Barriers to ownership and use of ITNs
On the demand side, affordability is well understood to be an important factor affecting access to ITNs; recognition which has contributed to mass distribution campaigns in Kenya and elsewhere. The survey data on reasons for not owning a bed net support that affordability was key before the campaigns. Affordability was raised in all FGDs as a barrier to access. Affordability barriers were attributed primarily to the actual cost of purchasing ITNs from different sources, but given the relatively remote location of some of these households, the indirect costs (transport, work lost in going to a central place to buy or wait for a bed net), appeared also to play a role:
"Only those with money, like those who have a salary every month can get an extra KES 100 to buy a net. For us who work on the farms, the money we get is only enough to buy food for the children" (FGD, Women)
"The main thing is lack of money. People who do not have nets now once had them, but they have grown old and there is no money to buy others" (FGD, Men)
While affordability was reported as a barrier to access in all FGDs, even after the campaigns, interviewees were also quick to point out that other factors related to acceptability and availability are also important determinants of access; in some cases more important barriers:
"We do not agree. It is not only the money...if it is the money why do people refuse to go for free nets?" (FGD, Men)
On the supply side, affordability factors included the cost of buying ITNs from wholesalers or manufacturers. The cost of acquiring ITNs was reported to be relatively high, and while the willingness to continue selling ITNs existed, the high cost of purchasing ITNs limited the suppliers' ability to stock them. Public health facilities in particular expressed concerns regarding shortage of funds to sustain ITN programmes following a policy change that reduced user fees significantly, and low sustainability of donor supported programmes:
"Getting money to buy the nets is a problem because we depend on the little amount collected through the user fees." (Health worker)
"They [referring to a donor] helped us to start the ITN project. They sold the nets to us at KES 15, although the actual price was KES 30. We then sold the nets to the community at KES 50 and made some profit. But this support came to an end without any explanation. We do not know what happened and we cannot get these nets again." (Health worker)
Community preferences and beliefs were identified primarily through qualitative work as important demand side determinants of access. Although people had a range of different preferences for ITNs, in general 'non-white' nets were reportedly preferred in all districts. White nets easily got dirty and were regularly associated with misfortunes, including bad dreams and deaths. Round ITNs were reported as easy to hang although they were uncomfortable to use during the hot season, while rectangular nets were cumbersome to hang but they enabled air circulation if they were large enough. Participants in 17 FGDs expressed concerns that community preferences were not considered in the design of interventions. In particular, it was reported that the rectangular ITNs distributed through the mass campaigns resembled a coffin, and that their white colour resembled a burial shrewd. It was reported in about half of the FGDs that some households who received free ITNs through the mass campaigns apparently did not use them. They were either returned to the distribution centres, thrown away, or used for other activities like fishing:
"If you are an adult who has never slept under a net all your life, then out of nowhere someone brings you a free white net, you have every reason to belief that you will die. A white net symbolises death. Sleeping under it invites death in the family" (FGD, Men)
"Many of us returned those nets [referring to ITNs distributed through the mass campaigns] to the dispensary at night, others burnt them and others tore them into pieces and used them to catch fish...that is the truth." (FGD, Men)
Community members reported that while they did not always use the ITNs provided through campaigns or through public health services for the intended purposes, this information can be hidden from researchers or outsiders:
"There is this time the government brought free nets and most of us got them [referring to ITNs distributed during mass campaigns]. However, the worst thing is that most of the people who got them in this village do not use them. Instead, they tear them up and use them as curtains or blankets. But when you people come to our homes to ask questions, we will not tell you that we have turned the nets into curtains or that we do not use them." (FGD, Men)
Health workers also expressed their concerns regarding community perceptions and their impact on uptake and acceptability of ITNs:
"Acceptability is not so good these days...the nets given for free are even fishing in the ocean...the rumours have really affected net usage here and how people perceive nets...especially white rectangular nets." (Health worker)
Another concern related to acceptability was targeting of women and young children. Community members were generally aware that pregnant women and children below five years are the most vulnerable to malaria. However, the link between targeting interventions and vulnerability was not always made or clear. Mistrust and suspicions regarding the reasons for targeting were reported in 11 FGDs, with people expressing fears that free ITNs would destroy the future generation. To the community, a useful commodity should be given to all irrespective of age or gender. The importance of information in minimising rumours and suspicions was also highlighted:
"Some people are suspicious that nets could kill people because they are free and are given to specific groups. If nets are good as they say, why are they not given to everybody?" (FGD, Women)
"We should be told or educated why it is only the women and children under five who are given free nets... that way people will stop being suspicious." (FGD, Men)
Other acceptability factors often grouped in the literature under social cultural barriers were illness perceptions and treatment seeking behaviour. Household size and structure were other important determinants of ITN ownership and use. It was reported that it was not always possible to acquire enough ITNs to cover all children within a household, and that children often slept on mats spread either in the common room or in the kitchen. Covering children sleeping on mats with ITNs was reported to be cumbersome and sometimes impossible, particularly when the nets were too short:
"It is the adults who use the nets instead of the children because children sleep in groups on a mat. It is also difficult to hang a net over a large mat. If you hang it on the roof, the net is too short, if you fix it on the wall it covers only half of the mat...and there is no large enough net to cover a large mat with a group of children." (FGD, Women)
"In most homes, people use tin lamps and because nets catch fire easily, people fear that it can be disastrous to have a net in the house...especially when the net is small and with children around." (FGD, Men)
Gender featured quite strongly in discussions, with women feeling that health education was targeted towards women, yet men control resources and are often the main decision makers in the households. Women therefore highlighted the need to involve men in malaria control:
"Another thing, our husbands always ignore these issues because when you tell him about buying a net for the child, he tells you to find your own means of buying a net to protect that child of yours...you see he leaves the child to you, that it is yours not his. If we [women] do not have the money, the nets get finished and we miss out. The other thing is that, you people talk to the women. How will the men know that nets are important, yet they are the ones who have the money? If they are enlightened through health seminars, they will know that nets are important, and then they can buy the nets for us and for the children." (FGD, Women)
"My husband says, 'I can see you are surrounding me with a net, if people start shouting out there for help, how easy is it going to be for me to come out of it?' But you know the child [who shares a bed with parents] always suffers from malaria and the father does not want to sleep under a net. Now tell me, how can I solve this? And when the child gets malaria and is crying, the father covers himself with a blanket and sleeps deeply." (FGD, Women)
The types of ITNs available in the market and the location of centres that sell them in relation to the location of the community influences access. Participants in 10 FGDs reported that ITN retailers are generally located in towns, while public health facilities are sparsely distributed and accessible only by poor roads which are impassable during the wet season:
"We did not get the free nets [referring to the mass campaigns] because the roads are very bad and the nets were issued in the rainy season. You have been here many times [referring to the research team] and you have seen the state of our roads. From the main road to the village, there is no road and where you passed today was a bush, we just cleared it the other day to make something that looks like a road. We can do that as a community, but we cannot build a bridge across the river." (FGD, Men)
Health workers expressed their willingness to deliver ITNs to the community, but lack of transport and poor infrastructure made them reluctant to distribute ITNs in the remotest areas of the districts. Some health workers could not distribute ITNs provided through the mass campaigns to the remotest areas due to lack of transport:
"The distance to the outreach centre is long, the roads are rough and we travel by a motorcycle. How many nets can one carry on a motorcycle?" (Health worker)
Even when ITNs were available, the limited variety impacted negatively on access. Subsidised ITNs provided through primary health care facilities or through other interventions were usually standard in shape, colour and size and did not always match people's demands:
"The nets available at the dispensary and the ones issued for free are square...they have four corners but they are not big enough...they are too short...they cannot reach the ground to cover children sleeping on a mat. Another thing is that some of us live in small houses where we also do the cooking. It makes us feel that since the net is white, the smoke will make it dirty...so we do not use it" (FGD, Women)
