Hello from Blantyre! We went up and down the countryside collecting data with the bCPAP team this week, which means that we got to see quite a few new hospitals and even more road. On the way, I thought about what I posted last week about poor malaria net and ARV usage. Why does ORS seem to have such better adherence than malaria nets? What is different about the technologies? What was the difference in the implementation strategy?

The Malawian highways are dotted with billboards. People lean against them in the trading centers and little kids climb on them in the mountains. It seems that the vast majority are pretty evenly split between telephone/internet companies (Airtel and TNM), beer, and internationally-funded health-related advertisements.

In particular in the healthcare sector, we see Thanzi-brand ORS advertisements all over. In the south part of the country, too, we started to see billboards and painted buildings for Chishango brand condoms (though their scarcity in the North might be an artifact of our being so close to St. Gabriel’s—the immediate surroundings are markedly Catholic.)

A major difference for implementation is that unlike malaria, for which many people feel they need to see a health care provider, HIV/AIDS transmission and dehydration prevention are thought of as issues for which people should take personal responsibility.

Because it was heavily subsidized by USAID until 2012, Thanzi was very cheap and widely available. Now a cheaper, Kenyan-produced brand has taken much of the market, but since the technology is still effective even when produced more cheaply (as far as I can tell, the biggest difference for the end-user is that Thanzi includes small pictorial instruction cards). The initiative behind Thanzi’s marketing, PSI, made ORS a standard part of patient care and worked with the Malawian government to work it in to the massive HSA program. Because the market was so well-primed by PSI from 1990-2012, there doesn’t seem to be a dip in ORS use with the change in companies. Thanzi ads are still up everywhere and I see ORS very widely available at grocery stores and for free at the hospitals.

Interestingly, PSI is also behind Chishango condoms. Though stigma clearly makes it slightly more complicated to paste “Chishango” across every building, the condoms are very widely available. In the cities, Aqua Pure water bottles carry a red ribbon and the statement “Aqua Pure Cares. Love Life. Avoid HIV/Aids.” Though I don’t necessarily agree that we can place the entire onus for prevention on individuals’ safe sex habits (other transmission risks like occupational hazards are often overlooked), conversations with people here have shown us that sexual safety tends to be considered a personal matter.  [2]

PSI has had less success, from what I can see, with its malaria nets and water purification systems. I think there’s less of an interested market because Malawians don’t think they’re as necessary. With HIV transmission prevention and dehydration prevention, PSI has been effective because they have either found ways to build a cultural concept of personal responsibility and importance or built on what was already there. [3]

 

[1] Gates Foundation Case Study on ORS in Malawi.

[2] This climate is sadly often observed in the breach—in discussion of times when personal agency is negated. I have heard it said, though I can’t find it specifically online, that roughly one in four Malawian women’s first sexual experience is forced.

[3] USAID evaluation, Sept. 2004.