3,000 children every day, should be effectively delivered to largely in Africa. At least 100 the poor communities has been a Tanzanian children die daily subject of debate. Formulating because of the disease. Another effective and sustainable mecha- high-risk group is pregnant nisms that guarantee access to women. However, all other adults ITNs by the most vulnerable has are also exposed to substantial been a challenge. Social market- risk of malaria. In Tanzania, ing programs offer a way to control and care of malaria puts a increase demand through promo- huge burden on financial and tion at the same time supplying economic costs both at micro and nets at subsidized prices. macro levels, thus translating into enormous poverty implica- The concept tions. As such, malaria has a potential in slowing down the Social marketing is an approach achievement of the MDGs in where the experience of commer- countries where it is endemic as cial marketing is applied to a is the case in many parts of product which has a social Tanzania. benefit, with the main motiva- Many efforts and resources tion being social improvement have been invested in search of rather than financial gain to the effective malaria control strate- marketer (Andreason, 1995). gies. Among few of the strategies Largely Population Service that have shown effectiveness International (PSI) and Ifakara Findings are insecticide-treated nets Health Research and Develop- (ITN). Such nets have been ment Centre (IHRDC) have proven to be effective, feasible implemented social marketing of intervention for reducing malaria insecticide-treated nets in morbidity and mortality. Tanzania. Here, we describe a At the African Summit on Roll specific social marketing pro- Back Malaria, African leaders gram, known as KINET, for insecticide-treated nets in two choice. Through local market ITNs included retail agents in each village and wholesalers in rural districts of Tanzania, research a brand name "ZUIA each division. The retailers were Kilombero and Ulanga, imple- MBU" (a kiSwahili phrase which chosen jointly by project staff and mented by IHRDC. The program means prevent mosquitoes) was community members; they aimed at achieving substantial identified for treated nets and and sustainable use of insecti- insecticide. included private shopkeepers, cide-treated nets in young chil- community leaders, health dren and pregnant women. The Marketing package workers and priests. A reward purpose of the program was well system was used for retailers and Product in line with the philosophy of wholesalers for reaching certain The nets were dark green high social marketing; it was there- sales targets. Over time, inactive quality polyester in two sizes: fore envisaged as the most retailers were replaced. Insecti- (100 x 180 x 150 cm and 130 x appropriate technique to reach cide retailers, in the initial 180 x 150 cm). The sizes were the target population with the distribution area were provided suitable for the local sleeping insecticide-treated nets as a with bicycles to be able to offer places. Insecticide water-based malaria control intervention. door-to-door treatment services. formulation of lambdacyhalothrin As the area expanded, the insec- Setting up the program (ICON TM) was packed in 6 ml ticide was sold as a dip-it-yourself sachet. kit containing a pair of gloves The program implemented delivery and instructions. The kits were of treated nets in five phases. By Promotion sold through shops (often were the end of the third year of the pro- Formative research was con- the same shops that sold treated gram implementation, a popula- ducted at baseline to explore nets). tion of about five hundred thousand community perceptions of severe The program relied on collabo- people in 112 villages had been childhood disease. In collabora- ration with public entities such covered. Phase one of the imple- tion with District Health Manage- as the district health manage- mentation covered the area with ment Team results of the re- ment team and Ministry of a demographic surveillance sys- search were used to develop a Health, the private sector such tem (DSS). range of promotional materials. as international and local suppli- Community participation was Promotional materials included: ers, local businessmen, and made central right from the de- billboards posted along main other non-governmental organi- signing stage of the program. roads, posters, leaflets, exercise zations involved in health. Community members were books used at primary schools, T- given a primary role in shaping shirts, umbrellas, caps, and Price the implementation activities. point-of-sale stickers and flags. Price was based on what the The research team in partner- Information Education and community indicated they were ship with