Community cooperatives and insecticide-treated materials for malaria control: a new experience in Latin America (original) (raw)

Background information

The general characteristics of the eight Mexican and six Colombian cooperatives, as well as the malariometric indices, are presented in Table 1. It can be seen that malaria endemicity was lower in Mexico and P. vivax prevailed, as compared to the Colombian areas where the annual parasite index was higher and P. falciparum was more prevalent. More than 50% of beds were covered with bednets. These had been purchased from local retailers at an average price between US$ 4.50 and 7 in Mexico and US$ 6 to 9 in Colombia.

Table 1 Background information on study districts in pre-intervention phase

Full size table

All cooperatives had an elected president, secretary and treasurer, and occasionally a vice-president. In most places the office-holders were women and they had their own building for ITM services. They had an average target population of 5,000–15,000 inhabitants; through several of them (particularly the cooperatives on the Pacific coast in Oaxaca, Mexico, and Chocó, Colombia) had far higher potential target communities. The Mexican cooperatives were located in rural areas (with communities of less than 2,500 inhabitants) and the Colombian cooperatives in urban areas (with roughly 5,000–15,000 inhabitants).

Services offered by ITM community cooperatives

In Table 2, the three basic types of ITM services offered by community cooperatives are presented:

Table 2 ITM services offered by community cooperatives in Mexico and Colombia and monthly sales

Full size table

    1. impregnation/re-impregnation services for existing nets only
    1. sale of bednets which have been bought on the market and then impregnated by the cooperative
    1. production of bednets and impregnation services.

The cooperatives of the second and third type additionally offer re-impregnation services in the community. In Colombia, selling impregnation kits to the public through two cooperatives and four pharmacies for self-dipping was also tested. It had, however, to be abandoned due to low sales probably related to insufficient promotion. One cooperative, formed by health workers from the social security system, offered impregnation kits during their house-to-house visits; however, people who bought such kits asked the health workers to do the impregnation for them on the spot.

The services were offered in three ways:

    1. ITMs are produced and sold from the cooperative's building or by cooperative members in their communities;
    1. through community outreach, with impregnation and/or sale of impregnated nets from a building (usually a school) in an outreach community;
    1. house-to-house impregnation in the community as a complementary measure for people who did not attend central-point dipping.

In Mexico, monthly sales rates of impregnation services were highest for the exclusive sale of impregnation/re-impregnation services while in Colombia they were highest for the production of nets plus impregnation (Table 2). This was largely due to an international NGO which bought impregnated nets from the cooperative. The factors related to these differences will be analysed in a later section.

Promotional activities

Promotion of ITMs by word-of-mouth was the most frequently used form of propaganda. This was particularly successful when cooperative members were used to going from house-to-house selling bread and other food or goods. A positive marketing effect was achieved when cooperatives had their own building in the centre of town with a visible logo in front.

The Mexican cooperative members in rural areas promoted ITMs in community meetings while the urban cooperative members in Colombia used a loud speaker (perífonéo) for promoting their products in the neighbourhood.

Low-cost marketing materials were provided by the research team which were reproduced by the counterpart institutions and handed over to the cooperatives. These included flyers, stickers, visors and – in Colombia – radio spots (six per day).

Facilitating impregnation services

In each group two people, using protective clothing, were trained to re-pack liquid insecticide from 1 litre bottles into smaller plastic bottles which could be easily closed with a screw-top. The advantages of this system were cost-reduction, management of small doses by the dippers, and the ease of changing the product according to availability. For instance, for one 14 m2 area either 7 ml of lambdacyhalothrin 2.5% CS or 14 ml of deltamethrin 2.5% SC were put into a bottle using either a pipette or a syringe; the cost of the re-packed unit for the impregnation of one net with lambdacyhalothrin was 0.6 US $ and with a deltamethrin tablet 2.3 dollar in 2001 in Colombia [7]. The price of the deltamethrin tablets dropped later in 2001 to 1.6 US $.

Impregnation was generally done using the "closed-bag system": Each net was placed in a plastic bag, water and insecticide were added, and the bag was closed and shaken for 10 minutes. Then it was dried either in the cooperative building or by users at home.

In this way, skin contact with insecticides was avoided and side-effects were minimised. Each cooperative had written instructions about procedures and the impregnation materials and supplies needed.

Control of sales; exemption mechanisms and forms of payment

Generally, the treasurer of each cooperative was responsible for administrative and financial control. This was based on the sales book. In this ledger the following information was registered for each sale: the name of the purchaser, the amount of money received and the date due for re-impregnation. Only in two Colombian cooperatives were the books inadequately kept at first. This was because members of the cooperative, which was too large, had started to sell ITMs on their own.

