If you have a magic bullet you want everyone to use, how much do you charge for it? Six dollars? Fifty cents? Nothing? The price of a malaria-preventing bed net in Africa is a matter of fierce debate among development experts. On the one hand, someone who buys the net should be more likely to use it than someone who gets it free. On the other hand, free nets should find their way into more households. When the goal is maximum coverage, “it’s not enough to say charging a positive price makes people more likely to use it, if significantly fewer people own it at that price,” says Jessica Cohen, assistant professor at the Harvard School of Public Health.
Cohen tried to find the price point that would get the most insecticide-treated nets into the hands—and over the beds—of the people who need them, specifically pregnant women and children under 5 years old. In 2007, she and her coauthor, UCLA economist Pascaline Dupas, distributed nets to 20 prenatal clinics in western Kenya and randomized the price at which those clinics could sell them. A few months later, the researchers followed the takers home. Their results: It was unequivocally better to give the nets away.
“What we found was that even very small increases in price reduced demand dramatically,” Cohen says. “If a hundred pregnant women would take a net when it was offered free, only 40 of them would take it at a 90 percent subsidy.”
This result was consistent with the observation that first spurred Cohen and Dupas to do the study. They had started the nonprofit TAMTAM to distribute free nets through prenatal clinics. “We saw big increases in attendance,” Cohen says. After a couple of years, Population Services International (PSI) took over distribution in the area. “They started charging just some small nominal fee for the nets,” Cohen says, “and we noticed that attendance rates went down to pre-TAMTAM levels.”
Maybe, though, women who had paid for the nets would also bother to sleep under them, because of the investment they had made. Oddly, says Cohen, that is not what she and Dupas found. “About 65 percent of women were using the nets regardless of what they had paid.” Although charging for the nets radically reduced demand, it did not significantly increase usage.
Desmond Chavasse, vice president for malaria control and child survival at PSI, says, “If you give people something free, then even if they have no intention of using it, they’re still going to accept it. Whereas no one would dream of paying for something that they had no intention of using.” He adds, “I would have thought that you would find higher usage rates amongst people who had paid.”
Both PSI and the government of Kenya now distribute free bed nets. Chavasse points out that increasing usage was not the only reason to charge—the money raised from net fees served as an important source of support for distribution programs. But as long as the funding holds up, “it’s a complete no-brainer,” says Chavasse. “There should be free nets available in every health facility in a malaria-endemic country where nets work.”
Jessica Cohen and Pascaline Dupas, “Free Distribution or Cost-Sharing? Evidence from a Randomized Malaria Prevention Experiment,” The Quarterly Journal of Economics, 125, 2010.
Read more stories by Jessica Ruvinsky.