A story in last week's New York Times served as another mouthpiece for critics of social marketing to get a few shots in [Distribution of Nets Splits Malaria Fighters; free registration required]. I, and others, have had a number of responses to this article. Since PSI was mentioned by name in the article, but not contacted by the reporter for any comments or response (students of media advocacy take note), our Global Director for Malaria Control sent off a letter to the NYT (yet to be published). There is also concern expressed by a few social marketers to me that this is another 'attack' that should have a response. The broader context to consider, that these critics really don't understand what social marketing is other than communication and distribution of highly subsidized commodities (a definition, btw you will find in no textbooks on social marketing), I will leave to others for now. Yet, because the NYT piece and critics have focused on the need to purge social marketing from malaria control efforts, allow me to put a few facts into evidence that you can read for yourself before jumping on this ideological bandwagon that all nets should be free nets.
First, let's look (free registration needed to read the next three links) at what the authors of the longitudinal study in Kenya published by Fegan et al last month in The Lancet that has been the stimulus for this latest flurry of activity really said: A combined approach of social marketing followed by mass free distribution of ITNs translated into child survival effects that are comparable with those seen in previous randomised controlled trials. Hardly seems like an endorsement of one approach over the other based on the empirical evidence and what would form the basis for a 'split among malaria fighters.'
What's more telling, and one that reporters (and their sources) seem to overlook are the commentary on the study and an editorial that examined the WHO's premature and perhaps inappropriate use of the results that also appeared in the same issue.
On the programmatic side, Kenya has taught us an important lesson: different components of the programme each contributed to the final high coverage-rate. By the end of 2006, nearly 10% of all bednets had been acquired from commercial retailers, 41% had been provided as subsidised bednets through clinics via social marketing, and 44% had been provided during the free mass distribution of 2006. Hence the different components had important additive effects… The mass distribution of free bednets in 2006 allowed a rapid increase in coverage for all children younger than 5 years with near-perfect equity (the poorest children benefiting as much as the better-off ones). On the other hand, the (socially marketed) clinic-distribution channel addressed the need for continuous protection of newly pregnant women and their newborn children, while commercially provided bednets gave a choice to the rest of the population. Infants are by far the group with the highest risk of dying from malaria, and the public-health system cannot rely exclusively on infrequent mass campaigns to protect them. Equity achieved through mass campaigns needs to be maintained over time (so-called temporal equity). Hence it is essential to have different strategies in place to ensure equitable and sustainable effects on health [Lengeler & de Sauvigny, 2007].
Those who defend the selling of nets or their social marketing have a weakening evidence base to draw on. But when the data and their interpretation are more complex than a press release can convey, the sensible approach is to wait. The agency statement can then be read alongside fully reported research findings. WHO's precipitate move to comment without reference to the full facts was reckless… UN agencies are willing to play fast and loose with scientific findings in order to further their own institutional interests…But the danger is that by appearing to manipulate science, breach trust, resist competition, and reject accountability, WHO and UNICEF are acting contrary to responsible scientific norms that one would have expected UN technical agencies to uphold. Worse, they risk inadvertently corroding their own long-term credibility [Editorial, 2007].
Now lets look at a the Position Statement from the WHO Global Malaria Programme (from the Executive Summary);
In most high-burden countries, ITN coverage is still below agreed targets. The best opportunity for rapidly scaling-up malaria prevention is the free or highly subsidized distribution of LLINs through existing public health services (both routine and campaigns). LLINs should be considered a public good for populations living in malaria-endemic areas. Distribution of LLINs should be systematically accompanied by provision of information on how to hang, use and maintain them properly. [emphasis in the original document]
Here are some more details from that statement that I include because they underscore how few differences exist between the approach WHO is advocating for (in official documents anyway) and the role of social marketing and commercial market approaches in helping achieve impact, sustainability and behavior change.
Free or highly subsidized distribution - In general, rapid scale-up in the coverage of target populations can be achieved most efficiently through the distribution of free or highly subsidized LLINs. Cost should not be a barrier to making LLINs available to all people at risk, especially young children and pregnant women. The role of vouchers/coupons as an LLIN delivery mechanism is the subject of much debate and should be considered in the light of local experience. Commercial markets are valuable sources of nets. Where strong commercial markets exist or are developing, they should be encouraged: they can provide important benefits, ensuring longer-term access and enhancing management of logistics and education efforts.
