Worldwide, there are an estimated 300–660 million cases of malaria each year, and one third of the human population is estimated to live in areas at risk for the most severe form of malaria, which is transmitted by Anopheles mosquitoes. Many studies have shown that daily use of insecticide treated bednets (ITNs) by a large proportion of households can greatly reduce malaria morbidity, and related deaths. Yet, ITN adoption remains low and regular re-treatment with insecticide, which is critical to bednets’ efficacy, is rare.
Recent evaluations have shown that distributing bednets for free can substantially increase take-up, and even make households more likely to buy a bednet in the future, but that charging even very small user fees significantly reduces adoption. However, public health agencies frequently have insufficient resources to provide free ITNs for all individuals at risk and thus may be interested in charging for ITNs to recover some of their costs. Yet this could lead to the exclusion of vulnerable individuals who do not have enough money to buy an ITN. One potential solution could be to provide households with small loans to purchase bednets, which could be paid back in small installments without a large one-time cost. Can microloans increase ITN ownership, re-treatment, and improve health?
Orissa is the most highly malaria endemic state in India. In 2007, one quarter of all malaria cases in India occurred in Orissa despite the state hosting less than 4 percent of the country’s population. On average, households participating in this study were living on just under US$1.50 per person per day. Two thirds of households had a bednet at the time of the intervention, almost all of which had been purchased in local markets. But bednet coverage was far from universal, as households had an average of one net for every three people and only about 13 percent of individuals slept under a net the previous night at the time of the baseline survey. Before the study, 12 percent of individuals tested positive for malaria and almost half were anemic. Malaria can severely worsen anemia because the parasite destroys red blood cells. A change in anemia rates is thus considered an important indicator of changes in malaria prevalence in a population.
Researchers tested whether using microloans to help poor households purchase ITNs was more or less effective than distributing them for free in terms of increasing bednet ownership and usage. They conducted the evaluation in partnership with the Bharat Integrated Social Welfare Agency (BISWA), a micro-lender with a large presence in rural Orissa. Researchers randomly selected 141 villages from communities where BISWA was working and randomly assigned them to one of three equally sized groups:
- The comparison group received no new products or services.
- In free villages, BISWA clients received up to four ITNs per household at no cost depending on their family size.
- In microfinance villages, BISWA clients were offered loan contracts to purchase ITNs and insecticide re-treatments.
In microfinance villages, the ITN offer price was not subsidized and included a mark-up to cover delivery and overhead costs to BISWA. The price was not negligible, corresponding approximately to three to five times the local daily agricultural wage. The pre-existing affiliation with BISWA was expected to encourage high repayment rates on the loans. Buyers in microfinance villages could decide between purchasing ITNs alone or purchasing a bundle which also included two future re-treatments with insecticide. Both contracts had a one-year repayment period and charged BISWA’s standard interest rate of 20 percent per year.
After six and twelve months, field workers returned to offer re-treatment at no cost both in free villages and to buyers who chose the bundle in microfinance communities. In microfinance villages, buyers who originally purchased only the bednet and not the re-treatment could re-treat the net for cash. A detailed follow-up survey was conducted shortly after the second re-treatment, between December 2008 and April 2009. Malaria prevalence and anemia were measured using rapid diagnostic tests, which require very small blood samples. They also gathered detailed information about the households’ social networks to examine whether the interventions increased ITN ownership and usage among non-BISWA clients.
Results and Policy Implications
Bednet take-up and use: Microloans increased ITN ownership and self-reported use, although not as much as free distribution. Fifty-two percent of households in microfinance villages purchased at least one ITN and 96 percent of households in free villages received at least one ITN. Relative to control areas, individuals were 9 percentage points more likely to have slept under a bednet the previous night in microfinance villages, and they were 38 percentage points more likely to have slept under a bednet in free villages, relative to comparison villages. ITN use was therefore significantly higher when ITNs were delivered at no cost, providing no evidence that free provision leads to lower bednet use. Past exposure to malaria was the strongest predictor of purchase in microfinance villages. Households repaid 64 percent of the loans on average, meaning that BISWA provided about a 36 percent subsidy per net.
Bednet re-treatment: In microfinance villages, re-treatment rates were significantly higher when ITNs were purchased bundled with two re-treatments. About half of the households who purchased ITNs chose to buy the ITN and the two re-treatments up front. Among these households, 84 percent received the first re-treatment and 74 percent received the second. On the other hand, among households who only purchased the ITN, 36 percent re-treated their ITNs once and 21 percent re-treated them twice. This suggests that commitment devices like bundled contracts can help increase health protecting behaviors in the future.
Health outcomes: Researchers found that the program had mixed results on malaria outcomes which may have been due to insufficient ITN coverage and use. In both free and microfinance villages, self-reported new malaria episodes decreased by about 0.55 episodes per household per year relative to comparison villages. Yet because respondents may not recall or know the number of malaria episodes they had in the past six months, this may not be the most reliable measure of malaria. The program did not reduce the percentage of people with the malaria parasite present in their blood at the time of the post-intervention survey, although there is some evidence of improvements in hemoglobin levels. Researchers conclude that the most likely explanation for these mixed results is that despite the increase in bednet ownership and use, the fraction of sleeping spaces protected by ITNs and regular use remained low after the intervention. Since ITNs were only offered to households with a BISWA client, about only 20 percent of households in each village were eligible to receive or purchase ITNs.