Beyond a free bed-net

Welcome to Kigoma, a region with the highest prevalence of malaria among children under the age of 5 and women in the country, yet, one of the places highly prioritised for distribution of free bed nets by the government and donors.

At 24 per cent, Kigoma’s malaria prevalence surpasses that of all other regions in Tanzania, as per Tanzania Malaria Indicator Survey 2017 (TMIS 2017), although 76 per cent of each of the region’s households own at least one insecticide-treated bed net.

Irony

Why is the malaria prevalence still high despite donor and government commitment to intervene and the high free bed net coverage in the region? Are the bed nets not being used properly? Or, what interventions—beyond giving free bed nets—must be put in place to curb malaria in the region?

To achieve the World Health Organisation’s recommendation of every two household members having a bed net in regions where malaria transmission is high, experts say the demand and use of bed nets must be explored.

The deputy program manager for the National Malaria Control Program (NACP), Dr Renata Mandike believes, “Owning a bed-net is one thing and using it, is another thing. We are aware of cases of people who don’t sleep under the bed nets for various reasons, even if they own them.” Dr Mandike, tells Your Health that the efforts to reverse the prevalence of malaria in the most affected region—and other areas where the disease is still prevalent—will have to go hand in hand with other factors such as mass public education for behavioral change and poverty eradication.

According to the current Household Budget Survey, Kigoma is the poorest region in Tanzania, with 48.9 per cent of its population living below the poverty line. The TMIS 2017 found that malaria prevalence decreases with increasing maternal education and household wealth.

Dr Mandike’s observation on behavioural change and poverty eradication partly echoes that of some researchers who—in a span of four years—have investigated how people own and use bed nets in Kigoma, the country’s poorest region.

Using bed-nets for fishing

For lack of education or failure to meet the cost appropriate fishing nets, some residents living close to Lake Tanganyika have resorted to using bed nets to fish, and this has been going on for years.

On Lake Tanganyika, which is partly in Kigoma, a spectacle of fishermen heading out for their nightly lamp-boat fishing trips, characterises the steep rocky shores of the world’s largest fresh water lake.

Four years ago, researchers went around this area, asking people whether or not the residents here were using bed nets for fishing.

What were the findings?

“…majority of respondents reported receiving their bed net for free (96.4 percent)… observing “many” residents of their village using bed nets for fishing (97.4 percent),’’ says the researchers’ 2014 study, titled: Fishing with bed nets on Lake Tanganyika: a randomized survey.

“The findings of this study raise concerns that the use of free malaria bed nets for fishing is widespread along Lake Tanganyika.

Further studies are indicated to fully define the scope of bed net misuse and the effects of alternative vector control strategies in water-based communities,’’ recommends the study in part.

Should they still be for free?

In Tanzania, there have been campaigns to ensure free access to bed nets to children under the age of five from 2008 and 2010 and free universal coverage campaigns in 2010, 2011 and 2015.

Some researchers are already urging the authorities to start thinking beyond giving free bed nets.

One study, titled: Demand and willingness-to-pay for bed nets in Tanzania: results from a choice experiment, explains that if people are given a chance to buy bed nets, coverage and use could increase, thereby reducing malaria incidence in affected areas.

When the study was published in the Malaria Journal last year, a senior research scientist from the National Institute for Medical Research (NIMR), Dr Amos Kahwa told Your Health that the study looked at whether or not people value the bed nets.

“There are people who were given free bed nets [in the past] and they chose to use them for other purposes such as turning them into fishing nets. There was need to find out whether people value them,” said Dr Kahwa.

One of the NMCP’s priorities is to increase ownership of at least one bed net for every 2 people to 85 per cent by the year 2020, says the TMIS 2017.

However, dealing with mosquitoes which transmit the malaria parasite means that Tanzania must focus on eliminating mosquitoes through the use of long lasting insecticide treated bed nets (LLITN), larvae source management (LSM) including use of biolarvicides and indoor residual spraying (IRS).

When geography is at play

Dr Mandike from NMCP spoke of carrying out interventions by considering the seasons. She says, during the TMIS 2017, it was found out that temperature change was one of the key determinants of malaria transmission.

“It has been shown that mosquito and parasite biology are influenced not only by average temperature, but also by the extent of the daily temperature variation. But also malaria cases have been found to spike during rainy seasons,’’ he points out.

Another study published in the Malaria Journal last year, found that behaviours associated with bed net use like; bed sharing, sleeping pattern and some physical bed net attributes compromise its effectiveness and supposedly increase of malaria infection to bed net users.

The study was titled: The underlying reasons for very high levels of bed net use, and higher malaria infection prevalence among bed net users than non-users in the Tanzanian city of Dar es Salaam: a qualitative study.

Here are key highlights of the recent Tanzania Malaria Indicator Survey that paint’s its regions’ picture on the status of malaria.