The income from ITM sales was meant to feed a revolving fund (60% to 70%) while the rest generated income for the cooperative members (see later "unit costs of impregnation"). The revolving fund was to be used for travel expenses and purchase of ITM materials. Indeed, most of the Mexican cooperatives after six to 12 months used their income exclusively for the revolving fund surplus was put in a bank account. In Colombia, in the initial phase an excessive use of funds was registered for personal purposes in two cooperatives so that only little money was left for purchasing the supplies ("sunset fund"). A second donation of insecticides and bednet fabrics had, therefore, to be provided in order to re-vitalise the cooperative. The next batch of supplies could be purchased with the revolving fund due to improved supervision and financial control.

In one cooperative in Colombia, composed of social security system health workers, the impregnation was offered for free as the insurance company considered malaria vector control to be part of the basic health plan. However, they claimed the insecticide from the district health team and the promotional materials from the research group.

Six of the eight Mexican cooperatives had informally established exemption mechanisms for the very poor (mainly widows with several children) who received ITMs for free. The costs were covered by the profit they had made by their sales and did not affect the price. The other cooperatives had not yet thought about this.

In most small businesses in Latin America, consumers tend to pay by instalments. This was also the case in the Mexican and Colombian cooperatives which – according to the interviews – did not cause problems.

Factors relating to the strengths and weaknesses of the cooperatives

In Fig 1 factors which favour or limit the success of ITM cooperatives are presented. "Internal factors" are directly linked to particular cooperatives and "external factors" are those beyond the control of cooperatives. Examples will be shown and analysed.

Figure 1

External and internal factors which favour or limit the success of cooperative-based ITM services.

Favourable factors

Support and supervision

Continuous support and supervision turned out to be essential for the cooperatives. In Mexico this work was done by IMSS-SOLIDARIDAD, a government organisation with a strong component of community health work and a sophisticated system of supervision. This led to the rapid development of the infrastructure and corporate identity of the cooperatives. Well-organised communities in the Mexican situation were essential for following up the activities of the cooperatives. In some cases community leaders were also involved – this was perceived by cooperative members to be a strengthening factor.

In the Colombian study areas, the MoH support was much less concrete so that most of the work had to be done by an academic institution, the Colombian Institute of Tropical Medicine, together with the research team. Furthermore, for security reasons, direct supervision of the cooperatives' work outside larger towns could be done only irregularly. This caused significant delays in their work and less stringent control of their activities.

Support by NGOs and health services

In Mexico, the National Institute for Amerindians (Instituto Nacional Indigenista) promoted the ITM cooperative for free on their local radio station thereby augmenting sales substantially among the target population. In Colombia, UNICEF donated net fabrics; an international NGO bought 3,700 impregnated bednets from two cooperatives and the local health service purchased 200 ITMs for free distribution among the poor.

Donation of materials and gain of prestige

Initial donations to the cooperatives of insecticides by the pharmaceutical industry and, to a small extent, by the MoH was an essential starting mechanism for impregnation activities – they helped to feed the revolving fund. The donation of promotional materials by the research team and of protective clothing by IMSS-SOLIDARIDAD in Mexico and by the research team in Colombia was important for creating a sense of corporate identity among cooperative members and a sentiment of not operating alone. It contributed also to a gain of prestige in the community.

Motivation of cooperative members

When asked about their motivation for working in the cooperatives, members in Mexico most frequently said it was "to contribute to the development of our communities", "to protect our children" and "to do something for our people". This was reconfirmed by the fact that in most Mexican cooperatives no personal income has not yet been taken from sales. In both Mexico and Colombia women mentioned also that they liked to work together and that the income generated by the sales would help to support their families. This was particularly stressed by the Colombian cooperatives which produced bednets themselves and were keen on selling them as quickly as possible.

Limiting factors

Paternalistic attitudes of health services; donation of nets

Health services and particularly vector-borne disease control programmes have accustomed populations to receiving services for free or to not receiving services at all. This was reflected in the occasional indiscriminate donation of impregnated or unimpregnated mosquito nets by VBDC staff without prioritising specific risk groups and, even worse, without indicating that nets have to be re-impregnated. Indiscriminate donations of bednets by the MoH occurred in all our study areas leading community members to ask: "Why does the cooperative sell the nets which we eventually get from the MoH for free"?

Continuation of residual house spraying

Malaria workers trained in residual house spraying are confused by the new strategy of bednet impregnation and some of them (both in Mexico and Colombia) expressed their concern at losing influence and control. "What do we have to do when people start to use insecticides?" was a question recorded in the interviews. Residual house spraying was done in all study areas at irregular intervals of from 6 months to 4 years. In two study areas in Mexico bednet users asked: "Do we need to impregnate our nets when the malaria [team] comes to spray our houses?"