Sustainability - LLIN distribution through campaigns offers opportunities to rapidly increase LLIN coverage in targeted communities (“catch-up”) but is most effective when implemented in parallel with continuous distribution through routine antenatal or immunization services to maintain coverage (“keep-up”). Long-term
sustainability requires an “enabling environment”, a vigorous campaign of public and privately funded demand creation, and communication campaigns for behavioural impact. Countries that have already achieved high coverage rates should assess their achievements, especially regarding coverage, access in
remote areas and equity, and should develop targeted strategies to fill the remaining gaps.
Research - The cultural factors that determine ownership, retention and use of ITNs, including LLINs, must be taken into consideration to ensure that communication and advocacy activities contribute to effective use of these nets. In this context, research into local perceptions of mosquitoes, malaria, ITNs/LLINs and washing practices is needed to inform the choice of media, messages and advocacy strategies. The ultimate aim should include a measurable increase in ITN/LLIN awareness and reported changes in ITN/LLIN retention and use.
Finally, the recently updated Strategic Framework for Scaling-up Insecticide-treated Net Coverage in Africa presented by the Roll Back Malaria partnership.
A two-pronged approach is needed to quickly reach high coverage, and then sustain high coverage.
The first priority is to accelerate achieving and exceeding the RBM and MDG targets using substantial public subsidies to guarantee access to ITNs for the most vulnerable. The parallel second priority is to be able to move seamlessly over time to a means of sustaining high coverage, even if large-scale subsidies are no longer available. In other words, a strategy to “catch-up” coverage must be linked to a strategy to “keep-up” coverage. We must avoid the trap where a singular focus on “quick wins” results in greater inequities later. Equally we must maximize the opportunity for these new investments to strengthen sustainable health systems that will serve effectively long into the future. For example, countries could link the subsidized delivery of free ITNs or high-value ITN vouchers to a national immunization campaign to rapidly achieve high coverage of infants and under-fives, and then continue with a system of subsidized delivery of ITNs or vouchers via a continuous targeting of pregnant women at ante-natal care clinics to maintain coverage. Moving to vouchers will pull commercial supply out to remote rural areas. Over the long term as malaria is controlled and household economies improve, the scale of subsidized delivery could gradually be reduced or focused and a culture of household transactions with an easily accessible local commercial source of ITNs will be in place for the majority of the population.
No country has yet done both catch-up and keep-up strategies at national scale. There is no text book on how this should be done. The goal is rapid, sustained, equitable, and effective coverage of the most vulnerable population. Planning a system that can achieve this raises important issues concerning subsidies, sustainability and the interaction between public and private sectors. These strategic issues are the focus of this document which examines the lessons learnt from current ITN programmes and reviews the broad options for maximizing the health impact of publicly-funded subsidies. Since the key to success in achieving rapid and sustained high coverage is complementarity between public and private sectors it also considers the best way to encourage the growth of a vigorous, competitive private sector. Some of the public sector actions required to bring this about are essentially temporary while others must be sustained over time. A national ITN partners task force or similar coordinating mechanism engaging a variety of public, private and NGO partners can help government to facilitate negotiation, coordination and complementarity in this scaling-up process. [emphasis added]
Several of my colleagues have counseled me that the media debate over social marketing is one of ideology (see Developmentalism), not evidence. And to some point I agree. Setting up a conflict between your position and that of another is out of any PR playbook aiming to get coverage, not truth. The nuances of science can be painful to contemplate for some, and responding to such challenges with reasoned arguments is not going to push the debate towards any resolution. But at least you now have some facts.
Of course, the collateral damage from such absolutist positions should also be considered. Abigail Keene-Babcock writes in response to this same NYT article:
A to Z is a family-owned producer of long-lasting anti-malarial bednets located in Tanzania. Recently, it has received patient capital to expand its production capacity; A to Z now produces 7 million nets a year, and it has become the third largest employer in the country. Its production costs are the same or lower than those of foreign bednet makers. Due to its proximity and familiarity with its target market, transportation costs are much lower and knowledge of the local environment and market dynamics is superior...to write off the potential of social marketing techniques to help create sustainable mechanisms that produce and deliver basic goods and services is dangerous. It not only condemns businesses that could potentially employ thousands of local workers and offer long-term solutions that will be there when aid money is not, but it permanently paints poor people as objects of charity, without the luxury of choice or the capacity to help themselves.