title: Cost-sharing strategies combining targeted public subsidies with private-sector delivery achieve high bednet coverage and reduced malaria transmission in Kilombero Valley, southern Tanzania.
abstract: BACKGROUND
  Cost-sharing schemes incorporating modest targeted subsidies have promoted insecticide-treated nets (ITNs) for malaria prevention in the Kilombero Valley, southern Tanzania, since 1996. Here we evaluate resulting changes in bednet coverage and malaria transmission.
  
  
  METHODS
  Bednets were sold through local agents at fixed prices representing a 34% subsidy relative to full delivery cost. A further targeted subsidy of 15% was provided to vulnerable groups through discount vouchers delivered through antenatal clinics and regular immunizations. Continuous entomological surveys (2,376 trap nights) were conducted from October 2001 to September 2003 in 25 randomly-selected population clusters of a demographic surveillance system which monitored net coverage.
  
  
  RESULTS
  Mean net usage of 75% (11,982/16,086) across all age groups was achieved but now-obsolete technologies available at the time resulted in low insecticide treatment rates. Malaria transmission remained intense but was substantially reduced: Compared with an exceptionally high historical mean EIR of 1481, even non-users of nets were protected (EIR [fold reduction] = 349 infectious bites per person per year [x4]), while the average resident (244 [x6]), users of typical nets (210 [x7]) and users of insecticidal nets (105 [x14]) enjoyed increasing benefits.
  
  
  CONCLUSIONS
  Despite low net treatment levels, community-level protection was equivalent to the personal protection of an ITN. Greater gains for net users and non-users are predicted if more expensive long-lasting ITN technologies can be similarly promoted with correspondingly augmented subsidies. Cost sharing strategies represent an important option for national programmes lacking adequate financing to fully subsidize comprehensive ITN coverage.
authors.affiliation: Ifakara Health Research and Development Centre, Box 53, Ifakara, Morogoro, United Republic of Tanzania. gkilleen@ihrdc.or.tz
authors.forename: G F
authors.initials: GF
authors.lastname: Killeen
authors.forename: A
authors.initials: A
authors.lastname: Tami
authors.forename: J
authors.initials: J
authors.lastname: Kihonda
authors.forename: F O
authors.initials: FO
authors.lastname: Okumu
authors.forename: M E
authors.initials: ME
authors.lastname: Kotas
authors.forename: H
authors.initials: H
authors.lastname: Grundmann
authors.forename: N
authors.initials: N
authors.lastname: Kasigudi
authors.forename: H
authors.initials: H
authors.lastname: Ngonyani
authors.forename: V
authors.initials: V
authors.lastname: Mayagaya
authors.forename: R
authors.initials: R
authors.lastname: Nathan
authors.forename: S
authors.initials: S
authors.lastname: Abdulla
authors.forename: J D
authors.initials: JD
authors.lastname: Charlwood
authors.forename: T A
authors.initials: TA
authors.lastname: Smith
authors.forename: C
authors.initials: C
authors.lastname: Lengeler
mesh_terms: D000818:Animals; D001512:Bedding and Linens / Q000706:statistics & numerical data*; D016000:Cluster Analysis; D005843:Geography; D006801:Humans; D007306:Insecticides / Q000627:therapeutic use; D008288:Malaria / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission; D009032:Mosquito Control / Q000191:economics / Q000295:instrumentation* / Q000706:statistics & numerical data; D015995:Prevalence; D017149:Private Sector / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D017150:Public Sector / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D013636:Tanzania / Q000453:epidemiology; D013997:Time Factors
chemical_list: D007306:Insecticides