Implementation of an insecticide treated bednet programme for malaria prevention through the primary health care system in Mozambique : socioeconomic factors associated with sustainability and equity.

Malaria is the principal cause of morbidity and mortality in Mozambique, accounting for more than 40% of the attendance in the public health clinics. Insecticide-treated bednets; (ITNs) have proved to be a cost-effective means of preventing of malaria. Most previous ITN projects have been implemented in pilots or trials and with substantial financial, human and technical resources. Presently however, in many African countries services can no longer be provided "free" (at no charge to users). There is still a lack of knowledge of how financially sustainable and equitable a cost-sharing ITN programme implemented through the primary health care system would be. In Mozambique no ITNs were available, and very few households had bednets before the start of this study. Thus before introducing an ITN programme in Mozambique, it was important to evaluate whether the primary health care system could deliver ITNs, and to determine how sustainable and equitable such a programme would be. The study which forms the basis for this thesis took place in Boane, Mozambique from, 1996 to 1998. The aim of the study was to determine how financially sustainable and equitable an ITN programme could be when implemented through the primary health care system, and how the socio-economic level of the community would affect such a programme. Bednets were treated with Lambdacyalothrin and sold at the health centre at price equal to the factory's wholesale price. The willingness to pay of the households, the ITN coverage which was achieved, the total cost of implementing the project, and the financial resources which would be required to implement a national ITN programme in Mozambique were calculated. The main findings of the study were as follows: - The Boane community accepted the ITNs very well. However, the purchase of ITNs was dependent on the socio-economic level of the buyer; poor households were less likely to buy than richer households (p<0.001). Thus, there was not an equitable distribution of ITNs in the community. - Many households whose stated maximum willingness to pay before the project was less than US$5 actually did pay that amount for an ITN during the project. Thus, willingness to pay was not a reliable way of predicting the households' probable purchase of ITNs. - The estimate of the cost of the project demonstrated that the financial cost per ITN delivered ($9.60) was much higher than the price at which the ITNs were sold to the consumers ($5 on average). Thus, the project was not financially sustainable. Moreover, given the cost structure covering a larger area or achieving wider coverage would have required an even higher level of subsidy. - In order to guarantee an equitable national ITN programme through the public health system in Mozambique, the govermnent will have to mobilise external donors to fmance the ITN programme. This study contributes to an understanding of the implications of how the price of ITNs affects the financial sustainability, equity and coverage of the programme, and makes recommendations for obtaining the funds required to heavily subsidise ITN programmes in Mozambique in particular, and in Sub-Saharan Africa in general.