High unit costs of impregnation

In Fig 2 the components of the direct financial costs of an impregnation service are presented. These include the insecticide, the dipping equipment (plastic bags, jars, gloves, mouth-protectors, aprons), repacking materials (plastic bottles with screw-tops, labels, syringes) and promotional materials (flyers, posters, stickers, visors) but exclude the costs of protective uniforms which were provided by the health services. The radio spots in Colombia have been excluded because at the time of the study these had been broadcast for two months only; this would have added a further US$2.0 per impregnation service sold.

Figure 2

Components of the direct financial costs of an impregnation service (Colombian model)

The higher the insecticide costs, the stronger the dependence on external support. Insecticide costs are particularly high in Colombia, due to import taxes and VAT. The cost of 1 litre lambdacyhalothrin 2.5% CS at the end of 2001 was US$105 to the public and US$84 to the MoH in Colombia. In Guatemala it was US$40 and in Ecuador US$27). Even when re-packing the insecticide into small one-treatment units, the price in Colombia was still high (US$0.87 for lambdacyhalothrin). The other cost components (Fig 2) and the small surplus for the cooperative (US$ 0.28) increased the price of one impregnation to US$1.50 which was, according to our discussions with cooperative members difficult to recover among the general public. As a result the Colombian cooperatives charged only US$0.50 per impregnation (which was accepted by the general assemblies of the communities involved), relying on donated insecticides by the MoH and the industry.

In 2002, one company started offering insecticide at a lower price (US$0.60 per impregnation unit) to reduce the dependence on subsidies is less. In Mexico, the insecticide price per impregnated net in January 2002 was only US$0.35 for deltamethrin SC (market price) and US$0.23 for lambdacyhalothrin CS (discount price offered by the national retailer to cooperatives) and the total cost of the impregnation service per net was US$0.7 (Fig 2). A price of US$ 1.00 was perceived to be reasonable by cooperative members and widely accepted by the community assemblies and the population. This resulted in a surplus of roughly US$0.30 for the cooperative per impregnated net.

When cooperatives were involved in business transactions, as in the case of the net-producing cooperatives in Colombia, they experience difficulties when ordering fabrics in large quantities from the capital city or when selling a high number of impregnated nets to an NGO. For such transactions, they needed official status with a company code and VAT registration. The solution was to affiliate the cooperative with a larger organisation which had a defined legal status. However, such affiliations imply charges and weaken the independence of the cooperative.

Excessive numbers of cooperative members and profit orientation

11 out of 14 cooperatives had three to five members. One in Mexico had four active members, but all 26 female spouses in the community insisted on participating in the sale of impregnated nets because no one wanted to be excluded. This was perceived as working well by community leaders and cooperative members, mainly because the cooperative was not profit-oriented and covered only travel expenses and the purchase of new materials and supplies. In contrast, in two Colombian cooperatives in an urban environment, 32 women in one and 11 women in the other produced nets and impregnated them, and they all wanted to get some profit from sales. This worked only because of the external support (see" Support by NGOs"). However, sustainability can only be guaranteed if external donors can be attracted, which is difficult to achieve.

Excessive emphasis on net production or net sales

The two Colombian cooperatives mentioned above paid almost exclusive attention to the production and impregnation of bednets, ignoring the large number of existing nets that needed to be impregnated in the community. Similarly, four Mexican cooperatives, which impregnate and sell pre-fabricated nets, put little emphasis on the impregnation of existing nets (see Table 2).

Poor financial management

All regularly supervised cooperatives kept their books in a satisfactory state with a transparent overview of income and expenditures; this was confirmed by the research team. Only two Colombian cooperatives, in areas of civil unrest, did not appear to correctly register their balance. This led to tensions with the supervisory team and to difficulties in rational budgeting.

A management problem appeared in one generally successful Mexican cooperative when a distant community asked for impregnation services and the cooperative members were fearful about increased transport costs. A simple cost calculation by the research team showed that they would have made a profit and satisfied their consumers if they had travelled.

Lack of initiatives and promotion

As cooperative members were not selected on the grounds of being business people with a talent for promoting and selling goods, this quality was randomly distributed among members. As a result, those cooperatives which had more members with a business spirit developed more initiatives in promoting ITMs than those where members were more shy in promoting their product to the public.

Low demand for ITM services by the population

ITM services paid for and offered through community cooperatives was a new departure for the populations of all study areas and substantial promotional efforts were needed to increase demand. Some of the factors explaining low demand have been mentioned. For example, donation of impregnated nets for free, dispersed populations in rural areas and lack of initiative by the cooperatives. The cost aspect was less important to the consumers when impregnation was sold at US$ 1.0 in Mexico and US$ 0.50 in Colombia. In Mexico there was a certain tendency for people to prefer more expensive bednets of higher quality over the cheaper ones of lower quality (expressed in the group interviews with cooperative members and individual interviews with ITM users).

Other reasons for low demand of ITM services, mentioned in interviews with cooperative members and ITM users and non-users in both countries, included: