(March 2000) Insecticide-treated materials (ITMs) are among the state-of-the-art technologies in malaria prevention. In trials in sub-Saharan Africa, the region of the world hardest hit by malaria, ITMs — primarily mosquito nets or bednets — have reduced the number and severity of cases of malaria. The treated mosquito nets have protected pregnant women and reduced mortality among infants and children, the most vulnerable populations.

Distribution of ITMs up to now has been mainly the province of international development organizations such as the World Health Organization (WHO), UNICEF, and the U.S. Agency for International Development (USAID). These agencies have stepped in because the nets and insecticide have proven so effective that access to them furthers public health. The use of treated bednets can reduce rates of severe malaria by an average of 45 percent and cut childhood mortality rates by between 25 percent and 35 percent, according to WHO.

International donors have also acted because providing ITMs on a large scale is exceedingly expensive. The retail price of a net ranges from $5 to $9, and the chemical treatment costs from $1 to $2 per year. WHO has estimated that Africa could use about 32 million nets a year, which would cost over $100 million. Few African governments or donors can grapple with that cost, according to WHO. So international donors have supported the public sector — mainly ministries of health — and nongovernmental organizations (NGOs) in selling health products and services at affordable prices and motivating people to use them.

Will Shaw, director of international public health with the Academy for Educational Development (AED), pointed out several limitations of donor-funded ITM programs. Research shows that the public sector reaches only a small proportion of the "public"; the private sector is more cost-efficient in bringing products and services to a wider segment of the public; and donor resources are insufficient, Shaw said.

A New Idea

USAID is trying a new approach, one that has potential for significantly improving public health and for being sustainable because it combines both public- and private-sector resources. Under a cooperative agreement signed last fall with USAID, AED will work with the S.C. Johnson company and other international and local partners on the Africa NetMark regional project, promoting the commercial distribution of ITMs. AED will educate people in selected African countries about the health benefits of using ITMs and how to apply pesticide to the nets. S.C. Johnson, a multinational maker of insect-control products, will invest in nets and insecticide, as well as in packaging, registering, distributing, and promoting the products to African consumers. The NetMark team believes that most people will be able to afford the products, and that prices may fall as S.C. Johnson achieves economies of scale from regional operations and from competitors entering the marketplace.

Lisa Jamu, ITM program manager with Population Services International (PSI), has reservations about NetMark: "What AED is doing is beneficial, and they probably will reach a certain percentage of the population; probably higher class, maybe into the middle class." Given the price of the nets, Jamu doesn't think that the commercial sector will be able to reach the poor rural areas where malaria hits hardest.

David McGuire, director of NetMark, believes the commercial approach will reach the rural areas as demand spreads from urban areas. "You get the opinion leaders and the trendsetters in the country to buy into what you're doing," he said. This initial support will hopefully create a norm for rural areas. McGuire also made clear that work with the public sector, which does serve the poor, would continue in tandem.

Experts including Jamu recognize the benefits of a dual approach. For instance, once nets are purchased, they need to be re-treated, and that takes time, effort, and money. Jamu feels that NGOs are well-suited to developing a "re-treatment culture." At the same time, the commercial sector brings research and development that may render the product increasingly convenient, according to Camille Saade, private-sector coordinator with the BASICS child survival project. He said that S.C. Johnson would look for ways to simplify re-treatment, extend its duration, and reduce its price.

Dennis Carroll, senior public health advisor at USAID, sees NetMark as a way to determine how many people each model can serve and how to achieve wider use with given resources. Mobilizing the commercial sector and learning how many Africans will buy nets from a commercial source "will help us understand how to better strategically use limited public-sector resources to go to those populations that will not directly benefit from the commercial sector," Carroll said.

[Note: At press time, the countries in which NetMark will be introduced first had not been finalized.]


Allison Tarmann is editor of Population Today.


For More Information

Contact Dennis Carroll (phone: 202-712-5009; e-mail: dcarroll@usaid.gov) or David McGuire (phone 202/884-8506; e-mail: dmcguire@aed.org) or send an e-mail to the project: netmark@aed.org.