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 surveysBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2434 (Published 02 July 2009) Cite this as: BMJ 2009;339:b2434
All rapid responses
Tanzania is to be congratulated on the effectiveness of the mosquito
net distribution so that by 2007 two thirds of households owned at least
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
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.
I work in Kagera and am distressed to see so many children die of malaria
Competing interests: No competing interests