Untangling the debate surrounding strategies for achieving sustainable high coverage of insecticide-treated nets.

On the question of how to achieve the goal of long-term high utilisation of insecticide-treated nets (ITNs), most protagonists fall into one of two camps: free distribution or market development. The 'free distribution' camp argue that given the health benefit to be gained and lives saved, not to mention the relative cost effectiveness of ITNs, such an intervention should be provided free and paid for by governments or donors. In addition, they argue that it is unrealistic to ask the poorest of the population, who are often the ones at most risk, to pay for an ITN, and this risks producing greater inequalities in health. The market advocates counter that free distribution compromises sustainability, both in terms of demand and supply. Firstly they argue that, without a price, people will be less inclined to value ITNs. In turn this could mean lower utilisation, and a lower inclination to replace such an asset at the end of its useful life. In addition, on the supply side, without a price there is little chance of a local market developing for ITNs, although this would be the surest way to ensure a sustainable supply. It is hard to argue with either viewpoint, as both have merit. This article considers three major issues in the debate, and attempts to draw policy conclusions.