Interviews with ITNs suppliers yielded similar results with many expressing concerns about the impact of limited choice on acceptability of free and subsidised ITNs:
"Many community members prefer round nets which are not available. When they come here, they will first ask if we have round nets...But that blue, square, net is what everybody gets. Others say they cannot pay KES 50 for a net that is too small [referring to the blue square net available in government facilities for KES 50 and sometimes for free" (Health Worker)
On the supply side, the location of ITNs manufacturers and wholesalers was identified as a barrier to access. Most ITNs manufacturers, wholesalers and distributors are located in urban areas, and while some deliver ITNs to rural areas, they are often reported as unreliable. Subsidised ITNs distributed through the public health sector were often delivered to district hospitals and primary health care facilities made their own arrangements to collect them from the district. Often this required transport and such funds were not always available:
"We usually contact the person in charge of supplying bed nets at PSI when the nets are over but he does not come immediately, it may take even months. We may go to the district hospital but the district hospital does not provide transport and most of the times we do not have money to transport the nets ourselves." (Health worker)
Market competition was reported as a challenge for the retail sector. Subsidised ITNs available in the public sector (ideally meant for the vulnerable groups), were sold to anyone who could afford them, rendering the services of retailers unattractive. Community members acknowledged that they were unlikely to buy ITNs from the retail sector when they knew they could 'illegally' acquire subsidised ITNs from the public health sector. Consequently, most retailers had stopped selling ITNs, while those that had ITNs in stock were unwilling to re-stock their shops because ITNs were taking too long to sell:
"Our businesses have been affected by the cheap and free nets being given out at the health facilities. No one buys nets from us anymore...so it becomes difficult for us to stock nets when no one is buying them. People know they can get cheaper ones from the dispensary." (Retailer)
Some people can afford to buy nets from the shops, but here is a situation where I can bribe those who give free nets with KES 20 to give me five nets. Why then should I bother to buy one from the shop? Therefore, we are the ones who kill government programmes through our corruption and we also kill the shops (FGD, Men)
The availability of subsidised ITNs to the larger population presented a leakage in the distribution system. Health workers and other individuals entrusted with the distribution of subsidised or free ITNs did not always adhere to the distribution guidelines. In almost all FGDs, participants reported that free ITNs were sold, and prices for subsidised ones increased. Selling free ITNs or increasing prices for the heavily subsidised ones posed an affordability barrier and undermined the potential for reaching the poorest groups with interventions:
"I speak as a dispensary committee member. The health worker stopped issuing free nets and instructed the watchman to sell the remaining nets through the rear window. Most mothers who had come to collect the free nets and did not have the money required were not given a net." (FGD, Men)
"Recently free nets were distributed but the people in charge demanded KES 10 from each potential beneficiary. They said it was for their lunch...those who did not have money did not get nets, while those who ran back home to get the money returned when nets had run out." (FGD, Women)
Interviews with health workers confirmed these concerns, but they also revealed the reasons why they did not always adhere to guidelines. Although health workers understood the importance of targeting, they did not always provide ITNs to vulnerable groups due to various reasons including: limited storage capacity; low sales resulting to lower profits especially where facilities used their own funds to stock ITNs; pressure from other community members to sell ITNs to everyone and; to help minimise suspicion and rumours and in the process address demand side barriers related to acceptability:
"Although the KES 50 nets are provided for children under five and pregnant women, we sell them to everybody because the dispensary health committee wants to make money, and again the community complains so much that they also need the nets. When the nets were reserved for children less than five years the community was suspicious of the motive behind the targeting...we had to sell the nets to others in the community to prove that there was no ill motive in targeting the young children." (Health worker)
Other supply side challenges often included high workload that burdens already overstretched health workers. Health workers reported that it was difficult to fully provide ITNs under existing programme rules and regulations. They failed to distribute ITNs during their routine health outreaches in remote areas because they found it cumbersome to keep records for their outreaches-as part of their job- and for ITN sales which was often seen as an extra activity.