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RESEARCH: Kara Hanson, Tanya Marchant, Rose Nathan, Hadji Mponda, Caroline Jones, Jane Bruce, Hassan Mshinda, and Joanna Armstrong Schellenberg Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys BMJ 2009; 339: b2434 [Abstract] [Full text]

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Bottom up is more effective

Rupert A Gude   (28 July 2009)

Bottom up is more effective 28 July 2009
Rupert A Gude, VSO Doctor Kagondo Hospital, Kagera Region, Tanzania Send response to journal: Re: Bottom up is more effective	Tanzania is to be congratulated on the effectiveness of the mosquito net distribution so that by 2007 two thirds of households owned at least one net. However the paper by Kara Hanson et al points out that inequity in distribution meant that children in the highest quintile were three times more likely to use a treated net than those in the poorest quintile. In the 2007/08 Tanzania Hiv/AIDs and Malaria Indicator Survey (THMIS 2007/08) Kagera Region in the north west of Tanzania has the dubious distinction of having the highest malarial parasitaemia rate of 42% in children 6 months to 5 years. This compares to a national prevalence of 18% and Arusha which has the lowest prevalence of 1%. It also points out that rural children are three times more likely to have parasites than urban children. Top down approaches are important to obtain rapid implementation of a programme but they often have gaps in implementation. Kagera Region has a very rural population with poor roads and low income. Another approach that is bottom up needs to be implemented in this Region if this high rate of parasitaemia is to be controlled. Katoke is a small community based around a teacher training college near the west shores of Lake Victoria and about 40 km south of Bukoba. The Katoke trust (www.katoketrust.com) has been largely involved in education but in 2002 with aid from Australia they set up a project to introduce bed nets into the local village. At that time 62% of villagers had had at least one attack of malaria in the last year. Less than 0.2% always used a bed net at night and only 4% had ever used a bed net. Volunteer village health workers were trained and many education sessions were held with the villagers. Subsidised bed nets were distributed. At the end of one year 33% of villagers always slept under a net and if they did only 18% had an episode of malaria in the year. The project was extended in 2005 to 3 more villages, some 10,000 villagers. After 4 years 95% of villagers always use a net and there was only an 8% risk of malaria in these people. Over forty years ago, Maurice King articulated the need for bottom up approaches in his excellent book ‘Medical care in developing countries’. Now that the bed net voucher scheme is up and running surely it is time for the huge investment from the United States, Britain and Switzerland to be diverted to more fundamental village based education. The Katoke pilot scheme has demonstrated remarkable drops in malaria illness in the local population. This should not be ignored. Maybe those villages in Kagera with the highest parasitaemia rates could be targeted first and with the expertise already available at Katoke it should be fairly easy to implement if the will is there. Competing interests: I work in Kagera and am distressed to see so many children die of malaria