district health manage- Communication (IEC) seminars willing to pay and experience ment team held sensitization were held for the sales agents, from previous net projects. The meetings with village leaders. and groups of specially recruited prices were near to cost recov- The meetings, in a form of open village resource people once in ery--consumer prices were set at discussions included general every six months. The resource TZS 3000 (US$ 5.00 in 1997) for a health issues, prevention of people included village leaders, net, and TZS 250 (US$ 0.42 in malaria sustainability and cost- village health workers, primary 1997) for a sachet of insecticide. recovery. Community preference school teachers and Maternal studies were conducted to iden- and Child Health (MCH) aides. Targeting tify size, quality and color of their The distribution system The program aimed at targeting the most-at-risk group, pregnant The distribution network of the women and young children. To achieve that, a discount system whether they owned a net and a reproduced from the World was developed. The system was similar question for other speci Bank Institute's Development based on a simple paper vouchers fied assets. Outreach, September 2005 issued through the MCH clinics. Using the reported ownership of edition. The vouchers were given to assets, quality of houses, and Rose Nathan and Hadji pregnant women when they occupation of the head of house- Mponda work for the Ifakara visited MCH clinics for antenatal hold, a statistical analysis (Prin- Research and Development care as well as to mothers of cipal Component Analysis) was Center in Tanzania, and children under five years of age. done to categorize the households Hassan Mshinda is the The voucher was worth TZS 500 into five wealth quintiles. The Director of the Ifakara Health (approx. US$ 0.5); therefore it survey and the analysis were Research and Development allowed the beneficiary to pur- done for the year of the start of Center. chase a Zuia Mbu net from a the program, 1997, and three retailer at a reduced price of TZS years after, 2000. References 2,500 (instead of TZS 3000). The The coverage, measured by retailers were reimbursed on percent of households with at Andreasen, A.R. Marketing Social their next order with an addition least one net, improved from 37 Change: Changing Behavior to of TZS 50 for each voucher as a per cent in 1997 to 73 per cent at Promote Health, Social Develop- handling charge. Implementation the end of 2000. Coverage among ment, and the Environment. San of voucher scheme reflected a the households categorized as Francisco: Jossey-Bass, 1995. successful public private mix. poorest improved from 20 per Armstrong Schellenberg J.R.M. et cent to 54 per cent, while among al. "The KINET project--An Reaching the poor the least poor (rich) households it overview. Improving child increased from 63 per cent to 92 KINET program had several survival in rural Tanzania: per cent. The poorest/least poor features which qualified it as a Insecticide treated 2001. ratio of the coverage increased pro-poor initiative. Those in- Nathan, R. et al. Mosquito nets from 0.3 to 0.6 over the three- cluded: and the poor: Can social mar- year period (Nathan et al., 2004). · Adoption of social marketing as keting redress inequities in a strategy to deliver the insec- access? Tropical Medicine and Conclusion ticide-treated nets - by default International Health 9, (2004) SM has no motive of financial 1121-1126. Social marketing was associated profit. with rapid overall improvements Roll Back Malaria. The African · Use of discount system facili- in net coverage, and the pace of summit on Roll Back Malaria, tated access to pregnant change was higher among the Abuja, Nigeria, April 25th, women and young children poorest than the least poor. It 2000. (WHO/CDS/RBM/ without excluding the poorest. should however, be noted that 2000.17). RBM Geneva; 2000. · The remotest rural settlements this success happened in the UNICEF. "Malaria Is Alive, Well & where the poorest are concen- presence of two enabling factors: Killing more than 3000 Chil- trated were reached with the the existing demand for mosquito dren a Day in Africa." WHO and insecticide-treated nets nets, which was extremely high UNICEF call for urgent increased through the established deliv- probably because of perceived effort to Roll Back Malaria. ery system. mosquito nuisance, and the (2003). http://www.unicef.org The program assessed the extent existing active private sector for to which it reached the poorest in nets (Nathan et al 2004). the served population. This was done through annual household This article was written by Rose coverage surveys within the DSS Nathan, Hadji Mponda, and area. Each household was asked Hassan Mshinda and has been